ND 136 Nutritional Assessment Lecture PDF

ND 136 NUTRITIONAL ASSESSMENT LECTURE PELIN BUGTONG-BELINO, RND, PhD. Department of Human Nutrition College of Home Economics and Technology Benguet State University  NUTRITIONAL ASSESSMENT  process by which the nutritional health of a...

ND 136 NUTRITIONAL ASSESSMENT LECTURE PELIN BUGTONG-BELINO, RND, PhD. Department of Human Nutrition College of Home Economics and Technology Benguet State University  NUTRITIONAL ASSESSMENT  process by which the nutritional health of an individual is evaluated, specific nutrient needs are estimated and plans for nutrition care are determined - process of determining the nutritional status of individuals or groups for the purpose of identifying nutritional needs and planning personal health care or community programs to meet these needs - interpretation of information from dietary, laboratory, anthropometric & clinical studies to determine the nutritional status of individuals or population groups. (Gibson, 2005) - appraisal of available information to provide a description of existing nutrition situation  Nutritional Status or Nutriture state of the body produced by the processes and results from the balance between supply of nutrients and utilization of the body - the condition of how well-nourished the human body (Ruiz et.al., 2006) as determined by anthropometric measurements, biochemical measurements of nutrients or their by-products in blood and urine, clinical (physical) examination, a dietary analysis and economic evaluation (Wardlaw & Hampl, 2007) Nutritional Care Process – a systematic problem-solving method used by nutritionist-dietitians to address nutrition-related problems by providing safe, effective and high- quality nutrition care (Lee & Nieman, 2010) Nutritional Care Process 1. Assessment 2. Diagnosis 3 Planning 4 Implementation 5 Evaluation Nutritional Care Process (ADIME) 1. Nutrition Assessment 2. Nutrition Diagnosis 3 Nutrition Intervention 4 Nutrition Monitoring 5 Nutrition Evaluation Nutritional Care Process  Other Terms used Nutritional Assessment Measurements- usually used in anthropometry. this refers to measures such as age, weight, height Index/Indices – combination(s) of measurements e.g. weight-for- age Indicator – relates to the use or application of indices e.g. rates/ratio (IMR, MMR) & proportions - type of information used to describe the kind of changes that can be accepted as measures of success; chosen depending on the kind of changes that are to be achieved - may be quantitative or qualitative  Other Terms used Nutritional Assessment Reference data – population characteristic or distribution properly derived from a large representative sample of the population which is reasonably healthy and well-nourished, against which indices are compared Cut-off points – based on the relationship between nutritional assessment indices and functional impairment and/or clinical signs of deficiency; used to classify malnourished individuals and determine prevalence of malnutrition  Table 1. Cut-off points used in classifying nutritional status of children, 0-10 years old (0-120 months) based on the World Health Organization – Child Growth Standards (WHO-CGS) as used in the National Nutrition Survey (FNRI, 2015) Indicator/Nutritional Status Cut-Off Points W eight-for-Age Underw eight + 2 SD Length/Height-for-Age Underheight/Stunted + 2 SD W eight-for-Length/Height Thin/W asting + 2 SD  Table 2.Cut-off points used in classifying nutritional status of children 0-5 years old (0-60 months) based on BMI-for-age (WHO-CGS) Nutritional Status Cut-off Points Severe thinness + 3SD  Table 3. Cut-off points used in classifying nutritional status of children, 5.08-19.0 years old (61-228 months) based on the 2007 WHO Growth Reference BMI-for-age Nutritional Status Cut-off Points Severe thinness +2SD (equivalent to BMI 30 kg/m2 at 19 yrs) Obesity Table 4. Cut-off points used in determining magnitude and severity of underweight and stunted children under-five years old (0 to 8 0 cm (~ 32 in) >8 8 cm (~ 35 in) Gib son: 9 0 cm  NUTRITIONAL ANTHROPOMETRY 6. Waist Hip Ratio (WHR) - provides an index of both subcutaneous and intra- abdominal tissue and therefore a valuable indicator of fat distribution ; abdominal-to- gluteal ratio  Locating the waist and hips  NUTRITIONAL ANTHROPOMETRY  Table 5. Classification and cut-off points for waist circumference and waist hip ratio by sex as used in the 2013 NNS (FNRI, 2015) Sex W aist Circumference Classification W aist Hip Ratio (cm) Male 1.0 F emale 0.8 5  NUTRITIONAL ANTHROPOMETRY 7. Skinfold thickness - assesses body composition, fat distribution hence calorie reserves  Sites: chest, triceps, subscapular, midaxillary, suprailiac, abdomen, thigh, medial calf  Various types of calipers (Left –Right: Slim guide, Fat control, Holtain, Lange & Harpenden)  NUTRITIONAL ANTHROPOMETRY 8. Mid-arm circumference (MAC) or Upper Arm Circumference - an indicator of muscle and subcutaneous adipose tissue which can also be used in equations for calculating arm muscle area and estimated body weight  is measured midway between the acromion and olecranon process  the arm is relaxed to the side with the palm facing the thigh after which a non- stretchable tape is placed around the arm perpendicular to the long axis of the arm and at the level of the triceps skinfold site  the tape should be in contact with the arm but without compressing the soft tissues  measurements are recorded to the nearest 0.1cm.  NUTRITIONAL ANTHROPOMETRY Systems in reporting anthropometric indices 1. Percentile System - refers to the rank position of the measurement value in relation to all (or 100%) of the measurements for the reference population ranked in order of magnitude 2. Z-score or Standard Deviation (SD) value system - number of standard deviations or Z scores below or above the reference mean or median value 3. Percent of mean or median system - ratio of measured value in individual ; expressed as percentage  NUTRITIONAL ANTHROPOMETRY Growth Monitoring - a tool to promote and sustain good health & nutrition in the first years of life and detect early growth failure due to lack of food, illness, wrong practice or a combination of these  Growth Monitoring Chart / Early Child Care & Development Chart - an important record in the Under-Five Clinic which serves as a diary or record of the child’s health & development, his growth, illnesses experienced, feeding & nutritional history & immunization Contains the growth curve (graphical representation of the clinical & nutritional status of children , as represented by changes in weight over time) Growth Monitoring Chart Growth Monitoring Chart WHO Growth Monitoring Chart  NUTRITIONAL ANTHROPOMETRY Calibration - The checking and adjusting of the weighing scale within possible and allowable error to: a) Make sure scale is within the tolerable limits of accuracy b) Detect beyond the tolerable levels of accuracy Recommended weighing scales (DOH, 1991) 1. Salter Scale 2. Beam Balance 3. Bar Scale NUTRITIONAL ANTHROPOMETRY Recommended Weighing Scales (DOH, 1991) NUTRITIONAL ANTHROPOMETRY Parts of a weighing scale 1. carriage 5. Dial (of salter scale) 2. platform (of platform scale) 6. Graduation on the bar or dial 3. adjustment screw 7. Balancing weight 4. bar (of bar & platform scale)  NUTRITIONAL ANTHROPOMETRY Sources of Error in weight and height taking All measurements Incorrect instrument Restless child Reading error- Getting the reading when pointer is not yet steady Recording errors Length Incorrect instrument Footwear or headgear not removed Head not held firmly against fixed end of length board Child not held straight along length board; body arched Knees bent  BIOCHEMICAL ASSESSMENT Biochemical assessment pertain to laboratory tests, mostly based on analysis of blood and urine samples which contain nutrient, enzymes and metabolites that reflect nutritional status  Other tests such as serum glucose, help pinpoint disease- related problems with nutritional implications  BIOCHEMICAL ASSESSMENT Advantages of Biochemical Measurements 1. Identify nutrient deficiency before clinical signs become apparent 2. Confirm clinical diagnosis since clinical signs are not often specific 3. Measures nutrient levels 4. Examines validity of dietary methods 5. Adjunct in assessing & managing nutritional status  BIOCHEMICAL ASSESSMENT Disadvantages of Biochemical Measurements 1. Influence of non-nutritional factors (disease, medications, technical problems) 2. Non-specificity 3. Not by itself sufficient  BIOCHEMICAL ASSESSMENT Criteria for an ideal biochemical test 1. specific 2. simple 3. inexpensive 4. reveals tissue depletion at an early stage 5. require less sophisticated equipment and skill  BIOCHEMICAL ASSESSMENT Categories of biochemical measurements (Lee & Nieman, 2010) 1.Static tests (direct)- measurement of a nutrient or metabolite (e.g. glucose for CHO, amino acids) in the blood, urine or body tissue interpretation of results maybe confounded by numerous factors  BIOCHEMICAL ASSESSMENT Static tests: Interpretation of results maybe confounded by numerous factors as follows: a. homeostatic regulation k. weight loss b. recent dietary intake l. hormonal status c. diurnal variation (daily changes) m. inflammatory stress d. hemolysis (serum / plasma) n. physical exercise e. sample contamination o. age, sex, ethnic group f. physiological state p. sampling/collection procedure g. infections q. accuracy & precision of method h. nutrient interactions r. sensitivity & specificity of method i. drugs j. disease states  BIOCHEMICAL ASSESSMENT 2. Functional tests (indirect)- based on the idea that the final outcome of a nutrient deficiency and its biologic importance are not merely a measured level in a tissue or blood, but the failure of one or more physiologic processes that rely on that nutrient for optimal performance Ex: dark adaptation test for vit. A impairment of immune system reduction in activity of enzymes w/c require a nutrient as coenzyme e.g. erythrocyte transkelotase for thiamin  BIOCHEMICAL ASSESSMENT Types of biochemical measurements 1. Measurement of nutrient or its metabolites in b. blood 1. whole blood 2. plasma 3. erythrocytes 4. leukocytes b. urine b.1. random sample first voided morning urine sample 24-hour specimen  BIOCHEMICAL ASSESSMENT 2. Measurements of one or more functions of the nutrient a. enzymatic test – measures the activity of an enzyme which requires the vitamin as a coenzyme added in vitro (test tubes)  Ex: For thiamin, measure pyruvate or lactate to show efficiency of thiamin in energy metabolism b. metabolic test – measures the rise in concentration of metabolite in blood or urine after administering a load of an appropriate precursor  Ex: Glucose test for thiamin where blood levels of pyruvate & lactate are determined  BIOCHEMICAL ASSESSMENT Assessment of performance of laboratory examination 1. Accuracy - a measure of the closeness of the results of the true value 2. Precision - reproducibility of the results on repeated testing Within assay variability – reproducibility from repeated measurements during the same time Between assay variability – reproducibility of measurements performed on the same specimen on at least 10 assays or days Factors Affecting Accuracy of Results Method of sample collection Method of transport and storage of samples Techniq ues employed (analytical method) Use of medications Infections or other pathological conditions alter b iochemical indicator  BIOCHEMICAL ASSESSMENT Common Laboratory Tests Test W hat it measures Plasma proteins Protein status Liver enzymes Liver function Blood Urea Nitrogen (BUN) Renal function Serum Electrolytes Urinary Urea Nitrogen (UUN) Protein Tissue Catab olism Excretion; Creatinine Height Index (CHI) Complete Blood Count (CBC) Anemia F asting Blood Sugar (F BS) Hypo/Hyperglcemia Total Lymphocyte Count (TLC) Immune F unction Alanine transaminase or ALT Heart and liver function (formerly SGPT) Aspartate transaminase Heart and liver function Serum amylase Pancreatic function  Selected assessment methods for vitamin and mineral status Nutrient Assessment Tests V itamin A Retinol-b inding protein; serum carotene Thiamin Erythrocyte transketolase activity; urinary thiamin Rib oflavin Erythrocyte glutathione reductase activity; urinary rib oflavin F olate Erythrocyte folate (liver stores), vit. B12 status; free folate in b lood V itamin C Serum or plasma vitamin C; Urinary vitamin C V itamin D Serum alkaline phosphatase V itamin E Serum tocopherol; erythrocyte hemolysis V itamin K Blood clotting time (prothromb in) Iron Hemoglob in, Hematocrit, Serum F erritin. Total Iron-b inding capacity, transferrin saturation, protoporphyrin, mean corpuscular volume, serum iron Iodine Serum protein-b ound iodine, thyroglob ulin, urinary iodine, TSH  Common Measurements 1. Protein status a. Creatinine Excretion - Creatinine is a product of skeletal muscle excreted in a relatively constant proportion to the mass of the muscle in the body The 24-hr excretion is compared with a standard b. Creatinine-Height Index (CHI) (Normal: >80%) - ratio of the patient’s measured 24-hour urinary creatinine CHI of 60-80% is considered as mild protein depletion; 40-60% moderate depletion and under 40% as severe depletion c. Nitrogen Balance d. Serum Proteins e.g. albumin (Normal: 3.5-5.0 g/L), transferrin (Normal: 200-400mg/dL), prealbumin, retinol-binding protein (Normal: 2.1-6.4 mg/dL)  Common Measurements 2. Iron status Stages of iron depletion 1. Depleted stores - measured by Serum Ferritin 2. Iron deficiency (no anemia) - measured by Transferrin Saturation 3. Iron deficiency Anemia - measured by hemoglobin and mean corpuscular volume (MCV)  Tests for evaluating nutrition-related anemias General Tests Normal Levels W hat it reflects Hemoglob in (Hb ) 5 m– 6y: 11g/dL Total amount of hemoglob in in red b lood cells  b lood O2 -carrying capacity 6.1-14 y: 12.0 g/dl Adult females: 12 g/dl Adult males: 13 g/dl Pregnant: 11g/dl Lactating: 12 g/dl Hematocrit (Hct) Males: 4 0 -5 7 % Percentage of RBC in total b lood volume F emales: 37 -4 7 % Red Blood Cell (RBC) Count Numb er of RBCs Mean corpuscular volume 8 0 -10 0 fL (femtoliter) RBC Size; determines if anemia is microcytic (iron deficiency) or macrocytic (folate or B12 deficiency) Low serum ferritin 4 y : >2 8 Low serum folate Progressing deficiency state of folate Low RBC F olate Later deficiency state of folate Low serum B12 Progressing deficiency state of B12 Serum Transferrin Receptor 10 1-9