1. Kerry Stone MS, RD,CNSC

2.  Identify clinical assessment measurements used to determine nutritional status.  Identify the difference between a Nutrition Risk Assessment and a Nutrition Assessment.  Identify how to calculate nutrition requirements.  State why nutrition assessment is important.

3.  Malnutrition is a measurably poor nutritional status resulting from:  Nutrient deficiency  Under or over nutrition  Nutritional imbalance or altered utilization  Impaired nutrient absorption The reported incidence of malnutrition in the hospital ranges from 30 to 50%. No single measurement is of consistent value.

4.  Many disease states have a nutritional component which can impact both clinical and financial outcomes. Nutritional risk assessment allows early identification of malnutrition or risk for becoming malnourished that can go unrecognized or untreated.  The goals of nutrition therapy should optimally be supportive of nutritional status, performance status, body composition, immune competence and quality of life.

5. Complications of malnutrition can be prevented and treated through: Nutrition screening for the level of risk by providing-  Nutrition counseling  Oral supplementation  Enteral nutrition  Parenteral nutrition

6.  Adequate – no nutritional deficiencies  Mild – at risk for developing deficiencies  Moderate – exacerbation of nutritional deficiencies if nutrition therapy is not initiated  Severe – significant nutrition intervention required to achieve a positive outcome

7. History Clinical Psychosocial Appetite-% of usual intake Nausea, vomiting Cognitive impairment Open wounds/pressure ulcers Diarrhea, constipation Depression Difficulty chewing, swallowing Limited mobility to cook, shop, prepare food Limited resources – includes transportation Changes in taste or smell Alcohol consumption, smoking Lives alone Inability or unwillingness to eat- anorexia or early satiety Medically restricted diet (COPD, CHF, HTN,DM, kidney/liver disease) Limited social support system Dental problems- Decayed or missing teeth/ill fitting dentures Complimentary or alternative medicine (CAM)/Herbs/ Supplement use Pain Mouth sores- thrush, stomatitis, dryness Involuntary weight loss or gain of 10 lbs. in I month Takes 2-4 or more medications daily

8.  Subjective Global Assessment (SGA) was first described by Baker in 1982. It was introduced to assess the patient for malnutrition at the bedside and had 5 components w/o the need for precise body composition analysis.  Today SGA has morphed to include disease specific evaluations and has been deemed the assessment method of choice for oncology, transplant, liver disease and dialysis patients.  It is the fastest and least complicated tool with high interobserver reproducibility and validity.

9.  Nutritional Assessment is a process in which the status of nutritional health of an individual is evaluated and specific nutrition needs are estimated to determine the preferred route of supportive nutritional care.  A complete nutrition assessment establishes individual goals and develops a plan of care to address the problems or needs identified from the assessment.

10. Information Gathering Body Composition Data Nutrient Intake / Dietary History Laboratory Evaluation Psychosocial / Functional Status Patient InterviewPhysical Exam for Fluid Status Cultural or Religious Preferences Nutritional Anemias i.e. Folate, Iron & B-12 Ethical issues & the pt’s right to autonomy Primary & Secondary Diagnosis. Look for fever & infection. Examination of the skin The quality & quantity of meals – 24 –hour recall or food diary Pre-albumin. Short ½ life. N= 20-50 mg/dL Income, education & other socioeconomic conditions such as chemical dependency Past medical & surgical history Examine the oral cavity Food allergies, intolerances or Fad diets Albumin. Long half life. N= 3.5-5.0 g/dL Environment or displacement Medication Review- include OTC Muscle definitionEating OutCholesterol/triglyc erides/ glucose Caregiver(s) Drug/Nutrient interaction Wasting, Sarcopenia Inability to feed self Liver Function Tests Bedridden, suboptimal activity Congenital or genetic conditions Drainage, lossesTotal Lymphocyte Count N= 1500 - 3000 mm2 Full capacity

11.  Marasmus – ICD-9 code: 261 AKA – adapted starvation Loss of body fat and skeletal muscle Preservation of visceral protein stores Cell mediated immunity and cardiac output are spared  Kwashiorkor – ICD-9 code: 260 AKA protein malnutrition Caused by acute illness or stress Edema may mask this condition. The patient can be obese Low or very low albumin Poor wound healing and infection risk

12. Mixed Protein Energy Malnutrition can be a life threatening condition that results from a combination of chronic energy deficiency and severe protein deficits. ICD-9 code: 263 Characteristics include: Loss of fat stores, skeletal muscle and visceral protein stores Usually vitamin and mineral deficiency, immune incompetence Edema

13.  Height  Height in inches X 2.54 = height in centimeters 5’9” = 69” X 2.54 = 175.26 = 175 centimeters  We need height to calculate energy requirements, determine ideal body weight and interpret body composition data.  According to Stewart*, The average difference between self reported height and measured height was not greater than +/- 0.9% and was not clinically significant.  Arm span is not influenced by age and may be used if appropriate.  Amputations and paralysis have adapted equations.  * Stewart AL. J Chronic Dis. 1982: 35: 205-309.

14.  Weight in pounds divided by 2.2 = weight in kilograms (kg)  We need as accurate information as possible because weight is used to determine daily energy requirements.  Parameters for evaluating significance of weight loss: IntervalSignificant LossSevere Loss 1 month 5% >5% 3 months 7.5% >7.5% 6 months 10% >10%

15.  Use the Metropolitan Life Height/ Weight Tables (1983) – Not over age 59  Hamwi Method: must know height Males: 106 lbs for the first 5 feet of height plus 6 lbs for each additional inch Females: 100 lbs for the first 5 feet of height plus 5 lbs for each additional inch This method is easy and is relatively accurate

16. Percent Weight Loss→ Take Actual weight divided by Usual body weight X 100 Example: 150 lbs divided by 180 lbs X 100 = 83% of usual Percent of Ideal Body Weight → Take Actual weight divided by Ideal body weight X 100 Example: 150 lbs divided by 160 lbs X 100 = 93% of ideal Adjusted Body Weight → for obesity Actual weight - Ideal body weight X 0.25* + Ideal body weight 220 lbs – 160 lbs X 0.25 + 160 lbs = 175 lbs * Assumes that 25% of body fat tissue is metabolically active

17.  Can not be used effectively for elite athletes or certain ethnic groups BMI = weight in kg height in (meters)₂  19-25 Appropriate weight for (19-34 years)  21-24.9 Appropriate weight for (>35 years)  25-29.9 Overweight  30-34.9 Obesity Grade I  35-39.9 Obesity Grade II  >40 Obesity Grade III (Morbid)  >50 Super Obesity  17-18.5 Mild malnutrition  16-17 Moderate malnutrition  <16 Severe malnutrition

18. Skeletal Muscle Measurement:  Mid- Arm Circumference (MAC): measures fat stores and muscle mass by measuring the circumference of the mid arm. It can determine marasmus.  Triceps Skin Fold (TSF): measures body fat reserves. Not as accurate in the obese patient and different value tables must be used for the elderly, children and ethnic groups. The “pinch” caliper test.  Mid-Arm Muscle Circumference (MAMC): measures skeletal muscle reserves – MAC – (3.14 (Π) X TSF) = MAMC  Must be done as serial measurements by the same person on the same arm to increase accuracy. But as good reference data.

19. Is conducted by placing 2 electrodes on the body to measure current in tissues that are rich in water such as muscle. Advantages- Easy, portable, rapid & safe. Disadvantages_ Accuracy is effected by hydration, exercise, amputation, eating, fever and obesity etc. Comments: Measurement must be taken after 4-hours of fasting and sedentary activity. Must lie down and be still for 10-minutes.

20.  Hydrodensity or underwater weighing – Most accurate Is not suited to individuals who are unable to maximally exhale, brush water bubbles away and those that are unwilling or unable to be totally submerged in a water tank.  Air displacement Plethysmography- Displacement of air is measured while the person sits inside a small chamber (BodPod). The calculation is similar to underwater weighing. Advantages – Easy if the equipment is available. No radiation. Disadvantages- Must remain still. No information on fat distribution.

21.  “ A picture is worth a 1000 Words”  Look at the patient and concentrate on the areas that reflect what the patient expressed in the nutrition history. Focus on high turn over rate areas. Area AppearanceNutrient Deficiency HairSparse, dry, dull, easily plucked Protein, Zinc, EFA SkinScaly, cracked Rash, Lesions B- vitamins, Vitamin A LipsCracks at the sides, swollen Vitamins B-2, B-3, B-6 EyesCornea, ConjunctivaIron, B-complex, Vitamin A TongueGlossitis, Magenta color Vitamins B-12, B-2

22.  A Nutrition Focused Physical Exam can yield important clues about micro and macro nutrient status. Unfortunately, clinical signs and symptoms of most nutrient deficiencies do not appear until an advanced state of deficiency exists.  In addition, the disease process, treatment or medication my mask or be confused with the symptoms of nutrient deficiencies.

23.  Resting Energy Metabolism (REE) includes energy required for the functioning of vital organs, muscles, skin and maintenance of body thermoregulation.  Indirect calorimetry provides an assessment of REE through the measurement of inspired oxygen to expired carbon dioxide. REE accounts for 60-70% of the total daily energy expenditure. With the multiplication of additional stress and activity factors a daily calorie need is established.

24.  An accurate assessment of energy needs is necessary to complete individual nutrition assessments and to determine the effectiveness of planned nutrition interventions.  Harris Benedict Equation calculates Resting Energy Expenditure Males: 66.47 + {13.75 x wt (kg)} + [5.0 x ht (cm)] – {6.76 x age(yrs)} 70 kg (154#) 66.47 + 962.5 + 876.3 – 270.4 = 1635 kcals Females: 655.10 + {9.56 x wt(kg)} +[ 1.85 x ht(cm)] – {4.68 x age(yr)} 55 kg (121#) 655.1 + 525.6+ 118.4 – 87.2 = 1112 kcals This must be multiplied by an activity and/or stress factor: Activity: Confined to bed = 1.0-1.2 Out of bed= 1.3 Injury or Stress – Surgery=1.0-1.2 Infection= 1.0-1.8 Trauma= 1.2-1.3 Moderate Stress (SBS, Cancer)=1.5 Burns/Transplant= up to 1.95 Note: The thermogenic effect of food represents 5-10% of kcals used by the body each day.

25. Problems:  Over predicts resting energy needs by 10%  When choosing a stress factor be conservative  Substantial limitations with age, certain ethnic groups and obesity  Don’t use adjusted body weight in this equation – it really underestimates kcal needs  Overall underestimates kcals by 35% and overestimates kcals by 43% in various populations when compared to measured REE.

26.  Is the best estimate at 10% off measured REE. Still has limitations with certain ethnic groups and age.  Works well with obese men. Underestimation=20% & overestimation =15% from measured in certain groups.  Calculates Resting Metabolic Rate or (RMR) Males: {9.99 x wt(kg)} + [6.25 x ht(cm)] – {4.92 x age(yr)} +5 70 kg (154#) 699.3 = 1095.4 – 196.8 = 1603 kcals Females: {9.99 x wt(kg)} + [6.25 x ht(cm)] – {4.92 x age(yr)} -161 55kg (121#) 549.45 + 1016- 196.8 – 161 = 1208 kcals ^ Stress / Injury factors follow the HB equation = 1.2-1.8 ^ 100 kcals more than predicted with the HB equation * Frankenfeld et al. JADA. 2005: (5) 105: 775-789.

27.  Status Kcals/ Kg  Obese 15-20  Sedentary/ Hospitalized 25-30  Moderately active or ill 30-35  Very active or ill 40  45 kcals/kg is the maximum recommended for an adult. This model is often referred to as the Hamwi method because it mirrors fluid recommendations.

28. Grams per kgProtein provision for 0.6-0.8Grade>2 hepatic encephalopathy, pre-renal w/o dialysis 0.8 – 1.0 Zero to low stress 1.0-1.2 Moderate stress (minor surgery, infection 1.3-1.5 Higher stress (major surgery, wound healing, dialysis) >1.5 Higher stress (peritonitis, burns, transplant, hypermetabolic states such as head injury

29.  Fluid requirements for adults can be estimated using the following equations: 1500 ml/m 2 1500 ml for the first 20 kg + 20 mL/kg over 20 kg 30-35 ml/kg (average adults) 30-35 ml/ kg (18-64 years of age) 30 ml/kg (55-65 years of age) 25 ml/kg (>65 years of age) 1 ml/ kcal 1ml/kcal + 100 ml/gm of nitrogen with losses

30. Nutrition Assessment is a vital part of the overall medical plan of care It allows us to recommend lab testing as appropriate and monitor nutrition effectiveness. Provides nutrition to assist with poor wound healing, shorter hospital stays, fewer re- admissions to the hospital and reduce the use of home health services.