1. Macronutrients: muscle and fat mass assessment
Andrea K. JeVenn, RD, LD, CNSC
Baltimore, June 12, 2015

2. OBJECTIVES
Understand the reason for performing a nutrition focused physical exam (NFPE)
Demonstrate a technique to accurately identify and grade malnutrition-related muscle and subcutaneous fat loss
Practice the demonstrated NFPE technique

3. Steps for Diagnosing Malnutrition
Step 1 – Determine Etiology:
Social / Environmental Circumstances
Chronic Illness
Acute Illness or Injury
Step 2 – Eval Characteristics: Energy Intake * Weight Loss
Muscle Mass Loss * Body Fat Loss
Fluid Accumulation
Hand Grip Strength
Step 3 – Is Pt Malnourished?
MODERATE
1 characteristic? NO
> 2 characteristics? YES!
SEVERE

4. What is nfpe?
Exam which uses physical assessment and physical function findings to help determine nutritional status and diagnose malnutrition
Components
Macronutrient-
Fat (orbital, triceps, ribcage) Muscle (temples, shoulders, clavicles, scapula, thigh, calves) Fluid-extremities
Micronutrient-
Skin, Nails, Hair, Head/neck, Oral cavity, Eyes, Nose/Face

5. Why should dietitians use NFPE?
Reveals & confirms problem areas that indicate malnutrition & micronutrient deficiencies
Academy has made the NFPE a standard of practice for RDs starting in 2012
Subjective Global Assessment (SGA)
Looks similar to newest adult malnutrition criteria - energy intakes, weight changes, muscle & fat loss, fluid status, functional capacity
SGA has been validated in multiple patient populations as a tool to assess malnutrition
ASPEN-Academy criteria was created to be a more objective framework for assessing malnutrition
Baker JP, et al. Nutritional assessment: a comparison of clinical judgment and objective measurements. NEJM, 1982.
Detsky AS, McLaughlin JR, et al. What is subjective global assessment? JPEN, 1987.

6. ASPEN-Academy Criteria
Sga vs new criteria
SGA
ASPEN-Academy Criteria
Weight Changes
1 week  12 months
Nutrition Intake Changes
5 days  1 month
Eval of GI Symptoms
Eval Functional Status
grip strength
Disease Process
acute, chronic inflammation vs. no inflammation
Fat Stores
eyes, upper arms, mid-axillary line
Muscle Wasting
temporalis, pectoralis/deltoids/trapezius, interosseous, quads/gastrocnemius
Edema/Ascites
extremities, sacral/scrotum/vulva
Some type of scoring system for SGA

7. How to Do It Techniques of the Physical Exam
Inspection
Most frequently used
Broad observation followed by closer look
Critical evaluation
Palpation
Examining body structures, pulsations by touch

8. Keep calm. Prepare Yourself.
Review the medical record, social history, labs, medications
Gather necessary equipment
Wash hands
Wear gloves/PPE when appropriate
Obtain patient’s nutrition history

9. Prepare the Patient. Introduce self & explain the process
Respect patient privacy & ask permission
Draw curtains, close doors
Expose areas of body only as needed
Use professional language

10. Exam Area: Temples - Temporalis Muscle
View patient when standing directly in front of them, ask patient to turn head side to side
Severe
Mild -Moderate
Normal
Hollowing, scooping, depression
Slight depression
Can see/feel well-defined muscle

11. Exam Area: Oribital Area - Fat Pad Around Eye
View patient when standing directly in front of them, touch above cheekbone
Severe
Mild -Moderate
Normal
Hollow look, depressions, dark circles, loose skin
Slightly dark circles, somewhat hollow look
Slightly bulged fat pads. Fluid retention may mask loss

12. Exam Area: Clavicle & Acromion Bone - Deltoid Muscle
Patient arms at side; observe shape
Severe
Mild -Moderate
Normal
Shoulder to arm joint looks square. Bones prominent. Acromion protrusion very prominent
Acromion process may slightly protrude
Rounded, curves at arm/shoulder/neck

13. Exam Area: Scapular Bone Region Trapezius, Supraspinatus, Infraspinatus Muscles
Ask patient to extend hands straight out, push against solid object.
Severe
Mild -Moderate
Normal
Prominent, visible bones, depressions between ribs/scapula or shoulder/spine
Mild depression or bone may show slightly
Bones not prominent, no significant depressions
Roll patient on side
or have them sit up
Have pt raise arm, push against something
as you look at posterior region of shoulder, scapular area

14. Upper arm Assessment Technique
Normal
Mild -Moderate
Severe

15. Exam Area: Upper Arm Region - Triceps/Biceps
Arm bent, roll skin between fingers, do not include muscle in pinch
Severe
Mild -Moderate
Normal
Very little space between folds, fingers touch
Some depth pinch, but not ample
Ample fat tissue obvious between folds of skin
2nd area of subcutaneous fat loss – TRICEPS
Pinch an inch – normal
Sometimes that area can just be flabby – need to feel the area to determine the skin/fat differentiation
Minnesota starvation experiment , Keys
After
Before
Keys A. JAMA. 1948;138:

16. Exam Area: Dorsal Hand - Interosseous Muscle
Look at thumb side of hand; look at pads of thumb when tip of forefinger touching tip of thumb
Severe
Mild -Moderate
Normal
Depressed area between thumb-forefinger
Slightly depressed
Muscle bulges, could be flat in some well nourished people
Difficult with the elderly

17. Exam Area: Thoracic & Lumbar Region –
Ribs, Lower Back, Midaxillary Line
Have patient press hands hard against a solid object
Severe
Mild -Moderate
Normal
Depression between the ribs very apparent; iliac crest very prominent
Ribs apparent, but depressions less pronounced; iliac crest somewhat prominent
Chest is full, ribs do not show. Slight to no protrusion of the iliac crest.

18. Exam Area: Anterior Thighs – Quadriceps
& Patellar Region
Ask patient to sit, leg propped up, knee bent
Grasp quads to differentiate muscle vs. fat tissue
Severe
Mild -Moderate
Normal
Depression/line on thigh, obviously thin
Bones prominent, little sign of muscle around knee
Mild depression on inner thigh
Knee cap less prominent, more rounded
Well rounded, well developed
Muscles protrude, bones not prominent
Lower body less sensitive to change
Could also be related to inactivity or bedrest
– discuss this w/ pt, understand their baseline
Positioning: bend leg at knee, hanging leg over side of bed
or propped up while lying on back

19. Exam Area: Posterior Calf Region - Gastrocnemius Muscle
Grasp the calf muscle to determine amount of tissue
Severe
Mild -Moderate
Normal
Thin, minimal to no muscle definition
Not well developed
Well-developed bulb of muscle
Lower body less sensitive to change

20. Things to Consider: Etiology of Muscle Wasting

21. Causes of Muscle Atrophy
Muscular dystrophy
Not moving (immobilization)
Osteoarthritis
Dermatomyositis and polymyositis
Rheumatoid arthritis  
Spinal cord injury
Stroke
Malnutrition
Amyotrophic lateral sclerosis (ALS or Lou Gehrig's disease)
Polio
Guillain-Barre syndrome
Motor neuropathy (such as diabetic neuropathy)
Injury
Burns
Long-term corticosteroid therapy

22. Summary: Fat loss 3 areas Orbital Region Upper Arm Area
Triceps
Biceps
Thoracic & Lumbar Regions
Rib cage
Lower back
Mid-axillary line
Fat pad under the eye
Use modified tricep skinfold test to determine fat loss of upper arm/tricep area
Mid axillary line, rib cage, lower back, iliac crest at hips / love handles

23. Summary: muscle loss Upper Body Lower Body Patellar Area
Temporalis
Clavical Bone Region
Pectoralis Major, Deltoid, Trapezius
Acromion Bone Region
Deltoids
Scapula Bone Area
Trapezius, Supraspinatus, Infraspinatus
Hands (Interosseous Muscles)
Lower Body
Patellar Area
Anterior Thigh (Quadriceps)
Posterior Calf (Gastrocnemius)