PSG PRODI GIZI CIREBON
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Nutritional Assessment
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NUTRITIONAL ASSESSMENT
Nutritional assessment refers to the condition of the body related to the intake and use of nutrients.
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An estimation based on information obtained from :
• Historical Information• Anthropometric measurement• Physical examination (clinical
and physical) • Laboratory examination
(biochemical)
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Historical Information
• Health history• Sosioeconomic history• Drug history• Diet history
QUANTITATIVE DAILY CONSUMPTION METHOD.
•recall (24 hours, 48 hours)•record (1-7 days )•weighed food records estimates of actual recent intakes
QUALITATIVE METHOD
•Dietary history•Food frequency
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FOOD RECALL METHOD (RESTROSPECTIVE DATA)
• respondent or parents are asked by nutritionist has been trained
• recall the respondent exact food intake during the previous 24 hour period or 2 x 24 hour period
• all foods and beverage consumed (including snacks)
• quantity• price, brand names ( if possible )• vitamine and mineral supplement use
is also noted • purchase value
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FOOD RECALL METHOD (RESTROSPECTIVE DATA)
• usually the preceding 1-7 days • used food models ( as memory aids )• information on the characteristics of
each food ( e.g. canned, fresh or frozen, enriched or unenriched )
• the number of meals eaten both at home and away from home
• quantities of foods consumed are usually estimated in household measures and
• entered on data sheet (use food composition table converted into grams)
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Flat slop syndrome may be a problem in 24 hour recall method, in this syndrome, individual appear to over estimate low intakes and under estimate high intakes, sometimes referred to as talking a good diet.
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FOOD RECORDS • respondent record at the time consumption
all foods and beverage (including snacks) • usually completed over at least a one-week
period • brand names, price• preparation and cooking are recorded • standart household measuring cups and
spoons and counts ( for eggs )• portion size measure are usually converted
into grams by investigator before calculating nutrient intakes ( use Food Composition Table=DKBM/Daftar Komposisi Bahan Makanan )
• usually 3, 5 or 7 days are used
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WEIGHED FOOD RECORD• weigh all foods and beverage
including snacks consumes by the subject during a specified time period
• details of methods of food preparation, description of foods and brand names
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DIETARY HISTORY• to estimate the usual food intakes of
individuals over a relatively long period of time
• carried out by a nutritionist trained• the general information obtained includes
detailed descriptions of foods, their frequency of consumption and usual portion size
• typical questions might be:” what do you usually eat for breakfast
• cross check for the information on usual intake obtained from the first stage
• frequency of consumption of specific food items
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FOOD FREQUENCY QUESTIONAIRE (RESTROSPECTIVE DATA)
• qualitative• descriptive information about
usual food consumptions pattern• the questionnaire consist of 2
components :a. list of foodb. a set of frequency of use response
categories
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List of the food
Amount 3 times a day
2 times a day once aday
6 times a week
5 times a week
4 times a week
3 times a week
2 times a week
One a week
sometimes
Rice
noodles
potatoes
cassava
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Anthropometric Measurements
• Measures of Growth and Development– Height– Weight– Head Circumference
• Measures of Body Fat and Lean Tissue– Fatfold Measures– Waist Circumference
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BODY HEIGHT
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• Must be calibrated• Accuracy up to 0.1 cm • Standing bare footed • Standing relaxed, backwards
towards the meter• Back of head, back, behind touch the
meter and forming a straight line • Straight sight, chin parallel to the
ground • Lower microtoise until it touches the
head • Read (up to 0.1 cm)• Take note
Body height is measured with microtoise
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If BH is lower than standard, energy/protein deficiency has happened for a prolonged period during growth (especially protein)
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BODY WEIGHT
• Must be calibrated• Minimally dressed• At the same time and condition
every day • Standing relaxed• Straight position • Chin parallel to the ground • Weight noted up to 0.1 kg
Instrument : balance scale, max. 140 kg
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By measuring relative BW : BW (kg)/BH (BH in cm – 100) . 100%The above formula is often used by clinicians and is related with relative risk factors for :
• Mortality • Morbidity• DM• Hyperlipidemia • Hypertension • Coronary heart disease
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The following combinations are possible : – BW/A, BH/A A = age – Combinations : BW and BH, SF at 4
spots, extremity circumferences (mid arm)
Measurement results vary depending on : – Age– Sex– Nutritional condition, i.e. energy and
protein
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BODY WEIGHT/BODY HEIGHT
• Is a sensitive index of nutritional status
• Hurdle : the presence of edema prevents the use of BW as a determining parameter SF and circumference measurements are needed
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BH/age : • Determining nutritional deficiency
in the past/during growth
To determine BW difference, a comparison is made between the current and the usual BW
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Recommended by Medical Nutritionist
• To establish DBW (desirable body weight) only by Clinician
• Reducing body weight ½ - 1 Kg/week
• Reducing body weight must be step by step
• Don’t skip meal (especially breakfast)
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Determination body weightIf < 30 yearsNormal BW = (BH – 100) – (10% (BH – 100))
e.g. BW = 70 Cm Normal BW = (170 - 100) – (10% (170 – 100))
70 – 7 = 63 Kg 100%If > 30 yearsNormal BW = (BH – 100)
= 170 – 100 = 70 Kg 100% Over weight : 110 – 120 %Obesity : > 120%
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•Body frame type
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Profession ( e.g. mannequin, athlete etc)
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BMI (Body Mass Index = Quetelet index )
• for most adult • indirect mesures of obesity • easy, quick and more prcise than skin fold
(SF) • cannot be used to distinguish between
excessive weight produced by adiposity, • muscularity or edema • more direct measure of obesity, such as SF
The ratio of BW/BH is termed Body Mass Index = Quetelet Index
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For e. g BH = 160 Cm BW = 70 Kg BMI = BW/ BH ( m² ) = 70 / (1,6)2 = 27.34(you may use Nomogram or WHO classification and disease – risks BMI = Weight (Kg) Height (m² )
= a definition of the level of adiposity
Waist circumference : Normal : Female < 0.8
Male < 0.9 There’s 2 type : 1. Apple type if Waist circumference > hip Risk faktor : coronary
Heart disease2. Pear type if Waist circumference < hip Risk faktor : - DM, Varices
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How to use Nomogram
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Measurement of Skin folds Thickness (SF)
• must be calibrated• usually at 4 spots :
– Triceps skinfold : measured at mid point of the back of the upper left arm
– Biceps : as the thickness of vertical fold on the front of the upper left arm
– (acromion – oleceranon – mid point) – Subscapular skin fold measured just below and
laterally to the angle of the left shoulder blade with the shoulder and left arm relaxed
– Suprailiaca skin fold measured in the mid axillary's line immediately superior to the iliac crest
Used skin fold caliper Lange
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Mid upper arm :• Taken at the midpoint between the
acromial and olecranon • Tend to parallel changes in muscle
mass • Particularly useful in the diagnosis of
PEM or Starvation • Used to monitor progress during
nutritional therapy • The arm should hang relaxed at the
patient’s side • Non stretch tape made of fiber glass or
steel
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Physical examination • Examination of the following
organs : – Eyes– Mucosal membrane – Skin – Hair– Mouth– Teeth– Glands – Lower extremities (edema)
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• Responsive• Gleaming eyes• Shiny hair • Good complexion• Normal appetite
The following are characteristics of a sufficiently-fed person :
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CLINICAL EXAMINATION
• Complaints• Daily food intake • Eating habit • Consumption pattern
Anamnesis, i.e. questions regarding
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• Observation • Palpation • Auscultation
Physical:
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• Usually non-specific symptoms• Only suitable for moderate and
advanced malnutrition • For early malnutrition other
examinations are needed
Clinical Examination:
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LABORATORY EXAMINATION(BIOCHEMICAL)
Assessment of Protein Status • to estimate avaibilability in biological
fluids and tissues • allow assessment of clinical,
subclinical nutrient deficiencies • objectives data used in assessing
nutritional status • to eliminate the inevitable
inconsitency associated subjective judgment
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LABORATORY EXAMINATION(BIOCHEMICAL)
Assessment of Protein Status Assessment the others nutrients
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I.Test of body composition – 3 methyl histidine in urine in (24 hour) – creatinine – height index (CHI)
II. Test of Catabolism Protein – nitrogen balance
III. Test of synthesis protein visceral– albumin– transferrin– RBP
IV. Test immunological – TLC– Hb– Skin test
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I.a. 3 methyl histidine : – an amino acid found only in muscle – excretion related to muscle mass – not useful in stressed patients or after intense muscular
activity b.CHI
– excretion related to muscle mass – limitation (diet meat, stress) creatinine increase, age and
renal insufficiency decreaseCHI = CHR(subject) x 100% CHR (ideal) CHR (creatinine hight ratio) % deficit = 100 – CHI (%) deficit 5 – 15% = mild 16 – 30 % = moderate .> 30 % = severe
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II. Nitrogen Balance Nitrogen Intake Nitrogen output = UUN plus obligatoryN loss (2-4) g
N intake = prod (gr) intake 6.25
N balance = protein intake (gram/day) – UUN + 4 6,25
UUN = urea urine nitrogen4 = nitrogen loss from feces and skin/sweat
if negative = catabolism 0 = catabolism + = anabolism
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III. a. Albumin• large body pool (3-5 gram/kg BW) • normal 3.5 – 5 gram/100 cc serum • mild protein depletion 2,8 – 3,5
gram/100 cc serum• moderate protein depletion 2,1 – 2,7
gram/100 cc serum • severe protein depletion < 2,1
gram/100 cc serum
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b. Transferrin– normal 200 – 300 mg%– mild protein depletion 150 –
200 mg%– moderate protein depletion
100 – 150 mg%– severe protein depletion < 100
mg%
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C. RBP–very sensitive –half life 12 hour–pool body size 2 mg/kgBW–normal 2.1 – 6.4 mg/dl
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IV. a. TLC• mild protein depletion 1200 – 2000 /mm³• moderate protein depletion 800 – 1199 /mm³• severe < 800 /mm³
b. Hb• normal male 16 gr% • normal female 12 gr%
c. Skin test• Evaluation of immune competence in relationship to
nutritional status • Requires precise knowledge of patient’s nutritional
intakes, metabolism state, current illness• Duration of the immune deficit
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• Understanding Nutrition, From appendix pages E1 – E23
• Krause’s : Food, Nutrition and Diet Therapy pg 361 – 378
• Gibson RS : Principles of Nutritional Assessment pg 4 – 52, 86, 97 –102, 182, 182 - 190, 307 – 320
• Przytulski & Lutz : Nutrition and Diet Therapy pg 11 – 16, 30
• Shils : Modern Nutriotion in Health Disease pg 851 – 852