Nutritional assessment

Major goals in the assessment of nutritional status include:

• identification of malnutrition, and its effects on an individual’s health status• identification of patterns of overconsumption, and their link with the development of obesity, diabetes, hypertension cardiovascular disease, and cancer• identification of nutritional parameters for optimal health and fitness

For being well nourished individuals should have 3-5 meals a day (every 4-6 hours except for the night time when the break should be 12 hours long) of caloric value adjusted to individual needs (depending on sex, age, health status) with right proportion of

proteins (9-13%), fats (29-33%) and carbohydrates (57-61% of caloric value).

Malnutrition

Malnutrition is basically defined as a lack of essential nutrients at the cellular level resulting from psychological, personal, social, educational, economic, cultural, or political factors in the individual’s environment.

Malnutrition may exist in the form of

primary deficiency, which occurs when a specific essential nutrient is lacking in the diet.

secondary deficiency disease due to the body’s inability to digest, absorb, metabolize, or use a specific nutrient properly or because the body has an increased requirement for or increased excretion of a specific nutrient.

Malnutrition

acute, a result of temporary conditions and reversible without long-term side effects

chronic, existing over a long period with possible irreversible consequences.

Malnutrition can be classified as follows

Marasmus- protein calorie malnutrition, evidenced by a client who exhibits weight loss, fat loss, and muscle wasting due to overall calorie-protein deprivation.

Kwashiorkor-protein malnutrition, evidenced by a client who has adequate fat reserves but, on testing, reveals significant deficits in protein status.

Kwashiorkor-marasmus mix.

Components of nutritional assesment are:

antropometric measurement (height, weight, BMI,WHR, skinfold thickness, circumference of head, chest, mid-arm),

biochemical measurement (total lymphocyte count, serum albumin, total iron binding capacity, creatinine height index, nitrogen balance, haemoglobin and hematocrit, serum glucose),

clinical examination dietary analysis (estimated calorie and protein

needs).

BMI (body mass index)

BMI ( body mass index) is calculated according to the following formula

BMI= weight in kilograms/ (height in meters)2

In developed countries recommended BMI for healthy adult individuals is 20-25kg/m2.

For developing countries it is 18,5 kg/m2. If BMI is > than the recommended it is defined

as overweight and obesity1degree obesity (overweight) BMI=25-30 kg/m2.2 degree obesity BMI=30-40 kg/m2.3 degree obesity BMI>40 kg/m2.

WHR (waist to hip ratio)

WHR (waist to hip ratio) is calculated according to the formula: WHR=waist circumference/ hip

circumference

Apple-shape obesity

WHR in women >0,8 and in men >1 (in obese individuals) shows the male type of obesity (typical for males, apple-like shape).

Pear-shape obesity

WHR in women <0,8 and in men <1 (in obese patients) shows the female (feminine, pear) obesity.

Possible incorrect supplementation of particular

nutrients: Excessive supply of animal protein- it provides 2-3 times more methionine amino acid than needed, if insufficient supply of vitamins B2, B6, B12, and folic acid coexist it leads to elevated levels of homocystein in the blood serum thus causing arteriosclerosis.

Excessive supply of mono-and dicarbohydrates- it leads to weight gain. With lack of proper regulatory hormones (insulin, adrenaline) it may lead to diabetes, hypo- or hyperglycaemia. Overconsumption of sucrose may cause vitamin B1,B2, B6 deficiency, whilst these vitamins are needed for its’ metabolism. Simple sugars age good fuel for bacteria on tooth enamel, thus encourage development of caries. They irritate the mucous membrane of digestive tract and cause excessive excretion of gastric juice.

Excessive supply of fats- especially of cholesterol and saturated fatty acids-together with low dietary fibre consumption it causes elevated levels of LDL in the blood serum ( lipoproteins of low density), what is detrimental to the blood vessels.

Saturated fatty acids elevate blood pressure, increase platelet aggregation, elevate factor VII level( causing clots). In smokers it quickly leads to formation of plaques in the arteries.

Polyunsaturated fatty acids ώ-6 and ώ-3 lower the blood pressure.

ώ-6 polyunsaturated fatty acids lower cholesterol levels in the blood serum and in LDL-s, they decreases the aggregation ability of platelets and decreases tromboxane synthesis.

ώ-3 polyunsaturated fatty acids lower VLDL level in the blood serum , but impair resistance to infections, glucose tolerance, may cause poor clotting ability of the blood and bleeding.

Monounsaturated fatty acids (e. g. linoleic- present in olive oil, rape oil)-lower cholesterol content in LDLs. They should be 10-15 % of total calorie supply.

Overuse of fats causes bile acids excretion; their metabolites are cracinogenic. Fats increase microsomal oxydation in enterocytes, what encourages growth of Clostridium and Enterobacter bacteria in the intestine. The bacteria cause excessive production of steroid sex hormones precursors out of cholesterol (e.g. excessive prolactine excretion, the hormone induces breast cancer).

Excessive supply of salt

causes hypertention, gastritis atrophicans, and stomach cancer. The recommended salt consumption is 3g/day.

Insufficient supply of dietary fibre

causes constipation, colon cancer, obesity, cholecystolithiasis (bile stones), atheromatosis.

Insufficient supply of calcium

causes bone demineralization, osteoporosis, colon cancer, angina pectoris. Recommended daily consumption of calcium is 1500mg/day. Wrong Ca/P proportion in meals may handicap Ca absorption. Recommended Ca/P ratio should be 2:1 in children and 1:1 in adults.

Insufficient supply of iodine

iodine is necessary for thyroid hormones production ( T3, T4) . The recommended daily consumption of J is 200mg in pregnant women, 90-120mg in newborn children and toddlers, young children 50-100mg, teenagers 100-150mg, healthy adults 150mg/day. Kitchen salt is enriched in J, other good sources of this element are: garlic, onion, strawberry, seafood. Lack of iodine causes goitre, hypothyroidism, cretinism in children.

Insufficient supply of iron

the recommended daily consumption is 8mg/100kcal. Insufficient iron supply affects usually

1. teenage girls who start menstruating, 2. young women (as they loose iron during menstruation),3. elderly people (due to poor absorption, digestive tract

diseases, interactions with medicines)4. intestinal parasites (tapeworms) may ‘steal’ iron which

leads to anemia and koilonychia (spoon-shaped nails) As a result of iron deficiency microcytic anaemia ( with too

mall erythrocytes) develops (clinical symptom-fatigue).

CalorieA unit of energy obtained from food. The calorie

is a measure of heat energy. One calorie is the amount of heat needed to raise the temperature of 1g of water by 1◦C.

The common unit of energy measurement in food is the Calorie, with a capital C, which is 1000calories (small c) or 1 kilocalorie (kcal). The International System of Units of heat energy uses the Joule (J) instead of the Calorie as the measurement for the energy content of food. The Joule equals roughly 250calories or 0,25Calories.

Classification of carbohydrates

The term carbohydrate comes from its chemical nature. It is composed of the elements carbon, hydrogen and oxygen. They are classified according to the number of basic sugar units making up their structure.

Monosaccharides

GlucoseFructoseGalactose

Disaccharides

SucroseLactoseMaltose

Polysaccharides

StarchGlycogenDextrins

Oligosaccharides

Dietary fiberCelluloseNoncellulose polysaccharidesLignin

Fructose is the sweetest of simple sugars. It is found in fruits and other substances, such as honey, high-fructose corn syrup. In human metabolism , fructose is converted to glucose and burned for energy.

Galactose is not found free in foods but is produced in human digestion from lactose (milk sugar) and is then changed to glucose for energy. This reaction is reversible and during lactation glucose may be reconverted to galactose for use in milk production.

Disaccharides

The disaccharides are double sugars composed of two monosaccharides linked together.

Sucrose = glucose + fructose

Lactose = glucose + galactose

Maltose = glucose + glucose

Sucrose is the common ‘table sugar’ made commercially from sugar cane and beets . It is the most prevalent disaccharide . It contributes some 30% to 40% of the total kilocalories in the American diet.

Lactose is the sugar in the milk. It is the least sweet of the disaccharides. When milk sours, as in the initial stages of cheese making, the lactose changes its form and separates out the liquid whey from the solid curd. The curd is then processed for cheese. Thus cheese has very little sugars or none.

Maltose occurs in commercial malt products of starch breakdown and in germinating cereal grains.

Polysaccharides

are made up of many single sugar (saccharide) units. The most important polysaccharide in human diet is starch. other forms are glycogen and dextrins. The nondigestable forms of dietary fiber, cellulose and other noncelluose polysaccharides, provide important bulk in the diet.

Starch is the most significant poysaccharide.It is a large complex compound made up of many coiled or branching chains of simple sugar (glucose) units. It yields only glucose on digestion. It is the most important source of dietary carbohydrate worldwide.

Glycogen-the animal storage compound comparable to starch in plants is glycogen. It is formed during cell metabolism and stored in relatively small amounts in the liver and muscle tissues.

Physiological effect of dietary fiber

water absorption (laxative effect)binding effect (influence blood lipid levels)colon bacteria effect (fermentation

substrates for bacterial action).

Functions of carbohydrates

Energy source. The daily dietary supply of carbohydrates should be sufficient to provide 50-55% of the total kilocalories. Carbohydrate foods must be eaten regularly and at moderate frequent intervals to meet the constant energy demands of the body.

Glycogen reserves. The liver and muscle glycogen reserves provide a constant interchange with the body’s overall energy balance system. Thus these reserves protect cells from depressed metabolic function and injury.

Protein-sparing action. Antiketogenic effect. Heart and Central Nervous System function. Fatty acids

are the preferred regular fuel for the heart muscle, the glycogen reserve in cardiac muscle is an important emergency source of energy. In a damaged heart, poor glycogen stores or low carbohydrate intake may cause cardiac symptoms and angina. A constant supply of carbohydrate is necessary for the proper functioning of the central nervous system. The brain contains no stored supply of glucose and is therefore especially dependent on constant supply of glucose from the blood. Profound hypoglycemic shock may cause irreversible brain damage

Foods rich in carbohydrates

breadcerealspastaricebananas potatoes

Lipids

Lipids are organic compounds soluble in chloroform, ether and other organic solvents but usually insoluble in water. They are esters of glycerol and fatty acids.

Lipids

Saturated (animal)Unsaturated (vegetable)

Foods rich in lipids are:

egg yolkbuttermargarinevegetable oilfatty meatfried foods contain 10-40% of fat (as they

soak)

Protein

The protein molecule is a complex structure made up of one or more chains of amino acids, which are linked by peptide bonds. Proteins are essential constituents of the body; they form the structural material of mussles, tissues, organs and are equally important as regulators of function as enzymes and hormones. Proteins are synthesized in the body from amino acids.

Classification of amino acids

There is a group of essential amino acids (histidine, isoleucine, leucine, lysine, methionine, phyenylalanine, threonine, tryptophan, valine)- they are the only ones we cannot make.

The remaining amino acids, which we can syntesize are nonessential amino acids (alanine, aspargine, aspartic acid, cystine, glutamic acid, glutamine, glycine, hydrxylysine, hydroxyproline, proline, serine, tyrosine)

Major minerals

calciumphosphorusmagnesiumsodiumpotassiumchloridesulfur

Trace elements

iron iodine zinc copper manganese chromium cobalt selenium molybdenum fluoride

Iron deficiency-microcytic anaemia,Iodine deficiency- goitre, hypothyroidism,

cretinismFluoride deficiency-dental cariesCalcium deficiency-rickets, osteomalatia,

osteoporosis

Vitamins

Water-solublevitamin C the B vitamins

(thiamin-B1, riboflavin-B2, niacin, folate, biotin, pyridoxine-B6, cobalamin-B12, pantothenic acid)

Fat-solublevitamin Avitamin Dvitamin Evitamin K

Vitamin A

(retinol) ia a fat-soluble vitamin that occurs preformed in foods of animal origin (especially milk products, egg yolk and liver) and is formed in the body from the pigment beta-carotene, present in cabbage, lettuce, and carrots. Retinol is essential for growth, vision in dim light, and the maintenance of soft mucous tissue. A deficiency causes stunted growth, night blindness, xerophthalmia, keratomalacia, and eventually blindness. The RDI is 750 microgram retinol equivalents for an adult ( 1 microgram ret inolequivalent=1microggam retinol or 6 microgram beta-carotene)

Vitamin B1

(thiamine, aneurine) is a vitamin of the B complex that is active in he form of thiamine pyrophosphate, a coenzyme in decarboxylation reaction in carbohydrate metabolism. A deficiency of vitamin B1 leads to beriberi. Good sources of the vitamin are cereals, beans, meat, potatoes, and nuts. The RDI is 1 mg for an adult.

Vitamin B2

(riboflavin) is a constituent of the coenzymes FAD ( flavine adenine dinucleotide) and FMN (flavine mononucleotide). Riboflavin is therefore important in tissue respiration. A deficiency of riboflavin causes ariboflavinosis. Good sources of riboflavin are liver, milk, and eggs. The RDI for an adult is 1.3-1.6mg.

Vitamin B6

(pyridoxine) from this vitamin is formed the coenzyme pyridoxal phosphate, involved in in the transamination of amino acids. The vitamin is found in most foods and deficiency is therefore rare.

Vitamin B12

(cyanocobalamin) ia s vitamin of the B complex. The form of vitamin B12 with coenzyme activity is 5-deoxyadenosylcobalamin, which is necessary for the synthesis of nucleic acids, the maintenance of myelin in the nervous system, and the proper functioning of folate, another B vitamin. The vitamin can be absorbed only in the presence of intrinsic factor, a protein secreted in the stomach. A deficiency of vitamin B12 affects nearly all the body tissues, particularly those containing rapidly dividing cells. The most serious effects are: pernicious anemia and degeneration of the nervous system. Good sources are liver, fish and eggs. The RDI for an adult is 3-4 micrograms.

Vitamin C

(ascorbic acid) is a water-soluble vitamin with antioxidant properties that is essential in maintaining healthy connective tissues and the integrity of cell walls. It is necessary for the synthesis of collagen. A deficiency of vitamin C leads to scurvy. The RDI is 30mg for an adult. Rich surces of vitamin C are citrus fruits and vegetables.

Vitamin D Is a fat-soluble vitamin that enhances the

absorption of calcium and phosphorus from the intestine and promotes their deposition in the bone. It occurs in 2 forms: ergocalciferol (Vitamin D2, calciferol) which is manufactured by plants and cholecalciferol (vitamin D3) which is produced by the action of sunlight on the skin. A deficiency of vitamin D, either from poor diet or lack of sunlight leads to decalcified bones and the development of rickets and osteomalatia. Good sources of vitamin D are liver and fish oils. The RDI is 10 micrograms for a child up to 5 years and 2.5 micrograms thereafter.Vitamin D overdose is toxic.

Vitamin E

It is a group of chemically related fat-soluble compounds (tocopherols and tocotrienols) that have antioxidant properties and are thought to stabilize cell membranes by prevening oxidation of their unsatuarated fatty acid components. The most potent of these is alphatocoferol. Good sources of vitamin E are vegetable oils, eggs, butter and wholemeal cereals. Deficiency is unlikely.

Vitamin K

Is a fat-soluble vitamin occuring in two main forms: phytomenadione (of plant origin) and menaquinone (of animal origin). It is necessary for the formation of prothrombin in the liver, which is essential for blood clotting, and it also regulates the synthesis of other clotting factors. A dietary deficiency does not often occur as the vitamin is synthesized by bacteria in the large intestine ; if occurs- causes haemorrharge.

Folate

(pteroylglutamic acid) is a B vitamin that is important in the synthesis of nucleic acids.The metabolic role of folate is interdependent with that of vitamin B12 and a deficiency of one may lead to deficiency of the other. A deficiency of folate results in megaloblastic anemia (with too big erythrocytes). Good sources are liver, yeast extract and green leafy vegetables. The suggested daily intake is 200 micrograms/day for an adult, which should be doubled before conception and during the first three months of pregnancy to prevent neural tube defects (spina bifida) and other congenital malformation (cleft lip and cleft palate) in the fetus.

Nicin (nicotinic acid)

Is a B vitamin. Nicotinic acid is a derivative of pyridine and is interchangeable with its amide, nicotinamide. Both forms of the vitamin are equally active. Nicotinamide is a component of the coenzymes NAD and NADP. A deficiency of the vitamin leads to pellagra (dermatitis). Good sources of the vitamin are meat, yeast extracts, and pulses. Nicotinic acid is used clinically as a lipid-lowering drug. It reduces the level of triglycerides and LDLs.

Deficiency of what micronutrient is likely to account for this rash following Roux-en-Y

gastric bypass?

1. Copper2. Thiamine3. Vitamin B64. Vitamin C5. Zinc

Answer

Zinc

A perioral erythematous desquamating rash associated with excoriations and honey-colored crusting is visible. Evaluation of a biopsy and the finding of a low zinc level were consistent with a diagnosis of acquired acrodermatitis enteropathica. The patient recovered after zinc supplementation.