Presentation on theme: "Nutritional Assessment Workshop"— Presentation transcript:
1 Nutritional Assessment Workshop Nicola RileyConcord Repatriation General HospitalEmma McNamara
2 What is Nutritional Assessment? “the evaluation of nutrition needs of individuals based upon appropriate biochemical, anthropometric, physical, and dietary data to determine nutrient needs and recommended appropriate nutrition intake including enteral and parenteral nutrition”- American Dietetic Association
3 Nutritional Assessment & Clinical Application - Overall View Nutrition Management:AssessmentInterventionFollow-up / ReviewEvaluationConsider:Health care settingDisease / conditionLifecycle / physiological state
4 Nutritional Status“Nutritional Status expresses the degree to which physiologic needs for nutrients are met”Optimal NS = Balance between intake and requirementMalnutritionstate caused by nutritional deficiencyReversible by providing appropriate nutrition supportDeficiency vs Overload(can be combination of both)“whole person” focus, not just disease or condition focus.
5 Nutritional RiskCritically unwell patients may be well nourished but high nutritional riskIllness, injury, infectionMetabolic derangementsMay have significant affect on nutritional statusMay lead to malnutritionCannot be corrected by nutrition support alonePatients at high nutritional risk will require early nutritional intervention and close monitoring
6 Why do we need to identify malnutrition? Malnutrition is associated with: length of stay in hospital complications hospital costs mortality rates
8 Nutrition Screening Tools Requirementsquick and simple to administersensitive enough to identify individuals at riskappropriate for client group being screenedcapable of being used by non-dietitiansreproducible when used by different observersable to guide non dietetic staff into taking appropriate action for findings recorded
9 Malnutrition Screening Tool (MST) Have you lost weight recently without trying?If NOIf unsureIf YES, how much weight have you lost?1 – 5 kg (2 – 11 lb)6 – 10 kg (1 – 1½ st)11 – 15 kg (1¾ - 2⅓ st)> 15 kg (> 2⅓ st)Unsure2134Have you been eating poorly because of a decreased appetite?If YESTotalIf the score is 2 or more please refer to the dietitian.(Ref: Ferguson M et al, Nutrition 15: , 1999)
10 The Short Nutritional Assessment Questionnaire (SNAQ) ScoreDid you lose weight unintentionally?>6kg in the past 6 month3>3kg in the past month2Did you experience a decreased appetite over the past month?1Did you use supplemental drinks or tube feeding over the past month?
12 Nutritional Assessment Tools No single / standard way of assessing nutritional statusVarious validated assessment tools developedsome disease specificsome age specific2 examplesMini Nutritional Assessment (MNA)Subjective Global Assessment (SGA)
13 Mini Nutritional Assessment (MNA) Screening and Assessment tool for the identification of malnutrition in the elderlyConsiders:Dietary Intake – foods, patternsWeight change, BMI, Muscle circumferencesFunctional impairment, Independence, Living arrangementsPsychological issues, Self assessment
14 Subjective Global Assessment Valid assessment toolStrong correlation with other subjective and objective measures of nutritionHighly predictive of nutritional status in a number of different patient groupsQuick, simple and reliable
15 Subjective Global Assessment…features Medical HistoryWeight changeDietary intakeGI symptomsFunctional impairmentPhysical ExaminationLoss of subcutaneous fatMuscle wastingOedema and ascites
16 Subjective Global Assessment …Classifications A Well nourishedB Moderately malnourished or suspected of malnutritionC Severely malnourished
17 Full Nutrition Assessment Step 1…Data collection Systematic ApproachAssessment based on clinical/psychosocial/physical informationDietaryAnthropometricBiochemicalPhysicalIncludingSubjective (eg. signs/symptoms of nutritional problem, appetite)Objective (eg. Lab results)
18 Data Collection… An Example… A B C D E A AnthropometryB Biochemical DataC Clinical signs and symptoms, medical conditionD Dietary IntakeE Exercise (Energy balance – expenditure)Consider current level, history and changes
19 Anthropometry Height Weight Weight history / pattern (% weight change) Weight for HeightBMIGrowth Pattern, head circumference (paediatrics)MAMCTSFWaist circumferenceHip circumferenceWHRBe aware of fluid status, presence of oedema.
20 Anthropometry – Body Composition Muscle, Fat, Bone, Water Body Mass:LBM – Body mass that contains small % (~3%) essential fat[Essential fat + Muscle + Water + Bone]Fat Free Mass (FFM)Fat Store:Essential Fat for physiological function, eg. fat stored in muscle, liver, heartStorage fat in adipose tissue – visceral fat and subcutaneous fat
21 Body Compostion cont’d. Practical Methods in Clinical Setting:Weight, height & weight HxSkinfolds, circumferencesTSF, MAMC,WHRMore precise, occasional use:Bioelectrical Impedance Analysis (BIA)FFM, % body fatDynamometry (grip strength)Precise, Expensive, Research purposes:CT, MRI, Dexascan, TBK,TBN
22 Biochemistry & other Blood Tests (See also disease/condition specific lectures) Objective measuresNo single test is diagnosticConsider “normal / recommended range” for various and combination of conditions, eg. age, gender, physiological state, disease type and stageConsider clinical significance of test resultTest result may reflect immediate intake (eg glucose) or long term status (HbA1c)
23 Other factors to Consider… Other factors can mask/influence test results eg.Acute phase response due to stress / injury ( reduced albumin)GI bleed (higher urea)blood transfusion (higher serum K and Hb)Surgery (lower Hb and albumin)
24 Acute Phase Response Inflammatory processes (shock, trauma, sepsis) liver protein synthesis shifts from visceral proteins, e.g. albumin and prealbumin to acute phase proteinsVisceral proteins may reflect ‘nutritional risk’ not nutritional status
25 Nutritional Indicators Ideal indicator or marker is sensitive and specific to nutritional intakeCommonly Used “Nutritional Indicators”AlbuminPre-albuminTransferrinRetinol-binding protein
26 Albumin Synthesised in the liver May be useful indicator of nutritional status in “healthy” person.Not a good indicator of protein status during critical illness (due to acute phase response)Long half life (14-20 days) and large body pool slow to respond to improvements in clinical status
28 Pre-albumin Also known as Transthyretin, thyroxine binding protein. Synthesised in the liverRelatively short half life (2 days)Negative acute phase reactant - with inflammatory responseMay be useful in healthy population
29 Transferrin and RBP Transferrin Retinol Binding Protein (RBP) Half life 8-10 daysPoor correlation with nutrition statusInvolved with iron transport, influenced by iron statusRetinol Binding Protein (RBP)Half life 12 hoursAffected by renal function, Vitamin A and Zn statusUnreliable measure of nutritional status
30 Biochemistry & other Blood Tests, cont’d (See also disease/condition specific lectures) Interference – drugs, samplingNutrient-nutrient interactions, drug-nutrient interactionsBe aware of hydration statusMust interpret lab results with other nutritional parameters
31 Clinical issues to consider: Medical history, treatment and medicationsSignificant factors affecting nutritional intakeFluid balance – input and output, Bowel habitsPhysical assessment of nutritional statusClinical signs and symptoms
33 Dietary Intake Is intake meeting requirement? (See relevant lectures in dietary intake, RDIs, etc)Is intake meeting requirement?Basic nutrition adequacySpecial requirement / disease / conditionsConsider factors affecting intakeConsider clinical, nutritional and psycho-social issuesMethods of collecting information/data?Relevant and practical
34 Exercise – Energy Balance Nutrition and exercise closely linked – metabolic and physical fitnessFunctional capacity and Nutritional statusCorrelation between muscle mass and physical strength, nutritional status and physical functionEnergy Balance to attain optimal weight and body compositionBed Rest / InactivityNegative effects on muscles, bone and CV system, eg. 8 g protein loss / day of bed restExercise – affects on appetite, bowel function
35 Estimating Nutritional requirements ConsiderEnergyProteinFluidRDIs for micronutrients
36 Estimating Energy Requirements Indirect Calorimetrypreferred methoduse of a metabolic monitor/cartmeasures respiratory gas exchangesDifferences in oxygen and carbon dioxide content between air going in and air coming out respiratory exchange energy expenditure(Ref: Mann & Truswell(ed) Essentials of Human Nutrition, Chap. 5)
37 Harris Benedict Equation Devised in 1919Multiple regression analysis of the gender, age, height and weight of 239 healthy volunteersRecent review of data and methodology - still valid (Frankenfield et al, 1998, JADA)Basal energy expenditure (BEE)= energy expended by a fasting subject at rest in a ‘thermoneutral’ environment
38 Harris Benedict Equation Males (kJ/24hr)BEE = (57.5 x W) + (20.9 x H) - (28.3 x A)Females (kJ/24hr)BEE = (40.0 x W) + (7.7 x H) - (19.6 x A)W = actual weight in kg, H = height in cm,A = age in years.
39 Schofield EquationOriginal equation (Schofield, 1985) derived from a study group of 5000 healthy adultsModified by COMA Panel on Dietary Reference Values (UK Dept of Health, 1991)excluded some data from developing nationsadditional equations for people over age of 75 yrs, based on Italian dataLimitations - ?validity with obese clients, some ethnic groups, ?applicable to Australian population.
42 Estimating Energy requirements Estimate BMR/BEE for healthy adult using predictive equationAdjust for stress using injury factorAdjust for activity using activityEnergy requirement = BEE x Injury/Stress factor x Activity factor
44 Injury Factors Medical (IBD, liver/pancreatic d) 1.1-1.2 Surgical (transpl, fistula)Cancer (tumour/leukaemia)Trauma (or minor burns)Sepsis (or other major infection)Major burns* Refer also to nutrition support and specific clinical lectures
45 Estimating Protein / Nitrogen Requirements From measuring Nitrogen losses from the body (urine, faeces, fistulae/drain losses, burn exudates)Urinary nitrogen excretion can be estimated by measuring urinary urea nitrogen(UUN) excretion from a 24hr urine sample.Urea production influenced by liver failure, sepsis, stress insensitive and unreliable in clinically unstable patients
46 Estimating Protein / Nitrogen Requirements Using RDA’sHealthy adult g/kg BWIncreased metabolic needs during periods of stressMild/intermediate stress stateeg surgery, fractures g/kg BWCancer g/kg BWMultiple trauma, /kg BWextensive burns(>30%)
47 Fluid Requirements Different methods used: 35 – 45 mL/kg body weight 30mL for older adults40 – 45 mL for active young adult0.24mL/kJ energy given1500mL + add 20mL per additional kg over 20kg