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NUTR 344: Clinical Nutrition 1 > 2. Nutritional Assessment Pt 2 > Flashcards

2. Nutritional Assessment Pt 2 Flashcards

1
Q

What is a biochemical assessment?

What does it detect?

A
  • Measurements of chemical markers in blood, urine, and other fluids and tissues
  • Detects subclinical nutrient deficiencies
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2
Q

What things can a biochemical assessment examine?

A
  • Visceral and somatic proteins
  • Hematological assessment
  • Lipid profile
  • Micronutrient assessment
  • Immunocompetence assessment
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3
Q

What can a biochemical assessment be affected by?

A
  • Nutritional status
  • Medication
  • Illness or physiological state
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4
Q

What are SI units and why are they used?

A
  • A uniform system of reporting lab values
  • Makes exchanging info between labs/disciplines easier
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5
Q

What are some SI base units?

A
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6
Q

SI unit style specifications

A
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7
Q

What type of protein status is reflected by serum proteins, RBCs, and WBCs?

A

Visceral protein status

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8
Q

Typically with malnutrition, organ mass and substrate supply will _______, which leads to a _____ in the synthesis of serum proteins.

A

Decrease; decrease

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9
Q

On average, every 1 dL contains what amounts of the following blood proteins?

  • Albumin
  • Fibronectin
  • Transferrin
  • Prealbumin
  • RBP (retinol-binding protein)
A
  • Albumin: 3.5-5 g/dL ******MOST USED/FOUND
  • Fibronectin: 220-499 mg/dL
  • Transferrin: 215-380 mg/dL
  • Prealbumin: 16-35 mg/dL
  • RBP: 2.1-6.4 mg/dL
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10
Q

Serum protein assessments have _____ sensitivity and specificity for nutritional status.

A

low

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11
Q

_____ ______ analysis can be influenced by:

  • Low protein intake
  • Altered metabolism and synthesis
  • Inflammation
  • Hydration
  • Medications
  • Pregnancy
  • Exercise
A

Serum proteins

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12
Q

The half-life of serum proteins are as follows:

  • *Albumin: 17-21 days
  • *Transferrin: 8-10 days
  • Prealbumin or TTR (transthyretin): 2-3 days
  • RBP: 10-12 hours

Why is the half-life important to know when implementing nutritional interventions?

A

In order to be able to see significant changes in protein levels (knowing when they’d occur)

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13
Q

Serum Proteins: Albumin

  • What is its function?
  • When are the levels high?
  • When are the levels low?
A
  • Function: maintain osmotic pressure; transport large insoluble molecules/drugs/Ca/Zn
  • High: dehydration; corticosteroids
  • Low: low protein intake; malabsorption; inflammation; nephrotic syndrome; trauma; surgery; edema; cirrhosis; overhydration; acute illness; aging
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14
Q

Serum Proteins: Transferrin

  • What is its function?
  • When are the levels high?
  • When are the levels low?
A
  • Function: iron transport
  • High: Fe deficiency; pregnancy
  • Low: inflammation; infection; acute illness; PEM
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15
Q

Serum Proteins: Transthyretin (TTR)

  • What is its function?
  • When are the levels high?
  • When are the levels low?
A
  • Function: transport of T3 and T4; complex with RBP
  • High: renal failure; Hodgkin’s disease
  • Low: liver diseases; PEM; inflammation; hyperthyroidism
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16
Q

Serum Proteins: Retinol-Binding Protein (RBP)

  • What is its function?
  • When are the levels high?
  • When are the levels low?
A
  • Function: retinol transport from liver to periphery; complex with TTR
  • High: renal failure
  • Low: Vit. A deficiency; Zn deficiency; liver diseases; inflammation; hyperthyroidism
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17
Q

What does PEM stand for?

A

Protein Energy Malnutrition

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18
Q

Albumin, transferrin, TTR, and RBP are ________ acute-phase proteins.

C-reactive protein (CRP) is a _______ acute-phase protein.

A
  • Negative
  • Positive
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19
Q

What is the difference between negative and positive acute phase proteins?

A
  • Negative: levels decrease by > 25% during inflammation, illness or metabolic stress
  • Positive: indicate increase in levels during mild/acute inflammation; **NOT A MARKER, but useful for interpreting other serum proteins
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20
Q

What are the normal, mild-chronic, and acute levels of positive acute-phase proteins?

A
  • Normal: <1 mg/L
  • Mild-chronic: 1-5 mg/L
  • Acute: >5 mg/L ****can be >50 mg/L!!!
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21
Q

Negative acute-phase proteins have levels that are decreased by >25% during periods of metabolic stress. This does NOT refer to a decrease in protein synthesis, but rather….

A

Extra vascularization that allows proteins to escape much easier.

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22
Q

Cutoffs for serum protein deficits

***memorize normal Albumin levels only***

A

Normal Albumin levels = 35-50 g/L

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23
Q

Nitrogen balance, urinary creatinine excretion, and immunocompetence are all assessments used to examine….

A

Somatic protein status

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24
Q

What do each of the following assessments test for?

  • Nitrogen balance
  • Urinary creatinine excretion
  • Immunocompetence
A
  • Nitrogen Balance: total protein losses and retention (not mass)
  • Urinary creatinine excretion: skeletal muscle mass (not total muscle)
  • Immunocompetence: total lymphocyte count (TLC)
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25
Q

Immunocompetence analysis of the TLC is influenced by:

A
  • Infection
  • Trauma
  • Diseases
  • Medications
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26
Q

What does it mean when a nitrogen balance is:

  • In balance
  • Positive
  • Negative
A
  • Balanced: anabolism=catabolism; normal/healthy adult
  • Positive: anabolism>catabolism; pregnancy, growth, recovery, athletic training
  • Negative: anabolism
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27
Q

How is the nitrogen balance calculated?

A
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28
Q

What does a negative nitrogen balance allow us to determine?

Can we say that there is tissue/muscle loss?

A

That the current intake of protein is insufficient to maintain N-balance.

More data is needed to determine tissue/muscle loss.

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29
Q

What are the limitations of nitrogen-balance testing?

What do errors typically point to?

A
  • Time consuming: 24h (ideally x3)
  • Prone to errors: protein intake estimations (self-reported); missed/incomplete urine collections; doesn’t account for misc. losses (diarrhea, vomit, leaks…)
  • Errors typically favor positive balances: due to overestimation of intake and underestimation of losses
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30
Q
  • Urinary creatinine excretion _______ with exercise, meat intake, menstruation, infection, fever and trauma.
  • Levels _______ with renal failure and age.
  • Excretion is proportional to _____ _____ _____.
A
  • Increase
  • Decrease
  • Skeletal muscle mass
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31
Q

What is the normal urinary creatinine excretion levels in adult men and women?

A
  • Men: 23 mg/kg IBW per 24h
  • Women: 18 mg/kg IBW per 24h
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32
Q

Muscle mass is proportional to the ______ of a person.

A

Height

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33
Q
  • The Creatinine Height Index (CHI) is:
  • How is it interpreted?
  • What are the limitations?
A
  • The observed creatinine excreted (mg) / expected 24h creatinine excretion (mg)
  • Mild depletion: 60-80%; Moderate depletion: 40-59%; Severe: <40%
  • Relies on complete 24h urine collection; meat-free diet prior to testing
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34
Q

Hematological assessments are when complete blood counts (CBC) are analyzed in order to diagnose for _______

A

Anemias

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35
Q

What is anemia?

What does it generally lead to?

A

Reduction in the quantity of hemoglobin or in the # or RBCs in blood.

It leads to a decreased oxygen carrying capacity.

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36
Q

How can erythrocytes be classified in hematological assessments?

A
  • Color: Hypochromic (pale), normochromic, hyperchromic (darker)
  • Size: microcytic (small), normocytic, macrocytic (larger), megaloblastic (abnormal)
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37
Q

Anemias can be due to deficiencies of (classification):

A
  • Iron (microcytic, hypochromic)
  • Folate (macrocytic, megaloblastic)
  • Vit B12 (macrocytic, megaloblastic)
  • Other nutrients like Vit C and E
  • Anemia of chronic diseases (normocytic, normochromic)
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38
Q

General lab tests for anemia test for (3):

A
  • Hemoglobin (g/L): total in RBC
  • Hematocrit (Hct): % of RBC in total blood volume
  • RBC count: x1012/L
  • Mean Corpuscular Volume (MCV): average RBC size; [Hct/RBC] x 10
  • Mean Corpuscular Hemoglobin (MCH): [Hb] in RBC (pg/cell)
  • MCHC: Hb/Hct
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39
Q

During PEM, hemorrhage, and other anemias, hemoglobin levels are _____ than normal levels.

A

Lower (<120 for women, <140 for men)

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40
Q

During dehydration, hematocrit % is ________ than usual. During hemorrhage and water overload, the % is ______ than normal.

A
  • Higher
  • Lower than 37 (women) or 40 (men)
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41
Q

Normal MCV and MCH values are:

A
  • MCV= 76-100 um3
  • MCH= 21-38 pg/cell
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42
Q

True or false:

It is impossible to measure the total body stores of iron. Markers need to be used instead.

A

True

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43
Q

Iron status assessments are performed by examining what (3) types of iron?

List in order of depletion during iron deficiency.

A
  1. Storage iron: in bone marrow, liver, spleen ***marker= Ferritin
  2. Transport iron: transferrin saturation; how it binds iron
  3. Essential iron: RBC, myoglobin, enzymes
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44
Q

In early stages of iron deficiency, this serum level will be low and can depict depleted iron stores.

A

Serum ferritin (<20 microg/L)

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45
Q

This serum level is low in early deficiency states and reflects binding to transferrin.

A

Serum iron (<0.65 mg/L)

46
Q

What does Total Iron Binding Capacity (TIBC) measure?

When is it high?

Why is it needed?

A
  • Measures saturation ability for transferrin
  • High in deficiency
  • Needed to calculate transferrin saturation
47
Q

Serum ferritin, serum iron, TIBC, transferrin saturation, and erythrocyte protoporphyrin are all lab tests for which kind of anemia?

A

Iron Deficiency

48
Q

Which iron deficiency test shows a decrease with diminished transport iron levels?

A

Transferrin saturation

[Serum iron/ TIBC] x 100%

49
Q

Which iron deficiency test (not often studied) increases during later deficiency states accompanied by limited Hb production?

A

Erythrocyte protoporphyrin

50
Q

During later stages of iron deficiency, what will Hb bind to instead of iron?

A

Zinc

51
Q

Serum folate (low in early state) and RBC folate (low in later states) are tests done to look for what kind of anemia?

A

Folate deficiency

52
Q

Megaloblastic and macrocytic RBCs, accompanied by normal vit. B12 levels and lower _____ serum and RBC levels, are indicative of what kind of anemia?

A

Folate deficiency

53
Q

Elevated levels of methylmalonic acid are a biomarker for early deficiency of ________

A

Vitamin B12

54
Q

Elevated levels of homocysteine are a biomarker for both ____ and _____ deficiency.

A

Vitamin B12 and Folate

55
Q

How does one test for a Vitamin B12 deficiency?

A

Analyzing serum B12 levels; would be low during the early stages of deficiency

56
Q

Different lab tests showing iron deficiencies at different stages

A
57
Q

Pre-menopausal women need more iron than men and are commonly deficient in iron (get less than 18 mg/day). Pregnant women need more iron than everyone. Why?

A

Physiological growth states and to make up for blood losses during menstruation.

58
Q

Clams, oysters and liver are excellent sources of _____ iron.

A

Heme

59
Q

Cooked legumes, seeds, fortified cereals and tofu are excellent sources of _____ iron.

A

Non-heme

60
Q

Risk factors for poor iron status include:

A
  • diet low in meat/fish/poultry
  • diet low in vitamin c
  • diet low in fortified foods (infants)
  • frequent consumption of tea and coffee with meals (tannins/polyphenols)
  • frequent consumption of iron inhibitors with meals (phytates, oxalates)
  • regular ASA use (aspirin) ****associated with blood losses
  • menorrhagia
  • 3 or more annual blood donations
  • pregnancy, multiple gestations, parity >3
61
Q

When diagnosed with iron deficiency, iron is often supplemented medicinally because it would take too long to replenish stores with food.

How can we maximize iron absorption from supplements?

A
  • eat on empty stomach (food decreases absorption by ⅓)
  • eat shortly afterwards to avoid irritating the stomach (dark stool, constipation…)
62
Q

Ferrous sulfate liquid or tablets are given 3x/day for a span of 6 months in order to treat…

A

iron deficiency anemia

63
Q

What are some more common lab tests for vitamin and mineral assessments other than iron?

A
  • Vitamin D
  • Folate
  • Vitamin B12
  • Thiamine (for alcoholism)
64
Q

What does a clinical assessment entail?

A
  • Includes a patient’s medical, social and psychological history
  • Includes a physical examination for clinical signs/symptoms of nutritional deficiencies
65
Q

What factors are important when looking at a patient’s history?

A
  • primary and secondary diagnosis
  • past medical history
  • weight history
  • body systems affecting nutrient intake
  • social history (religion, shopping, cooking, family, socioeconomic…)
66
Q

Normal hair is shiny and not easily pluckable. Signs of malnutrition could include hair being dry, brittle, graying early, or alopecia.

What could the individual potentially have deficiencies in?

A
  • Protein
  • Energy
  • Zinc
  • Copper
  • EFA
67
Q

Healthy, nourished faces are uniform and aren’t swollen. Signs of malnutrition can make the face look full, puffy, or have drawn in cheeks.

What might the individual possible be deficient in?

A
  • Protein
  • Energy
68
Q

Normal, nourished eyes appear bright, clear, shiny, and have moist membranes. Malnutrition signs could include dryness, pallor, or corneal vascularization.

What might the individual be deficient in?

A
  • Vitamin A
  • Iron
  • B vitamins
69
Q

Normal, nourished lips appear pink, moist and smooth. Malnutrition symptoms may appear as angular stomatitis or cheilosis.

What might the individual be deficient in?

A
  • Niacin
  • Riboflavin
  • Iron
  • B6
70
Q

Normal, nourished tongues appear pink, moist, smooth, and have taste buds. Malnutrition symptoms can include the tongue appearing magenta, being painful, having edema, taste changes, or glossitis.

What might the individual be deficient in?

A
  • B vitamins
  • Zinc
  • Vitamin A
  • Iron
71
Q

Normal, nourished gums are pink, while normal teeth are white and shiny. Malnutrition symptoms can show gums bleeding, receding or having gingivitis or stomatitis. Teeth can have caries,

What might the individual be deficient in?

A
  • Vitamin C
  • Folate
  • B12
  • Protein
  • Energy
  • Fluoride
72
Q
A
73
Q
  • 24-h recall
  • Food record or diary
  • Food frequency questionnaire
  • Direct observation
  • Tech-based methods

The above listed are all potential methods for assessment of what?

A

Diet

74
Q

The choice of dietary assessment method depends on:

A
  • Individual vs group
  • Nutrients of Interest
  • Goal: quick estimation vs precise
75
Q
  • How many 24-h recalls are usually gathered to assess usual intake?
  • What are the advantages of the 24-h recall?
  • What are the disadvantages?
A
  • At least 3
  • Advantages:
  • quick and cheap
  • element of surprise
  • low patient burden
  • literacy independent
  • Disadvantages:
  • memory dependent
  • over/under-estimations
  • high inter-interviewer variability
76
Q
  • What is the usual time period measured for food records?
  • What are the advantages of the food record?
  • What are the disadvantages?
A
  • 3-7 days
  • Advantages:
  • greater precision than 24-h recall
  • not memory dependent (record as you eat)
  • considered actual intake
  • Disadvantages:
  • time consuming
  • might influence eating behavior (not usual intake)
  • requires motivation and literacy
77
Q
  • Which method of dietary assessment involves a survey of intake over a specific time, a food list, and the consumption frequency of foods?
  • What are the advantages of this method?
  • What are the disadvantages?
A
  • Food frequency questionnaire
  • Advantages:
  • quick and cheap
  • can examine specific nutrients
  • can be used in large studies
  • considered usual intake
  • Disadvantages:
  • qualitative info is less accurate
  • memory dependent
  • difficult since not meal based
  • requires motivation and literacy
78
Q
  • Which dietary assessment method is used in a controlled setting but doesn’t represent usual intake?
  • What are the advantages of this method?
  • What are the disadvantages?
A
  • Direct observation
  • Advantages:
  • more precise
  • not memory/literacy dependent
  • patient is unaware of assessment
  • Disadvantages:
  • high staff burden
  • may be intrusive
  • difficult to attain and interpret
79
Q

What are possible tech-based methods of dietary assessments?

A
  • Web-based
  • Mobile applications (be cautious about sources of info)
80
Q

Which assessment is similar to the assessment of a client’s social history?

A

Environmental assessments

81
Q

What do environmental assessments look into?

A
  • socio-economic status, food security and access to food
  • education, food and nutrition literacy
  • ability/time to cook
  • working schedule, travel
  • allergies, intolerances, restrictions
  • cognitive function
  • …
82
Q

What is a common method of performing a functional assessment?

A

Handgrip strength:

  • measured by dynamometer
  • repeated 3 times on dominant hand
  • >23 kg (women); >35 kg (men)
83
Q

What are methods (other than handgrip strength) for performing functional assessments?

A
  • gait speed
  • chair stand
  • activities of daily living (ADL): bathroom, ….
  • instrumental activities of daily living (IADL); groceries, intellectual work, …
  • self-reported perception of activities
84
Q

The NCP (Nutrition Care Process) model is ________ and centered around the ______.

A
  • cyclic
  • patient
85
Q

What is a PES statement used for?

What does PES stand for?

A
  • Used for nutritional diagnosis
  • P= problem; diagnostic label for nutrition problem
  • E=etiology; root cause of nutrition problem
  • S=signs & symptoms; measurable evidence of nutrition problem

*

86
Q

When writing PES statements, what are 2 things that are imperative to remember?

A
  1. Structure/wording of sentence:
    - “ (problem) related to (etiology) as evidenced by (signs&symptoms)
  2. Problem portion is nutritional, not medical:
    - can be solved with a nutritional intervention
    - ex: Low serum ferritin= medical, is a symptom/sign; Inadequate iron intake= nutritional
87
Q

Under periods of stress/injury (hospitalization), which portion of the TEE increases?

A

REE (or BMR) increases, while the TEF and PA decrease.

88
Q

What is the difference between BEE and REE?

A
  • BEE: Basal energy expenditure
  • overnight fast
  • REE: Resting energy expenditure
  • short term fast (5h)
89
Q

Which is larger? BEE or REE?

A

REE

90
Q

Indirect calorimetry measures REE by examining…

  • What is the name and equation for the factor being analyzed?
  • What is the equation called that calculates the energy?
A

… the quantity of oxygen consumed (VO2) and CO2 produced (VCO2) from substrate utilization and energy related processes.

  • Respiratory Quotient (RQ): VCO2/O2
  • Weir equation: REE (kcal/day)= 1.44 x (3.9 x VO2 + 1.1 x VCO2)
91
Q

What percentage of REE should nutrition support cover?

A

100%

92
Q

Elevated REE/BEE measurements from indirect calorimetry are signs of….

A

Inflammation and stressors

93
Q

Other than indirect calorimetry, what are other methods of predicting REE estimates?

A
  • Harris-benedict
  • Mifflin-St. Jeor
  • FAO/WHO
  • Rule of thumb (*not based on height, weight, age, and sex)
94
Q

What is the equation used to estimate TEE?

A

TEE= REE x Activity Factor (AF) x Stress Factor (SF)

95
Q

Harris-Benedict Equation

What are the limitations of this eq?

A
  • Tends to overestimate REE by 5-15%; except in males >65 (underestimates)
  • Can’t be used with obese individuals
  • More frequently used in hospital settings
96
Q

Mifflin-St Jeor:

  • What does this method do better than others?
  • What weight is used?
A
  • Better predicts REE in non-obese and obese subjects
  • Uses current body weight
97
Q

FAO/WHO Equations (men)

A

FAO/WHO Equations (women)

98
Q

The Rule of Thumb calculation is quick and simple.

  • How do we calculate it?
  • Who is it suitable for?
  • How is it used commonly?
  • What weight do we use when?
  • What is the risk of using this quick calculation? How can we balance it out?
A
  • 25-35 kcal x body weight (kg)
  • Mostly for non-obese, non-hospitalized adults
  • Common Uses:
  • 25 kcal for low level of activity, overweight or poor appetite
  • 30 kcal for usual moderate activity, non-obese
  • 35 kcal for higher active/needs
  • What weight to use?
  • if BMI = 16-29.9; used current weight
  • if BMI >30; use ideal or healthy body weight
  • Risk:
  • overestimation of REE
  • balance with results from Mifflin-equation
99
Q

PAL levels

A

Stress factors

100
Q

More Stress Factors

A
101
Q

IOM TEE equation example

A
102
Q

What is the PA?

What are the levels?

A
  • Physical activity coefficient (different from PAL)
103
Q

What are the new recommendations for daily protein intake in healthy adults and older adults?

When and how will they vary?

A
  • Healthy adults: 1.0 g/kg/day
  • Older adults: 1.0-1.2 g/kg/day
  • Vary depending on physiological or disease state: 1.2-2.0 g/kg/day
104
Q

What are the different methods of calculating fluid requirements?

A
  • Weight
  • Weight and age
  • Energy requirements
  • Fluid balance (***preferred method)
105
Q

Fluid requirement (weight)

A

Fluid requirement (weight and age)

106
Q

Fluid requirements ( energy expenditure, and fluid balance)

A
107
Q

What do we consider fluids?

When do our fluid requirements change?

A
  • Substances that are liquid at body temperature
  • Change with various disease conditions
108
Q

What are some symptoms of dehydration?

Which are influenced by blood plasma volume?

A
  • Thirst (when 1-2% of body water is lost)
  • Dark urine, increased urine specific gravity
  • Decreased skin turgor
  • dry mouth and lips
  • Tachycardia
  • Headache
  • Lowered body temperature
  • Restlessness, confusion
  • Rapid weight loss (1 kg = 470 mL)
  • Increased Na, albumin, BUN, creatinine, Hb, Hct
109
Q

What are some symptoms of overhydration?

A
  • increased blood pressure
  • decreased pulse rate
  • edema
  • decreased Na, K, albumin, BUN, creatinine, Hb, Hct
  • Rapid weight gain
110
Q

The following nutrients require more consideration for older adults above 65 years of age. Why are each of them important?

  • Energy
  • Protein
  • Calcium
  • Vitamin D
  • Vitamin B12
  • Fluids
A
  • Energy: reduced due to lower FFM (sarcopenia) and lower activity; lower appetites
  • Protein: 1-1.2 g/kg/day, might need to be higher depending on condition
  • Calcium: decreased Ca absorption with age
  • Vitamin D: less efficient synthesis by skin, kidney conversion and exposure
  • Vitamin B12: less efficient absorption due to achlorhydria
  • Fluids: decreased sense of thirst, presence of other diseases (confusion)
111
Q

What are non-nutritional considerations for older adults (above 65) that can be associated with nutrition-related health issues?

A
  • Dental status (mastication)
  • Swallow function (dysphagia)
  • GI function
  • Medical diagnosis (-ses)
  • Polypharmacy
  • Social environment (independent? isolated?)
  • Cognitive function
  • Functional ability

NUTR 344: Clinical Nutrition 1 (15 decks)

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