1. Nutritional Assessment Focusing on Office Anthropometrics 60th Annual Obesity & Associated Conditions Symposium, American Society of Bariatric Physicians; New Orleans; November, 2010

2. Joan Temmerman, MD, MS, FAAFP, CNS Medical Bariatrician, Clarian Bariatrics Assistant Professor of Clinical Medicine, Dept. of Medicine, Indiana University School of Medicine Diplomate, American Board of Bariatric Medicine Diplomate, American Board of Family Medicine Fellow, American Academy of Family Physicians Certified Nutrition Specialist

3. Objectives Review specific issues in providing respectful care for bariatric patients Apply nutritional assessment to bariatric patients Define anthropometrics Discuss importance Review techniques and methods Review equipment used

4. Everyone on the Healthcare Team is important!

5. Beauty comes in all shapes and sizes

6. Empathetic encounters Patient-centered interactions Respect and sensitivity Communication – establishing rapport – attentive listening – exploration of concerns Avoid criticizing patients Partnership

7. Empathetic encounters user-friendly office Accessibility to office Office comfortable Sturdy armless chairs Adequate restrooms Large gowns Step stool for exam tables Adequate equipment

8. Nutritional Assessment Dietary assessment Anthropometrics Biochemical tests Clinical evaluation

9. Dietary Assessment Tools 1. weight history 2. dieting history 3. dietary patterns -food diary or daily food record (-3 day diet record) -food frequency questionnaire -24 hour recall -diet history interview

10. What are Anthropometrics? The physical dimensions and composition of the body Anthropometry is the measurement of body size, weight, and proportions Valuable for assessing nutritional status Lee RD, Nieman DC. Nutritional Assessment, 5 th edition, 2010.

11. Anthropometrics Height (stature) Weight BMI Body composition Measurements

12. Important clinical decisions based on weight and stature Measurements must be as accurate and precise as possible

13. Measuring Height (stature) Do not just ask! No shoes!! Head positioned in Frankfort horizontal plane

14. Frankfort horizontal plane

15. Stadiometer Beam perpendicular Eyes looking straight ahead Heels together; toes pointed slightly outward Weight evenly distributed Contact points: - both heels -buttocks -shoulder blades -back of head Deep breath; stand as tall as possible

16. Weight One of the most important measurements Private setting Scale that can weigh all patients Record weight silently Avoid making comments (focus on non-weight outcomes )

17. Body Mass Index (BMI) Height and weight must be accurate to calculate BMI correctly BMI most widely used measurement to assess weight status Obesity= excess body fat (not excess weight)

18. BMI

20. Limitations of BMI Does not directly measure body fat Does not provide information on body composition May be abnormal for muscular person Doesn’t predict fat distribution Doesn’t take into account age or gender

21. 13% body fat 26% body fat Limitations of BMI

22. Body Composition The quality of weight (i.e. fat and lean tissue) is more important than weight quantity

23. Body Composition weight % fat free mass (lean body mass) % fat mass

24. What is normal range of body fat? Guidelines vary As people age, they tend to lose muscle mass and gain fat Sarcopenic obesity: BMI 30%

25. Healthy body fat women: 20-35%

26. Healthy body fat men: 8-22%

27. Methods to measure body composition Hydrostatic (underwater) weighing Skinfold measurements Bioelectrical Impedance Analysis (BIA) Air displacement (Bod Pod) Dual energy x-ray absorptiometry (DEXA)

28. Hydrostatic (underwater) Weighing The volume of submerged object = volume of displaced water Standard laboratory (research) technique Not practical for testing large numbers

29. Patient submerged All air expelled from lungs 3-4 measurements averaged Takes about 20 min Uncomfortable; difficult for some Requires specialized equipment

30. Skinfold measurements calipers

31. Skinfold measurements

32. Skinfold limitations May be difficult in obese patients Hard to locate proper site Skinfold may be too large for caliper Reliability of measurements in obese unknown; not accurate in extremely obese Blackburn,G. Ed., 1994. Obesity Pathophysiology Psychology and Treatment

33. Bioelectrical Impedance Analysis (BIA) Painless electrical current; instrument measures resistance Calculates body water, fat-free mass and body fat % More accurate than skinfold measurements Affected by hydration Contraindicated for pacemakers and defibrillators.

34. BIA

37. Air Displacement Plethysmography: Bod Pod

38. Bod Pod Similar to water displacement except air displaced Rapid, accurate analysis (3-5% error) Easy for special populations (elderly, disabled, children) Provides resting metabolic rate (RMR) and total energy expenditure (TEE) Costly (machine ~ $40,000)

39. Dual energy x-ray absorptiometry (DEXA)

40. DEXA Originally developed to assess bones Widely used for body composition Quick (3 minutes), safe Measurements may be affected by thickness and bone

41. Measurements - Waist -Hips -Neck -Arm -Thighs

42. Waist Circumference (WC) Distribution of fat very important Apple shape high risk Abnormal WC linked to cardiometabolic disease Superior to BMI in predicting health risks

43. Fat distribution critical Energy is stored in adipose tissue Largest organ in body Extensive blood supply Excess intra- abdominal fat (apple shape) is high-risk

45. Increased abdominal fat Independent risk factor, even when BMI is not markedly increased WC better predictor of total abdominal fat than waist-to-hip ratio (WHR)

46. Measure waist to detect abdominal obesity Landmarks: top of iliac crest (hip bone)

47. Measuring waist with pannus

48. Hips largest circumference below umbilicus

49. Measurements Thigh: just below gluteal fold neck

50. Other office measurements Vital signs Include BMI and waist circumference as vital signs Blood pressure

51. Measuring Blood Pressure Correct cuff size critical Use larger BP cuffs when appropriate Large adult cuff: mild to moderate obesity Thigh cuff: severe obesity (arm>16 inches) Patient sitting; arm relaxed; elbow heart level

52. Anthropometrics Simple, safe, non-invasive Inexpensive, portable equipment Produce accurate and precise data when obtained by trained personnel Assess long-term nutritional status Disadvantages: – Don’t assess short-term nutritional status – Unable to assess nutritional deficiencies Boyle MA, Holben DH. Community Nutrition in Action, 5 th edition, 2010.

53. Summary Accurate anthropometric measurements are cornerstone of nutritional assessment BMI screens for degree of obesity Body composition (weight quality) key measurement Fat distribution predicts health risks

54. Additional Resources follow this link to view the process for obtaining an accurate height. http://www.youtube.com/watch?v=0LNCuP24MSc. http://www.youtube.com/watch?v=0LNCuP24MSc follow the following link to view proper technique for obtaining an arm circumference, waist circumference, buttocks circumference and thigh circumference. http://www.youtube.com/watch?v=KacU_TW50Zo.

55. Additional Resources To view the techniques for conducting a subscapular measurement, suprailiac skinfiold measurement, and biocromial breadth view the video below or follow this link: http://www.youtube.com/watch?v=SXFSvTCHPXo View the video below or follow this link to see how a Bod Pod is used to measure body composition. http://www.youtube.com/watch?v=elobnbT33yo