Nutritional Assessment

Definition

The study of fundamental principles of normal nutrition as they relate to human life and growth from conception through senescence, interpretation of current nutrition information, and application of nutrition knowledge in the establishment of good eating habits in health and disease.

Course Objectives Upon completing this course, you will be able to:• 1. Identify fundamental concepts of nutrition and discuss the application of these

concepts in• promoting good health and preventing disease.• 2. Describe physical and chemical properties of nutrients and discuss how these

nutrients• function in the body.• 3. Identify important food sources of major nutrients.• 4. Trace the digestion, absorption, metabolism and excretion of major nutrients.• 5. Describe the interdependence of nutrients.• 6. Determine nutrients needs for pregnancy, lactation, infancy, childhood, adolescence,• adulthood and the aged.• 7. Evaluate dietary intakes using food composition tables and plan food intakes to meet

the• energy and nutrient needs.• 8. Identify reliable sources of nutrition information.• 9. Integrate the role of nutrients as they relate to nutritional status in health,

performance and• disease.• 10. Identify the need and techniques used for nutritional assessment and monitoring.

Dietary Assessment

A patient’s nutritional status can be evaluated by using and integrating information obtained from a past medical history, family history and a social history. It is worthwhile to assess the nutritional status of every patient. Many complaints such as fatigue, headaches, and digestive disturbances can be improved by simple changes in diet. Nutrition also plays a pivotal role in prevention. Nutritional assessment becomes especially important when the patient has certain nutritional "red flags", such as:

• Elderly • No regular exercise regime and/or sedentary lifestyle • Recent loss of 10% or more of usual body weight • Alcoholism • Taking drugs such as steroids, immunosuppressants • Infection, protracted fever, trauma • Malabsorption syndromes, draining abscesses, renal

dialysis • Receiving simple intravenous solutions without oral

intake for >10 days

Past Medical History

• Immunizations, hospitalizations, operations, major injuries, chronic illnesses, and significant acute illnesses

• Current or recent prescription medications, vitamins and minerals, laxatives, topical medications, OTC medications, and nutritional supplements

• Potential drug-nutrient interactions, such as those caused by potassium-wasting diuretics

• Food allergies or lactose intolerance

Family History

• Family history of cancer, diabetes, heart disease, hypertension, obesity, and osteoporosis

• Parents, siblings, children, spouse: include ages, current health status, and cause of death if deceased

Social History

• Occupation, daily exercise pattern, marital and family status

• Economic status, educational level, residence, emotional response to illness and coping skills

• Duration and frequency of use of substances, including tobacco, alcohol, illegal drugs, and caffeine

Assessing Your Patient’s Dietary Intake

24-hour Recall• An informal, qualitative method in which you ask the patient to

recall all of the foods and beverages that were consumed in the last 24 hours, including the quantities and methods of preparation.

• An advantage of this method is that dietary information is easily obtained. It is also good during a first encounter with a new patient in which there is no other nutritional data. Patients should be able to recall all that they have consumed in the last 24 hours.

• A disadvantage of this method is that it is very limited and may not represent an adequate food intake for the patient. Data achieved using this method may not represent the long-term dietary habits of the patient. Estimating food quantities and food ingredients may be difficult especially if the patient ate in restaurants.

Usual Intake/Diet History• This method asks the patient to recall a typical daily intake pattern,

including amount, frequencies and methods of preparation. This intake history should include all meals, beverages and snacks.

• Advantages of this method are that it evaluates long-term dietary habits and is quick and easy to do. Based on the information acquired, you may identify patients who would benefit from meeting with a registered dietitian.

• A disadvantage of this method is that a limited amount of information on the actual quantities of food and beverages is obtained. Also, this method only works if a patient can actually describe a "typical" daily intake, which is difficult for those who vary their food intake greatly. In these patients it is would be advisable to use the 24-hour recall method. Another disadvantage is that patients may not include foods that they know are unhealthy.

• An excellent method to better understand a patient’s nutritional status is to use a usual intake and lifestyle recall. This consists of asking the patient to run through a typical day in chronological order, describing all food consumption as well as activities. This method is very helpful because it may reveal other factors that can affect the patient’s nutritional and overall health. [For example: (1) the patient sits in traffic for a 3-hour round trip each day; (2) the patient comes home from work late and eat dinner just before bedtime; or (3) the most exercise the patient gets is walking to and from the parking lot at work.]

Food Frequency Questionnaire• This method makes use of a standardized written

checklist where patients check off the particular foods or type of foods they consume. It is used to determine trends in patients’ consumption of certain foods. The checklist puts together foods with similar nutrient content, and frequencies are listed to identify daily, weekly, or monthly consumption.

• An advantage of this method is that it makes it possible to identify inadequate intake of any food group, so that dietary and nutrient deficiencies may be identified. The questionnaire can be geared to a patient’s pre-existing medical conditions.

• Disadvantages include patient error in filling out the questionnaire and no way to find out how foods are prepared. Patients may over- or under-estimate food quantities.

Dietary Food Log • This method asks the patient to record all food, beverage and

snack consumption for a one- week period. Specific foods and quantities should be recorded. The data from the food log may later be entered into a computer program, which will analyze the nutrient components of the foods eaten according to specific name brands or food types. Patients are asked to enter data into the food log immediately after food is consumed so they do not forget.

• The most important advantage of this method is that a computer can objectively analyze data obtained. Data on calorie, fat, protein and carbohydrate consumption can be obtained. Also, since patients are asked to enter data immediately after eating, the data is more accurate than other methods.

• Disadvantages include patient error in entering accurate food quantities. In addition, it is possible that the week long food log does not accurately represent a patient’s normal eating habits since they know the foods they eat will be analyzed and therefore may eat healthier.

Generic Nutrition Questionnaire

• Would you describe you appetite as hearty, moderate, or poor?

• Are you on a special diet? Specify the type of diet. Who recommended the diet? If you have been on a special diet in the past, define it.

• Have you ever had any problems with weight? Underweight or overweight?

• Do you eat at approximately the same time every day? • Do you skip meals? If so, when? • Do you usually eat between meals? What do you snack

on most often? • Are there any foods you do not eat because you don’t

think they are good for you? If yes, what?

• Are there any foods you do eat regularly because you think they are good for you? If yes, what?

• Are there any foods you cannot eat? What happens when you eat this food?

• Are there foods you avoid because you don’t like them? • How is your food usually prepared, e.g. baked, broiled,

fried? • Are you on a diet now to lose or gain weight? If yes,

what kind? Who recommended it? • How do you feel about your weight? • Are you taking any vitamin or mineral supplements?

What and how often? • Do you smoke? How many cigarettes (cigars or chewing

tobacco) per day?

• Do you drink any alcohol? How much per day and when? • How often do you exercise? What types of exercise do

you do? • Who in the house plans the meals? Buys the food?

Prepares the food? • Are there times in the month when there isn’t enough

money for food or you run out of food? • How many of your meals are eaten at home? School?

Work? Restaurants? • How many hot meals do you eat per week? • What condiments do you use? Examples include butter

on bread, sugar on cereal, salad dressing, gravy, etc.

Assessment of Nutritional Statusfor Adults, Using Weight and Height

Take action when there is:

• Unintended weight loss of 6 to 7 Kg within a month (even without calculating BMI).

• Continued unintended weight loss for more than 2 months

• BMI below 18.5 • BMI 30 and above

• Do not use BMI for pregnant women

1. Measure weight:• Make sure the scale pointer is at zero beforetaking a measurement.• The person is required to dress in lightclothes and take off shoes. Women shouldremove scarf.• He/she must stand straight and unassistedon the centre of the balance platform.• The weight should be recorded to the nearest

0.1kg.

2. Measure height:

• The person is required to remove his/her shoes, stand erect, looking

straight in a horizontal plane with feet together and knees straight. The

heels, buttocks, shoulder blades and the back of the head should touch

against the wall.

3. Calculate Body Mass Index (BMI):

• Convert cm to meters ( 1 metre = 100 cm)

• Calculate BMI using this formula: BMI = Weight in kilograms

(Height in m)2

BMI references:

• <18.5 = Underweight

• 18.5-24.9 = Normal weight

• 25-29.9 = Overweight

• 30 and above=Obese

(Source: WHO, 1995)

Do large doses of vitamin C prevent the common cold?

There is little in well-designed, placebo-controlled, double-blind studies to support the claims that vitamin C prevents the common cold. Studies done with numerous individuals showed that vitamin C supplementation did NOT reduce the incidence of colds but the number of days with symptoms of a cold was slightly less. A 500 mg dose is no more effective than a much larger dose.

Will pantothenic acid restore my gray hair to its original color?

Only if you are a rat. A pantothenic acid deficiency in a rat produces gray hair, but gray hair in a human is not affected by this B vitamin.

Why don't people in Mexico develop pellagra since their diet is high in corn?

The staple, tortillas, are made from masa harina. Masa is corn meal that has been soaked in an alkaline solution. This alkali soaking permits the corn meal to be manipulated (with water) to form tortillas, but it also releases the niacin bound in corn.

Is a raw egg in orange juice a healthy breakfast drink? (Remember the movie

Rocky?)

NO, for two reasons. First uncooked egg white has a protein, avidin, which binds to biotin, a B vitamin. Large quantities of raw egg can produce a deficiency of this vitamin. Second, raw eggs may carry salmonella and E. coli bacteria that are known to cause food intoxication. So cook your eggs until the yolks are slightly firm

Is it best to give a one-year-old child skim milk rather than whole milk?

Absolutely not. Young children need fat and cholesterol for growth and brain development. The importance of fat for an infant is shown by the fat content of breast milk, which accounts for about HALF its calories.

Is honey a natural product that is useful for curing hiccups in infants?

No. Infants should never be given honey, as the botulism spores that it contains may cause botulism. Try a teaspoon of freshly made sugar syrup instead to stop hiccups.

Is tomato sauce a healthy food for men?

Yes, especially for men. High dietary intake of lycopene, the red pigment found in tomatoes, has been associated with a reduced incidence of prostate cancer

Can you can eat as many high fiber foods as you want because dietary fiber does not

contribute any calories to our diet?

No. We used to think this was true, but now we know that some forms of soluble fiber are partially broken by bacteria. It is estimated that 10-15% of the calories in our diet may be from fiber.

Should sugar be avoided in the diet because it causes hyperactivity, heart

disease, and obesity?

No. Sugar has been shown NOT to be related to any specific disease. The concern is that sugar provides calories without other nutrients (it has low nutrient density). Also sucrose is a food for bacteria on the teeth. So if you eat sugar, floss your teeth afterwards and make sure that it does not substitute for nutrient dense foods.

Is margarine better for you than butter?

It is best to use small quantities of both. Butter has saturated fats which raise cholesterol. But the trans fatty acids that are formed in margarine when it is hydrogenated raise the LDL (bad) cholesterol and lower the HDL (good) cholesterol.

Are olive and canola oils better for you than corn and soybean(vegetable) oils?

This is probably true. The omega-6 fatty acids from the latter increase the risks of developing certain cancers

Is a supply of 300 mg dietary cholesterol the only cholesterol that your body needs is?

No. Cholesterol is needed to make bile acids (to help digest food), sex hormones, adrenal hormones, and vitamin D. Your body makes about 800-1500 mg/day because it is so essential.

Is liver a terrific food that should be consumed at least once a week?

No, liver is high in cholesterol. In addition, it serves as a detoxifying organ for the body. It will store pesticides and heavy metals if they are ingested.

Is it o.k. to eat a lousy diet as long as you take a vitamin pill each day?

We wish this were true. Natural foods contain many substances which have not yet been identified. For example, 20 years ago we did not know about the importance of various phytochemicals in fruits and vegetables in the protection against cancer. The only way to really protect yourself is to eat a wide variety of nutritious foods.

Is zinc a critical nutrient for adolescent boys?

You better believe it. Zinc deficiency in young men in the Middle East was found to result in impaired sexual development and growth failure.

Can too many alcoholic drinks at one time can kill you?

Yes! Yes! Yes! Fortunately, most people will pass out before drinking a lethal dose (0.5% blood concentration or about 25 shots) but this is dependent on your body size, recent food intake, genetics, sex, age, and drinking habits. What may happen is that you asphyxiate on your vomit while you are passed out.