NA part 2 Flashcards
What is biochemical assessment and why is it important?
Measurement of nutritional markers in blood, urine (and other fluids and tissues)
• Detects subclinical nutrient deficiencies- nutritional deficiencies that are not yet severe and don’t show physical symptoms
What do biochemical assessment examine?
- Visceral and somatic proteins
- Hematological assessment
- Lipid profile
- Micronutrient assessment
- Immunocompetence assessment mainly through lymphocyte count
What are biochemical markers affected by?
- Nutritional status, medication, illness/physiological state
What is visceral protein status reflected by? Why do we need to sample it
serum proteins, RBC, WBC
we cannot do a biopsy of vital organs to test the status of vital proteins, but we can test serum proteins
Malnutrition causes decrease in oran mass and substrate supply and thus inflicts a decrease a decrease in the synthesis of serum proteins
What are the components of the blood
- Albumin- most abundant
- Fibronectin
- Transferrin (includes prealbumin aka transthyretin (thryoid hormone transport) and retinal-binding proteins
Are serum proteins are good markers of malnutrition?
No They are indeed affected by malnutrition and thus can serve as markers of it but-> Low sensitivity and specificity for nutritional status; influenced by: - Poor protein intake - Altered metabolism and synthesis - Hydration - Inflammation - Pregnancy - Medications - Exercise
How does inflammation affect serum proteins?
Decreases the level of serum proteins
What are the lives of various serum proteins
- Albumin (most abundant) - T 1⁄2 17-21 days
- Transferrin- T 1⁄2 8-10 days
- Prealbumin or transthyretin (TTR) - T 1⁄2 2-3 days
- Retinol Binding Protein (RBP) - T 1⁄2 10-12 hours
Why would we need to know half-lives of serum proteins? What are the ways of overcoming the problems we encounter?
important to know half-lives when we implement treatment to see if we are improving when on treatment
sometimes the change is not reflected during re-assesment as albumin doesn’t have time to be replaced as it has along half life.
this however can be overcome by measuring prealbumin
Function of albumin
Maintains osmotic pressure
Transport of large insoluble molecules, drugs, calcium, zinc
Function of transferrin
Iron transport
Function of TTR
Transport of T3 and T4
Carrier for RBP (retinol binding protein)
Function of RBP
Retinol transport from liver to periphery Circulates with TTR
When is albumin high and low
High- during dehydration
Low- during low protein intake, malabsorption, trauma, surgery, overhydration, edema, acute illness, aging, inflammation
When is transferrin high; low
High- during Fe deficiency, pregnancy, chronic loss
Low- during acute illness, chronic infection, PEM, systemic disease
When is TTR high; low
High- during renal disease, Hodgkins disease (blood cancer that starts in the lymphatic system)
Low- during Liver disease, PEM, chronic loss, malabsorption, hyperthyroidism
When is RBP high; low
High- during renal disease
Low- during Vitamin A deficiency, zinc deficiency, hyperthyroidism, liver disease
What is the connection between cytokines and acute phase proteins?
cytokines stimulate liver to make acute phase proteins
Name negative acute phase proteins
How are they affected by inflammation, illness or metabolic stress?
Albumin, transferrin, TTR and RBP are negative acute- phase proteins: levels decrease by >25% during inflammation, illness or metabolic stress
Describe C-reactive protein (CRP)?
What is used to asses?
What are the normal levels
C-reactive protein (CRP) is a positive acute-phase protein
– Used to detect mild or acute inflammation –> Normal <1, mild chronic 1-5, acute >5 mg/L
– Not a nutritional marker but very useful to interpret other serum proteins
CRP is also a marker of CVD
Which organ makes C-reactive protein?
liver
What are the cutoff for albumin?
Normal level is above 35g/L
Name ways to assess somatic protein status
Nitrogen balance
Creatine excretion
Immune function
What does nitrogen balance assess?
- Reflects total protein retention or losses (but not mass)
What does creatinine excretion assess?
reflects skeletal muscle mass
• excretion is proportional to skeletal muscle mass
What does immune function assess?
it is measured via total lymphocyte count, which is used to assess infection, trauma, diseases, medications as these conditions lower the lymphocyte count
What do visceral proteins assess?
Somatic?
visceral proteins (VPs) such as albumin, retinol-binding protein (RBP), transferrin and transthyretin are used to monitor the metabolic response to nutritional support. thus, visceral proteins are used to asses the status of nonmuscular protein making up the organ Somatic protein us used to assess skeletal muscle status
when would nitrogen balance be positive?
Positive (anabolism>catabolism)
- Pregnancy, growth, recovery from illness, athletic training
when would nitrogen balance be negative?
Starvation, trauma, surgery, poor quality protein intake, inadequate protein intake
how to calculate nitrogen balance?
N Balance (g/day) = (pro intake g/6.25) - (UUN g + 4)
1 g nitrogen = 6.25 g protein (N comprises 16% of proteins)
• Total 24-h UUN (mmol) = (UUN mmol/L)(24h-urine volume L)
Conversion factor: 1 mmol UUN = 0.028 g UUN
• factor 4 is g of protein from N excretion via skin and feces
URINARY, NOT BLOOD UREA!
collect urine over 24h
calculate nb
Pt intake of 62.5 g protein/day and excretion of 200 mmol/L UUN in 2.0 L of urine
UUN (g) = (200 mmol/L x 0.028) x 2 L = 11.2 g N balance = 62.5/6.25 - (11.2 + 4) = - 5.2 g
negative balance: current intake is insufficient to maintain N balance
Nitrogen balance limitations
• Time consuming: 24h (ideally 3x24h )
• Prone to errors:
– Protein intake: estimated vs. measured
– Missed or incomplete urine collections
– Does not account for losses due to diarrhea, vomiting, wound leaks,…
• Errors always favor a MORE POSITIVE BALANCE (overestimation of intake + underestimation of losses)-> have to keep it in mind when we do calculations as the results may be worse than it seems
When would creatinine excretion increase? Decrease?
- Increase with exercise, meat intake, menstruation, infection, fever, trauma
- Decrease with renal failure (as creatinine is filtered by kidneys) and age
Where is creatinine excreted? WHere is it stored
in urine
it is stored in SKELETAL muscle
What are the normal values for creatinine excretion?
USING IDEAL BODY WEIGHT
- Women: 18 mg/kg IBW
- e.g. 50.9 kg female excretes 916 mg/24 h
- Men: 23 mg/kg IBW
- e.g. 77 kg male excretes 1771 mg/24 h
how to calculate creatinine height index and interpretation
Creatinine Height Index CHI =
observed 24h creatinine excreted (mg)/ expected 24h creatinine excretion (mg)
Interpretation:
60-80% mild depletion
40-59% moderate
<40% severe
What are the limitations of creatine excretion measures?
- Rely on complete 24h urine collections: errors
- Meat-free diet prior to testing
Some available laboratory results of Mr. G.:
- S. Albumin 37 g/L
- S. Transferrin 3.0 g/L
- S. Prealbumin 0.14 g/L
• Does this data correspond to a PEM diagnosis?
Albumin and transferrin levels are normal
Prealbumin levels is a bit low
1) he has diarrhea, so these values could be even lower-> not normal—> PEM
when we rehydrate, the change will be fast
What is a hematological assessment?
Complete blood count (CBC): erythrocytes (number, size, shape, color) to diagnose anemia(s)
What are the classifications of RBC in anemia based on color
- Hypochromic (pale color)
- Normochromic
- Hyperchromic (darker color)
What are the classifications of RBC in anemia based on the size
- Microcytic (small cells)
- Normocytic
- Macrocytic (large cells)
- Megaloblastic- big and abnormally shaped
What are the possible deficiencies that cause anemia?
- Iron (microcytic, hypochromic)
- Folate (macrocytic, megaloblastic)
- Vitamin B12 (macrocytic, megaloblastic)
- Other micronutrients (Vitamin C, E)
- Anemia of chronic diseases (normocytic, normochromic)- due to blood losses
no effect on color and shape
Name possible general tests for anemia
- Hemoglobin
- Hematocrit
- RBC count
- mean corpuscular volume
- mean corpuscular Hb
- MCHC
Describe Hb test for general anemia
Routinely done measured in g/L deficit <120 women; <140 men - Total amount in RBC - Decreased during PEM, hemorrhage and other anemias
Describe hematocrit test for general anemia
measured in % deficit <37 women; <40 men) - % of RBC in total blood volume - Increased during dehydration - Decreased during hemorrhage and water overload
What are the RBC count units and anemia cutoffs?
x10^12/L,
deficit <4.2 women; <4.5 men
Describe MCV test for general anemia
Mean Corpuscular Volume (MCV)- a measure of shape
- RBC size: microcytic (<76) vs. macrocytic (>100 um3)
- MCV = [Hct / RBC] X 10
Describe MCH test for general anemia
Mean Corpuscular Hemoglobin (MCH)
Measures Hb concentration in the cell, not in the blood
-> serves as an indicator of colour
(in pg/cell): hypochromic (<21) vs. hyperchromic (>38)
Describe MCHC test for anemia
Mean corpuscular Hb concentration
Hb/Hct
Ratio of Hb to Hematocrit
What is the order of iron depletion during deficiency
Storage iron ↓ Transport iron ↓ essential iron
Where and how is iron stored? How are iron stores tested?
Iron is stored in the liver, bone marrow, spleen in the form of ferritin
By testing ferritin levels
Where and how is iron transported? How are iron transport tested?
by transferrin
- transferrin saturation is measured
NOT THE CONCENTRATION
How are essential iron levels measured
By measuring the function of RBC, myoglobin and enzymes since their function is affected by iron depletion
Name laboratory tests for iron deficiency anemia
- serum ferritin
- serum iron
- total iron binding capacity (TIBC)
- transferrin saturation
- erythrocyte protophyrin
Describe serum ferritin test for iron deficiency anemia
Serum Ferritin (deficit <20 μg/L) - Low in early deficiency state - Depleted iron stores
Describe serum iron test for iron deficiency anemia
Serum iron is a medical laboratory test that measures the amount of circulating iron that is bound to transferrin (90%) and serum ferritin (10%).
- reflects iron bound to transferrin;
- Low in early deficiency state
deficit <0.65 mg/L
if transferrin is less saturated—> it has __ saturation capacity
if transferrin is less saturated—> it has high saturation capacity
Describe TIBC test for iron deficiency anemia
Total Iron Binding Capacity, TIBC
(deficit >4.5 mg/L; N=2.4-4.5 mg/L)
- Measures the saturation ability for transferrin, high in deficiency
- Needed to assess transferrin saturation
Describe transferrin saturation test for iron deficiency anemia
- Progressively decreases with diminished transport iron
- [S. iron / TIBC] X 100%
Describe Erythrocyte Protoporphyrin test for iron deficiency anemia
Erythrocyte Protoporphyrin (>3 mg/L) - Increases in later deficiency state with limited Hb production
at late stages of anemia protoporphyrin links with __, instead of iron
at late stages of anemia protoporphyrin links with zinc, instead of iron
name Laboratory Tests for Folate Deficiency anemia
- serum folate
- RBC folate
- folate deficiency
Describe serum folate test for folate deficiency
Serum Folate (N= 4.5-45 nmol/L) - Low in progressing deficiency state
Describe RBC folate test for folate deficiency
RBC Folate
- Low in later deficiency state
reflects longer time (prolonged) of folate deficiency
Define criteria to diagnose folate deficiency
low serum and RBC folate + megaloblastic, macrocytic RBC (+ normal B12)
to differentiate form B12 deficiency confirm with RBC folate or serum folate measure
However, both can be low at the same time
Name Laboratory Tests for Anemia: Vitamin B12 Deficiency
Serum B12
Describe B12 anemia tests
Serum B12 (N=120-500 pmol/L)
- Low in progressing deficiency state
- megaloblastic, macrocytic RBC + serum total cobalamin
- Biomarker: ↑ methylmalonic acid (early)
- Biomarker of B12 and folate deficiency: ↑homocysteine
Describe what occurs when FE stores are depleted?
- Transferrin saturation starts to decreases
- Serum ferritin decreases at slower rate
- Free erythrocyte protoporphyrin increases
- RBC iron levels start to decline and hits 0-> ID anemia
- Hb concentration decreases and is absent at Fe deficiency anemia
Is RBC iron affected as soon as Fe stores start to be depleted?
no, only after stores are fully depleted
What is considered to be an excellent, good and source o HEME iron
Excellent Sources (>3.5 mg): Clams, oysters, liver Good Sources (>2.1 mg): Beef cooked, blood pudding, turkey (dark meat ) Sources (0.7 mg): Chicken, ham, lamb, pork, veal, halibut, haddock, perch, salmon, shrimp
What is considered to be an excellent, good and source o NON-HEME iron
Excellent Sources
(>3.5 mg): Cooked legumes, seeds, fortified cereals, tofu
Good Sources (>2.1 mg): Canned legumes, enriched egg noodles, dried apricots
Sources (>0.7 mg): Nuts, sunflower seeds, cooked pasta, bread, bran muffin, cooked oatmeal, wheat germ
What are the risk factors of poor iron status?
- Diet low in meat, fish, poultry
- Diet low in vitamin C
- Diet low in fortified foods (infants)
- Frequent consumption of tea and coffee w/meals (tannins and polyphenols)
- Frequent consumption of iron inhibitors w/meals (phytates, oxalates)
- Regular ASA use (aspirin)
- Menorrhagia (excessive menstrual losses) • 3 or more annual blood donations
- Pregnancy, multiple gestations, parity >3
What is iron supplementation: name, administration recommendations and how to asses its efficiency?
• Ferrous sulfate (200 mg TID X 6 months) 3 times/day
• 3 X better absorption with ferrous than other forms • Liquid or tablet form
• Expect a rise in hemoglobin of 1 g/L per week
RE-TEST
How to maximize iron supplement absorption?
- Take on an empty stomach with liquid • Food decreases absorption by 1/3
- BUT careful of side effects (take before/with snack)
WHat is the chem 7 panel tests
Blood urea nitrogen Serum chloride CO2 creatinine glucose serum potassium serum sodium
What does clinical assessment include>
- Includes patient’s medical, social, and psychological history
- Physical examination for clinical signs and symptoms of nutritional deficiencies
What is included in patient history>
- Primary and secondary diagnosis • Past medical history
- Weight history
- Factors affecting nutrient intake (body systems)
- Social history (religion, socioeconomic, shopping, cooking, family)
Hair as a sign of malnutrition + potential deficiency that might be causing it
Dry, dull, alopecia, brittle, early graying
POSSIBLE DEFICIENCY in:
Protein, energy, zinc, copper, EFA
Face as a sign of malnutrition + potential deficiency that might be causing it
Fullness, puffy, cheeks drawn i
may be a result of protein or energy deficiency
Eyes as a sign of malnutrition + potential deficiency that might be causing it
Dryness, pallor, corneal
vascularization
Potential Vit A, iron, B vitamin deficiency
Lips as a sign of malnutrition + potential deficiency that might be causing it
Angular stomatitis, cheilosis
Sign of Niacin (B3), riboflavin, iron, B6 deficiency
Tongue as a sign of malnutrition + potential deficiency that might be causing it
Magenta, painful, edema, smooth, taste changes, glossitis
Sign of B vitamins, zinc, vit A, iron deficiency
Gums and teeth as a sign of malnutrition + potential deficiency that might be causing it
Bleeding receding gums, gingivitis, stomatitis, caries
Potential sign of Vit C, folate, B12, protein, energy, fluoride deficiency
Skin as a sign of malnutrition + potential deficiency that might be causing it
Dryness, scaliness, delayed wound healing,
Vit A, zinc, EFA, protein, vit C, biotin
Nails as a sign of malnutrition + potential deficiency that might be causing it
Spoon nails, egg shell nails
Potential sign of Iron, chromium, vit A deficiency
Musculoskeletal condition as a sign of malnutrition + potential deficiency that might be causing it
Wasting, tenderness, weakness, bone pain
Potential sign of Protein, energy, thiamin, calcium, vit D deficiency
Neurological condition as a sign of malnutrition + potential deficiency that might be causing it
Sensory loss, confusion Depressed reflexes,
dementia, tetany
Potential sign of thiamin, B6, niacin, B12, protein
tetany-> calcium, magnesium deficiency
Abdomen as a sign of malnutrition + potential deficiency that might be causing it
Distention, flatus
Potential sign of Protein, energy, lactose intolerance deficiency
Which dietary assessment method provides the data that is used for nutritional counselling
Food records
Who can perform nutrition screening? Why is it good?
Nutrition screening can be performed by dietetic technicians or other trained personnel, which allows for a more efficient and cost-effective collection and identification of at-risk patients.
What is pathophysiology?
alterations from normal anatomy and physiology that occur as a result of disease or injury
Describe CHO counting
Carbohydrate counting concentrates on estimation of carbohydrate only and is used primarily by individuals with diabetes who are balancing their insulin dosages with dietary intake of carbohydrate.
What do DRI allow to evaluate?
allow evaluation of energy, protein, vitamin, and mineral intakes for healthy people.
Which diets can be assessed using RDA, AI, and UL?
The RDA, AI, and UL can be used to assess diets of INDIVIDUALS.
What can UL be used for?
The UL values can assist in assessing a patient’s use of supplements and whether their current dosage poses any health risk.
Describe DV
The DV were established to assist consumers in interpreting nutrition labeling information. These standards set target goals for fat, saturated fat, cholesterol, total carbohydrate, fiber, sodium, potassium, and protein for a 2000- and 2500-kcal reference diet (note that these are different from the DRI goals). In general, the DV are much more useful to the consumer purchasing groceries than the dietitian performing a nutrition assessment
When is adult considered to be at nutritional risk in terms of weight loss vs time?
In general, an adult is considered at nutritional risk if there is a >5% unexplained weight change in less than 1 month or >10% in a 6-month period
What are the weight circumference cut-offs?
Waist circumference of >40 inches (102 cm) for men or >35 inches (88 cm) for women is considered to be predictive of obesity and chronic disease risk in Caucasian, African-American, Hispanic, and Native- American populations. Within Asian populations: >90 cm in men and >80 cm in women
skinfold measurement involves measuring a double fold of _ and __ while excluding __
skinfold measurement involves measuring a double fold of skin and subcutaneous adipose tissue while excluding muscle tissue.
Describe tricep skinfold measure
Triceps skinfolds are taken on the nondominant arm, halfway between the olecranon and acromial processes.
Which other measurement can be combined with tricep skinfold measure?
midarm circumference measurement can be combined with triceps skinfold measurement to indirectly estimate arm muscle area and arm fat area
What are the cut-offs for mid-arm circumference measure?
An individual who is below the 5th percentile or greater than the 95th percentile may be at nutritional risk
What can DEXA measure?
DXA measures three compartments: mineral mass, mineral-free mass, and fat mass. DXA provides information on fat distribution among the right and left arms, legs, and trunk masses.
What do somatic and visceral proteins refer to?
Somatic protein refers to skeletal muscle.
Visceral protein refers to non-muscular protein making up the organs, structural components, erythrocytes, granulocytes, and lymphocytes, as well as other proteins found in the blood.
Interpretation and Evaluation of Creatinine Height Index
For this test, a 24-hour urine collection is performed and the total amount of creatinine excreted in that 24-hour period is compared with either a standard based on height or (as a percentage) to a standard excretion for a particular reference individual of a specific height, gender, and age.
Albumin measure limitations
Albumin has a long half-life (approximately 20 days), which decreases its sensitivity to short-term changes in protein status or to short-term interventions to improve protein status.
Albumin synthesis is also affected by acute stress and the inflammatory response. On the other hand, albumin levels will be higher with dehydration and when individuals are prescribed anabolic hormones and corticosteroids.
How can transferrin be measured?
Transferrin can be measured directly or calculated from total iron binding capacity (TIBC)
What is a transferrin measure limitation?
Transferrin’s primary limitation is that its concentration is directly affected by iron status. When iron stores are decreased, transferrin levels will increase to accommodate the need for increased levels of transport. Other disease states such as hepatic and renal disease, inflammation, and congestive heart failure can also affect transferrin levels.
What is the role of prealbumin?
Prealbumin is responsible for transport of thyroxine and is associated with retinol-binding protein.
Why is prealbumin measure test considered to be so acurate?
Research has shown that because of its very short half-life (2 days), prealbumin levels respond to short-term modifications in nutritional intake and interventions.
What is one of the most sensitive visceral markers?
RBP is considered to be one of the more sensitive indicators of protein status in the non–critically ill. Theoretically, it should reflect short-term changes and responses to nutrition support interventions.
When will hematocrit decrease? in terms of anemai
Hematocrit, like hemoglobin, will be decreased only in the final stages of iron deficiency. Hematocrit is affected by other nutrient deficiencies as well as by hydration status.
What is the most variable part of a person’s TEE?
Physical activity (PA) is the most variable portion of an individual’s energy needs and fluctuates depending on the type, duration, and intensity of physical activity.
How is 24-h recall done?
Asks about intake during the previous 24 h then works in reverse order through the previous 24 hours. The clinician questions the client about activities during the period in order to stimulate the client’s memory. At the end of the recall, the clinician reviews the information to verify serving sizes and preparation methods and asks for clarification if needed.
What are the advantages of 24h recall
- Quick and inexpensive
- Element of surprise
- Low patient burden
- Literacy independent
What are the disadvantages of 24h recall
- Memory dependent (elderly and children) - Overestimation/underestimation
- High inter-interviewer variability
- 24-hour recall does not always reflect typical eating patterns, since day-to-day dietary intake may vary considerably
How are food records done
- Recorded or weighed for a given time period
* Assesses actual or usual intake
What are the advantages of food records
- Greater precision than 24-h recall
- Not memory dependant (you record as you eat)
- Considered actual intake
What are the disadvantages of food records
- Time consuming
- May not reflect “normal” eating patterns, may change behavior
- Pt must be literate and motivated (writing, weighing, time consuming
- Accuracy is dependent on the client accurately reporting typical daily intakes.
Additionally, there is a heavier burden on the client, who must make a commitment to record his or her intake.
How are food frequency questionnaires done
Foods are organized into groups, and the client identifies how often and in what quantities he or she consumes a specific food or food group
What are the advantages of food frequency questionnaires
- Quick, inexpensive
- Can examine specific nutrients
- Can be used in large studies (epidemiological) - Considered usual intake
What are the disadvantages of food frequency questionnaires
- Qualitative information and less accurate
- Memory dependant
- Difficult since not meal based
- Pt must be literate and motivated (writing, time consuming)
Describe direct observation
- most detailed and precise
• Used in controlled setting
• Does not represent usual intake
direct observation advantages
- More precise
- Not memory or literacy dependent - Pt unaware of assessment
direct observation disadvantages
- High staff burden
- May be intrusive
- Difficult to attain and interpret
What are the components of TEE?
TEF (<10%)
Physical Activity (20-30%)
REE or BMR (65-70%)
+ injury/stress factor in sick patients
What is the best method to measure BEE
Indirect calorimetry
What is higher- REE or BEE?
REE is higher than BEE
What is the principle of indirect calorimetry?
- Measures the quantity of O2 consumed and CO2 produced by energy related processes
- From this, heat (i.e. energy) production is calculated
Which substrate has the highest RQ?
carbohydrates
What is the preferred equation for calculating estimated REE?
Mifflin- St. Jeor
What is the bases of REE calculations?
indirect calorimetry
BMR vs REE
basal energy expenditure: patient needs to be fasted and absolutely rested for 12h
REE (resting energy expenditure) or RMR (resting metabolic rate)- the individual is resting in a comfortable position without any other restrictions.
What is the TEE equation using the stress and activity factors?
REE x Activity Factor x Stress Factor
What are the downsides of Harris-Benedict equation?
Tends to overestimate REE by 5-15%
- Except in males >65 where it underestimates REE
- Do not use with obese individuals as it will be inaccurate
What is the factor that predicts REE? What are the gender related outcomes because of this factor?
lean muscle mass is the factor that predicts REE, thus the equations are different as men tend to have higher muscle mass
the more variables in the equations, the more __ it is
the more variables in the equations, the more precise it is
What are the benefits of Mifflin-St Jeor equation?
- no calculation of ideal or target weight, thus can be used for obese patients as well -> Use current body weight
- Better predicts REE in non-obese and obese subjects.
What is the simple and quick calculation?
What are the uses?
- 25-35 kcal/kg body weight for non-obese adults
Common usage:
• 25kcal/kg for low level of activity or overweight or
small appetite
• 30 kcal/kg for usual moderate activity, non-obese
• 35 kcal/kg for higher active or higher needs
FOR NON-HOSPITALIZED PATIENTS ONLY
Which weight do we use for simple TEE calculations?
• If patient BMI=16-29.9, use current weight
• If obese (BMI≥30), use ideal or healthy body
weight
PAL factors for IOM
PAL is an “indicator” of PA
PA = 1.00 if PAL is estimated to be ≥ 1.0 < 1.4 (sedentary)
PA = 1.11 if PAL is estimated to be ≥ 1.4 < 1.6 (low active)
PA = 1.25 if PAL is estimated to be ≥ 1.6 < 1.9 (active)
PA = 1.48 if PAL is estimated to be ≥ 1.9 < 2.5 (very active)
What are the DRIs for protein?
–DRIs: EAR= 0.66 g/kg/d RDA=0.8 g/kg/d
WHat is the FAO recommendation for protein?
–FAO/WHO: 0.75 g/kg body wt/day
What is the possible actual recommendation for protein?
Healthy adults: 1.0 g/kg/day Elderly adults: 1.0-1.2 g/kg/day
Wha is considered as a fluid?
fluid is anything that is liquid at body temperature
What are the fluid requirements based on weight
- 100 ml/kg body weight for 1st 10 kg
- 50 ml/kg body weight for next 10 kg
- 20 ml per kg body weight for each kg above 20 kg
EXAMPLE: 70 kg male
• (100 X 10) + (50 X10) + (20 X 50) = 2500 ml
What are the fluid requirements based on weight and age
- 16-30 years, active: 40 ml/kg body weight
- 20-55 years: 35 ml/kg body weight
- 55-75 years: 30 ml/kg body weight
- > 75 years: 25 ml/kg body weight
EXAMPLE: 70 kg, male, 40 y.o. • 35 X 70 = 2450 ml
What are the fluid requirements based on energy
- 1 mL/ kcal
- EXAMPLE: 70 kg, male, 40 y.o., 2500 kcal • 1X2500=2500mL
What are the fluid requirements based on fluid balance
- Urine output + 500 mL/day
What are the dehydration symptoms
- Thirst (1-2% of body water lost)
- Dark urine, increased urine specific gravity- BEST indicator
- Decreased skin turgor
- Dry mouth, lips
- Tachycardia
- Headache
- Lowered body temperature
- Restlessness, confusion
- Rapid weight loss (1 kg = 470 mL)
- Increased Na, albumin, BUN, creatinine, Hb, Hct
WHat are over hydration symptoms?
- Increased blood pressure
- Decreased pulse rate
- Edema
- Decreased Na, K, albumin, BUN, creatinine, Hb, Hct
- Rapid weight gain e.g. 1kg per day
What are the energy recommendations for elderly
- Reduced due to reduced LBM and activity = low appetite
due to changes in body composition (less active/lean tissue) even if the body weight is not changing-> increased adipose tissue
also activity level decreases
thus eat less, but high quality food should be eaten in order to provide sufficient protein as protein requirement is quite high
What are the protein recommendations for elderly
- 1-1.2 g/kg/day, may be higher if other conditions present
What are the fat recommendations for elderly
Careful evaluation of balancing: too high vs too low
connected to CVD, thus might be on low fat diet
the older the patient, the less strict should the diet be as there are no recommendations for fat restrictions in elderly-> low fat diet is not necessarily recommended
80+ people with no CVD and diabetes-> no restrictions
good sources of fat should be suggested
What are the calcium recommendations for elderly
- Decreased Ca absorption with age (DRI=1200 mg >50 y)
thus calcium intake should be higher to get enough
What are the vitamin D recommendations for elderly
Less efficient synthesis by skin, kidney conversion,
and exposure-> higher intake should be provided
What are the fluid recommendations for elderly
- Decreased sense of thirst, presence of other diseases-> intake should be higher
Why would we carry out a functional assessment
Assesses muscle strength which correlates with muscle mass
if you are implementing nutritional approach you can measure changes in the grip strength before changes are detected by anthropometry (e.g. dexa)
changes in grip strength due to the treatment is observed quicker than the changes in muscle mass -> a marker of whether treatment is successful or not
How is functional assessment of handgrip strength done?
with a dynamometer
- Repeated 3x on DOMINANT hand
What is the normal strength range (functional assessment)
- ≥20 kg women, ≥30 kg men
WHat is the prevalence of malnutrition?
15 – 80%* in community, hospitals and long-term care (highest)
What is canadian malnutrition task force?
assess malnutrition, finding causes and barriers
What are the elements of screening for malnutrition?
- Current condition
- Stable condition?
• Will condition deteriorate? -> ↓ food intake
• Impact of disease on deterioration?
How is current condition a marker of malnutrition?
– BMI 18.5-20 kg/m2 = risk; <18.5 kg/m2 = means lean mass which is indicative of malnutrition
– or: MAMC or calf circumference
How is stability of the condition a marker of malnutrition?
Involuntary weight loss is a marker of malnutrition
– Severe: >5% in 1 month or 10-15% in 6 months – Moderate: >5% in 3 months
How is deterioration of the condition a marker of malnutrition?
decreased food intake is the indicator
- can be estimated or measured
What are the 2 questions and the evaluation of the canadian Nutrition screening tool
1) Have you lost weight in the past 6 months WITHOUT
TRYING to lose this weight?
(If the patient reports a weight loss but gained it back, consider it as NO weight loss).
2) Have you been eating less than usual FOR MORE THAN
A WEEK?
Two “YES” answers indicate nutrition risk and an assessment has to be done
what is the time span over which a canadian nutrition screening tool has to be used?
if the stay os longer than 3 days-> have to revaluate no matter the initial result
What is Nutritional Screening Risk (NSR)?
- Used to detect presence of malnutrition and risk of developing it during hospitalization
- The only validated instrument (with level 1 evidence)
How is NSR done?
has 2 element:s
1) prescreening
Yes: If the answer is ‘Yes’ to any question, the main screening is performed.
No: If the answer is ‘No’ to all questions, the patient is re-screened at weekly intervals.
2) Main screening
- Includes nutritional disorder and illness severity (mild, moderate, severe) aspects which are both ranked from 1 to 3
Score more or equal to 3: the patient is nutritionally at-risk and a nutritional care plan is initiated
Score less than 3: weekly re-screening of the patient.
What is the purpose of Etiology-based Malnutrition Definitions
analyzes whether malnutrition is solely based on the nutrition or its also due to the disease
Etiology-based Malnutrition Definitions
https://image.slidesharecdn.com/ntpchapter3-160313161531/95/ntp-chapter-3-57-638.jpg?cb=1457885760
How would the presence of inflammation be determined?
c-reactive protein would be the best marker
No inflammation if CRP is below 3mg
Describe MNA
Mini Nutritional Assessment
mostly to detect malnutrition in older people
but also to asses mobility
psychological disease and stress factor is an important integrated facto is this assessment
Transferrin and albumin are both low during __
Transferrin and albumin are both low during acute illness and PEM
TTR is low during __, transferrin is high
TTR is low during chronic loss, transferrin is high
TTR and albumin are low during __
TTR and albumin are low during malabsorption
Common PAL factors (NOT IOM!)
Chair or bed bound-
Seated work w/ little movement; little or no leisure activity-
Seated work w/requirement to move; little strenuous activity
Chair or bed bound- 1.2 x REE
Seated work w/ little movement; little or no leisure activity- 1.3-1.5 x REE
Seated work w/requirement to move; little strenuous activity- 1.6-1.7 x REE
Common stress factors Elective surgery Multiple trauma Severe infection Cancer Fever
Elective surgery 1.0-1.1 x REE Multiple trauma 1.4 x REE Severe infection 1.2 - 1.6 x REE Cancer- 1.1-1.45 x REE Fever 1.2 x REE per 1oC >37oC
AMDR ranges
10-35% protein
45-65% CHO
20-35% fat
