Nutrition assessment and counseling10/9/09
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| A= | A = anthropometric data (pages 401-405) Body measurements
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| B= | B = biochemical data (pages 411-425) Laboratory tests
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| C= | C = clinical data Signs and symptoms
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| D= | D = dietary data Typical (chronic) Acute if assessing effects of intervention
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| Infants and toddler Anthropometric head circumferance | Infants/toddlers Head circumference (page 404 for technique) Why only on birth-36 months chart? Why only helpful to about age 2?
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| Infants and toddler Anthropometric body length | Height/length When to use birth-36 versus 2-20 yrs for a 2-year old?
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| Plotting on CDC growth curves | Plotting on CDC growth charts Should follow approximately consistent growth pattern Deviate > 2 percentile curves a concern
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| Look at growth curves |
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| Anthropometric data for children/adolescents | Children/adolescents Height for age/gender Weight for age/gender Weight for height for age/gender BMI for age/gender Between 5th and 85th percentile Monitor growth pattern Consistent pattern Deviate > 2 percentile curves a concern
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| Adults anthropometric data | Adults Height/weight Percent desirable weight BMI Weight change Waist circumference (fat distribution) Body composition % fat Muscle mass Bone density
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| Hamwii formula | Hamwii formula Female: 100 pounds for first 5 feet (60 inches) + 5 pounds per inch over 5 feet Male: 106 pounds for first 5 feet (60 inches) + 6 pounds per inch over 5 feet
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| Metropolitan Life Insurance Tables | Metropolitan Life Insurance Tables (Miller method) Female: 119 pounds for first 5 feet (60 inches) + 3 pounds per inch over 5 feet Male: 135 pounds for first 5 feet (60 inches) + 3 pounds per inch over 5 feet
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| What do both Hamwii and Metropolitan Life Insurance Tables do? | *Note: to get range for either method, use plus or minus 10% of final answer. Absolute number depends on frame size.
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| Used to account for muscle mass in testing | body composition tests
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| Things to consider when using the desired weight formulas? | Height/weight tables Most developed using life insurance data (mortality) Potential bias (insured only, specific subgroups overrepresented) Data collection methods not always standard
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| Things to consider when using the desired weight formulas? (continued) | Methods to estimate frame size vary* Elbow breadth, height/wrist circumference Confounding variables not always effectively controlled Cigarette smoking affected ↑ in desirable weights from 1959 to 1983 Metro Life tables
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| *see frame size determination on page 1214 |
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| Evaluating weight status using desirable weight: Underweight | Underweight: < 90% of desirable weight
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| Normal Weight: | Normal weight: 90-120% of desirable weight
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| Overweight | Overweight: > 120% of desirable weight
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| Obese | Obese: > 130% of desirable weight
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| I should be 110 +/- 10lbs according to Hamwii |
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| Significant weight loss | Significant weight loss 5% loss in 1 month 7.5% loss in 3 months 10% loss in 6 months
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| Severe weight loss | Severe weight loss > 5% loss in 1 month > 7.5% loss in 3 months > 10% loss in 6 months
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| BMI for adults indicates what? | -risk of chronic disease when <18.5 and >24.9 -Correlated with percent body fat ↑ muscle mass not accounted for -Not as useful for athletes, ↑ lean mass High BMI not as likely to indicate risk of chronic disease or correlate with % body fat
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| Obese BMI Class III | Obese: Class III: ≥ 40.0
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| Obese BMI class II | Obese: Class II: 35.0 – 39.9
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| Obese Class I BMI | Obese: Class I: 30.0 – 34.9
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| Overweight BMI | Overweight: 25.0 – 29.9
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| Underweight BMI | Underweight: < 18.5 Normal weight: 18.5 – 24.9 Overweight: 25.0 – 29.9
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| Normal Weight | Normal weight: 18.5 – 24.9
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| Underweight | Underweight: < 18.5
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| Measurement methods Weight Hydrostatic weighing | Hydrostatic weighing Traditionally the “gold standard)
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| Measurement methods weight Skinfold | Skinfold measurement Why need at least 3 sites? people put on fat differently Why are more sites better? Why are recommended sites different for men and women?
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| Measurement methods Weight Electrical impedance | Electrical impedance-Electrical signals Why is height included in calculation?
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| Measurement methods Weight DXA | DXA Provides info on fat, lean, bone mass
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| Measurement methods Weight: Air displacement | Air displacement (i.e. BodPod) uses similar theory
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| Body Composition for Adults: Cutoffs and Age | Cutoffs increase with age Some ↑ in body fat normal with aging Small ↑ does not appear to ↑ risk for chronic disease But, can delay or reduce ↑in body fat via physical activity
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| Body Composition for Adults: Who has higher % body fat? Why? | Women can be higher % body fat without increased health risk Minimum % body fat higher for women Essential fat necessary for reproductive health Essential fat necessary for successful pregnancy
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| Body Composition for adults: | Type of fat/where deposited Physiological need for essential fat
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| What type of fat is correlated with risk of chronic disease | Visceral fat most closely associated with risk of chronic disease
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| What is WHR? | Waist/hip ratio (WHR) originally used to estimate visceral fat Waist circumference now used rather than waist/hip ratio Better correlation with abdominal visceral obesity. WHR poor predictor in women
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| *measurement of waist circumference described on page 403 |
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| Body fat distribution waist to hip daata | Waist Circumference Cutoff Values: Higher Risk of Chronic Disease Women: > 35 inches (88 cm) Men: > 40 inches ( 102 cm) Men naturally have larger waists so risk does not increase at the same cutoff value
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| Estimating Skeletal Muscle Reserves | Estimate bone-free arm muscle area (AMA) Need: Midarm Circumference + Triceps skinfold Formula on page 404, Figure 14-16 FYI, don’t memorize! Helps to evaluate possible protein-energy malnutrition
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| what is Kwashikor? | Kwashiorkor Primary deficiency is protein
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| Kwashikor-weight and muscle effects? | Some weight loss or decreased growth Some muscle wasting
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| Kwashikor and coloration of skin and hair | Changes color due to lack of melanin (a protein)
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| Kwashikor and Edema | Edema ↓ albumin and other serum proteins to produce colloid oncotic pressure
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| Kwashikor and fatty liver | Enlarged fatty liver
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| Kwashikor and Protein carriers | Protein carriers to transport fat out of liver ↓
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| Kwashikor and hair | Dry and brittle hair, easily plucked
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| Kwashikor and skin | Skin may develop lesions; patchy and scaly
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| Kwashikor and protein deficiency | Healing compromised due to protein deficiency
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| maramus describe | Marasmus Protein and energy deficiency (↓ overall intake)
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| Maramus cont. | Severe weight loss or decreased growth Severe muscle wasting No detectable edema Liver not fatty or enlarged Skin dry, thin Hair sparse, thin, easily plucked Protein deficiency Multiple micronutrient deficiencies
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| Static Nutrient or metabolite in blood, urine or body tissue Not always helpful due to homeostatic regulation Functional Body process dependent on specific nutrients Example: dark adaptation with Vitamin A Often not specific
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| Used for assessing chronic protein status ½ life = 18-20 days Specificity fairly low
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| Protein status and transferrin | Serum transferrin ½ life = 8-9 days Affected by iron status (↑ with depleted iron stores) Specificity fairly low
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| Protein status Serum prealbumin | Serum prealbumin (transthyretin) Used for monitoring treatment effects ½ life = 2-3 days May be ↓ by renal insufficiency (protein-wasting) ↓ by zinc deficiency (Zn required for synthesis and secretion by liver)
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| Protein status Serum retinol-binding protein | Protein status Serum retinol-binding protein ½ life = 12 hours Affected by vitamin A status (↓ in vitamin A deficiency) Elevated in renal failure (apo-RBP not catabolized by kidneys)
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| Protein status-serum proteins consideration | When using serum proteins to assess protein status May be maintained even with protein-energy malnutrition May be decreased by acute inflammation even with adequate protein status
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| Protein status-serum proteins consideration cont | Retinol-binding protein least affected Can use markers of inflammation to assess likelihood of inflammation effect on serum proteins
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| Inflammatory biomarker Can help to determine when hypermetabolic phase of acute inflammation diminishes Serum proteins then more indicative of protein status Especially important if using albumin or pre-albumin
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| Iron status and serum Useful? | Iron status Serum iron not useful due to daily and diurnal variation Serum ferritin level (storage protein for iron in liver) Decreases in first stage of iron deficiency May increase with inflammation
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| Transferrin saturation involvement in iron status | (transport protein for iron) Decreases in second stage of iron deficiency
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| Erythrocyte protoporphyrin and iron status relationship | (pre-RBC made in kidney) Increases in second stage of iron deficiency
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| Hemocrit and iron status | Hematocrit (% red blood cells in total blood volume) Decreases in third/fourth stage (anemia) of iron deficiency
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| TIBC is what? | (total iron-binding capacity = available binding sites on transport protein)
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| Hemoglobin and iron status | Hemoglobin (O2-carrying protein in peripheral blood)Decreases in third/fourth stage (anemia) of iron deficiency
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| Micronutrients assessments | Micronutrients Serum levels sometimes helpful Homeostatic control problematic Tissue levels sometimes helpful Depends on where nutrient may be deposited Functional tests sometimes helpful May not be specific; sometimes difficult to measure
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| Hair content and micronutrient assessment | What about hair content? Long-term or chronic intake Contamination a problem Not all minerals appreciably deposited in hair May be useful for trace minerals Analysis not yet standardized with “normal” values
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| Micronutrient Status Assessment Vitamin B12/ Folate: define | RBC or serum folate Serum B12 Homocysteine level (elevated with deficiency of either one) Schilling test for B12 absorption (page 424)
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| Micronutrient Status Assessment Vitamin B12/ Folate: What type of test is it? | Functional test-but which one?
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| Micronutrient Status Assessment Vitamin B6 | Vitamin B6 Serum pyridoxal phosphate (PLP) concentration
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| Micronutrient Status Assessment Vitamin D | -Plasma 25-hydroxyvitamin D (25-OH-D3) -Lowest threshold value to prevent secondary hyperparathyroidism, increased bone turnover, bone mineral loss, seasonal variation in parathyroid hormone
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| What would the first test for Vitamin A be? | Vitamin A Plasma retinol (active vitamin A) if stores depleted or toxicity
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| Other vitamin A tests? | Liver stores measured via relative dose response Dark adaptation measurement for night blindness Histological assessment of the eye Conjunctival impression cytology (CIC) Examine conjunctiva for changes associated with vitamin A deficiency
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| the two Vitamin C level tests | Vitamin C Plasma and serum ascorbic acid concentrations for recent intake White blood cell ascorbic acid for assessment of body stores
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| Calcium assessment | Calcium No routine biochemical method available Serum level not useful due to homeostatic control Bone mineral content used most often CT, DXA
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| Magnesium tests | Magnesium Serum magnesium routinely assessed
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| Problems with Magnesium test? | Problems with this: Only 1% of body magnesium in blood Appears to be homeostatically controlled Low sensitivity and specificity RBC and peripheral lymphocyte Mg may be better indicators of long-term status
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| zinc tests? | Serum or plasma zinc level used most often Decreases only in severe deficiency, indicating loss from liver and bone Not specific (influenced by stress, infection, diurnal variation, etc.)
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| Problems with zinc test? | Homeostatic control makes assessment difficult
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| What tests are not useful for zinc levels? | Zn-dependent enzyme are not good indicators Urinary and hair zinc not valid indicators
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| Why is hair and urinary not good zinc indicators? | Urinary excretion remains constant over wide range of intakes and decreases only with severe deficiency Low hair Zn may be associated with chronic suboptimal intake but concentration depends on delivery to root and rate of hair growth
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| Why should physicians talk to patients about nutrition? | -8 of 10 leading causes of death related to nutrition -Access to patients -Patients listen to/respect physicians -Physicians (should) know their patients -Physical status -Emotional status -Lifestyle habits
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| What does physician talking to patients about nutrition? | Increase likelihood of patients to lose weight
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| Why do physicians not talk to patients about nutrition status? | Time Training Counseling expertise Personal health behaviors Personal health status Money (reimbursement)
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| How to tell patient to change nutrition | Discuss rationale for behavior change -Assess current behavior -Behavior Readiness to change -Past efforts Knowledge of risks related to current behavior -Reasons for changing or maintaining current behaviors
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| Why should you Provide strong, clear message about what behaviors need to be changed | -Include rationale/reasons for suggested changes -Set clear goals for behavior change Involve patient -Express empathy about difficulty of behavior change -Discuss potential barriers to behavior change
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| Why and how should you refer patient to dietitian or qualified nutrition counselor when appropriate | -Interested patient -Complicated behavior changes necessary -Often covered by insurance
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| Follow Up-why is this important with respect to nutrition counseling | -Discuss progress at next office visit -Schedule appointment specifically for follow up -Check in via telephone
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| Give some nutrition/lifestyle resources | -MyPyramid online -Dietary Guidelines Consumer Brochure -CDC Consumer Information -State and local health departments -Major Associations provide patient information Drug companies
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| How does physician's personal health reflect on nutrition counselling | Unhealthy drs don't give as much nutritional counselling
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| Important things to consider when giving nutrition counselling. | Anything is better than nothing at all Acknowledging the problem is key The more specific, the better (obesity article) The more tailored, the better “watch your diet” doesn’t work “diet sheet” alone not very effective for most patients
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