NUTRITIONAL ASSESSMENT

(PENILAIAN STATUS GIZI)

Dr. I Wayan Weta, MS 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
ABCD of nutritional Assessment:  Anthropometric  Biochemical test  Clinical observation  Diet evaluation and personal histories

Methods of Obtaining Intake Data

 Direct observation and nutrient analysis: can be

used only in controlled settings; doesn t represent usual intake; calorie counts fall into this category  Food record or diary: prospective tool; asks client to record or weigh food intake for a specific time period  Food frequency questionnaire: retrospective; asks client to complete a survey about food intake over a specific time period  24-hour recall: retrospective tool; asks client about food intake during the previous 24 hours

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/Nutrition History Information

Food/Nutrition History Information cont d

Food consumption of individuals



Quantitative: Twenty four hour recalls method Repeated Twenty four hour recalls method Estimated food record Weight food record

24-Hour Recall
Strengths Less likely to modify dietary behavior Quick and inexpensive Low client burden Literacy independent Weaknesses Memory dependent Overestimates low intake Underestimates high intake High-inter-interviewer variability

Food Records
Strengths Greater precision than single 24-hour recall Not memory reliant Weaknesses Eating behavior may change Literate and numerate dependent; requires knowledge of portion sizes High client burden

Considered actual intake

Food Frequency Questionnaire

Strengths
Low client burden Quick and inexpensive

Weaknesses
Primarily provides qualitative information Literate and numerate dependent

Can examine specific Memory dependent nutrients Considered usual intake Cognitively difficult since food list not meal based Easily standardized Accuracy improves when combined with other data

Direct Observation
Strengths Low client burden Client unaware of assessment Not memory or literacy dependent Weaknesses High staff burden Intrusive Difficult to attain and interpret Does not represent usual intake Expensive

NCI Food Frequency Questionnair e

Food Diary

Whats wrong with this picture?

Name :_____________________ Adress: _____________________ Time 6.00-10.00 Breakfast 10.00-12.00 Snack 12.00-13.00 Lunch 13.00-18.00 Snack 18.00Dinner Name of food/drink

Date :____/____/____ Day of week : __________________ Description of ingridient Amount (house hold) gram

Addition questions: Was intake unsual in any way? If yes, in what way?

Yes/No

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

Food Frequency Questionaire (FFQ) Semi Quantitative Food Frequency Questionaire (SQ-FFQ)
Food item Freq/ day Freq/ week Freq/ month House hold portion gram

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
ADIPOSE TISSUE ASSESSED BY 25% Triceps Skinfold Body Weight Arm Muscle Circumference Body Weight Creatinine Creatinine Height Index Serum Albumin, Transferrin

SOMATIC PROTEINS 30%

VISCERAL PROTEINS 8% PLASMA PROTEIN EXTRACELLULAR SKELETON 3% 20% 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) Measure Fat Free Mass (fat free-mass, lean body mass) Measure Fat Mass (body fat mass)

2.

3.

Growth Measurement
1. 2. 3. 4. 5.

Head Circumference Body weigh : infant, children, adult. Body Length and height BW altering Ratio BW/BH

MEASUREMENT OF THE LENGTH OF AN INFANT AND CHILD

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.

Fatfold Measurements

SKINFOLD CALIPERS MEASURE THICKNESS OF SUBCUTANEOUS FAT IN MILLIMETERS

Courtesy Dorice Czajika-Narins, PhD

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 Underweight Normal range Overweight
   

BMI (kg/m2) <18.5 18.5 - 24.9 > 25.0 25.0 - 29.9 30.0 - 34.9 35.0 - 39.9 > 40.0

PrePre-obese Obese class I Obese class II Obese class III

Classification of overweight and obesity by BMI, Waist Circumference And Risk of co-morbidities. coClass BMI
(kg/m2) underweight Normal


LWC
<90 cm (men) <80 cm (women)

HWC
>90 cm (men) >80 cm (women)

<18.5 18.5-22.9 18.523.0-24.9 23.025.0-29.9 25.0>30.0

Low (but increase others

clinical problems)

Average Increase Moderate Severe Very severe

Average Increase Moderate Severe

Overweight Obese I Obese II

Fat distribution
Gynoid obesity Android obesity

Weight Gain Guidelines

 Underweight prior to pregnancy, <18.5 BMI
28 - 40 lbs (12,5-18 kg) 12,5-

 Healthy weight prior to pregnancy, 18.5-24.9

BMI

25 - 35 lbs (11,5-16 kg) 11,5- kg)

 Overweight prior to pregnancy,24.9-29.9 BMI

15 - 25 lbs (no less than 15 lbs) (7-11,5 kg) 7 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 (kg) 12,512,5-18 11,511,5-16 7-11,5 6 + TM I (kg) 2,3 1,6 0,9 + TM II & III (kg/mgg) 0,49 0,44 0,3 -

BB kurang
(BMI<19.8)

BB normal
(BMI 19,8-26) 19,8-

BB lebih
(BMI >26-29) >26-

Obese
(BMI >29)

Expected Weight Gain

Grafik pertambahan berat pada kehamilan

Trimaster I 10 kg Trimaster II Trimaster III 10 kg

5 kg

5 kg

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 Albumin Normal > 3.5 Mild 3.1-3.5 3.1Moderate 2.1-3.0 2.1Severe < 2.1 t 1/2 20 d

Transferrin

>200

151-200 151-

100-150 100-

<100

8d

Prealbumin

>15

10-15 10-

5-10

<5

2 -3 d

Total Lymphocyte Count (TLC)

> 2000 1200-2000 1200-

800-1199 800-

< 800

Clinical Observation


Clinical Sign of Malnutrition:

Skin, hair, eye, nail etc

Vital Sign and Physical Examination:

Pulse rate Respiration Temperature Blood pressure

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%+ 5-5.9% 3-4.9% 2-2.9% 0-1.9% 4 pts; 3 pts; 2 pts; 1 pts; 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 stress temp 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 patient s ability to follow the prescribed nutrition therapy

NUTRITION PROGNOSTIC

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 Mild malnutrition Moderat to severe malnutrition : >100 : 97.5-99.9 : <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

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. Krause s : 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.

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