NUTRITIONAL STATUS ASSESSEMENT

Prof Cristian Serafinceanu

Institutul de Diabet, Nutritie si Boli Metabolice N.
Paulescu

WHY SHOULD DOCTORS

BE CONCERNED ABOUT NUTRITION?

Diet and physical activity are linked to more

deaths each year than any single factor other
than cigarette smoking.

As health care providers, we can do more for

our patients by helping them eat healthy and
exercise regularly than any other intervention.
B Brenner, 2007

Nutritional care algorithm (nutritional medical

therapy) for renal patients
1
2
3.
4.
5.

nutritional screening
nutritional antecedents
nutritional behavior
clinical examination
biologic parameters

Identification of therapeutic goals:

1. Reasonable
acceptable for
own lifestyle
2. Negotiable
3. Adjustable

Periodic evaluation:
1. results monitoring - redefining goals
1. solving current problems

Nutritional medical intervention:

1. Diet
2. Nutritional supplements

NUTRITIONAL ASSESSMENT
Significant antecedents:

1.

Physiologic
Pathologic
Therapeutic

Known nutritional problems or deficits

Chronic use of drugs with nutritional effects (i.e. chimiotherapy)

Psycho-social antecedents:
Alcohol or drug abuse
Smoking
Financial and social status
Marital status

Specific signs and symptoms for nutritional deficiencies

Subjective global assessment:

1.
2.

Evaluation of muscular waste

Evaluation of subcutaneous tissue
Presence of oedemas
Dialysis related items

NUTRITIONAL SCREENING

Basal (level I): detection

of nutritional risk
factors

-body mass index

-eating habits
-living environment
-functional status

Complete (level II): for

patients at nutritional
risk

-history of weight changes

(6 mo)
-mid-arm circumference
-triceps skinfold
-mid-arm muscle area
-serum albumin
-total plasma cholesterol
-clinical features
-drug prescriptions
-mental/cognitive status

REFERENCE VALUES: CLASSIFYING

MALNUTRITION
Age

BMI

Malnutrition

>= 18 years

<16
16 16,9
17 18,5
>= 18,6

Severe
Moderate
Mild
Normal

14 17 years

<16,5

Present

11 13 years

<15

Present

NUTRITIONAL SCREENING II

Eating habits (topics)

-not have to eat enough (each day)

-usually eats alone
-poor appetite
-special (restrictive) diets
-does not eat vegetables, fruit or milk at least
once daily
-difficulties in chewing or swallowing
-more than two alcoholic drinks per day (one
for women)
-has pain in mouth , teeth or gums

NUTRITIONAL SCREENING III

Living environment

-poor

income

-lives alone
-housebound
-is unable (or prefers not) to spend money on
food

NUTRITIONAL SCREENING IV

Functional status - needs assistance (usually or

always) with:

-bathing
-dressing
-toileting (grooming)
-eating (preparing food)
-walking (traveling)
-shopping (for food)

REFERENCE VALUES FOR

ANTHROPOMETRIC MEASUREMENTS IN
ADULTS (HAMMOND KA ET AL, 2004)
Target
population

Mid-arm
circumference
(MAC)

Triceps
skinfold
(TS)

Mid-arm
muscle area
(MAMA)

Females 3040y

28.6

24.2

32.4

Females 6070y

31.7

14.5

35.4

Males 30-40y

31.9

13

55.8

Males 60-70y

32.8

14.2

51

NUTRITIONAL SCREENING V

Clinical features and mental/cognitive

status:

-evident problems with mouth, teeth, gums

-difficulties with chewing
-angular stomatitis
-glossitis
-skin lesions (dry, loose, wounds, etc.)
-history of bone fractures
-clinical evidence of mental status impairment
-depressive illness (Geriatric Depression Scale,
etc.)

NUTRITIONAL HISTORY: DEFICIENCY

SYNDROMES I
Mechanism

History of

Suspected
deficiency

Alcohol abuse

Protein, vitamins
B

Avoidance of
Vitamin C, folates,
vitamins B
fruits, vegetables
Inadequate
intake

Inadequate
absorption

Avoidance of
meat , eggs

Protein, vitamin
B12

Habitual
constipation

Dietary fibre

Poverty, isolation

Energy, protein

Drugs (antacids,
laxatives,
anticonvulsivants)

Various nutrients

NUTRITIONAL HISTORY: DEFICIENCY

SYNDROMES II
Mechanism

Inadequate
absorption

History of

Suspected
deficiency

Malabsorption
(diarrhea, weight
loss, steatorrhea)

Liposoluble
vitamins
(A,D,E,K), energy,
protein

Parasites
Pernicious anemia

Iron, vitamin,
B12

Gastro-intestinal surgery

Decreased
utilization

Drugs
(anticonvulsivants,
antimetabolites,
isoniazide)
Inborn errors of
metabolism

Various

NUTRITIONAL HISTORY: DEFICIENCY

SYNDROMES III
Mechanism

Increased losses

History of

Suspected
deficiency

Alcohol abuse

Magnesium, zinc

Blood loss

Iron

Centesis (ascitic,
pleural)

Protein

Uncontrolled
diabetes mellitus

Energy, protein

Diarrhea

Protein,
electrolytes

Nephrotic
syndrome

Protein

Dialysis

Protein, vitamins
(water soluble)

NUTRITIONAL HISTORY: DEFICIENCY

SYNDROMES IV
Mechanism

Increased
requirements

History of

Suspected
deficiency

Fever,
hyperthyroidism

Energy

Physiologic
demands
(adolescence,
pregnancy,
lactation)

Energy, various
nutrients

Surgery, burns,
trauma

Energy, protein,
vitamin C

Infection,
hypoxia

Energy

Smoking

Vitamin C, folates

CLINICAL NUTRITION EXAMINATION (MAHAN LK,

2004) I
Organ/
syste Abnormal finding
m

Nutritional
deficiency

Non-nutritional
association

essential fats, vit.A

environmental

niacin or tryptophan

chemical burns,
Addisons disease

pallor

iron, vit B12

hemorrhage,
pigmentation
disorders

Petechiae,
ecchymoses

Vit K, C

Liver disease,
aspirin overdose

nails

spoon-shaped

iron

pulmonary or heart
chronic disease

hair

lack of shine, easy

pluckable

proteins, Zn, linoleic

acid

hypothyroidism,
chemotherapy,
psoriasis

dry, scaly

Skin

hyperpigmentation
of sunlight exposed
areas

CLINICAL NUTRITION EXAMINATION (MAHAN

LK, 2004) II
Organ/system

Abnormal
finding

Nutritional
deficiency

Non-nutritional
association

eyes

dry, grayish,
night blindness

Vit A

Gauchers
disease

lips

bilateral (angular
stomatitis) or
vertical cracks
(cheilosis)

Vit B2, B6, niacin

dentures
problems,
herpes, syphilis,
AIDS

tongue

magenta, loss of
papillae, swollen

Vit B2

Crohndisease,
bacterial or
fungal infections

gums

spongy,
bleeding,
receding

Vit. C

Drugs (dilantin),
lymphoma,
thrombocytopeni
a, aging, poor
dental hygiene

parotid glands

Bilateral
enlargement

Protein
deficiency

Tumors,
hyperparathyroi
dism

MARKERS OF VISCERAL PROTEIN

STATUS I
Paramete Norma Plasmati
l range c life (d)
r
(g/l)

Normal
function

Nutritional
significance

Albumin

35-45

18-20

Coloid-osmotic
pressure

late malnutrition
marker

Transferrin

2.6-4.3

8-9

plasma iron
carrier

malnutrition (more
early) marker; negative
inflammation marker

Prealbumin
(transthyre
tin)

0.2-0.4

2-3

Thyroid
hormones
transporter

Malnutrition (early
marker); acute
hypercatabolic states

Rhetynol
binding
protein
(RBP)

0.37

0.5 (12h)

Pro-vitamin A
transporter

Proteic intake
markerhypercataboli
c states

Insulin-like
growth
factor 1
(IGF 1)

0.55-1.4
UI/ml

2-6 h

Anabolic
growth factor

Immediate proteic
intake marker

SUBJECTIVE GLOBAL ASSESSMENT II (DETSKY

AS ET AL, JOURNAL OF AMERICAN MEDICAL
ASSOCIATION 271:54-58, 1987)
1. Weight Change
Maximum body weight _______________
Weight 6 months ago _______________
Current weight

_______________

Overall weight loss in past 6 months _______________

Percent weight loss in past 6 months _______________

Change in past weeks: _______increase

_______no change

________decrease

2. Dietary Intake (relative to normal)

_________ No change

Duration: __________ Weeks

_________Change

Type: __________ Increased intake

__________ Suboptimal solid diet
__________ Full liquid diet
__________ IV or hypocaloric liquids
__________ Starvation

3. Gastrointestinal Symptoms (lasting >2 weeks)

__________ None
__________ Nausea

__________ Vomiting

____________ Diarrhea

___________ Anorexia

SUBJECTIVE GLOBAL ASSESSMENT II (DETSKY

AS ET AL, JOURNAL OF AMERICAN MEDICAL
ASSOCIATION 271:54-58, 1987)

4. Functional Capacity
___________ NO dysfunction
___________ Dysfunction

Duration: ____________ weeks

Type: ____________ Works suboptimally
____________ Ambulatory
____________ Bedridden

PHYSICAL EXAMINATION
(For each trait specify: 0 = normal; 1+ = mild; 2+ = moderate; 3+ = severe)
__________ Loss of subcutaneous fat (shoulders, triceps, chest, hands)
__________ Muscle wasting (quadriceps, deltoids)
__________ Ankle edema
__________ Ascites

SUBJECTIVE GLOBAL ASSESSMENT RATING (select one)

__________ A = well nourished
__________ B = moderately (or suspected of being) malnourished
__________ C = severely malnourished

ROSPEN, Poiana Braov, 2004

MODIFIED SGA SCORE FOR CHRONIC KIDNEY

DISEASE PATIENTS
Parameter
/score

Weight
changes/6
mo

no

5%

5-10%

10-15%

15%

Dietary
intake
changes/ 6
mo

no

Suboptimal
solid food

Moderate
global
decrease

Liquid/hypoca
loric diet

starvation

Digestive
symptoms

no

nausea

Vomiting/oth
er moderate

Frequent
diarrhea/vomi
ting

Anorexia

Functional
status

Good/norm
al for age

Walking
difficulty

Usual efforts
difficulty
(housekeepi
ng)

Minimal
efforts
difficulty
(toileting)

Bedriding

Comorbidities

No

mild

moderate

1 severe

Multiple,
severe

Dialysis
duration**

Less than
12 mo, RRF

Less than 12
mo, no RRF

12-24 mo,
RRF

24-48 mo,
RRF

More than
48 mo

MODIFIED SGA SCORE FOR CHRONIC

KIDNEY DISEASE PATIENTS

Malnutrition:

-absent: 0 4
-mild:

58

-moderate: 9 14
-severe: 15 -24

ANTHROPOMETRIC ASSESSMENT OF
NUTRITIONAL STATUS I
1.

Classifying nutritional deficits in weight - for height: reference values (Torm B, Chen F,
1994)

Weight - for - height ratio = actual body

weight/reference weight for height (RWH)
RWH = 50+0,75(H-150)+(Age-20)/4

Normal: 90-110%
Mild deficit: 80-89%
Moderate deficit: 70-79%
Severe deficit: <70% (or with oedemas)

ANTHROPOMETRIC ASSESSMENT OF
NUTRITIONAL STATUS II

2. Body mass index (BMI, Quetelet index)

3. Tricipital skinfold (TS)

4. Mid-arm circumference (MAC)

5.Mid-arm muscular area (MAMA)

(MAC - TS)2/12.56

All anthropometric measurements must be interpreted for age, sex, race

BIOCHEMICAL ASSESSMENT OF NUTRITIONAL

STATUS

Indication = patients with significant risk of malnutrition

after nutritional history and physical examination (SGA).

Aim = to detect specific nutritional deficiencies before onset

of clinic or anthropometric manifestations.

Protein status: central for the prevention, diagnosis and treatment

of malnutrition:

Bi - compartmental pattern (of evaluation):

Metabolic active proteins (30 50%)

Muscle (somatic) proteins (75%)

Visceral proteins (25%)

Metabolic inactive proteins (50 70%):

Bones, joints

Iron status.
Calcium and phosphorus status .
Vitamins status.

PROTEIN METABOLISM STATUS ASSESSMENT

I

Nitrogen balance = ratio between the

amount of nitrogen consumed as proteins
and the amount excreted by the body.

The expected value for healthy adults is 1 the

rate of proteins synthesis (anabolism) equals the
rate of protein degradation (catabolism)
Formula: PRO(g)/6,25 = UUN(g) 4(g), where:

PRO: protein ingestion/24h(g)

6,25: protein nitrogen index
UUN: urinary urea nitrogen/24h (g)
4(g): constant for non urea nitrogen + non
urinary nitrogen (stool, sweat)

Disequilibrium of nitrogen balance need dietary

and/or non dietary correction (i.e.: increased
losses in critically ill patients).
ROSPEN, Poiana Braov, 2004

PROTEIN METABOLISM STATUS ASSESSMENT

II

a. Somatic protein status

Lean body mass assessment (muscle mass)

can be estimated by the 24h urinary
creatinine excretion comparing with a
standard (expected) excretion based on height

Urinary creatinin excretion:

Is a constant on ideal weight:

23 mg/Kgc/day in men

18 mg/Kgc/day in women

Its variation is exclusively determined by height

(see standards in table)
ROSPEN, Poiana Braov, 2004

NUTRITION COUNSELING OBJECTIVES

1)

2)

3)

4)

Include questions about diet and exercise in all

your routine patient histories.
Assess all patients height, weight and BMI.
Measure waist circumference when appropriate.
Help patients understand the association
between their diet and exercise habits and their
risk for chronic diseases.
Begin to negotiate realistic lifestyle changes
that can be achieved and maintained over time.