Introduction to Clinical
Nutrition
What is it?
How is it important?
WELCOME YOU ALL
Presented by
Dr. (Lt Col) Sarder Mahmud Hossain, PhD
Associate Professor
NUB
There is definite association of Nutrition
with infection, immunity, fertility,
MCH, family health has significant
relations.
Also
non-communicable
diseases like CHD, HTN, Cancer and
Diabetes are also coming up to the
surface as due to nutritional factors.
Illness
Example : Cancer
Altered
Food Intake
Examples: Loss
of appetite,
altered food
likes/dislikes,
difficulty chewing
and swallowing,
reduced saliva
secretion
Altered
Digestion and
Absorption
Examples:
radiation enteritis,
surgical resection
of GI tract,
diarrhea
Altered
Metabolism
Example:
increased energy
needs due to
altered energy use
in cancer
Malnutrition
Altered
Nutrient
Excretion
Examples: fecal
loss of fat-soluble
vitamins and
calcium in clients
with cancers that
affect enzyme
secretion or bile
salt production
Nutritional Epidemiology
includes
a. Nutritional Status of the community.
b. Nutritional & Dietary surveys.
c. Nutritional surveillance.
d. Nutrition & Growth monitoring.
e. Nutritional Rehabilitation.
f. Nutritional Indicators.
g. Nutritional Interventions.
How Quickly The Dietary
Pattern/Intake Change
10
1977-78
1999-01
8.0
8
7.0
6
5.0
4
3.5
2.8
2.2
1.7
1.6
2
0.8 0.9
2.0
1.1
0.5 0.3
0
Coffee
and tea
Soft drinks Fruit drinks
Alcohol
Milk
Other milk Fruit juice
bev
So: Dr. Barry Popkin, USA
Beverage Consumption1999-2001
Percentage of total daily kcal
from each beverage
Calorie Proportions Per Beverage
Soft drinks
Fruit juice
Other milk beverages
Fruit drinks
Alcohol
Milk
Coffee and tea
25
20
15
10
5
0
All ages
2-18 yr olds
19-39 yr olds
40-59 yr olds
60+ yr olds
The Beverage Panel
The University of North Carolina at Chapel Hill
Source:Nielsen & Popkin 2004 Am J Prev Med 27: 205-10.
Clinical Nutrition
(Medical Nutrition Therapy)
Purpose
– To achieve or maintain good nutritional status.
American Dietetic Association
– Professional organization representing
Registered Dietitians (RD) and Dietetic
Technicians (DTR)
Patient Care: Team Approach
(Interdisciplinary)
• Physician
• Registered Dietitian
• Registered Nurse, Licensed Vocational
Nurse, Certified Nursing Assistant
• Pharmacist
• Speech Therapist
• Occupational Therapist
• Social Worker
The Nutrition Care Process
• Identifying and meeting a person’s nutrient and nutrition
education needs. Five steps:
1. Assess Assessment of nutritional status
2. Analyze assessment data to determine nutrient
requirements
3. Develop a nutrition care plan to meet patient’s nutrient
and education needs.
4. Implement: Implement care plan
5. Evaluate: Evaluate effectiveness of care plan: ongoing
follow-up, reassessment, and modification of care plan.
THE PATIENT
SHOULD BE AN ACTIVE
PARTICIPANT IN THE
CARE PROCESS!
Assessing Nutritional Status
• Historical Information
• Physical Examination
• Anthropometric Data
• Laboratory Analyses
Historical Information
• Health History (medical history) - current
and past health status
– diseases/ risk factors for disease
– appetite/food intake
– conditions affecting digestion, absorption,
utilization, & excretion of nutrients
– emotional and mental health
Historical Information
• Drug History
– prescription & OTC medicine
– illicit drugs
– nutrient supplements, HERBS and other
“alternative” or homeopathic substances
– multiple medicine (who’s at risk?)
Meds can alter intake, absorption, metabolism, etc.
Foods can alter absorption, metabolism, & excretion of
medicine.
Historical Information
• Socioeconomic History - factors that affect one’s
ability to purchase, prepare, & store food, as well
as factors that affect food choices themselves.
– Food availability (know local crops/produce)
– Occupation/income/education level
– Ethnicity/religious affiliations
– Kitchen facilities
– Transportation
– Personal mobility (ability to ambulate)
– Number of people in the household
Historical Information
• Diet History—analyzing eating habits, food intake,
lifestyle, so that you can set individualized,
attainable goals.
–
–
–
–
–
–
–
–
Amount of food taken in
Adequacy of intake – omission of foods/food groups
Frequency of eating out
IV fluids
Appetite
Restrictive/fad diets
Variety of foods
Supplements (overlaps)
Historical Information
• Tools for taking a diet history:
–
–
–
–
–
24 hour recall
Usual intake – can find trends, such as breakfast/snacks
Food Frequency Questionnaire/Checklist
Food Records
Observing food intake
• Analysis of Food Intake Data
• INDIVIDUAL NEEDS FOR NUTRIENTS VARIES
Assessing Nutritional Status
• Historical Information
• Physical Examination
• Anthropometric Data
• Laboratory Analyses
Physical Examination: “A picture is
worth a thousand words.”
• Weight status
• Mobility
• Confusion
• Signs of nutrient deficiencies/malnutrition
– esp. hair, skin, GI tract including mouth and tongue
• Fluid Balance (dehydration/fluid retention)
A picture speaks
Physical Examination: “A picture is
worth a thousand words.”
• Limitations of Physical Findings
– Depends on assessor!
– Many physical signs are nonspecific: ie. cracked lips
from sun/windburn vs. from malnutrition,
dehydration…
Assessing Nutritional Status
• Historical Information
• Physical Examination
• Anthropometric Data
• Laboratory Analyses
Anthropometric Data - physical measurement
of the body
anthropos = human
metric = measure
• Indirect assessment of body composition and development
• Used in Nutrition Assessment:
– Measures using height and weight
– Measures of body composition (fat vs. lean tissue)
– Functional Measures
Anthropometric Data
Measures Using Height and Weight
BMI Body Mass Index
wt (kg)
ht (cm)2
or
wt (lb) X 705
ht (inches) 2
Anthropometric Data
Measures Using Height and Weight
•
•
•
•
18.5-24.9
25+
30+
Pros:
– many studies have identified the health risks
associated with a wide range of BMIs
– easy to look up on chart
– screening tool
Anthropometric Data
Measures Using Height and Weight
• Limitation: BMI can misclassify up to one
out of four people.
– Does not account for fat distribution
– Doesn’t account for LBM - may misclassify
frail/sedentary or very muscular people
Example: Height & Weight Table For Women
Feet Inches
Small Frame Medium Frame
Large Frame
5' 1"
106-118
115-129
125-140
5' 2"
108-121
118-132
128-143
5' 3"
111-124
121-135
131-147
5' 4"
114-127
124-138
134-151
5' 5"
117-130
127-141
137-155
5' 6"
120-133
130-144
140-159
5' 7"
123-136
133-147
143-163
5' 8"
126-139
136-150
146-167
5' 9"
129-142
139-153
155-176
Weights at ages 25-59 based on lowest mortality. Weight in pounds
according to frame (in indoor clothing weighing 3 lbs.; shoes with 1"
heels)
Anthropometric Data
Measures Using Height and Weight
Assessing “Ideal Body Weight”
Hamwi Equation:
• Females: 100# for first 5' of height, plus 5# per
inch over five feet
• Males: 106# for first 5 ' of height, plus 6# per
inch over five feet
• +/- 10% to calculate a range
(for those under 5' tall, subtract 2 lb. per inch under
5')
** Amputations, immobility:
7%
Whole
arm
6.5%
43%
Below elbow 3%
Hand 1%
Above knee 13%
Below knee 6%
Foot 1.8%
Whole
leg
18.5%
Interpretation
%IBW
Actual (present) weight X 100 = %IBW
IBW
Example: 5' 6" woman weighs 160#. What is
her % IBW?
• 160 - 130 = 30X100
------------------------=
130
?????
Interpreting % IBW
 200% IBW = morbidly obese (or 100# over IBW)
 120 % (130%) = obese
110 - 120 = overweight
90 - 109 = normal
80 - 89 = mildly compromised nutrition status (mild
malnutrition)
70-79 = moderate
< 70% = severe
Anthropometric Data
Measures Using Height and Weight
• Assessing “Usual Body Weight”
Actual (present) weight X 100 = % UBW
UBW
• example: 110# female lost 10# over past month
• 110/120 x 100 = 91.6% UBW, or loss of about 8%
Interpreting % UBW
85-90% mild
75-84% moderate
<75% severe
OR wt. change (unintentional weight loss)
mild
moderate
severe
1 week
1-2%
>2
1 month
5
>5
3 months
7.5
>7.5
6 months
10
10-15
>15
Anthropometric Data
Measures of Body Composition
(fat vs. lean tissue)
Body Fat Measurements
• Fat-fold (skinfold)
• waist-to-hip ratios
• hydrodensitometry (hydrostatic weighing)
• bioelectrical impedance
Anthropometric Data
Measures of Body Composition
Mid arm muscle circumference – indirectly
measures protein status by estimating arm
muscle mass.
• Mid arm circumference (AMC) and triceps
fat-fold (TSF) plug into an equation:
Anthropometric Data
Functional Measures of Nutrition Status
1.
2.
3.
4.
5.
6.
Weight
Height
TSF
BSF
Sub scapular Skin-fold thickness
Supra iliac Skin-fold thickness
Summing Up
• Anthropometric measures provide valuable
information regarding body wt. and
composition
• Do not reflect nutrition status alone
• Accuracy requires on the skill of the
assessor
• Caution interpreting results
Assessing Nutritional Status
• Historical Information
• Physical Examination
• Anthropometric Data
• Laboratory Analyses
Laboratory Analyses
• Help determine what’s happening on the inside
of the body
• Automated measurements of several blood
components from a single blood sample
Laboratory Analyses
Interpreting Biochemical Tests
• Many can be skewed with fluid retention or
dehydration.
• Over-hydration can cause _____ numbers
• Dehydration can cause ______ numbers
• These are clues that anthropometrics are
probably skewed as well.
Normal
hydration
Overhydrated =
diluted blood
Dehydrated =
concentrated blood
1 dl blood
10 mg/dl
5 mg/dl
20 mg/dl
Laboratory Analyses:
Biochemical Tests Of Protein Status
• Somatic proteins - physical work
• Serum/visceral proteins (circulating proteins &
proteins found in the liver, kidneys, pancreas,
and heart)
maintain fluid balance
synthesize enzymes and hormones
mount immune response
heal wounds
• Therefore, protein status is an indicator of
immune response.
Laboratory Analyses:
Biochemical Tests Of Protein Status
Serum Albumin:
–
–
–
–
–
>50% total serum protein
Helps maintain fluid and lyte balance
Transports many nutrients, hormones, drugs, etc.
Used as indicator of protein status (visc. protein stores)
Half life ___________
3.5-5.0 = adequate
2.8-3.4 = mildly depleted
2.1- 2.7 = moderately depleted
<2.1 = severely depleted visceral protein stores
Laboratory Analyses:
Biochemical Tests Of Protein Status
– Levels  :
– Levels  :
Normal:
Mild
Moderate
Severe
>200 mg/dl
150-200 mg/dl
100-149 mg/dl
<100 mg/dl
N balance (g) = protein intake - (UUN + 4)
6.25
• “4” represents non-urea N+ lost in feces, urine,
skin, and respiration
• every 6.25 grams of protein contains 1 gram of
nitrogen
• Goal for repletion :
Laboratory Analyses:
Biochemical Tests Of Immune Function
•
•
•
•
Total WBCs
Normal: 5,000-10,000/mm3
Possible critical values: <2500 or >30,000/mm3
High vs. low values?
• Total Lymphocyte Count (TLC)
Measured from % lymphocytes and total WBC count
Equation: TLC = % lymphocytes X Total WBC/mm3
Normal: >1500 mm3
Mild: 1200 - 1500
Moderate: 800-1199
Severe: <800
What do unusually high numbers indicate?
Laboratory Analyses:
Hematological Assessment – looking at blood cells and
detecting anemias
Hematology Assessment – morphology &
physiology of blood cells. Helps detect the presence
of anemias.
• Hemoglobin (Hgb, Hb)
– main functional constituent of the RBC, serving as
the oxygen-carrying protein
–  level may indicate depleted iron stores BUT
•
12-16 g/dl females
14-18 g/dl males
Laboratory Analyses:
Hematological Assessment
• Hematocrit (Hct) – % of RBCs in the total
blood volume.
–
Commonly used to diagnose Fe def., but also
inconclusive
–  values indicate incomplete Hgb formation,
which is manifested by ____________,
______________ RBCs
Males: 42%-52%
Females: 37%47%
Anemias:
• Normocytic, normochromic anemia:
– Iron def detected early (RBCs)
• Microcytic hypochromic:
– Fe-def detected late (or lead poisoning)
• Microcytic, normochromic:
– Renal disease (2’ loss of EPO)
• Macrocytic, normochromic:
– B12 or folate def (or chemo)