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Dr.Nishan Silva
• Nutritional care
• Body mass index
• Basal metabolic rate
• Recommended Daily allowances
• Physical Measurements
• Energy expenditure
The Nutrition Care Process
• Identifying and meeting a person’s nutrient and nutrition
education needs. Five steps:
1. Assess Assessment of nutritional status
2. Analyze Analyze assessment data to determine nutrient
3. Develop Develop a nutrition care plan to meet patient’s
nutrient and education needs.
4. Implement: Implement care plan
5. Evaluate: Evaluate effectiveness of care plan: ongoing
follow-up, reassessment, and modification of care plan.
Assessing Nutritional Status

• Historical Information
• Physical Examination
• Anthropometric Data
• Laboratory Analyses
Good nutritional history should be
General clinical examination, with
special attention to organs like hair,
angles of the mouth, gums, nails, skin,
eyes, tongue, muscles, bones, & thyroid
Detection of relevant signs helps in
establishing the nutritional diagnosis
Anthropometric Data –
physical measurement of the body

anthropos = human metric = measure

• Indirect assessment of body composition and

• Used in Nutrition Assessment:
– Measures using height and weight
– Measures of body composition (fat vs. lean tissue)
– Functional Measures
• W/A: combined measurement:
– NO individual diagnosis but trend assessment
– For growth monitoring and FU
• W/H indicates degree of wasting
– Individual diagnosis
– Community diagnosis
– Sensitive to change
• H/A indicates linear growth retardation
– not sensitive to change
– slow progress
– Community diagnosis
Body Mass Index
Nutritional Indices in Adults
• The international standard for assessing body
size in adults is the body mass index (BMI).
• BMI is computed using the following formula:
BMI = Weight (kg)/ Height (m²)
• Evidence shows that high BMI (obesity level) is
associated with type 2 diabetes & high risk of
cardiovascular morbidity & mortality
Measures Using Height and Weight

BMI Body Mass Index

wt (kg)
ht (m)2

wt (lb) X 705
ht (inches) 2
International classification of BMI
• Height –
1.96 m (6 ft 5 in)

• Weight –
125 kg (276 lb; 9 st 10 lb)

• BMI – 32.55 kg/m2

•Still … BMI – 32.55 kg/m2
Run 100m

in 10.8 s!!!!
Measures Using Height and Weight
Cons: BMI can misclassify up to one
out of four people.
– Does not account for fat distribution
– Doesn’t account for LBM - may
misclassify frail/sedentary or very
muscular people
Other anthropometric Measurements

• Mid-arm circumference
• Skin fold thickness
• Head circumference

• Hip/waist ratio

• Head/chest ratio
Measuring weight - Video
Measuring weight
Measuring weight
Measuring Height - video

Measuring Length - video
Circumferences - video
Skin fold thickness - video
Skin fold thickness - video
Growth percentile charts
Growth charts

What is normal

When can you

call it abnormal?

When does it
tends to change?

• Objective with high specificity & sensitivity
• Measures many variables of nutritional
significance (Ht, Wt, MAC, HC, skin fold
thickness, waist & hip ratio & BMI).
• Readings are numerical & gradable on
standard growth charts
• Readings are reproducible.
• Non-expensive & need minimal training
Limitations of Anthropometry
Inter-observers errors in measurement

Limited nutritional diagnosis

Problems with reference standards, i.e.

local versus international standards.

Arbitrary statistical cut-off levels for what

considered as abnormal values.
Energy Expenditure

Humans oxidise (metabolise)

carbohydrate, protein, fat (and
alcohol) to produce
Energy is used to….
• To maintain body functions - to breathe, to
keep the heart beating, to keep the body
warm and all the other functions that keep
the body alive.
• For physical activity - for active movement
- muscle contraction.
• For growth and repair, which require new
tissues to be made
• Energy can be measured in either joules
or calories
• 1 kcal = 4.184 kj
• The average daily energy intake in the UK
is 10250kJ (2450 kcal) for men and
7030kJ (1680 kcal) for women.
• The energy in the diet is provided by
carbohydrate,protein, fat and alcohol.
A gram of…..
• carbohydrate (starch or sugar)
provides 16kJ (3.75 kcal)
• protein provides 17kJ (4 kcal)
• fat provides 37kJ (9 kcal)
• alcohol provides 29kJ (7 kcal)
Energy Expenditure…
The energy expenditure
(EE) of a man or woman
over a whole day is
often divided into
different components,
which can be
individually determined.

These are:
Basal metabolic rate
Diet induced
Thermogenesis (DIT),
activity (PA)

total energy

Basal Metabolic Rate
• is the amount of daily energy
expended by humans (and other
animals) at rest.

• Rest is defined as existing in a

neutrally temperate environment
while in the post-absorptive state.
• Basal metabolism is usually by far the largest
component of total caloric expenditure.
• Basal metabolic rate is usually expressed in
terms of daily rates of energy expenditure.
• The primary organ responsible for regulating
metabolism is the hypothalamus.
• The basal metabolic rate varies between
Energy Expenditure at Rest
• Basal Metabolic Rate
– BMR is rate of energy expenditure fasted,
rested and supine conditions in thermoneutral
– Resting metabolic rate (RMR) is rate of energy
expenditure when at rest but not basal
– BMR proportional to BSA, after age 20 reduces
2% & 3% per decade in women and men,
Factors effecting BMR
• Regular exercise – Keeps BMR elevated
at rest
• Muscle mass – More muscles – more
• Diet – Severe calorie restriction reduces
• Food type – Proteins increase BMR
Factors effecting BMR
• Hormones – Thyroxine
• Stress – Increases BMR
• Age – Reduces BMR
• Gender – Males higher
• Body temperature – Elevates BMR

• ? What happens to BMR in an infection /

Dietary reference intakes (DRI)
• Recommended Dietary Allowance
• Adequate Intake (AI)
• Tolerable Upper Intake Level (UL)
• Estimated Average Requirement (EAR)
Recommended Daily
Recommended Dietary Allowance
• It is the average daily level of
intake sufficient to meet the
nutrient requirements of nearly all
(97%-98%) healthy people.