1. Nutritional Analysis and Assessment
Leslie Young MS RD LDN
Nutritional Analysis and Assessment
Unit 1: Introduction to Nutritional Assessment

2. Introduce Myself Leslie Young Registered/Licensed Dietitian
Masters Degree Human Nutrition
Full time Faculty NS Dept
Married to Jeff.Our son is almost 3-Andrew
This pic of Andrew is from last year-
need to update 

3. NS 210 Course Syllabus Review
Course Description
This course includes the study of methods and equipment used for nutritional analysis in health, obesity, and malnutrition. Students learn how to utilize the software-based and manual data-gathering systems to assess nutritional status.

4. Course Syllabus Review Continued
Course Outcomes
Upon successfully completing this course, you will be able to:
List the equipment used to assess markers for obesity and malnutrition.
Critically appraise various methodologies and equipment used for nutritional analysis.
Assess the nutritional status of individuals.

5. Course Syllabus Review Continued
Class Time: seminar each week.
Office Hours
By appointment AIM leslieyoung79
AIM
If you are not an AIM Member you can download the free service by visiting the following site:

6. Course Syllabus Review Continued
Instructors Grading Criteria/Timetable
Late Policy: no late work allowed without extenuating circumstances/instructor prior approval
How to Label your Work
Projects
username-project-unit#.doc.
Allen-Anatomical Terminology-Unit 3.doc.
Seminars
username-seminar-unit#.doc
TAllen-Seminar-Unit 3.doc
Instructor’s Grading Criteria/Timetable:
All course projects submitted on time will be graded within five days of their due date (the Sunday of the following unit). Late work will be graded within five days of the submission date. Seminar Option 1 grades will be updated within 48 hours of the scheduled seminar. Seminar Option 2 grades and Discussion board grades will be updated each week no later than Sunday of the week following the Unit’s completion. 
Late Work Policy:
Extenuating Circumstances: If you have extenuating circumstances that prevent you from completing projects, quizzes, seminars or participating in the class, please contact the instructor to make alternative arrangements. The possibility of alternative arrangements is at the discretion of the instructor. Active communication is the key to overcoming any hurdles you may encounter during the term. It is your responsibility to inform the instructor (ahead of time, whenever possible) of extenuating circumstances that might prevent you from completing work by the assigned deadline. In those situations, we will work together to come up with a mutually acceptable alternative. Prior notification does not automatically result in a waiver of the late penalties. Please note that evaluation of extenuating circumstances is at the discretion of the instructor and documentation may be required for verification of the extenuating circumstance. Examples of extenuating circumstances may include but are not limited to: personal/family member hospitalization, death in the family, weather/environmental evacuation due to fire/hurricane, or active military assignment where internet connectivity is unavailable for a limited time period. Computer-related issues, internet connectivity issues and clinical blocks are not considered extenuating circumstances.
How to Label Your Work:
Projects: Please label your projects: username-project-unit#.doc. For example, a student named Tina Allen would name her file Allen-Anatomical Terminology-Unit 3.doc. T
Seminar Option 2: Please label your seminars: username-seminar-unit#.doc (for example, TAllen-Seminar-Unit 3.doc)
Subject Lines: Please start your subject lines in correspondence with Course & section username: SUBJECT_OF_MESSAGE (for example, HS101-3-TAllen: Question regarding project)

7. Overview Review of Nutritional Assessment Methods Dietary Standards
Anthropometrics
Biochemical
Clinical
Dietary
Dietary Standards
The relationship between nutrition and health has long been recognized. Scientific evidence confirming this relationship began accumulating as early as the mid-eighteenth century, when James Lind showed that consumption of citrus fruits cured scurvy.
Before the middle of the 20th century, infectious disease was the leading cause of death worldwide, and nutrient deficiency disease and starvation were common. B/c of advances in public health, medicine, and agriculture, chronic diseases such as coronary heart disease, cancer and stroke no surpass infectious diseases as the leading cause of death in developed nations, and hunger and nutrient deficiencies are less common.
Although many factors contribute to the high incidence of chronic disease, diet plays an important role in 5 of the 15 leading causes of death in the US, and excessive alcohol consumption is a prominent factor in 3 of the 15. The increasing prevalence of overweight and obesity is a particularly troubling global trend, even in developing nations where malnutrition, hunger, and starvation are also common. Epidemiologists have coined the term globesity to identify what many regard as a global epidemic of obesity.
Continuing the presence of nutrition-related disease makes it important that health professionals be able to assess nutritional status to identify who might benefit from nutrition intervention and which interventions would be appropriate.

8. Nutritional Screening and Nutritional Assessment
the process of identifying characteristics know to be associated with nutrition problems.
Nutrition Assessment is the first of four steps in the Nutrition Care Process.
Nutritional Screening “is the process of identifying characteristics known to be associated with nutrition problems. Its purpose is to pinpoint individuals who are malnourished or at nutrition risk. Nutritional screening allows persons who are at nutritional risk to be identified, so that a more thorough evaluation of the individual’s nutritional status can be performed.
Nutrition Assessment is the first of four steps in the Nutrition Care Process. Nutrition assessment is an attempt to evaluate the nutritional status of individuals or populations through measurements of food and nutrient intake and nutrition-related health. Nutritional assessment techniques can be classified according to four types: anthropometric, biochemical or laboratory, clinical and dietary. Use of the mnemonic “ABCD” can help in remembering these four types.
Our expanded ability to alter the nutritional state of a patient and our increased knowledge of the relationship between nutrition and health has made nutritional assessment an important tool in healthcare.
Are any of you aware of the new Nutrition Care Process initiated by the American Dietetic Association?
It is a method of identifying and evaluating data needed to make decisions about nutrition-related problems/diagnosis. While the type of data may vary among nutrition settings, the process and intention are the same. When possible, the assessment data is compared to reliable norms and standards for evaluation. Further, nutrition assessment initiates the data collection process that is continued throughout the nutrition care process and forms the foundation of reassessment and reanalysis of the date in Nutrition Monitoring and Evaluation (Step 4).

9. Nutrition Assessment Methods
Anthropometrics
The objective measurements of body muscle and fat
Biochemical/Laboratory
Tests based on blood and urine- can be important indicators of nutritional status
Influenced by other nutritional factors as well
Clinical Data
Information about the individuals medical history – acute and chronic illness, etc.
Dietary Methods
24 Hour recall
Food frequency questionnaire
Anthropometrics are the objective measurements of body muscle and fat. They are used to compare individuals, to compare growth in the young, and to assess weight loss or gain in the mature individual. Weight and height are the most frequently used anthropometric measurements, and skinfold measurements of several areas of the body are also taken.
Biochemical/Laboratory tests based on blood and urine can be important indicators of nutritional status, but they are influenced by non-nutritional factors as well. Lab results can be altered by medications, hydration status, and disease states or other metabolic processes, such as stress. As with the other areas of nutrition assessment, biochemical data need to be viewed as a part of the whole.
Clinical data provides information about the individual's medical history, including acute and chronic illness and diagnostic procedures, therapies, or treatments that may increase nutrient needs or induce malabsorption. Current medications need to be documented, and both prescription drugs and over-the-counter drugs, such as laxatives or analgesics, must be included in the analysis. Vitamins, minerals, and herbal preparations also need to be reviewed. Physical signs of malnutrition can be documented during the nutrition interview and are an important part of the assessment process.
Dietary Methods - There are many ways to document dietary intake. The accuracy of the data is frequently challenged, however, since both questioning and observing can impact the actual intake. During a nutrition interview the practitioner may ask what the individual ate during the previous twenty-four hours, beginning with the last item eaten prior to the interview. During the nutrition interview, data collection will include questions about the individual's lifestyle—including the number of meals eaten daily, where they are eaten, and who prepared the meals. Information about allergies, food intolerances, and food avoidances, as well as caffeine and alcohol use, should be collected. Exercise frequency and occupation help to identify the need for increased calories. Asking about the economics of the individual or family, and about the use and type of kitchen equipment, can assist in the development of a plan of care. Dental and oral health also impact the nutritional assessment, as well as information about gastrointestinal health, such as problems with constipation, gas or diarrhea, vomiting, or frequent heartburn.

10. Healthy People 2010
Increase proportion of adults who are at a healthy weight
Reduce the proportion of adults who are obese
Reduce the proportion of children and adolescents who are overweight or obese
Reduce growth retardation among low-income children under age 5
Increase the proportion of persons aged 2 years and older who consume at least 2 daily servings of fruit
Objectives related to nutrition and health have a prominent place in the Healthy People 2010 objectives. Skill in applying nutritional assessment techniques will play a major part in the health professional’s efforts to help achieve these objectives.
Top 5 Healthy People 2010 objective of 18
Page 6 in text box 1.2

11. Protein Energy Malnutrition (PEM)
An excessive loss of lean body mass resulting from inadequate consumption of energy and/or protein or resulting from the increased energy and nutrient requirements of certain diseases
It is estimated that as many as ¼ of all patients in long term care facilities and half o all patients in acute-care hospitals suffer from PEM. Patients with PEM tend to have longer hospital stays and higher incidence of complications and mortality. Relatively simple techniques often can identify patients at nutritional risk.
Prevalence of PEM in LTC facilities ranges from 19-27%
Prevalence of PEM in acute care hospitals ranges from 33-58%
Identifying patients at nutritional risk is a major activity necessary for providing cost-effective medical treatment and helping contain health care costs. Good medical practice and economic considerations make it imperative that hospital patients e nutritionally assessed and that steps be taken, if necessary to improve their nutritional status. Evaluation of a patient’s weight, height, midarm muscle area, and triceps skinfold thickness and values from various laboratory tests can be valuable aids in assessing protein and energy nutrition. Some researchers believe that rapid, non-purposeful weight loss is the single bets predictor o malnutrition currently available.

12. Nutritional Assessment and Diabetes
Goals for persons with Diabetes are based on:
Dietary history
Nutrient intake
Clinical data
Nutritional assessment is now a major component of the American Diabetes Association’s nutrition recommendations and principles for people with diabetes.
Goals for persons with diabetes are based on dietary history, nutrient intake and clinical data. A thorough knowledge of the patient gained through nutritional assessment will assist you as the dietitian – the primary provider of nutrition therapy – in guiding the patient to a successful treatment outcome. The role of nutrition assessment in managing diabetes is discussed further in chapter 8.

13. Nutritional Assessment: Heart Disease and Cancer
Diabetes
serum lipoprotein
Male sex
Abdominal obesity
Cigarette smoking
Advancing age
Overweight and obesity
Nutritional assessment also plays a significant role in identifying diet-related risk factors for heart disease and cancer in monitoring efforts to reduce risk.
In the boxes above we are looking at categories of coronary heart disease risk factors. There are 3 different types of risk factors: causative, conditional and predisposing.
Which of the risk factors listed below heart disease are causative? Which are Conditional? And which are Predisposing?
Causative: Cigarette smoking, diabetes, advancing age,
Conditional: Triglycerides, serum lipoprotein,
Predisposing: overweight and obesity, male sex, abdominal obesity
The American Cancer society guidelines on nutrition and physical activity for cancer prevention can be found on page 10 of your text box 1.4

14. Review of Unit 1: Introduction to Nutritional Assessment
Nutritional assessment is central to monitoring and improving nutritional status
Nutritional assessment is an attempt to evaluate the nutritional status of individuals
Nutritional assessment is central to current government efforts to monitor and improve the nutritional status of its citizens. It is also essential for nutritional epidemiologist and other nutrition researchers investigating links between diet and health.
Nutrition assessment is an attempt to evaluate the nutritional status of individuals or populations through measurements of food and nutrient intake and nutrition-related health. Nutritional assessment techniques can be classified according to four types: anthropometric, biochemical or laboratory, clinical and dietary. Use of the mnemonic “ABCD” can help in remembering these four types.

15. Dietary Standards Common standards for evaluating nutrient intake
Dietary Reference Intakes
Dietary Guidelines for Americans
Regulations governing the nutritional labeling of food
The MyPyramid Food Guidance System
A variety of standards for evaluating the food and nutrient intake of groups and individuals include the Dietary reference intakes, the dietary guidelines for Americans, regulations governing the nutritional labeling of food, the MyPyramid food guidance system and various graphics developed to pictorially communicate recommendations for food intake and principles of good nutrition. Although most of these standers originally were designed to serve as standards for nutritional status, they are also useful as standards for evaluating the amounts and proportions of macronutrients, micronutrients and various food components consumed by individuals and groups
Recognition of diet’s role in health and disease has led to numerous efforts in the past several decades to formulate dietary guidelines and goals to promote health and prevent disease. A clear consensus has developed among most dietary guidelines and goals; dietary patterns are important factors in several of the leading causes of death, and dietary modifications can, in a number of instances, reduce one’s risk of premature disease and death. Nutrition assessment is pivotal to improving dietary intake, thus reducing disease risk and improving health.

16. DRI’s DRI’s include 4 Reference Values
Estimated Average Requirement (EAR)
Adequate Intake (AI)
Tolerable Upper Level (UL)
Recommended Dietary Allowance (RDA)
The DRI’s include four reference values: Estimated Average Requirement (EAR), Adequate Intake (AI), Tolerable Upper Level (UL), and Recommended Dietary Allowance (RDA). In addition the DRI’s include an Estimated Energy Requirement and Acceptable Macronutrient Distribution Ranges that suggest the percent of kilocalories to be obtained from total fat, essential fatty acids, carbohydrate, and protein

17. Estimated Average Requirement (EAR)
Definition
“The daily intake value that is estimated to meet the requirement, as defined by the specified indicator of adequacy, in half to he apparently healthy individuals in a life stage or gender group
The EAR is defined as the daily intake value that is estimated to meet the requirement, as defined by the specified indicator of adequacy in half o the apparently healthy individuals in a life stage or gender group. The EAR serves as the basis for setting the Recommended Dietary Allowance (RDA). If an EAR cannot be established, then an RDA cannot be set. These are shown on page 19, table 2.2
Because of individual biological variation in nutrient absorption and metabolism, some individuals have a relatively low (lower than average) requirement for a nutrient, while others have a relatively high (higher than average) requirement.
ERA’s are sometimes, of necessity, based on scanty data or data drawn from studies with design limitations.
The criteria used in setting the EAR include the amount needed to prevent classic deficiency disease, amounts of the nutrient or its metabolites measures in various tissues during depletion-repletion studies or during induced deficiency states in health adult volunteers and the amount needed to adequately maintain a certain metabolic pathway that is dependent on the nutrient in question.

18. Adequate Intake (AI)
A value based on experimentally derived intake levels or approximations of observed mean nutrient intakes by a group (or groups) of healthy people
Observational standards - observed or experimentally derived approximations of average nutrient intake that appear to maintain a defined nutritional state or criterion of adequacy in a group of people
If insufficient data are available to calculate an ERA, and thus and RDA cannot be set for a particular nutrient, a separate reference intake, known as the Adequate Intake (AI) is used instead of the RDA. Adequate Intake is defined as a value based on experimentally derived intake levels or approximations of observed mean nutrient intakes by a group (or groups) of healthy people.
AI’s are observational standards – they are based on observed or experimentally derived approximations of average nutrient intake that appear to maintain a defined nutritional state or criterion of adequacy in a group of people. Because AI’s are set using healthy groups of individuals they are expected to meet or exceed the actual nutrient requirement in practically all healthy members of a specific life stage and gender group.. Like the RDA, the AI is intended to serve as a goal for the nutrient intake of health individuals.
Unlike the RDA however the AI is used when data on nutrient requirements are lacking, and consequently grater uncertainty surrounds the AI. It’s use indicates a need for additional research on the requirements of that particular nutrient or food component.

19. Tolerable Upper Intake Level (UL)
“The highest level of daily nutrient intake that is likely to pose no risk of adverse health effects in almost all individuals in the specified life stage group.”
Upper Limit is defined as :“The highest level of daily nutrient intake that is likely to pose no risk of adverse health effects in almost all individuals in the specified life stage group.” The UL is not intended to be a recommended level of nutrient intake but, rather, an indication of the maximum amount of a nutrient that can, with a high degree of probability, be taken on a daily basis without endangering one's health – in other words, the maximum amount that likely can be tolerated by the body when consumed on a daily basis. The term adverse effect is defined as “any significant alteration in the structure or function of the human organism” or any “impairment of a physiologically important function that could lead to a health effect that is adverse.”
The UL was created in response to concerns about the potential for excessive nutrient intakes resulting from recent increases in consumption of nutrient – fortified foods and dietary supplements. Just as inadequate nutrient intake can adversely affect health so can excessive nutrient intake

20. Recommended Dietary Allowance
The average daily dietary intake level that is sufficient to meet the nutrient requirement of nearly all (97% to 98%) healthy individuals in a particular life state gender group.
The average daily dietary intake level that is sufficient to meet the nutrient requirement of nearly all (97% to 98%) healthy individuals in a particular life state gender group.
In recent decades, as chronic degenerative disease have supplanted infectious and nutrient-deficiency diseases as the lading causes of death, there has been growing interest in the role of diet and nutrition in decreasing chronic disease risk, conditions that the RDA’s fail to adequately address. For example the RDA provided no recommendations for carbohydrate, dietary fibers, total fat, saturate fat, or cholesterol. There were no nutrient recommendations for orders persons and no recommendations for food components that are not traditionally defined as nutrients (phytochemicals, aspartame, caffeine, and alcohol. In addition the recommended nutrient intake levels of the RDA’s were generally limited to amounts obtainable through diet alone, and there was no guidance on the safe and effective use of vitamin, mineral and other nutrient supplements despite considerable public interest in use of such supplements.

21. Uses Of DRI’s (Daily Reference Intake)
For an Individual
EAR: Use to examine the probability that usual intake is inadequate
RDA: Usual intake at or above this level has a low probability of inadequacy
AI: Usual intake at or above his level has a low probability of inadequacy
UL: Usual intake above this level may place an individual at risk of adverse effects from excessive nutrient intake
For a Group
EAR: Use to estimate the prevalence of inadequate intakes within a group
RDA: Do not use to assess intakes of groups
AI: Mean usual intake oat or above this level implies a low prevalence of inadequate intakes
UL: Use to estimate the percentage of the population at potential risk of adverse effects from excessive nutrient intake
The suggested uses of the DRI’s fall into two broad categories: assessing nutrient intakes and planning or nutrient intakes. Each of the two categories is further divided into sues pertaining to individuals and uses pertaining to groups. The uses of the DRI’s for assessing and planning the intakes of apparently healthy individuals and groups are outlined in boxes 2.3 and 2.4 on page 31 of your text.
The DRI’s are not intended to serve as the only means of assessing the nutritional adequacy of an individual’s diet. An individual’s actual nutrient requirement can vary widely from the group average (the EAR) and without various biochemical and physiologic measures it is impossible to determine whether an individual’s actual nutrient requirement is close to the group EAR, greater than the EAR, or less than the EAR. In addition, intake of most nutrients varies considerably from one day to the next, requiring many days of measurement to estimate usual nutrient intake. Consequently when assessing the adequacy of an individual's diet, use of multiple nutritional assessment methods – dietary, anthropometric, biochemical, and clinical – must be considered.

22. Dietary Guidelines Dietary Guidelines
Goals or standards primarily intended to address the more common and pressing nutrition-related health problems of chronic disease
Maintenance of healthy body weight, decrease consumption of fat, increased consumption of complex carbohydrates and use of alcoholic beverage in moderation, if at all.
Dietary guidelines, or goals, are dietary standards primarily intended to address the more common and pressing nutrition-related health problems of chronic disease. They often are expressed as nonquantitative change from the present average national diet or from people’s typical eating habits.
Since the late 1960’s numerous dietary guidelines have been issued by Western governments and various health organizations. Overall, they have consistently called for maintenance of healthy body weight, decrease consumption of fat (especially saturate fat and now trans fat) increased consumption of complex carbohydrates and use of alcoholic beverages in moderation, if at all.

23. Nutrition Labeling Nutrition Labeling began in 1963
Nutrition Labeling and Education Act passed in 1990
RDI’s and DRV’s are collectively referred to as the Daily Values
Nutrition labeling in the United States began in 1973, when the Food and Drug Administration established the U.S. Recommended Daily Allowances (U.S. RDA’s). In 1990, Congress passed the Nutrition Labeling and Education Act, which made sweeping changes in nutrition labeling regulations, replaced the U.S. RDA’s with the Reference Daily Intakes (RDI’s) and established the Daily Reference Values (DRV’s). The RDI’s and DRV’s are collectively referred to as the Daily Values.

24. Food Guides Nutrition education tools
Foods are classified into groups according to their similarity in nutrient content
Example
Food Guide Pyramid
Food guides are nutrition education tools that translate dietary standards and recommendations into understandable and practical forms for use by those who have little or no training in nutrition. Generally, foods are classified into groups according to their similarity in nutrient content. If a certain amount of food from each group is consumed, a balanced and adequate diet is thought to likely result. A familiar example of a food guide is MyPyramid.

25. Food Exchange System
Simplifies meal planning for those with limited energy consumption
Helps to ensure adequate nutrient intake
Originally developed for those with diabetes
The food exchange system simplifies meal planning for persons limiting energy consumption and helps ensure adequate nutrient intake. Originally developed to facilitate meal planning for persons with diabetes, it is easily adapted to personal food preferences and is useful for quickly approximating kilocalorie and macronutrient levels in foods. The specified serving sizes of foods within each exchange list are approximately equal in their contribution of energy and macronutrients.
The system categorizes foods into 3 main groups – the carbohydrate group the meat and meat substitutes group and the fat group. The carbohydrate group lists foods that supply most of their energy in the form of carbohydrates: Starches, fruits, dairy products, vegetables and other carbohydrates. The meat and meat substitutes group includes foods that serve as good protein spruces, supply variable amounts of fat, and generally provide little, if any, carbohydrate. Foods in this group are listed on the basis of the amount of fat they supply: very lean, lean, medium-fat, high fat. Foods in the fat group provide fat and little if any, protein and carbohydrate. The fats are divided among three lists on the basis of the major fatty acids they supply: monounsaturated, polyunsaturated, and saturated. There is also a “free foods lists” and a list of combination foods and fast foods.

26. Due This Week
Introduce Yourself
Weekly Discussion Board
Unit 1 Quiz