Download Nutritional assessment

Nutritional assessment
Major goals in the assessment of
nutritional status include:
•identification of malnutrition, and its
effects on an individual’s health status
•identification
of
patterns
of
overconsumption, and their link with the
development of obesity, diabetes,
hypertension cardiovascular disease, and
cancer
•identification of nutritional parameters
for optimal health and fitness
For being well nourished individuals should have
3-5 meals a day (every 4-6 hours except for the
night time when the break should be 12 hours
long) of caloric value adjusted to individual needs
(depending on sex, age, health status) with right
proportion of
proteins (9-13%),
fats (29-33%)
and carbohydrates (57-61% of caloric value).
Malnutrition
 Malnutrition is basically
defined as a lack of
essential nutrients at the
cellular level resulting
from psychological,
personal, social,
educational, economic,
cultural, or political
factors in the individual’s
environment.
Malnutrition may exist in the
form of
 primary deficiency, which occurs when a
specific essential nutrient is lacking in the
diet.
 secondary deficiency disease due to the
body’s inability to digest, absorb,
metabolize, or use a specific nutrient
properly or because the body has an
increased requirement for or increased
excretion of a specific nutrient.
Malnutrition
 acute, a result of temporary conditions and
reversible without long-term side effects
 chronic, existing over a long period with
possible irreversible consequences.
Malnutrition can be classified as
follows
 Marasmus- protein calorie malnutrition,
evidenced by a client who exhibits weight
loss, fat loss, and muscle wasting due to
overall calorie-protein deprivation.
 Kwashiorkor-protein
malnutrition,
evidenced by a client who has adequate fat
reserves but, on testing, reveals significant
deficits in protein status.
 Kwashiorkor-marasmus mix.
Components of nutritional
assesment are:
 antropometric measurement (height, weight,
BMI,WHR, skinfold thickness, circumference of
head, chest, mid-arm),
 biochemical measurement (total lymphocyte
count, serum albumin, total iron binding capacity,
creatinine height index, nitrogen balance,
haemoglobin and hematocrit, serum glucose),
 clinical examination
 dietary analysis (estimated calorie and protein
needs).
BMI (body mass index)
 BMI ( body mass index) is calculated
according to the following formula
 BMI= weight in kilograms/ (height in
meters)2
 In developed countries recommended BMI for
healthy adult individuals is 20-25kg/m2.
 For developing countries it is 18,5 kg/m2.
 If BMI is > than the recommended it is defined
as overweight and obesity
 1degree obesity (overweight) BMI=25-30 kg/m2.
 2 degree obesity BMI=30-40 kg/m2.
 3 degree obesity BMI>40 kg/m2.
WHR (waist to hip ratio)
 WHR (waist to hip ratio) is calculated according
to the formula:
 WHR=waist
circumference/
hip
circumference
Apple-shape obesity
 WHR in women >0,8
and in men >1 (in
obese individuals)
shows the male type of
obesity (typical for
males, apple-like
shape).
Pear-shape obesity
 WHR in women <0,8
and in men <1 (in
obese patients) shows
the female (feminine,
pear) obesity.
Possible incorrect
supplementation of particular
nutrients:
Excessive supply of animal protein- it
provides 2-3 times more methionine amino
acid than needed, if insufficient supply of
vitamins B2, B6, B12, and folic acid coexist
it leads to elevated levels of homocystein in
the
blood
serum
thus
causing
arteriosclerosis.
Excessive supply of mono-and dicarbohydratesit leads to weight gain. With lack of proper
regulatory hormones (insulin, adrenaline) it may
lead to diabetes, hypo- or hyperglycaemia.
Overconsumption of sucrose may cause vitamin
B1,B2, B6 deficiency, whilst these vitamins are
needed for its’ metabolism. Simple sugars age
good fuel for bacteria on tooth enamel, thus
encourage development of caries. They irritate the
mucous membrane of digestive tract and cause
excessive excretion of gastric juice.
Excessive supply of fats- especially of cholesterol
and saturated fatty acids-together with low dietary
fibre consumption it causes elevated levels of LDL
in the blood serum ( lipoproteins of low density),
what is detrimental to the blood vessels.
Saturated fatty acids elevate blood pressure,
increase platelet aggregation, elevate factor VII
level( causing clots). In smokers it quickly leads to
formation of plaques in the arteries.
 Polyunsaturated fatty acids ώ-6 and ώ-3 lower
the blood pressure.
 ώ-6 polyunsaturated fatty acids lower
cholesterol levels in the blood serum and in LDLs, they decreases the aggregation ability of
platelets and decreases tromboxane synthesis.
 ώ-3 polyunsaturated fatty acids lower VLDL
level in the blood serum , but impair resistance to
infections, glucose tolerance, may cause poor
clotting ability of the blood and bleeding.
 Monounsaturated fatty acids (e. g. linoleicpresent in olive oil, rape oil)-lower cholesterol
content in LDLs. They should be 10-15 % of total
calorie supply.
 Overuse of fats causes bile acids excretion; their
metabolites are cracinogenic. Fats increase
microsomal oxydation in enterocytes, what
encourages
growth
of Clostridium and
Enterobacter bacteria in the intestine. The bacteria
cause excessive production of steroid sex
hormones precursors out of cholesterol (e.g.
excessive prolactine excretion, the hormone
induces breast cancer).
Excessive supply of salt
 causes hypertention, gastritis atrophicans,
and stomach cancer. The recommended salt
consumption is 3g/day.
Insufficient supply of dietary
fibre
 causes constipation, colon cancer,
obesity, cholecystolithiasis (bile stones),
atheromatosis.
Insufficient supply of calcium
 causes bone demineralization, osteoporosis,
colon
cancer,
angina
pectoris.
Recommended daily consumption of
calcium is
1500mg/day. Wrong Ca/P
proportion in meals may handicap Ca
absorption. Recommended Ca/P ratio
should be 2:1 in children and 1:1 in adults.
Insufficient supply of iodine
iodine is necessary for thyroid hormones
production ( T3, T4) . The recommended daily
consumption of J is 200mg in pregnant women,
90-120mg in newborn children and toddlers,
young children 50-100mg, teenagers 100-150mg,
healthy adults 150mg/day. Kitchen salt is enriched
in J, other good sources of this element are: garlic,
onion, strawberry, seafood. Lack of iodine causes
goitre, hypothyroidism, cretinism in children.
Insufficient supply of iron
the recommended daily consumption is 8mg/100kcal.
Insufficient iron supply affects usually
1. teenage girls who start menstruating,
2. young women (as they loose iron during menstruation),
3. elderly people (due to poor absorption, digestive tract
diseases, interactions with medicines)
4. intestinal parasites (tapeworms) may ‘steal’ iron which
leads to anemia and koilonychia (spoon-shaped nails)
As a result of iron deficiency microcytic anaemia ( with too
mall erythrocytes) develops (clinical symptom-fatigue).
Calorie
 A unit of energy obtained from food. The calorie
is a measure of heat energy. One calorie is the
amount of heat needed to raise the temperature of
1g of water by 1◦C.
 The common unit of energy measurement in food
is the Calorie, with a capital C, which is
1000calories (small c) or 1 kilocalorie (kcal). The
International System of Units of heat energy uses
the Joule (J) instead of the Calorie as the
measurement for the energy content of food. The
Joule equals roughly 250calories or 0,25Calories.
Classification of carbohydrates
The term carbohydrate comes from its
chemical nature. It is composed of the
elements carbon, hydrogen and oxygen.
They are classified according to the
number of basic sugar units making up
their structure.
Monosaccharides
 Glucose
 Fructose
 Galactose
Disaccharides
 Sucrose
 Lactose
 Maltose
Polysaccharides
 Starch
 Glycogen
 Dextrins
Oligosaccharides
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Dietary fiber
Cellulose
Noncellulose polysaccharides
Lignin
 Fructose is the sweetest of simple sugars. It
is found in fruits and other substances, such
as honey, high-fructose corn syrup. In
human metabolism , fructose is converted to
glucose and burned for energy.
 Galactose is not found free in foods but is
produced in human digestion from lactose
(milk sugar) and is then changed to glucose
for energy. This reaction is reversible and
during lactation glucose may be
reconverted to galactose for use in milk
production.
Disaccharides
The disaccharides are double sugars
composed of two monosaccharides linked
together.
Sucrose = glucose + fructose
Lactose = glucose + galactose
Maltose = glucose + glucose
 Sucrose is the common ‘table sugar’ made
commercially from sugar cane and beets . It is the
most prevalent disaccharide . It contributes some
30% to 40% of the total kilocalories in the
American diet.
 Lactose is the sugar in the milk. It is the least
sweet of the disaccharides. When milk sours, as in
the initial stages of cheese making, the lactose
changes its form and separates out the liquid
whey from the solid curd. The curd is then
processed for cheese. Thus cheese has very little
sugars or none.
 Maltose occurs in commercial malt products of
starch breakdown and in germinating cereal
grains.
Polysaccharides
are made up of many single sugar
(saccharide) units. The most important
polysaccharide in human diet is starch.
other forms are glycogen and dextrins. The
nondigestable forms of dietary fiber,
cellulose
and
other
noncelluose
polysaccharides, provide important bulk in
the diet.
 Starch is the most significant poysaccharide.It is a
large complex compound made up of many coiled
or branching chains of simple sugar (glucose)
units. It yields only glucose on digestion. It is the
most important source of dietary carbohydrate
worldwide.
 Glycogen-the
animal
storage
compound
comparable to starch in plants is glycogen. It is
formed during cell metabolism and stored in
relatively small amounts in the liver and muscle
tissues.
Physiological effect of dietary
fiber
 water absorption (laxative effect)
 binding effect (influence blood lipid levels)
 colon bacteria effect (fermentation
substrates for bacterial action).
Functions of carbohydrates
 Energy source. The daily dietary supply of
carbohydrates should be sufficient to provide 5055% of the total kilocalories. Carbohydrate foods
must be eaten regularly and at moderate frequent
intervals to meet the constant energy demands of
the body.
 Glycogen reserves. The liver and muscle glycogen
reserves provide a constant interchange with the
body’s overall energy balance system. Thus these
reserves protect cells from depressed metabolic
function and injury.
 Protein-sparing action.
 Antiketogenic effect.
 Heart and Central Nervous System function. Fatty acids
are the preferred regular fuel for the heart muscle, the
glycogen reserve in cardiac muscle is an important
emergency source of energy. In a damaged heart, poor
glycogen stores or low carbohydrate intake may cause
cardiac symptoms and angina. A constant supply of
carbohydrate is necessary for the proper functioning of the
central nervous system. The brain contains no stored
supply of glucose and is therefore especially dependent on
constant supply of glucose from the blood. Profound
hypoglycemic shock may cause irreversible brain damage
Foods rich in carbohydrates
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bread
cereals
pasta
rice
bananas
potatoes
Lipids
Lipids are organic compounds soluble in
chloroform, ether and other organic solvents
but usually insoluble in water. They are
esters of glycerol and fatty acids.
Lipids
 Saturated (animal)
 Unsaturated (vegetable)
Foods rich in lipids are:
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egg yolk
butter
margarine
vegetable oil
fatty meat
fried foods contain 10-40% of fat (as they
soak)
Protein
 The protein molecule is a complex structure
made up of one or more chains of amino
acids, which are linked by peptide bonds.
Proteins are essential constituents of the
body; they form the structural material
of mussles, tissues, organs and are equally
important as regulators of function as
enzymes and hormones. Proteins are
synthesized in the body from amino acids.
Classification of amino acids
 There is a group of essential amino acids
(histidine, isoleucine, leucine, lysine, methionine,
phyenylalanine, threonine, tryptophan, valine)they are the only ones we cannot make.
 The remaining amino acids, which we can
syntesize are nonessential amino acids (alanine,
aspargine, aspartic acid, cystine, glutamic acid,
glutamine, glycine, hydrxylysine, hydroxyproline,
proline, serine, tyrosine)
Major minerals
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calcium
phosphorus
magnesium
sodium
potassium
chloride
sulfur
Trace elements
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iron
iodine
zinc
copper
manganese
chromium
cobalt
selenium
molybdenum
fluoride
 Iron deficiency-microcytic anaemia,
 Iodine deficiency- goitre, hypothyroidism,
cretinism
 Fluoride deficiency-dental caries
 Calcium deficiency-rickets, osteomalatia,
osteoporosis
Vitamins
Water-soluble
 vitamin C
 the B vitamins
(thiamin-B1,
riboflavin-B2, niacin,
folate, biotin,
pyridoxine-B6,
cobalamin-B12,
pantothenic acid)
Fat-soluble
 vitamin A
 vitamin D
 vitamin E
 vitamin K
Vitamin A
 (retinol) ia a fat-soluble vitamin that occurs preformed in
foods of animal origin (especially milk products, egg yolk
and liver) and is formed in the body from the pigment betacarotene, present in cabbage, lettuce, and carrots. Retinol
is essential for growth, vision in dim light, and the
maintenance of soft mucous tissue. A deficiency causes
stunted growth, night blindness, xerophthalmia,
keratomalacia, and eventually blindness. The RDI is
750 microgram retinol equivalents for an adult ( 1
microgram ret inolequivalent=1microggam retinol or 6
microgram beta-carotene)
Vitamin B1
 (thiamine, aneurine) is a vitamin of the B
complex that is active in he form of
thiamine pyrophosphate, a coenzyme in
decarboxylation reaction in carbohydrate
metabolism. A deficiency of vitamin B1
leads to beriberi. Good sources of the
vitamin are cereals, beans, meat, potatoes,
and nuts. The RDI is 1 mg for an adult.
Vitamin B2
 (riboflavin) is a constituent of the
coenzymes FAD ( flavine adenine
dinucleotide) and FMN (flavine
mononucleotide). Riboflavin is therefore
important in tissue respiration. A deficiency
of riboflavin causes ariboflavinosis. Good
sources of riboflavin are liver, milk, and
eggs. The RDI for an adult is 1.3-1.6mg.
Vitamin B6
 (pyridoxine) from this vitamin is formed the
coenzyme pyridoxal phosphate, involved in
in the transamination of amino acids. The
vitamin is found in most foods and
deficiency is therefore rare.
Vitamin B12
 (cyanocobalamin) ia s vitamin of the B complex. The form
of vitamin B12 with coenzyme activity is 5deoxyadenosylcobalamin, which is necessary for the
synthesis of nucleic acids, the maintenance of myelin in
the nervous system, and the proper functioning of folate,
another B vitamin. The vitamin can be absorbed only in the
presence of intrinsic factor, a protein secreted in the
stomach. A deficiency of vitamin B12 affects nearly all the
body tissues, particularly those containing rapidly dividing
cells. The most serious effects are: pernicious anemia and
degeneration of the nervous system. Good sources are
liver, fish and eggs. The RDI for an adult is 3-4
micrograms.
Vitamin C
 (ascorbic acid) is a water-soluble vitamin
with antioxidant properties that is essential
in maintaining healthy connective tissues
and the integrity of cell walls. It is
necessary for the synthesis of collagen. A
deficiency of vitamin C leads to scurvy.
The RDI is 30mg for an adult. Rich surces
of vitamin C are citrus fruits and vegetables.
Vitamin D
 Is a fat-soluble vitamin that enhances the
absorption of calcium and phosphorus from the
intestine and promotes their deposition in the
bone. It occurs in 2 forms: ergocalciferol
(Vitamin D2, calciferol) which is manufactured
by plants and cholecalciferol (vitamin D3)
which is produced by the action of sunlight on
the skin. A deficiency of vitamin D, either
from poor diet or lack of sunlight leads to
decalcified bones and the development of
rickets and osteomalatia. Good sources of
vitamin D are liver and fish oils. The RDI is 10
micrograms for a child up to 5 years and 2.5
micrograms thereafter.Vitamin D overdose is
toxic.
Vitamin E
 It is a group of chemically related fat-soluble
compounds (tocopherols and tocotrienols) that
have antioxidant properties and are thought to
stabilize cell membranes by prevening oxidation
of their unsatuarated fatty acid components. The
most potent of these is alphatocoferol. Good
sources of vitamin E are vegetable oils, eggs,
butter and wholemeal cereals. Deficiency is
unlikely.
Vitamin K
 Is a fat-soluble vitamin occuring in two main
forms: phytomenadione (of plant origin) and
menaquinone (of animal origin). It is necessary for
the formation of prothrombin in the liver, which is
essential for blood clotting, and it also regulates
the synthesis of other clotting factors. A dietary
deficiency does not often occur as the vitamin is
synthesized by bacteria in the large intestine ; if
occurs- causes haemorrharge.
Folate
 (pteroylglutamic acid) is a B vitamin that is important in
the synthesis of nucleic acids.The metabolic role of folate
is interdependent with that of vitamin B12 and a deficiency
of one may lead to deficiency of the other. A deficiency of
folate results in megaloblastic anemia (with too big
erythrocytes). Good sources are liver, yeast extract and
green leafy vegetables. The suggested daily intake is 200
micrograms/day for an adult, which should be doubled
before conception and during the first three months of
pregnancy to prevent neural tube defects (spina bifida)
and other congenital malformation (cleft lip and cleft
palate) in the fetus.
Nicin (nicotinic acid)
 Is a B vitamin. Nicotinic acid is a derivative of
pyridine and is interchangeable with its amide,
nicotinamide. Both forms of the vitamin are
equally active. Nicotinamide is a component of the
coenzymes NAD and NADP. A deficiency of the
vitamin leads to pellagra (dermatitis). Good
sources of the vitamin are meat, yeast extracts, and
pulses. Nicotinic acid is used clinically as a lipidlowering drug. It reduces the level of triglycerides
and LDLs.
Deficiency of what micronutrient is likely to account for this rash following Roux-en-Y
gastric bypass?
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1. Copper
2. Thiamine
3. Vitamin B6
4. Vitamin C
5. Zinc
Answer
 Zinc
 A perioral erythematous desquamating rash
associated with excoriations and honey-colored
crusting is visible. Evaluation of a biopsy and the
finding of a low zinc level were consistent with a
diagnosis of acquired acrodermatitis
enteropathica. The patient recovered after zinc
supplementation.