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NUTRITIONAL ASSESSMENT

(PENILAIAN STATUS GIZI)

Dr. I Wayan Weta, MS, SpGK


School of Medicine
Udayana University
The purpose of Nutritional
Assessment

IDENTIFICATION OF NUTRITIONAL
DEFICIENCIES
CLASSIFICATION OF MALNUTRITION
ESTIMATION OF NUTRITIONAL
REQUIRMENTS
Identification Nutrition-Related Conditions
Nutritional Assessment

S.O.A.P.

SUBJECTIVE DATA

OBJECTIVE DATA

ASSESSMENT

PLAN
Nutrition Support Team

Physician Dietitian
- Diagnosis - Nutritional Assessment
- Placement of CVC - Enteral Nutrition
- Team Leader - Transitional Feedings

Nurse Pharmacist
- Maintenance of CVC - Admixture Preparation
- Physical Assessment - Admixture Formulation
- Patient Training - Drug-Nutrient
Interactions
Nutritional Assessment

ABCD of nutritional Assessment:


Anthropometric
Biochemical test
Clinical observation
Diet evaluation and personal
histories
Diet evaluation and personal
histories
Specific 24-Hour Food Record
Diet History
Periodic Food Record
Food Frequency Questionaire (FFQ),
Semi Quantitative FFQ (SM-FFQ)

The problem under/over-reporting


Food consumption of individuals
Quantitative:
Twenty four hour recalls method

Repeated Twenty four hour recalls

method
Estimated food record

Weight food record


Name :_____________________ Date :____/____/____
Adress: _____________________ Day of week : __________________

Time Name of Description of Amount gram


food/drink ingridient (house hold)
6.00-10.00
Breakfast

10.00-12.00
Snack
12.00-13.00
Lunch

13.00-18.00
Snack
18.00-
Dinner
Addition questions:
Was intake unsual in any way? Yes/No
If yes, in what way?

Do you take vitamin or mineral supplement? Yes/No


If yes, how many per mday? (....) per week? (.....)
If yes, what kind? (give brand if posible)

Multi vitamin:_________________________________________

Iron :___ mg, Ascorbic acid:_____mg,

Other (list):
Qualitative Foods Dietary
Assessment
Food History

Foods Frequency Questionaire (FFQ)

Semi Quantitative Food Frequency


Questionaire (SM-FFQ)
Dietary history
Dietary history (consist of 3 component):
The First : the 24 hours recall of actual intake
The Second: Cross check for information, and usual
portion sizes in common household measures.
The third : a three day foods record using
household measures.
work day,
Saturday,
and Sunday

Average daily intake = 5X work day+Saturday+Sunday


7
Food Frequency Questionaire (FFQ)
Semi Quantitative Food Frequency Questionaire (SQ-FFQ)

Food item Freq/ day Freq/ week Freq/ House gram


month hold
portion
Evaluation of nutrient intake data

Recommended Nutrient intakes (RNI):


recommended to certain nutrient such as:
protein, Calcium, Phosphorus, iron, vit. A, Vit.
D, Vit. C, Folate, Vit. E, Vit. B12, Magnesium,
Zink, Iodine.
Recommended Dietary Allowance (RDA):
Recommended to almost all of nutrient
Evaluating nutrient intake of individuals

Nutrient adequacy ratio (NAR):

NAR = subject daily intakes of nutrient


RDA of nutrient
Mean adequacy ratio (MAR):
MAR = Sums of NAR for (X) nutrients
(X)
Evaluating nutrient intake of individuals

Index of nutritional quality (INQ):


INQ = Amount of nutrient in 1000 kcal of food
Allowance of nutrient per 1000 kcal.
Comparison of individual intake data to RDA
Standard deviation score (Z score):
Z score = individual nutrient intake mean value group
SD value for nutrient for the group.
Body composition and
Anthropometric Measurement
Two Compartment
Fat Mass
Free Fat Mass :
Water
Glycogen
Protein
Mineral
Fat Mass
The averages fat mass of :
- Women: 26.9% of BW
- Men : 14,7% of BW
Fat mass:
- Essential fat
- Reserve (storage) fat
Reserve Fat:
- Men : 12 % BW
- Women : 15% BW
Distributed in :
Inter and intra muscular fat.
Around (and protects) the organ and GIT
Sub-cutan fat
Based on its metabolic activity reserve
fat, divide into:
Peripherally subcutan fat (extremity)
Centrally subcutan fat (in trunkle/body area)
Visceral fat (intra abdominal)
Fat Mass and Obesity
Peripherally subcutan fat (extremity) :
Peripheral , Gynoid, Pear form Obesity.

Centrally subcutan fat (in trunkle/body area):


Subcutan central obesity, Apple form Obesity.

Visceral fat (intra abdominal):


Central, android, Aple form Obesity.
Essential Fat Mass:
- Bone marrow
- Central Nervous system
- Mamma gland
- Etc.
Essential Fat Mass :
- Men 3 % (2,1 kg)
- Women 9% (4,9 kg)
Fat Free Mass
Protein: skeletal muscle, organ muscle.
Mineral
Bodys fluid
BODY COMPARTMENTS
ASSESSED BY
ADIPOSE TISSUE 25% Triceps Skinfold
Body Weight
Arm Muscle
SOMATIC PROTEINS 30% Circumference
Body Weight
Creatinine Height Index

VISCERAL PROTEINS 8% Serum Albumin,


Transferrin
PLASMA PROTEIN 3%

EXTRACELLULAR 20%

SKELETON 10%
Anthropometric Measurement

Definition:
Measurement various dimension of the
human body, and its composition, in all
level of ages and nutritional status.
(Jelliffe, 1966).
Functions of Anthropometrical
Data
1. Measure the Growth Rate ( in Children)

2. Measure Fat Free Mass (fat free-mass,


lean body mass)

3. Measure Fat Mass (body fat mass)


Growth Measurement
1. Head Circumference
2. Body weigh : infant, children, adult.
3. Body Length and height
4. BW altering
5. Ratio BW/BH
Anthropometrics

Sex (m/f)
Height (H)(cm)
Weight (W)(kg)
Usual weight (UW)(kg)
W as (%) of UW
Ideal Body weight (IBW)(kg)
W as (%) of IBW
Anthropometrics

Triceps skinfold (TSF) (mm)


TSF as (%) of standard
Midle Arm circumference (MAC)(cm)
MAC as (%) of standard
Midle Arm muscle area (%) of a standar.
IDEAL BODY WEIGHT (IBW)

FEMALE:
IBW=100 LB +(5 LB X EVERY INCH >5 FT)

MALE:
IBW=106 lb +(6 lb FOR EVERY INCH >5 FT)
IDEAL BODY WEIGHT (IBW).
Hamwi Equetion

Men (kg) = 48 + (H*-152) x 1,06

Women (kg) = 45,4 + (H*-152) x 0,89

* H in cm
Anthropometrics

Weight: Weight loss:


1-2% past week
5% over the past month
7.5% during previous 3 moths
Or 10% past 6 months.

More than this rate--- severe.


Anthropometrics

Height:
Body Mass Index (BMI)
BMI= Weight (kg)/Height2 (m2)
Body Measure:
Mid Arm Circumference (MAC)
Triceps skinfold (TSF)
MAMC = MAC - {3.14XTSF}
Nutritional status based on BMI
and IBW
BMI (kg/m2) Nutritional state BW/IBW (%)
>30 Obese >120
25.1 29.9 Overweight 111 -119
18,5 25.0 Normal 90 110
17,0 -18,4 Mild PEM 80 - 89
16.0 16.9 Moderate PEM 70 -79
<16.0 Severe PEM <70
CALSSIFICATION OF OVERWEIGHT
AND OBESITY (WHO)

Classification BMI (kg/m2)


Underweight <18.5
Normal range 18.5 - 24.9
Overweight > 25.0
Pre-obese 25.0 - 29.9
Obese class I 30.0 - 34.9
Obese class II 35.0 - 39.9
Obese class III > 40.0
Classification of overweight and obesity by BMI,
Waist Circumference And Risk of co-morbidities.

Class BMI LWC HWC


(kg/m2) <90 cm (men) >90 cm (men)
<80 cm (women) >80 cm (women)

underweight <18.5 Low (but increase others Average


clinical problems)

Normal 18.5-22.9 Average Increase

Overweight 23.0-24.9 Increase Moderate

Obese I 25.0-29.9 Moderate Severe

Obese II >30.0 Severe Very severe


Fat distribution
Gynoid obesity Android obesity
Weight Gain Guidelines

Underweight prior to pregnancy, <18.5 BMI


28 - 40 lbs (12,5-18 kg)
Healthy weight prior to pregnancy, 18.5-24.9
BMI
25 - 35 lbs (11,5-16 kg)
Overweight prior to pregnancy,24.9-29.9 BMI
15 - 25 lbs (no less than 15 lbs) (7-11,5 kg)
Obese prior to pregnancy, >30 BMI, 15 lb
min (6 kg).
Pregnancy is NOT a time to diet
Pertambahan berat badan
selama kehamilan
BMI + total + TM I + TM II &
(kg) (kg) III
(kg/mgg)
BB kurang 12,5-18 2,3 0,49
(BMI<19.8)

BB normal 11,5-16 1,6 0,44


(BMI 19,8-26)

BB lebih 7-11,5 0,9 0,3


(BMI >26-29)

Obese 6 - -
(BMI >29)
Expected Weight Gain
Grafik pertambahan berat pada kehamilan
Trimaster I Trimaster II Trimaster III
10 kg 10 kg

5 kg 5 kg

0 0
Biochemical Test
Plasma Protein:
albumin,
hemoglobin,
hematocrit;
Additional:
prealbumin,
Thyroxin binding protein,
serum transferrin, or TIBC,
ferritin
Urinary
Protein metabolism: 24 hour urine test
Creatinin High Index (CHI)
CHI = Urinary Creatinine 24 hours X 100%
Expected Creatinin urine in IBW
Expected creatinin urine:
- men = 23 mg/kg IBW/24 hours
- women= 18 mg/kg IBW/24 hours
Interpretation:
- CHI > 80% : normal
-CHI 60-80% : moderate depletion skeletal muscle
-CHI 40-50% : Severe depletion of skeletal muscle
Urinary

N Balanced =
(protein intake:6.25) (urinary urea Nitrogen+4)

Interpretation:
+ : Anabolic state
0 : Balanced state
- : catabolic state
Biochemical Test (continued)

Immune System Integrity:


Anergy:
Lymphocyte count (TLC)
Skin testing
Delayed sensitivity (Mumps or PPD
tuberculin)
Biochemical Test (continiud)

Laboratory Determinations:
Serum albumin (g/dL)
TIBC (g/dL)
Serum transferrin (TFN) (g/dL)
White blood cell count (No/mm3)
Total Lymphocyte count (No/mm3)
24-h urinary urea Nitrogen (g)
24-h urinary creatinine(mg)
CHI (%) standard
OBJECTIVE DATA
SOMATIC COMPARTMENT
MARKER Normal Mild Moderate Severe t 1/2

Albumin > 3.5 3.1-3.5 2.1-3.0 < 2.1 20 d

Transferrin >200 151-200 100-150 <100 8d

Prealbumin >15 10-15 5-10 <5 2-3 d

Total > 2000 1200-2000 800-1199 < 800


Lymphocyte
Count (TLC)
Clinical Observation
Clinical Sign of Malnutrition:
Skin, hair, eye, nail etc
Vital Sign and Physical Examination:
Pulse rate
Respiration
Temperature
Blood pressure
Diet evaluation and personal
histories
Specific 24-Hour Food Record
Diet History
Periodic Food Record
Food Frequency Questionaire (FFQ),
Semi Quantitative FFQ (SM-FFQ)

The problem under/overreporting


Diet and Nutrition Status

Protein intake (g)


Energy intake (Kal)
Nitrogen balance
Obligatory nitrogen loss (g)
Net protein utilization
Basal energy expenditure (BEE) (Kal)
Energy intake (%) of BEE
Skin test result (mm)
ESTIMATION OF CALORIC REQUIRMENTS

HARRIS BENEDICT EQUATIONS

MALE
BEE = 66 + (13.7 X Wt) + (5 X Ht) (6.8 X Age)

FEMALE
BEE=655 + (9.6 X Wt) + (1.7 X Ht) (4.7 x Age)

Wt in Kg Ht in cm Age in years
ESTIMATION OF CALORIC REQUIRMENTS

HARRIS BENEDICT EQUATIONS

CAL REQ=BEE X ACTIVITY FACTOR X INJURY FACTOR

ACTIVITY FACTORS
1.2 CONFINED TO BED
1.3 AMBULATORY
1.4 ACTIVE
ESTIMATION OF CALORIC REQUIRMENTS

HARRIS BENEDICT EQUATIONS


CAL REQ=BEE X ACTIVITY FACTOR X INJURY FACTOR
INJURY FACTORS
1-1.2 MINOR SURGERY
2.1 SEVERE THERMAL BURN
1.2-1.5 PERITONITIS
1.35 SKELETAL TRAUMA
1.4-1.8 SEPSIS
1.75 AIDS
1.14-1.37 SOFT TISSUE TRAUMA
ESTIMATION OF CALORIC REQUIRMENTS

SHORT CUT METHOD

MAINTENANCE : 30 KCAL/KG
MODERATE STRESS : 35 KCAL/KG
SEVERE STRESS : 40 KCAL/KG

(CRITICAL CARE PATIENT PROVIDE : 25 KCAL/KG)


ESTIMATION OF PROTEIN REQUIRMENTS
BASED ON WEIGHT

PATIENT STATUS GM/KG/DAY


NORMAL PATIENT 0.8-1
MULTIPLE TRAUMA 2
ACUTE RENAL FAILURE 0.5-0.8
CHRONIC RENAL FAILURE 0.8-1
RENAL FAILURE /DIALYSIS 1-1.2
HEPATIC FAILURE 0.5
Prognostic Nutritional Index
(PNI)
Developed by Mullen (1979)
PNI (%) =
158-(16.6*ALB)-(0.78*TSF)-(0.2*TFN)-(5.8*DCH)
ALB (g/dL), TSF (mm), TFN (transferrin) (mg/dL),
DCH (Delayed Cutaneous Hypersensitivity): 0=-,
1=<5mm, 2=>5mm
Risk:
Low :<40%
Intermediate: 40-50%
High :>50%
Nutrition Risk Index (NRI)

NRI = 15.19*ALB + 0.417* % UBW

Indicates:
Normal : >100
Mild malnutrition : 97.5-99.9
Moderat to severe malnutrition : <97.5
Hospital Prognostic Index
(HPI)
HPI=
(0.91*ALB)-(1.00*DCH)-(1.44*SEP)+(0.98*DX)-1.09

ALB(g/dL), DCH: 1=+, 2= -, SEP: 1=+, 2= -, DX: 1=ca, 2=


others
Mortality Risk:
Low :<-1
Intermediate : -1 --+1
High :>+1
Analysing Nutritional Data

Nutritional diagnosis
Primary and Secondary Nutritional
Disease
Nutrition-Related Conditions
Problem list
Select appropriate categories with a check mark. Numerical value are
assigned and used for secoring. Patient may self-report the section 1-4;
medical or nutritional staff will complete number 5,6 and the SGA score.

SUBJECTIVE GLOBAL
ASSESSMENT (SGA)
SUBJECTIVE GLOBAL ASSESSMENT
(SGA)
1. Weight
2. Food Intake (over past month)
3. Symptoms (longer than 2 weeks)
4. Functional capacity (activity over the past
mounth)
5. Disease and its relation to nutritional
requirement
6. Physical
1. Weight
Weight ________ kg Height _________ cm
Overall loss in past 6 months: Amt.=#______kg
% loss= _______
20%+ = 4 pts;
10-19.9% = 3 pts;
6-9.9% = 2 pts;
2-5.9% =1 pts;
0-1.9% = 0 pts
Overall loss in past 1 month: Amt.+# ______kg;
%loss= _______
10%+ 4 pts;
5-5.9% 3 pts;
3-4.9% 2 pts;
2-2.9% 1 pts;
0-1.9% 0 pts
Change in past 2 weeks:
_____increased (0)
______ no change (0)
_____decreased (1).
2. Food Intake (over past month)
______ No change recently (0)
______ Change:
_____More than usual (0)
_____ less than ususal (1)
Now taking :
_____ normal food but less than normal (1)
_____ litle solid food (2)
_____only liquids (3)
_____only nuytritional supplement (3)
_____very litle of anything (4)
____ only tube feeding or nutrition by vein (5)
Supplement (Circle) : nil, vitamin, mineral # _______freq. Per
week
3. Symptoms (longer than 2 weeks)
____ No problems eating (0)
____ nausea (1)
____ vomiting (3)
____ diarrhea (3)
____ constipasi (1)
____ mouth sore (2)
____ dry mouth (1)
____ Anorexia (3)
____pain(3) ____ (where_____)
____things taste funny or have no taste (1)
____ smells bother (1)
____Other (1) _____________(depression, financial worries,
dental problems, etc).
4. Functional capacity (activity over the past
mounth)
__ Normal with no limitation (0)
__ not ususal, but up and about with normal activity (1)
__ No feeling up to most thing, but in bed less than half the day
(2)
__ able to do little activity and spend most of the day in bed or
chair (3)
__ seldom out of the bed (4)
5. Disease and its relation to nutritional
requirement:
Primary diagnosis (specify) ________stage______
cancer (1),
AIDS (1),
Pulmonary or cardiac cachexia (1),
pressure ulcers/wound/fistula (1),
trauma (1),
age greater than 65 y (1)
Metabolic demand (stress):
___ no stress --- no stress, fever, steroid (0)
___low stresstemp 99-101 less than 72 hours,
low dose steroids (0)
6. Physical (for each trait specify : 0=normal,
1+=mild, 2+= moderate, 3+=severe)
___loss of subcutaneous fat (triceps, chest)
___ascites
___muscle wasting (quadriceps, deltoid)
___mucosal lession
___ankle edema
___cutanous lessions
___sacral edema
___Hair change
SGA rating (select one):
A
B
C

A _____Well nourished (no weght loss or recent


nonfluid gain; no intake deficit or recent
improvment of noted; no symptom of
nutritional impact; no functional deficit or recent
improvment noted; no physical deficit or
improvment shown recently)
B_____Moderately (or suspected of being)
malnourished ( 5% weght loss in 1 month or
10% in 6 months; severe deficit intake;
presence of nutritional impact symptoms;
moderate functional deficit or recent
deterioration; evidence of mild to moderate
loss of subcutaneous fat and/or musclemass
and/or muscle tone on palpation)
C_____Severely malnourished (over 5% weight
loss in 1 month or over 10% in 6 months; severe
deficit intake; presence of nutritional impact
symptom;several functional deficit or recent
functional deterioration; obvious sign of
malnutrition such as severe loss of subcutaneous
tissues or posible edema)
Nutritional Diagnosis

Nutrient deficiencies
Underlying disease requiring modified
nutrient or food plan
Personal culture and ethnic needs
Economic need
Drugs information that interact with food and
nutrient
Primary and Secondary
Nutritional Disease
Primary deficiency disease:
Lack of essential nutrient on the diet
Secondary deficiency disease:
Results from one or more barriers to
use of the nutrient after consumed
food.
Nutrition-Related Conditions

Two major Nutritional task:


1. Identify person at risk of malnutrition
because of their disease, injury or life style.
Heart disease, hypertension, diabetes, liver and
renal disease.
Surgery, etc.
2. Analysis of intake to monitor effectiveness
of treatment
Problem List

Concider to every aspects of patient


Indicators of Nutritional supporting to
Hospitalized patient :
Albumin serum <5 g/dL
Decresed wight >10%
MAC < centil 5
Limphocyte count < 1200/mm3
Eating disorder more than a week.
Nutrition Intervention:
Food Plan and Management
Basic concepts of diet therapy:
Normal nutrition
Disease application
Individual adaptation
Practioner awareness
Nutrition Intervention:
Food Plan and Management
Managing the mode of feeding:
Oral diet
Tube feeding
Peripheral Vein Feeding
Total Parenteral Nutrition (TPN)
Evaluating:
Quality Patient Care
General concideration:
1. Estimate the achievement of nutritional
therapy goals.
2. Judge the accuracy of intervention
actions
3. Determine patients ability to follow the
prescribed nutrition therapy
Monitoring routine
Nutritional indexs
Antrophometric
Biochemicals
Clinical sign
Dietary assessment
Evaluating:
Quality Patient Care
Quality Patient Care:
1. Cost-effectiveness
2. Provison of nutritional services by
the most qualified personnel.
Evaluating:
Quality Patient Care
Collaborative roles of the nutrition
supporting team:
Coordinator
Interpreter
Teacher or Counselor
Summeries
Nutritional assessment:
The first step of medical nutrition Therapy
Begin with patient and family
The patient medical record: Communication among
health care team members
Porpuse , Identify:
Nutrient deficiency
Nutritional status
Nutrient requirement
Nutritional relative diseases
Evaluation and monitary medical nutrition
intervention
Refferences

Gibson RS. Principles of Nutritional Assessment.


Oxpord University Press, 1990
Jeejeebhoy KN. Current therapy in nutrition. BC
Decker Inc. Toronto, 1988
Mahan LK, Arlin MT. Krauses : Food, Nutrition and
Diet Therapy. 8th ed. WB Sounders Co. Philadelphia,
1992.
Williams SR, Schlenker ED. Essensials of Nutrition &
Diet Therapy. 8th ed. Mosby, 2003.
See you later

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