nutritional assessment Flashcards
what are the three components of total energy expenditure
basal energy expenditure (55-65% of total calories), thermal effect of feeding (10% of calories), and activity energy expenditure (25-33%).
how many kcal/kg will maintain body weight in hospitalized pt?
30-35 kcal/kg of body weight will maintain weight. However, acutely or severely ill patients (trauma, burn patient, etc.) may require 35 - 40 Kcal/kg.
What are the risk factors that contribute to malnutrition and obesity?
-minority pop (african american and mexican americans) -lifestyle= biggest factor -1%= neuroendocrine
obesity
-BMI>30 -waist >40’ in men and >35’ in women
what pops does malnutrition effect?
Older persons who live alone Chronically ill patients (renal failure, CHF, end-stage COPD, celiac disease, etc.) Adolescents who eat and diet erratically Cancer patients undergoing chemotherapeutic or radiation protocols or other nutrient- Drug interactions Alcoholics Homelessness, low socioeconomic status (not enough money for regular intake)
what it the exception that has nutritional deficits without weight loss
anemia secondary to strict vegetarian or vegan diets may have B12 deficiency.
DETERMINE acronym (to screen for nutritional status)
Disease: any disease that makes it hard to cook, eat or shop Eating poorly: too much, too little, drinking too much alcohol; older adults lose the ability to taste salt, and over compensate; they also have a decreased smell which may make it difficult to identify spoiled food. Tooth loss or mouth pain: poor fitting dentures, lost teeth, dental carries Economic hardship: low nutritional food choices, prepackaged or convenience foods that are high in sodium, potassium and sugar. Reduced social contact: loneliness, social isolation or lack of motivation to eat. Multiple medications: drugs can alter the sense of taste & smell, change saliva excretion, irritate the stomach, interfere with absorption, etc. Involuntary weight loss: assess any change in weight Need for assistance with self-care Elderly years: > 80 years old are ‘elderly’
What medications affect nutritional status?
how much weight loss is considered significant.
Unintentional weight loss of 5% over 6 months or 10% over one year
how do you calculate weight change
%weight change = [(usual weight – current weight)/ usual weight] x 100
what are interview questions with weight loss?
- Decreased caloric intake: anorexia, early satiety, difficulty chewing or swallowing, inability to
feed self or obtain food, social isolation or depression - Malabsorption and maldigestion: diarrhea, fatty malodorous stools, change in bowel habits/
- Impaired metabolism or increase requirements: fever, pregnancy, chronic disease, etc.
- Increased losses or excretion: draining fistula or open wounds, diarrhea, excessive vomiting
What are physical exam findings that provide clues to nutritional status?
Vital signs: height, weight and BMI:
BMI = weight (kg)/height (meters)2
Tricep skinfold thickness assesses subcutaneous fat. Approximately 50% of body fat is
subcutaneous.
Rapid weight gain is more likely related to fluid retention. Weight loss, however, is more
likely related to tissue loss.
site, sign, deficiency chart
what is the MINI NUTRITIONAL ASSESSMENT
It is specific for screening patients > 65 years old.
12-14 points: Normal nutritional status
8-11 points: At risk of malnutrition
0-7 points: Malnourished
What physical exam maneuvers can provide information about nutritional status?
Appearance: muscle mass, hair texture, nail health, skin texture
Muscle strength: grip strength—ask patient to squeeze index and middle fingers for 10
seconds; ambulation—walk across the room and back; lower extremity strength against
resistance;
What labs are helpful in identifying nutritional deficiencies?
.
Labs that correlate with inflammation may indicate underlying pathology or illness, such as C-
reactive protein, elevated WBC and albumin
what albumin levels indicate systemic inflammatory response?
Albumin <3.5 g/dL is considered to indicate a mild systemic inflammatory response.
A value of < 2.4 g/dL represents a severe systemic
inflammatory response, reflecting systemic inflammation that produces anorexia (limiting food
intake) and increases protein catabolism and thus accelerates the development of protein-
calorie malnutrition.
what potential deficiency can CBC find?
Iron, B12, folate
what potential deficiency can TSH find?
iodine
what potential deficiency can total protein, albumin find?
protein calorie malnutrition
characteristics of scurvy
the ‘four Hs” are characteristic of scurvy: hemorrhagic signs, hyperkeratosis of the
hair follicles, hypochondriasis and hematologic abnormalities. Perifollicular petechiae are the
characteristic cutaneous finding. Keratotic plugging of the hair follicles, lead to hair shafts that
are curled in follicles capped by keatotic plugs leading to ‘corkscrew hairs.’ Hemorrhagic
gingivitis, friable gingiva, delayed wound healing and depression may also occur.
pellegra characterstics
Niacin deficiency (vitamin B3); Characteristic “Three Ds” Diarrhea, dermatitis (photosensivity) and dementia. The dermatologic findings are on sun exposed areas.
rickets characterizations
Rickets is a result of deficient mineralization of osteoid matrix before closure of the
epiphyseal plate causing softening and weakening of bones in infants and children. The
mineralization impairment may be secondary to abnormal calcium, phosphorus, or vitamin D
metabolism leading to accumulation of osteoid before epiphyseal closure, compromising bone
stability at sites of rapid bone growth. When this occurs in adulthood after epiphyseal closure, it
is referred to as osteomalacia.
b12 deficiency
Glossitis, hyperpigmentation, and canities are the main dermatologic
manifestations of vitamin B 12 deficiency. The tongue is bright red, sore, and atrophic. Linear
atrophic lesions may be an early sign. The hyperpigmentation is generalized, but more often it is
accentuated in exposed areas, such as the face and hands, and in the palmar creases and
flexures, resembling Addison disease. The nails may be pigmented. Premature gray hair
(canities) may occur paradoxically. Megaloblastic anemia is often present. Weakness,
paresthesias, numbness, ataxia, and other neurologic findings occur.
What do you think is the recommendation for an
adult for vegetables/day? Fruits?
6-9 fruits and veggies
what is the mediterranean diet?
• Plant based: fruits, vegetables, nuts, grains, seeds, beans and olive oil
• Eggs, dairy, poultry and fish are eaten several times/week, but the
portions are small
• Minimal intake of red meat, refined sugar, flour, butter and fats
(except for olive oil)
• Includes: 1-2 glasses of red wine/d*
What nutritional
deficiency may result in a
strict vegetarian or vegan
diet?
B12 (cobalamin)
what is the current recommendation for salt?
less than 2300 mg/d
what is the DASH diet? what are the results?
- limits sodium to 2300 mg/d
- lowers blood pressure and LDL cholesterol
what are the food label laws?
Ingredient lists: descending order of
predominance.
Mandatory labeling of major allergens: i.e Milk,
eggs, peanuts
Vary between countries
can have a generic statement ‘contains
milk’
*vit D, K, Ca, and Fe are required. Vit A and C are optional
Salt/Sodium-Free
• Very Low Sodium
• Low sodium
• Reduced Sodium
• Light in Sodium or Lightly Salted
• No-Salt-Added or Unsalted
means less than 5 mg of sodium per serving.
means less 35 mg of sodium or less per serving.
means 140 mg of sodium or less per serving.
means at least 25% less sodium than in the original
product.
means at least 50% less sodium
than the regular product.
no salt added during processing. Does not mean no sodium in product
- fat free
- low fat
- reduced fat or less fat
- trans fat free
Fat-free means the food has less than 0.5 grams (g) of fat per serving.
• Low-fat means 3 g of fat or less per serving.
• Reduced fat or less fat means the food has at least 25% less fat than the
regular product.
• Trans fat free means the food has less than 0.5 g trans fat per serving. Even
though a food says “trans fat free,” it may still contain 0.49 g trans fat. Eating
many servings of a food with small amounts of trans fat per serving can add
up.
what are 2 common conditions that put people at high nutritional risk
-chornic alcoholism and recreational drug use
what goes in objective for nutrional assessment
• Vital Signs: height, weight, BMI or
waist measurement
• Eyes
• Tongue, Teeth & gums
• Muscle mass
• Skin integrity—wounds, wound
healing
• Subcutaneous fat
• Hair & Nails
• Mental status
what labs would you get for nutrional assessment
- CBC (MCV)
- WBC
- Albumin (inflammation)
- Total protein
- TSH
What does Vit A do?
• Fat-soluble
• Requirement for epithelial
functions
• Proliferation of basal cells,
hyperkeratosis and formation of
stratified cornified squamous
epithelium
• Integral component of rhodopsin
and iodopsin
• Worse with conditions that have
fat malabsorption
sources of Vit A
- Milk
- Fish oil
- Liver
- Eggs
- Carrots
- Squash
- Greens
what disease processes may lead to Vit A deficiency
A. Crohn’s disease
B. Celiac disease
C. Bariatric surgery
D. Chronic mineral oil use for constipation
What does Niacin (B3) do?
• Niacin is required as a coenzyme
to form nicotinamide adenine
dinucleotide or nicotinamide
adenine dinucleotide
phosphate.
• There are more than 200
enzymes that require the active
coenzyme forms of niacin.
• Other symptoms are diarrhea, dementia, and pigmented
dermatitis in sun-exposed areas.
• Glossitis, stomatitis, vertigo and
burning paresthesia’s are also
common.
pellagra
Pellagra: chronic disease affecting
GI tract, nervous system and skin.
3D’s: diarrhea, dementia &
dermatitis (phototoxicity)
-vit B3 deficiency
sources of niacin (B3)
- Meats, poultry, fish
- Legumes
- Wheat
- Synthesized in body from tryptophan
what does vit B12 do?
• Absorbed in the distal ileum
after binding to gastric intrinsic
factor
• More common with GI
abnormalities (celiac disease,
pancreatic disorder, atrophic
gastritis)
• Adults have large body stores
• Deficiencies may take 3-6 years
after GI abnormalities develop
sources of B12
- Eggs
- Dairy products
- Meats, liver
NONE IN PLANTS
what does B12 deficiency cause?
-hyperpigmentation in creases and flexures
-Megaloblastic anemia
-Thrombocytopenia with
anemia
-Weakness, paresthesias,
numbness, ataxia
what does Vit C do?
• Biologic antioxidant and free
radical scavenger
• Necessary for biosynthesis of
bile acids, collagen and
norepinephrine
symptoms of Vit C def
• fatigue,
• depression
• widespread abnormalities of
connective tissue
PE findings Vit C deficiency
- Inflamed gingiva
- Petechia
- Hemorrhage
- Impaired wound healing
- Hyperkeratosis
- Bleeding into body cavities
*corkscrew hairs
what is linked to Vit D deficiency?
-osteoporosis and sarcopenia
*imp for muscle and bone
about Vit D
• Skin produces Vitamin D with
sun exposure
• Aggressive SPF use and
decreased sun exposure may
predispose to osteomalacia
• Milk & dairy products are often
fortified with Vitamin D
Which is a risk
factor for vitamin D deficiency?
A. Elderly nursing home resident
B. Treatment for seizure disorders
C. Dark-skinned patients living in
northern climates
D. Patients with milk allergy
What lab may exist
with a strict vegan
diet?
-megaloblastic anemia (B12 def)
what is the most likely deficiency?
vit A (epithelium)
what is the most likely deficiency?
vitamin C
what is the most likely deficiency?
-Vit B12 = creases and folds
*note niacin= sun exposed areas)
what is most likely deficiency?
A. Riboflavin
B. Niacin
C. Iron
D. Folate
what is most likely deficiency?
vit D
what is the most likely deficiency?
Niacin (sun exposed area)
what is the most likely deficiency?
-vit C (perifollicular purpura and ecchymosis)
what is most likely deficiency?
-iron (spoon nail)
what is most likely deficiency?
A. Riboflavin
B. Pyridoxine
C. Niacin
D. Iron
what diagnosis would require
- Low salt
- 1 gm sodium
- 2 gm sodium
- 3 gm sodium
diet
CV disease
what diagnosis may require consistent carb diet?
diabetes
