Nutritional Assessment

Cape Town Sept-Oct 2015

GOES

Nutritional Screening and Assessment

• Nutritional assessment

– Detailed examination of metabolic, nutritional or functional variables by an expert dietician

• Nutritional screening

– Rapid and simple process conducted by admitting staff or community health care teams-defining patients who are at risk or not at risk of malnutrition

Nutritional Assessment, Definition

•A detailed examination of metabolic, nutritional or functional variables by an expert clinician, dietitian or nutrition nurse”

• Kondrup J, et al. ESPEN Guidelines for nutrition screening. Clin Nutr 2003;22:415-21

• Nutrition assessment must be an integral part of the medical evaluation of hospitalized children

• Nutritional status should be monitored regularly in children

Under 5 undernurished and stunted children

Lancet 2013

Under 5 undernurished and stunted children

The 20 countries with the highest burden of undernutrition

• stunting prevalence ≥20% in children under the age of 5

Trends in prevalence and numbers of children with stunted growth

Trends in prevalence and numbers of overweight (WHZ >2) children

Previous one as a detailed graph

Maternal & child malnutrition

Short term-consequences

Growth impairmentMortalitiyMorbidity Disability

Black RE, et al. Lancet 2008

Previous one as a detailed graph

Long term-consequences

Adult sizeIQ

Economic productivityMetabolic and CVD

Black RE, et al. Lancet 2008

Maternal & child malnutrition

Prevalence of undernutrition in hospitalized children

Merrit et al., Am J Clin Nutr 1979; Parsons, Am J Clin Nutr ; 1980;Hendricks et al.;Dogan et al., Turk J Gastroenterol, 2005; Mareletti et al., Arch Pediatr 2005;Joosten et al. Curr Opin Pediatr 2008.

6-50%

Factors that affect nutritional status in hospitalized children

Presence of malnutrition

Presence of a chronic disease

Acute medical condition:

Infection

Trauma

Surgery

Diagnostic tests

Procedures

Medications

Hospital environment

Adverse effects of undernutrition -hospitalized patients

Increased infectious complications

Delayed recovery

Increased length of stay (Increased costs)

Increased readmision

Increased mortality

BMI <2 to 3 SDS and a BMI <3 SDS was associated with a 1.3 (1.01, 1.55)and 1.6 (1.27, 2.10) days longer LOS

BMI <2 SDS was also associated to more frequent occurrence of diarrhea (22%vs 12%)and vomiting (26% vs 14%)

Can’t we just look and diagnose?

Measured the ability of 3 experienced childcare professionals to grade the nutritional status of patients of varying ages and nutritional status.

All subjects (n=44) were in hospital for at least 3 days to enable complete assessment, and were unknown to the panel of assessors.

Cross JH, et al. Arch Dis Child 1995; 72: 60-1

Children were grouped (according to MUAC

measurement) to one of 4 categories: A - severe malnutrition

B - mild malnutrition

C – normal

D - obese

Cross JH, et al. Arch Dis Child 1995; 72: 60-1

Can’t we just look and diagnose?

Percent of correct observations of nutritional status by clinical assessors

classed according to age group

0-12 months

1-5 years 5-16 years

Total correct observation

10% 55% 60%

Unanimously correct

10% 47% 44%

Cross JH, et al. Arch Dis Child 1995; 72: 60-1

Nutritional assessment goals

• Confirm normal growth and development

• Establish nutritional status

• Evaluate the risk of under nutrition/ overweight

• Provide guidelines for nutrition therapy

• Monitor the impact of nutrition therapy

Components of Nutritional Assessment

• Medical history

• Physical examination

• Anthropometric measurements

• Dietary intake and energy requirements

• Body composition

• Biological parameters

Food Intake Assessment

Causes

Inadequate

intake

Lack of food (poverty), Incorrect food preparation,

Abnormalities of sucking, swallowing and deglutition, Lack

of appetite (anorexia)

Increased loses Vomiting, Diarrhea

Increased

metabolic

demands

Infection, Inflammation, Cardiac disorders

Alteration of the

nutrients’

metabolism

Drugs, Hormonal abnormalities

Particular food

habits

Vegetarians, Vegans

Medical and Diet History

Diet history

Appetite, composition of typical meals, food preference and aversion, food allergy and intolerance

Dietary assessment

Dietary records

24-h recalls

Food-frequency questionnaire

Intake observations

Anthropometric Measurements

Assessment of weight changes: Calibrated scales

Assessment of linear growth:Length (<2y), height (>2y)

Assess parents and siblings

Anthropometric Measurements

Traditional tools (edema etc. ):MAC TSF

Body composition DEXA BIA Air plathysmography

Anthropometric Measurements

• At four sites –• Triceps skinfold

• Biceps skin fold

• Subscapular skinfold

• Supra-iliacal skin fold

• Measured by caliper usually 3 times

• On left side

• The skin fold thickness is an index of body fat

Skinfold thickness

Anthropometric measurements

• Measured at the midpoint of the upper arm on the left side with arm relaxed and bent for 90º

• Standards are age and gender dependent

• Indicative of muscle mass and subcutaneous fat

• Changes are relatively easy to detect

Mid upper arm circumference

Anthropometric measurements

Growth AssessmentWHO Anthro software

1 year 2 years 3 years 4 years 5 years

WHO Growth Standards2006

Mean length from birth to 24 months for the six MGRS sites

Age (days)

Mean

of L

eng

th(c

m)

0 200 400 600

50

60

70

80

BrazilGhanaIndiaNorwayOmanUSA

WHO Child Growth Standards

Weight-for-ageLength/height-for-ageWeight-for-length/heightBody mass index-for-ageMid-upper arm circumference-for-ageTriceps skinfold-for-ageSubscapular skinfold-for-ageHead circumference-for-age

Growth velocity

WeightLength/heightHead circumference•Arm circumference•Body mass index

WHO Child Growth Standards

Reference charts vs Growth standards

• Reference charts: Describe growth of representative children living in a defined geographical area (CDC) for healthy children or specific medical conditions (CP, Down, Turner, premature)

• Growth Standards: Describe growth of highly selected children’ population, aim to be representative of population of country or region (WHO 2006 chart growth standards)

Reference charts Healthy children (CDC, UK)

Specific medical conditions

Cerebral Palsy

Down syndrome

Turner syndrome

Premature infants

Evaluation of measurements Percentiles

the value of variable in accordance with population distribution

Percentage of the median

(observed/median value of population) x 100

Z score

number of SD’s from the median (50th centile)

Detects movement toward or away from the median and is more sensitive then centile changes

Percentiles 3

50

97

Standard Deviation

-4

-2

0

Evaluation of measurements

Definitions and Criteria

MildMalnutrition

Moderate Malnutrition Severe Malnutrition

Gomez 75-90%Standard WT

60-74% standard WT <60% standard WT

Tanner <5th percentile WT for HT

Waterlow 80-90% weight for height

70-80% WT for HT <70% WT for HT

WHO <-2 to -3 SDS WT for HT <-3 SDS WT for HT

Olsen BMI, Weight and length for age <5th percentile. Wt deceleration crossing more than 2 major % lines

Physical Examination

• Loss of fatty tissue and muscle strength

• Signs of malnutrition or micronutrient deficiency

• Thorough exam of skin, hair, nails, oral cavity, teeth and skelet

Physical Examination

Manifestations Possible etiologyGeneral Underweight, overweight,

edema

Short stature

Apathy, irritability

Caloric/ protein malnutrition

Caloric excess

Skin and mucous

membranes

Pallor, dryness, dermatitis,

petechiae

Delayed wound heeling

Iron, zinc,

Thiamin, ascorbic acid,

EFA deficiency

Subcutaneous

tissue

Decreased/ increased/ edema Caloric deficit/ excess

Protein malnutrition

Muscle tissue Wasting and pain Caloric/ protein malnutrition

Thiamin deficiency

Skeleton Craniotabes, parietal and frontal

bossing, epiphyseal

enlargement, pigeon chest,

beading of ribs

Calcium

Vitamin D deficiency

Physical Examination

Manifestations Possible etiologyHair and nails Alopecia, thin or sparse,

depigmented

Friable, koilonychia

Zinc, iron

Biotin, vitamin A, K, niacin

EFA

Lips and gums Cheilitis, stomatitis, gingivitis,

bleeding

B vitamins, ascorbic acid

Teeth and tongue Caries, abnormal enamel

Smooth, red/pale, painful

Deficiency/ excess fluoride

Niacin, riboflavin, B12

Eyes Dryness, keratomalacia

Circumcorneal injection

Retinitis pigmentosa

Photophobia

Vitamin A

Riboflavin

Vitamin E

Zinc

Nutritional Deficiencies

Manifestations Possible etiology

Gastrointestinal Diarrhea

Hepatomegaly (fatty liver)

Zinc

Caloric/protein malnutrition

Cardiovascular Cardiomyopathy

Arrhythmia

Selenium, thiamine

Potasium, calcium, phosphor

Endocrine Hypothyroidism, goiter

Glucose intolerance

Hypogonadism

Iodine

Chromium

Caloric/protein malnutrition

Neurologic Peripheral neuropathy

Motor peripheral neuropathy

Vibratory peripheral neuropathy

Sensory peripheral neuropathy

Ataxia

Psychomotor change, confusion

Thiamine, pyridoxine

Thiamin, B12

Thiamin, B12

Thiamin

Vitamin E

Caloric/protein malnutrition

Others Altered taste

Parotid enlargement

Zinc

Caloric/protein malnutrition

Vitamins Deficiency ExcessVitamin A (retinol) Night blindness, xerophtalmai

Folicular keratosis, poor growth

Hepatomegaly, alopecia

Headache, high ICP

Vitamin D (cholecalciferol) Rickets, osteomalacia Hypercalcemia

Vitamin E (tocopherol) Hemolytic anemia Altered hematopoesis

Vitamin K (menaquinone) Bleeding, bruising Hemolytic anemia

Vitamin B1 (thiamine) Beriberi, ataxia, neuritis, cardiomyopathy None known

Vitamin B2 (riboflavin) Cheilosis, glossitis, seborrhea None known

Vitamin B6 (pyridoxine) Seizures, anemia, hyperirritabilitty Neuropathy

Pantotenic acid Infertility, growth delay, vomiting Diarrhea

Niacin Pellagra (dermatitis, dementia, diarrhea) Vasomotor instability,

flushing

Folate Megaloblastic anemia, stomatitis, glossitis, NTD in

pregnancy

None known

Vitamin B12 (cobalamine) Megaloblastic anemia, neurologic deterioration,

MMA

None known

Biotin Dermatitis, vomiting, anorexia, hair loss None known

Vitamin C (ascorbic acid) Scurvy (purpura, petechiae, periodontal gingivitis),

joint tenderness

? "rebound deficiency"

symptoms with chronic high

intake

erum proteins

Plasma protein

Pool size and half-life

Plasma level Factors of variation

Albumin Large pool sizeHalf life: 15-20 days

36-45 g/l Protein-energy malnutritionLiver failureProtein-losing enteropathyProtracted infectious state

Thyroxin-binding pre-albumin

Small pool sizeHalf life: 2-3 days

0,32-0,35 g/l Protein-energy malnutritionLiver diseaseHyperthyroidismInflammatory disease

Goulet. Baillieres Clin Gastroenterol.1998.

Biochemical parameters

erum proteinsPlasma protein

Pool size and half-life

Plasma level Factors of variation

Retinol-binding protein

Small pool sizeHalf life: 12 hours

60+/- mg/l Protein-energy malnutritionInflammatory diseaseVitamin A, zinc deficiencyLiver disease (hepatitis, cirrhosis, cancer)Glomerulonephritis and renal tubular defect increase level

Transferin Large pool sizeHalf life: 8 days

2-4 g/l (age dependent)

GlomerulopathyProtein-losing enteropathyLiver failureProtein-energy malnutritionInflammatory diseaseIron deficiency

Biochemical parameters

Goulet. Baillieres Clin Gastroenterol.1998.

Specific nutrients (as indicated by history and examination)

Immune function

Total lymphocyte count

Delayed cutaneous hypersensitivity

Protein metabolism

Nitrogen balance

Protein turn over studies

Urinary elimination of muscle metabolytes

creatinine and 3-methyl histidine (24 hours, correlates with FFM)

Creatinine-height index (adults)

Biochemical parameters

Sexual maturation (Tanner scale)

Measured in:

Stunted growth

Pubertal delay

Pubertal advance

X-ray of left wrist

Skeletal maturation

Body composition measurements

• Used to determine

• bone mineral content

• Lean tissue mass

• FBM

Dual-energy X-ray absorptiometry (DXA)

Body composition measurements

• Based on conduction of a very week alternating current trough the body which is delivered via two electrodes placed on hand and opposite foot

• BIA is a method for measurement of body water which is used to calculate FFM

Bio-electrical impedance analysis (BIA)

Body composition measurements

• Densitometric technique

that uses air displacement

rather than water immersion

Air Platismography

Nutritional screening

• Rapid and simple process conducted by admitting staff or community health care teams-defining patients who are at risk or not at risk of malnutrition

Screening ToolsStudy Population Content/ Items Conclusions

Sermet-Gaudelus,et al.

296 children1m-?Medical /surgical

Food intake 910Pain (1)Medical condition (0-3)

Children at nutritional risk (high risk >2-3) had:-Weight loss> 2%-Food intake <50%

Secker, Jeejeebhoy, et al.(SGNA)

175 children1m-17.9ySurgical

Past weight lossParental heightFood intakeGI symptomsFunctional capacityPhysical examinationClinical diagnosis

Malnurished children had:-More infections-Longer LOS

McCarthy, et al.STAMP

ChildrenMedical /surgical

Clinical diagnosis Food intakeAnthropometry

72% sensitivity90% specificity comparedto full nutritional assessment

Geresimides, et al.PYMS

274 childrenMedical /surgical

BMI (0-2)Recent weight loss (0-2)Food intake (0-2)Medical condition (0-2)

Sensitivity (%) 59Specificity (%) 92PPV (%) 47NPV (%) 95

Hulst, et al.STRONGkids

424 children1m-17.7yAcademic/ general

Subjective assessment (1)High-risk disease (2)Food intake (1)Weight loss (1)

Children at risk (score 4-5) had:-Lower SD scores Wt/Ht-Longer LOS