Handbook For Nutritional Assessment Through Life Cycle: April 2016

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NUTRITION AND DIET RESEARCH PROGRESS
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HANDBOOK FOR NUTRITIONAL
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ASSESSMENT THROUGH
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LIFE CYCLE
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NUTRITION AND DIET
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RESEARCH PROGRESS
Additional books in this series can be found on Nova‟s website
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under the Series tab.
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Additional e-books in this series can be found on Nova‟s website
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under the eBooks tab.
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NUTRITION AND DIET RESEARCH PROGRESS
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HANDBOOK FOR NUTRITIONAL
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ASSESSMENT THROUGH
LIFE CYCLE
b l
P u
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GHAZI DARADKEH
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M. MOHAMED ESSA
e
AND
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NEJIB GUIZANI
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No New York
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2016 by Nova Science Publishers, Inc.
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All rights reserved. No part of this book may be reproduced, stored in a retrieval system or transmitted
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in any form or by any means: electronic, electrostatic, magnetic, tape, mechanical photocopying,
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NOTICE TO THE READER
The Publisher has taken reasonable care in the preparation of this book, but makes no expressed or
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implied warranty of any kind and assumes no responsibility for any errors or omissions. No liability is
assumed for incidental or consequential damages in connection with or arising out of information
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contained in this book. The Publisher shall not be liable for any special, consequential, or exemplary
damages resulting, in whole or in part, from the readers‟ use of, or reliance upon, this material. Any
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parts of this book based on government reports are so indicated and copyright is claimed for those parts
to the extent applicable to compilations of such works.
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Independent verification should be sought for any data, advice or recommendations contained in this
book. In addition, no responsibility is assumed by the publisher for any injury and/or damage to
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persons or property arising from any methods, products, instructions, ideas or otherwise contained in
this publication.
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This publication is designed to provide accurate and authoritative information with regard to the subject
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matter covered herein. It is sold with the clear understanding that the Publisher is not engaged in
i
rendering legal or any other professional services. If legal or any other expert assistance is required, the
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services of a competent person should be sought. FROM A DECLARATION OF PARTICIPANTS
JOINTLY ADOPTED BY A COMMITTEE OF THE AMERICAN BAR ASSOCIATION AND A
COMMITTEE OF PUBLISHERS.
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Additional color graphics may be available in the e-book version of this book.
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Library of Congress Cataloging-in-Publication Data
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ISBN: 978-1-63482-768-3
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Library of Congress Control Number: 2015961019
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Published by Nova Science Publishers, Inc. † New York
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CONTENTS
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Preface
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Acknowledgments ix
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Synopsis xi
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List of Abbreviations xiii
Chapter 1 Nutritional Assessment during Pregnancy 1
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Chapter 2 Nutritional Assessment during Lactation 15
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Chapter 3 Nutritional Assessment of Infancy and Childhood 27
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Chapter 4 Nutritional Assessment in Adolescents 49
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Chapter 5 Nutritional Assessment in Adults 65
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Chapter 6 Nutritional Assessment of Elderly 91
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Glossary 121
About the Authors 143
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Index 145
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PREFACE
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Nutritional care and management is an essential and vital component of
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patient care. Nutritional care process provides the basis of nutrition diagnosis
and it starts with nutritional assessment. Basic and advanced practice skills to
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perform complete and accurate nutrition assessment are needed.
This pocket guide to nutrition assessment aims to provide clinical
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dietitians, with up-to-date information, tools, and techniques which may be
used for nutritional assessment. In this book, clinical dietitians will use the
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equations for energy, protein and other nutrient estimations. This pocket guide
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will cover the nutrition assessment of people throughout their lifetimes, from
pregnancy to old age.
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Charts, tables and graphs, which can be used by practitioners as quick
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reference tools for nutritional assessment, hydration status, nutrient
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deficiencies and/or excess and body composition, are included in this pocket
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guide.
Nutritional assessment includes dietary history, physical assessment,
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biochemical assessment, anthropometric assessment and nutrients estimations.
In addition to nutritional assessment guidance, clinical dietitians will be
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guided also with data evaluation and how to make dietary intervention.
This pocket guide book contains chapters about nutritional assessment
v
during pregnancy, infantcy, childhood and adolescence, adulthood and old
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age.
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ACKNOWLEDGMENTS
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We are greatfully indebted to members of our families for their constant
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support and understanding to complete this book in right time.
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Special thanks to Dr. Sylvia Quintana, Oman for language and technical
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editting.
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We thank the Nova Science Publishers, INC USA and its staff for their
patience and assistance of this book publication stages.
c e Ghazi Daradkeh
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M. Mohamed Essa
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Nejib Guizani
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SYNOPSIS
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Nutritional assessment has been considered as a cornerstone of nutritional
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diagnosis, management, intervention and dietary planning. Specific criteria,
methods and procedures should be used for different age groups through a
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person‟s life cycle based on the requirements of each age group. Use of precise
and accurate nutritional assessment tools and procedure to detect those who
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are malnourished or at risk of malnutrition will help dietitians to create an
accurate dietary plan and intervention, which may help in quality of life
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improvement.
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This hand book includes the details of each assessment method for
different age groups, from pregnancy to old age. It will be used as a quick,
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practical guide and reference for clinical dietitains. It includes dietary,
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anthropometric, biochemical and clinical assessments.
c i NEED FOR THE BOOK
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As a member of a medical team, a dietitian should put his/her input (i.e., a
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dietary plan) as a part of a comprehensive treatment plan, which is basically
based on nutritional assessment. As each age group has specific methods,
v
procedures, calculations and requirements, this book discusses in detail all the
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components of nutritional assessment for each group, to be easy, quick, direct
and available for clinical dietitians in the field. This book includes the
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equations, tables, figures, and procedures for comparison with the normal
references to be documented in patient records. Dietitians‟ communication
with each other and healthcare providers will be through these
documentations; in addition, this book will benefit nutrition and dietetics
xii Ghazi Daradkeh, M. Mohamed Essa and Nejib Guizani
.
students, clinical dietitians, and health care providers (doctors, nurses,
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pharmacists and other disciplines). It may be used as a text book in universities
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as well.
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LIST OF ABBREVIATIONS
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AC Arm Circumference
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ADH Attention Deficit Hyperactivity
AFI Arm Fat Index
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AGA Approprate for Getational Age
AMA Arm Muscle Area
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ASPEN American Society for Parenteral and Enteral Nutrition
BMI Body Mass Index
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BUN Blood Urea Nitrogen
c
CAMA Corrected Arm Muscle Area
CC Calf Circumference
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CHO Carbohydrate
e
cm Centimeter
i
DBW Desirable Body Weight
c
dl Deciliter
ELBW Extremely Low Body Weight
S
ESPEN European Society of Parenteral and Enteral Nutrition
FFQ Food Frequency Questionnaire
a
GIT Gastrointestinal Tract
Gm Gram
v
GNRI Geriatric Nutrition Risk Index
o
Ht Height
HDL High Density Lipoprotein
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Hr Hour
Hgb Hemoglobin
Htc Hematocrit
IDA Iron Deficiency Anemia
xiv Ghazi Daradkeh, M. Mohamed Essa and Nejib Guizani
.
IDD Iodine Deficiency Disorder
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IQ Intelligence Qutenet
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IOM Institute of Medicine
I
IBW Ideal Body Weight
In Inch
,
IV Intra Venous
g
IU International Unit
Kg Kilogram
in
KH Knee Height
L Liter
h
lb Pound
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LBW Low Birth Weight
l
LDL Low Density Lipoprotein
LGA Large for Gestational Age
b
M Meter
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MAC Mid Arm Circumference
mcg Microgram
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mEq MilliEquivalent
MGRS. Multicenter Growth Reference Study
ml Milliliter
e
mmHg Millimeter Mercury
c
mm Millimeter
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mmol Millimol
MNA Mini Nutritional Assessment
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mOsm Milli Osmolar
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MUAA Mid Upper Arm Area
c
MUAFA Mid Upper Arm Fat Area
MUAC Mid Upper Arm Circumference
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MUAMA Mid Upper Arm Muscle Area
NCHS National Center for Health Statistics
a
Ng Nano Gram
v
NIA Nutrient Intake Analysis
NPO Nothing Per Os
o
NL Non lactating
NP Non pregnant
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NPNL Non pregnant non lactating
PEM Protein Energy Malnutrition
Pg Pictogram
QI Quetelets Index
List of Abbreviations xv
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R Ratio
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RDA Recommended Dietary Allowance
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RN Registered Nurse
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SD Standard Deviation
SGA Small for Gestational Age
,
TSF Triceps Skin Fold
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UAC Upper Arm Circumference
VAD Vitamin A Deficiency
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VLBW Very Low Birth Weight
WC Waist Circumference
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WHO World Health Organization
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WHR Waist Hip Ratio
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wt Weight
µ Micro
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Chapter 1
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NUTRITIONAL ASSESSMENT
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DURING PREGNANCY
INTRODUCTION
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Maternal nutrition has a critical role in the reduction of both maternal
morbidity and mortality. The term Maternal Nutrition refers to nutritional
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status during any stage of a woman´s reproductive age that eventually could
affect her health and that of the fetus and infant. There are heightened nutrient
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needs during pregnancy; without an increase in caloric and nutritional intake
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to meet the increased demands during this period, the fetus uses its own
reserves making it more susceptible to pregnancy-related complications [1].
i e
Women´s nutritional status is most vulnerable during pregnancy; maternal
malnutrition becomes a cycle when malnourished mothers give birth to low
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birth weight infants who in turn become malnourished mothers themselves [2].
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 Basic nutritional evaluation tools during pregnancy will be detailed in
this chapter, these must be used especially in high risk populations
a
that include: Pregnant adolescents especially those out of wedlock [3,
v
4].
o Women with low prepregnancy weight.
o
o Women with unfavorable prognostic factors e.g., Obesity and
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anemia.
o Women with a history of low birth-weight infants.
o Women who don‟t gain sufficient weight during their
pregnancy.
2 Ghazi Dradkeh, M. Mohamed Essa and Nejib Guizani
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o Women with a frequent history of conception.
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o Women of low socioeconomic status.
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o Women with diseases that can influence the nutritional status
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e.g., Allergy, diabetes, tuberculosis, drug addiction, and
mental depression.
When nutritional assessment has been carried out successfully and high
risk populations have been identified the next step would be to follow the
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recommendations detailed below: [5]
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 Recommendation 1: Preconception folic acid; folic acid is provided
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as supplements in addition to the adequate intake of high folic acid
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food sources.
 Recommendation 2: Proper antenatal care which ensures a proper
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weight gain during pregnancy.
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 Recommendation 3: Iron and vitamin A supplementation during
pregnancy.
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 Recommendation 4: Nutritional counseling and education to ensure a
healthy diet during both pregnancy and lactation.
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 Recommendation 5: Breast feeding and nutritional education during
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emergencies.
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The main forms of maternal malnutrition include [6, 7]:
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 Macronutrient deficiencies: (Protein Energy Malnutrition - PEM)
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which is managed by ensuring adequate variety of foods to include the
6 major groups, adequate frequency of food intake, adequate amounts
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of food, and proper personal and environmental hygiene.
 Micronutrient deficiencies: such as vitamin A deficiency (VAD),
a
iron deficiency anemia (IDA), and iodine deficiency disorders (IDD);
these conditions result in increased risk of low birth weight, maternal
v
mortality, and neonatal and infant mortality. Anemia accounts for
o
approximately 20% of maternal deaths as it increases the risk of both
hemorrhage and prolonged labor, which can lead to sepsis.
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Management of micronutrient deficiency consists of supplementation
with fortified foods and mineral/vitamin formulations, and adequate
intake of foods rich in micronutrients such as fruits, dark-green and
brightly colored vegetables.
Nutritional Assessment during Pregnancy 3
.
Dietitians play a vital role in the delivery of care to the patients; as an
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integral part of the health care team; providing patients with optimal care.
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Dietitians must have guidelines for giving legal aspects of documentation and
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avoid the pitfalls of improper investigation, assessment process, and
documentation [8, 9].
,
Causes and consequences of maternal Malnutrition [6]:
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Causes and consequences of maternal Malnutrition [6]:
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Consequences:
Immediate causes:
Maternal Health
h
o Infections and o Increased risk of
diseases. maternal death
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o Poor access to o Increased risk of
basic health
l
infections.
services (e.g. o Anemia
Underlying Causes: inadequate iron o Compromised
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and folic acid immune
o Inadequate
supplementation) functions.
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maternal care.
o Frequent o Lethargy and
o Household food
parasites and weakness.
insecurity.
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infections. o Lower
o Unhealthy
o Inadequate food productivity.
environment,
intake due to diet
insufficient
characterized
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health services,
bylow, highly Infant/child Health
and poor hygiene
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variable over
and sanitation.
seasons, and o Increased risk of
oftenlow nutrient fetal and
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neonatal death.
density.
o Intrauterine
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growth
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retardation, low
birth weight,
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preterm birth.
o Compromised
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immune
functions.
Basic Causes o Birth defects.
o Cretinism and
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o Political structure reduced IQ.
o Resources and their control
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o Heavy workloads
o Frequent births
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o Harmful local practices and food taboos.
o Intra-household food distribution does not favor women.
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.
GOALS AND OBJECTIVES
The main purpose of the maternal nutritional assessment is to support
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health care providers in the provision of maternal nutrition care and support
,
services, it can also be used by health training institutions and other
organizations, as well as other governing bodies implementing maternal
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nutrition interventions. These guidelines were established to break the
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intergeneration cycle of maternal malnutrition through outlining special
nutritional aspects that enable optimal nutritional status of the mother as well
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as providing much safer and ideal birth outcomes. Furthermore, to improve the
knowledge and skills necessary for the service providers at all levels to
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adequately respond to both maternal and infant nutritional needs; provide a
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basis for advocacy efforts which garner support for the maternal nutritional
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intervention at all levels.
To contribute to the reduction of maternal malnutrition the
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implementation of the following goals must be achieved: [5, 6]:
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 To improve the knowledge and skills of service providers at all levels
to respond to maternal and child nutritional needs.
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 To improve provision of quality maternal and child nutritional
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services at community and health facility level.
 To advocate for support of appropriate interventions that address
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maternal nutrition at all levels.
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 To facilitate health care providers and other stakeholders in
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interpersonal nutrition education and counseling, community
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dialogue, developing the health education for improved maternal
nutrition.
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 To strengthen integration of nutrition interventions for adolescent,
pregnant, and lactating women within existing health services.
va NUTRITIONAL ASSESSMENT FOR PREGNANCY
No Pregnant females who are in general at risk for nutritional problems at

even greater risk, and because of the importance of nutrition in the course and
outcome of pregnancy, all pregnant women should have a formal assessment
.
of their nutritional status at the beginning of their prenatal care with ongoing
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surveillance throughout the pregnancy [6].
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The purpose of the nutrition assessment is to:
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 Evaluate the nutritional status of the pregnant.
,
 Identify those pregnant who are at nutritional risk.
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 Formulate an individualized nutrition care plan with follow-up.
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The Nutritional assessment takes into account different aspects: including
relevant obstetric, medical, psychology and diet history, BMI along with
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weight gain, and lab tests and values.
1. Relevant History
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In order to have much more precise information; the following steps will
help [10, 11].
Obstetric History
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 Women with previous pregnancies may be at increased nutritional risk
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as a result of depleted nutrient reserves, the length and time between
pregnancies can play a vital role as well especially if the time between
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pregnancies is less than one year.
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 History of pre-term delivery (<37 weeks of gestational) or low/high
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birth weight of infants the first could indicate nutritional problems
c
while the latter may suggest latent diabetes.
 History of weight gain during previous pregnancies and any
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pregnancy-related complications e.g., gestational diabetes,
hypertension, anemia, vomiting and nausea.
a
 Previous use of supplements or drugs e.g., contraceptives.
 The experience of breastfeeding.
o v Psychological History
 Economic status since limited and low income may mean limited food
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availability.
 Living situation.
 Access to medical care.
 Emotional health or any psychological/mental- related problems.
.
 Education level
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 Employment situation.
I n
Medical History
 The presence of any chronic or metabolic diseases e.g.,
,
cardiovascular, renal diseases or cystic fibrosis.
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 Physical disabilities
 Previous history of eating disorders e.g., anorexia and bulimia
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nervosa.
 Past or current intake of cigarettes smoking or alcohol.
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 Previous nutritional deficiencies.
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 History of medication usage.
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 Status of physical activity (type, duration, and intensity).
2. Anthropometric Measurements [12]
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 Pre-pregnancy BMI Classifications: According to recommendations
set by the Institute of Medicine (IOM).
Pre-pregnancy BMI categories
c e Values (kg/m2)
n
Underweight < 19.8
Normal 19.8-26
e
Overweight 26.1-29
i
Obese >29
c
 Pregnancy weight gain recommendations:
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Pre-pregnancy BMI Recommended total 1st trimester 2nd and 3rd
categories (kg/m2) weight gain trimester
a
Underweight 12.5-18 2.3 0.49
v
Normal 11.5-16 1.6 0.44
Overweight 7-11.5 0.9 0.30
o
Obese 6-7 ……… ………
Twins (any BMI) 16-20 ……… ………
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Triplet (any BMI) 23 ……… ………
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 MUAC (Mid-Upper Arm Circumference) [13]:
MUAC is a good indicator of the protein reserves of a body, and a thinner
nc
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arm reflects wasted lean mass, i.e., malnutrition. The WHO Collaborative
,
Study 1995 showed MUAC cut-off values of < 21 to 23 cm as having
significant risk for low birth weight (LBW).
g
in
3. References of Laboratory Values during Pregnancy
h
(According to University of Texas Southwestern Medical Center,
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Department of Obstetrics and Gynecology, Dallas, TX, USA) [14]:
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Table 1. Hematology
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Tests Non-pregnant 1st trimester 2nd trimester 3rd trimester
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Erythropoietin (U/L) 4–27 12–25 8–67 14–222
Ferritin (ng/ml) 10-150 6-130 2-230 1-116
Hemoglobin (g/dl) 12-15.8 11.6-13.9 9.7-14.8 9.5-15.0
e
Hematocrit (%) 35.4-44.4 31.0-41.0 30.0-39.0 28.0-40.0
TIBC (µg/dl) 251-406 278-403 Not reported 359-609
c
RBC (x 106/mm3) 4.0-5.2 3.42-4.55 2.81-4.49 2.71-4.43
WBC (x 106/mm3)
n
3.5-9.1 5.7-13.6 5.6-14.8 5.9-16.9
Platelet (x106/L) 165-415 174-391 155-409 146-429
e
Transferrin (mg/dl) 200-400 254-344 220-441 288-530
i
MCH (pg/cell) 27-32 30-32 30-33 29-32
MCV (µm3) 79-93 81-96 82-97 81-99
c
Lymphocytes (x 103/mm3) 0.7-4.6 1.1-3.6 0.9-3.9 1.0-3.6
Neutrophils (x 103/mm3) 1.4-4.6 3.6-10.1 3.8-12.3 3.9-13.1
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Table 2. Blood Chemistries
a
v
ALT (U/L) 7–41 3–30 2–33 2–25
o
AST (U/L) 12–38 3–23 3–33 4–32
Alk-Phos (U/L) 33–96 17–88 25–126 38–229
Pre-albumin (mg/dl) 17–34 15–27 20–27 14–23
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Albumin (g/dl) 4.1–5.3 3.1–5.1 2.6–4.5 2.3–4.2
Bilirubin (mg/dl) 0.3–1.3 0.1–0.4 0.1–0.8 0.1–1.1
Calcium (mg/dl) 8.7–10.2 8.8–10.6 8.2–9.0 8.2–9.7
Chloride (mEq/L) 102–109 101–105 97–109 97–109
Creatinine (mg/dl) 0.5–0.9 0.4–0.7 0.4–0.8 0.4–0.9
.
Table 2. (Continued)
nc
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Lactate dehydrogenase 115–221 78–433 80–447 82–524
,
(U/L)
Magnesium (mg/dl) 1.5–2.3 1.6–2.2 1.5–2.2 1.1–2.2
g
Phosphate (mg/dl) 2.5–4.3 3.1–4.6 2.5–4.6 2.8–4.6
Total Protein (g/dl) 6.7–8.6 6.2–7.6 5.7–6.9 5.6–6.7
in
Sodium (mEq/L) 136–146 133–148 129–148 130–148
BUN (mg/dl) 7–20 7–12 3–13 3–11
Uric acid (mg/dl) 2.5–5.6 2.0–4.2 2.4–4.9 3.1–6.3
h
Copper (µg/dl) 70–140 112–199 165–221 130–240
is
Vitamin B12 (pg/ml) 279–966 118–438 130–656 99–526
Vitamin D (pg/ml) 25–45 20–65 72–160 60–119
l
Zinc (µg/dl) 75–120 57–88 51–80 50–77
Folate (ng/ml) 5.4–18.0 2.6–15.0 0.8–24.0 1.4–20.7
b
Creatine kinase-MB (U/L) <6 Not reported Not reported 1.8–2.4
Troponin I (ng/mL) 0–0.08 Not reported Not reported 0–0.064
Tests
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Table 3. Blood Glucose
Pregnant women (all trimesters)
e
Fasting blood glucose < 95 mg/dl
c
1 Hour postprandial < 130-140 mg/dl
2 Hour postprandial < 120 mg/dl
n
Hemoglobin A1C (%) 4-6
75gm oral glucose test
e
Fasting 5.1 mmol/l
i
1 hour 10 mmol/l
2 hour 8.5 mmol/l
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Tests c Table 4. Endocrine & Sex Hormones
Non-pregnant 1st trimester 2nd trimester 3rd trimester
a
Sex hormone binding globulin 18–114 39–131 214–717 216–724
v
(nmol/L)
Progesterone (ng/mL) <1–20 8–48 Not reported 99–342
o
Testosterone (ng/dL) 6–86 25.7–211.4 34.3–242.9 62.9–308.6
Estradiol (pg/mL) <20–443 188–2497 1278–7192 6137–3460
N
Aldosterone (ng/dL) 2–9 6–104 9–104 15–101
Cortisol (_g/dL) 0–25 7–19 10–42 12–50
Parathyroid hormone (pg/mL) 8–51 10–15 18–25 9–26
Thyroid stimulating hormone 0.34–4.25 0.60–3.40 0.37–3.60 0.38–4.04
(TSH) (_IU/mL)
.
Table 5. Lipids
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Total cholesterol <200 141–210 176–210 176–210
,
(mg/dl)
HDL-C (mg/dl) 40–60 40–78 52–87 48–87
g
LDL-C (mg/dl) <100 60–110 77–110 101-110
TG (mg/dl) <150 40-150 75-150 131-150
4. Dietary Intake/Needs [1]
h in
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 Estimated Needs: According to National academy of science institute
l
of medicine guidelines for pregnancy:
b
BMI (kg/m2) Estimated calories intake/kg/day
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Underweight (<19.8) 36-40
Normal Weight (19.8-26) 30
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Overweight (26.1-29) 24
Obese (>29) 12-18
Twin Gestational Addition of 500 Kcal/day to the above recommendations
c e
According to the caloric distribution during pregnancy, carbohydrate
is 45-55%, protein 15-20% and fat is 35%.
n
 Estimated needs from fluid: The recommended fluid needs for
e
pregnancy (8-10 cups/day) around 2000 -2500 ml.
c i
According to Institute of Medicine (IOM):
S
The needed components Estimated needs for pregnant women
Energy (Kcal) + 0 (1st trimester)
a
+ 340 (2nd trimester)
+ 452 (3rd trimester)
v
Protein (g) 71
Vitamin A (mcg) 750-770
o
Vitamin D (meg) 5
Vitamin E (mg) 15
N
Vitamin K (meg) 75-90
Vitamin C (mcg) 80-85
Thiamin (mcg) 1.4
Riboflavin (mg) 1.4
Niacin (mg) 18
.
(Continued)
nc
The needed components Estimated needs for pregnant women
I
Vitamin B6 (mcg) 1.9
Folate (mcg) 600
,
Vitamin B12 (mcg) 2.6
Calcium (mg) 1300
g
Phosphorus (mg) 700-1250
Magnesium (mg) 350-400
in
Iron (mg) 27
Zinc (mg) 11-12
h
Iodine (mcg) 220
l is
PROPER WAYS OF CARRYING OUT THE HISTORY
b
OF DIETARY INTAKE
u
The purpose of assessing the dietary intake is to evaluate the nutritional
P
quality of the diet. Food intake information may be obtained by different
methods including: 24-hour food recall, food frequency questionnaire, food
record; and diet history.
e
The method chosen depends on the specificity desired, the time available,
c
the cooperation of the patients, and the training of the personnel.
n
Dietary Assessment methods
e
Methods Strength Limitation Application
i
24-hours Does not require Dependent on Appropriate for most
recall(15) literacy, Relatively respondent‟s memory, people as it does not
c
low respondent Relies on self-reported require literacy, Useful for
burden, Data may be information, Requires the assessment of intake of
S
directly entered into a skilled staff, Time a variety of nutrients and
dietary analysis consuming, Single recall assessment of meal
program, May be does not represent usual patterning and food group
a
conducted in-person intake. intake, Useful counseling
or over the telephone. tool.
v
Food Quick, easy and Does not provide valid Does not provide valid
frequency affordable, May estimates of absolute estimates of absolute intake
o
(16-18) assess current as well intake of individuals, for individuals, thus of
as past diet, In a Can‟t assess meal limited usefulness in
N
clinical setting, may patterning, May not be clinical settings, May be
be useful as a appropriate for some useful as a screening tool,
screening tool. population groups. however, further
development research is
needed.
.
Dietary Assessment methods
c
Methods Strength Limitation Application
n
Food Does not rely on Recording foods eaten Appropriate for literate and
I
record memory, Food may influence what is motivated population
(19-27) portions may be eaten, Requires literacy, groups, Useful for the
,
measured at the time Relies on self-reported assessment of intake of a
of consumption, information, Requires variety of nutrientsnd
g
Multiple days of skilled staff, Time assessment of meal
records provide valid consuming. patterning and food group
in
measure of intake for intake, Useful counseling
most nutrients. tool
h
Diet Able to assess usual Relies on memory, Time Appropriate for most
history intake in a single consuming (1 to 1-1/2 people as it does not
is
(28) interview, hours), Requires skilled require literacy, Useful for
Appropriate for most interviewer. assessing intake of
l
people. nutrients, meal patterning
b
and food group intake,
Useful counseling tool.
CASE STUDY
P u
e
Mrs. Jo is a 27- year- old woman, at 29 weeks of pregnancy; her pre-
pregnancy weight was 63 kg, height 158cm. She asked her doctor to refer her
c
to a dietitian to discuss her nutritional status. She was asked to record her food
n
intake for 3 days prior to the appointment. Results of dietary analysis
performed by the dietitian showed the following average caloric and nutrient
i e
intake levels:
c
Energy: 1850 Kcal
S
Protein: 65 gm
Vitamin B 12: 1.7mcg
Vitamin D: 5 mcg (200IU)
a
Zinc: 12mcg
v
1. Calculate Mrs, Jo BMI?
o
2. What is the recommended weight gain for Mrs. Jo?
3. Is Mrs. Jo consuming enough energy and protein?
N
4. Based on the presented information, which nutrients are consumed in
amounts that are below the RDI standard for pregnancy?
.
REFERENCES
[1] Lorna, D. & Ruth, D. (2013). Nutrition in Pregnancy and Childbirth:
nc
I
Food for Thought. Routledge, New York; USA.
,
[2] Jacotot. B, Campillo. B, Nutritional Epidemiology and Prevention in
Human Nutrition, edition. Masson, Paris; 2003, 311p; 273-274.
g
[3] Morris, C. (2011). Dietitians’ guide to assessment and documentation.
in
Jones and Bartlett publishers, New York, USA.
[4] Prado C., Rovilles S. F. Acevedo P. Nutritional state of the pregnant
h
women of Maghrebian origin and their infants: the situation in France
and Spain, Anthropo, 2004. 7, 139-144.
is
[5] Costello, A.M., Osrin, D. (2003). Micronutrient status during pregnancy
l
and outcomes for newborn infants in developing countries. Journal of
Nutrition, 133: 1757s-1764s.
b
[6] Anthony, K. (2010). Guidelines on maternal Nutrition, 1st edition.
u
Ministry of health, Uganda.
[7] Fowles, E.R. (2004). Prenatal Nutrition and Birth Outcomes. Journal of
P
Obstetric, Gynaecological, & Neonatal Nursing, 33: 809-822.
[8] Fall, C.H, Yajnik, C.S., Rao, S., Davies, A.A., Brown, N. & Farrant, H.J.
e
(2003). Micronutrients and foetal growth. Journal of Nutrition, 133:
c
1747s-1756s.
[9] Gibney. M.J., Margetts, B.M., Kearney, J.M & Arab, L (eds). (2007).
n
Public Health Nutrition. Chapter 3: Assessment of nutritional status in
e
individuals and populations. Blackwell Publishing Company: USA.
i
[10] Li XY, Jiang Y, Hu N, Li YC, Zhang M, et al. (2012) [Prevalence and
c
characteristic of overweight and obesity among adults in China, 2010].
Zhonghua Yu Fang Yi Xue Za Zhi 46: 683–686.
S
[11] Han Z, Mulla S, Beyene J, Liao G, McDonald SD (2011) Maternal
underweight and the risk of preterm birth and low birth weight: a
a
systematic review and meta-analyses. Int J Epidemiol 40: 65–101. doi:
10.1093/ije/dyq195.
v
[12] Kruger, HS. (2005). Maternal anthropometry and pregnancy outcomes: a
o
proposal for the monitoring of pregnancy weight gain in outpatient
clinics in South Africa. Curationis 28(4): 40-49.
N
[13] Cogill B. Anthropometric indicators measurement guide Series Title II
Indicators Guide. Revised edition. Food and Nutrition Technical
Assistance Project (FANTA). 2003.
.
[14] Larsson A, Palm M, Hansson L-O, et al. Reference values for clinical
c
chemistry tests during normal pregnancy. Br J Obstet Gynaecol
n
2008;115:874.
I
[15] Thompson F, et al: need for technological innovation in dietary
assessment. J Am Diet Assoc 110:48,2010.
,
[16] Willett WC, Sampson L, Stampfer MJ, et al. Reproductibility and
g
validity of a semiquantitative food frequency questionnaire. Am J
Epidemiol 1985;122:51-65.
in
[17] Salvini S, Hunter DJ, Sampson L, et al. Food-based validation of a
dietary questionnaire: the effect of week-to-week variation in food
h
consumption. Int J Epidemiol 1989;18:858-67.
is
[18] Liu S, Sampson L, Hu F, Willett W. Methodological consideration in
l
applying metabolic data to an epidemiologic study using a semi-
quantitative food frequency questionnaire. Eur J Clin Nutr
b
1998;52:S87(abstr).
u
[19] Lafay L, Mennen L, Basdevant A, et al. (2000) Does energy intake
underreporting involve all kinds of food or only specific food items?
P
Results from the Fleurbaix Laventie Ville Sante (FLVS) study. Int J
Obes Relat Metab Disord 24, 1500–1506.
e
[20] Samaras K, Kelly PJ & Campbell LV (1999) dietary underreporting is
prevalent in middle-aged British women and is not related to adiposity
c
(percentage body fat). Int J Obes Relat Metab Disord 23, 881–888.
n
[21] Luhrmann PM, Herbert BM & Neuhauser-Berthold M (2001)
e
Underreporting of energy intake in an elderly German population.
i
Nutrition 17, 912–916.
c
[22] Hirvonen T, Mannisto S, Roos E, et al. (1997) Increasing prevalence of
underreporting does not necessarily distort dietary surveys. Eur J Clin
S
Nutr 51, 297–301.
[23] Mahabir S, Baer DJ, Giffen C, et al. (2006) Calorie intake misreporting
a
by diet record and food frequency questionnaire compared to doubly
labeled water among postmenopausal women. Euro J Clin Nutr 60, 561-
v
565.
o
[24] Koebnick C, Wagner K, Thielecke F, et al. (2005) An easy-touse
semiquantitative food record validated for energy intake by S84 K.
N
Poslusna et al. using doubly labelled water technique. Eur J Clin Nutr
59, 989–995.
.
[25] Kretsch MJ, Fong AK & Green MW (1999) Behavioral and body size
c
correlates of energy intake underreporting by obese and normal-weight
n
women. J Am Diet Assoc 99, 300–306, quiz307–308.
I
[26] Hoidrup S, Andreasen AH, Osler M, et al. (2002) Assessment of
habitual energy and macronutrient intake in adults: comparison of a
,
seven day food record with a dietary history interview. Eur J Clin Nutr
g
56, 105–113.
[27] De Vries JH, Zock PL, Mensink RP, et al. (1994) Underestimation of
in
energy intake by 3-d records compared with energy intake to maintain
body weight in 269 nonobese adults. Am J Clin Nutr 60, 855–860.
h
[28] Aronson V, Fitzgerald B, Hewes LV, eds. Guidebook for nutrition
is
counselors, 2nd ed. Prentice Hall, Englewood Cliffs, New Jersey, 1990.
b l
P u
c e
en
c i
S
va
No
c .
I n
Chapter 2
g ,
h in
is
DURING LACTATION
b l
u
Nutritional assessment of lactating women is important for prioritizing,
designing and creating intervention programs for maternal nutrition
P
improvement. Nutritional assessment should be comprehensive and include
analysis of eating behavior, food resources, lifestyle choices, cultural
e
practices, food intake, and appetite and food preferences. During lactation
nutritional requirements are greater than during pregnancy. To achieve proper
c
lactation and sustain nutrient stores without depletion, mothers should be
n
counseled about their nutrients need, particularly intake of protein, vitamins
and calcium [1]. Child mortality risk is increased among severely
i e
malnourished mothers due to reduction in lactation performance [2]. On
average 0.7 to 0.8 liters of milk is produced per day, containing 330
c
milligrams of calcium per liter. Because of milk quality depends on mothers
diet, at least 500 calories/day extra is required to compensate daily milk
S
production [3].
va ANTHROPOMETRIC ASSESSMENT
o
Body composition indices can be estimated by anthropometric
N
measurements. Biceps, triceps, supra-iliac, and subscapular skinfold thickness
is measured by a Holtain skinfold caliper (UK) [4]. These indices are used to
estimate body density [5]. Body fat (BF) and body fat percentage by using the
Siri equation [6], Fat Free Mass (FFM) is calculated based on maternal body
.
weight (BW) as FFM = BW – BF [7, 8]. Mild to chronic under nutrition is
c
defined as BW less than 52 kg and FFM less than 42.8 kg respectively [9].
n
During lactation Butte et al. 1984 [10] and at 6 months postpartum [11],
I
many anthropometric indicators change from pre pregnancy values. The rate
of these changes is affected by many factors including: delivery route and
,
edema during pregnancy [12], parity, maternal age, pre-pregnancy weight,
g
postpartum weight [13] and weight gained during pregnancy [14].
Heinig et al., 1990 [15] found that during the first 4 to 6 postpartum
in
months weight loss ranged between 0.6 to 0.8 kg/month. Postpartum loss is
continued up to 12 months but at a slower rate than in the first 6 months.
h
Significant relation was found between lactation score (a measure of the
is
intensity and duration of breastfeeding) and weight loss. The strongest relation
l
between weight loss and lactation score was between 2.5 and 6 months
postpartum [16], decrease of biceps, subscapular and suprailliac skinfold
b
thickness was reported during 4 – months postpartum while an increase in
u
triceps was reported [17].
P
BIOCHEMICAL ASSESSMENT
e
Hemoglobin is one of the most important biochemical indicators of
c
nutritional anemia which is defined as values less than 12g/dl. [18], while
n
serum ferritin concentration is considered an indicator of iron status depletion,
it is classified as shown in Box 1 [19] .
c i e Box 1. Classification of Iron Store Depletion
S
Ferritin Concentration µg/L Depletion of Iron Store
< 12 Severe
12 – 29 Marginal
a
≥ 30 Normal
v
Serum retinol concentration is an indicator of vitamin A deficiency and
o
classified as shown in Box 2 [20].
During lactation blood values of vitamins, minerals, hormones, protein
N
metabolism and other metabolites are affected, for example, in lactating
women the level of insulin and glucose are very different than in the same
women after cessation of lactation [21, 22, 23, 24] reported that concentrations
of vitamins and minerals change during lactation, for example, increase of
Nutritional Assessment during Lactation 17
.
serum zinc concentration and decrease of serum copper between first and
c
second weeks and between 19th and 21st weeks of lactation. A lower nitrogen
n
balance was reported among lactating women compared with non-lactating
I
postpartum and nulliparous women at similar levels of nitrogen intakes.
,
Box 2. Classification of Vitamin A Depletion
g
Serum Retinol Vitamin A
in
< 0.35 µmol/L Deficient
< 0.70 µmol/L Marginal
h
Table 1. Sample Meal Pattern 1800 Calories
l is
Meal Milk Fruit Vegetables Bread Meat Fat
b
Breakfast 1 1 - 2 - 1
Snack - 1 - 1 - 1
u
Lunch - 1 2 2 2 2
Snack - 1 - 1 - 1
P
Dinner - 1 1 2 2 2
Snack 1 1 - - - -
e
Meal
Breakfast
n
Milk
1 1
c
Fruit Vegetables
-
Bread
3
Meat
-
Fat
2
e
Snack - 1 - 1 - 1
i
Lunch - 1 2 2 2 2
c
Snack - 1 - 1 - 1
Dinner - 1 1 2 2 3
S
Snack 1 1 - 1 - -
va Meal Milk Fruit Vegetables Bread Meat Fat
o
Breakfast 1 2 - 3 - 2
Snack - 1 - 1 - 1
Lunch - 1 2 2 3 2
N
Snack - 1 - 1 - 1
Dinner - 1 1 3 2 3
Snack 1 1 - 1 - -
.
Table 4a. Nutrient – Dense Food(38)
nc
Calcium Rich Food Folic Acid Rich Food Vitamin C Rich Food
I
Milk leafy vegetables citrus fruits and juices
Yoghurt green beans strawberries
,
Cheese legumes broccoli
Sardines/salmon with bones whole grain cereals cabbage
g
Dark green leafy vegetables fruits Potato
in
Dried beans and peas
Fortified Tofu
Fortified tortillas
h
Fortified orange juice
is
Table 4b. Nutrient – Dense Food(38)
Vitamin A Rich Food

Dark green leafy vegetables
Zinc – Rich Foods
beef
b l Vitamin– B6 – Rich Foods

banana
u
Dark orange/yellow poultry watermelon
vegetables
P
Liver seafood meat
Egg yolk eggs seafood
e
Cheese legumes potatoes
Milk yoghourt sweat potatoes
c
Margarine whole grains nuts
n
Seeds
Fortified cereals
c i e ENERGY RECOMMENDATION
S
Energy requirements during lactation are 2700 calories per day. This
recommended energy includes: quantity of milk produced, body fat stores that
a
supply energy for lactation, and the efficiency of the ratio of maternal energy
v
to milk energy [25]. The ratio of energy in the milk to the amount of energy
spent in producing the milk is called the efficiency of milk production. An
o
efficiency of 80% was recommended by world health organization [26], while
97% efficiency of human milk was reported by [27] an additional of 500
N
calories per day during lactation over the non pregnant state for the first six
months of the postpartum. The additional amount of energy over non pregnant
non lactating (NPNL) can be achieved by increasing energy intake, reducing
energy expenditure by decreasing physical activities, increasing the efficiency
.
of energy use for basal or postprandial metabolism and using tissue energy
c
reserves. As a general rule and according to RDA, to ensure adequate intake of
n
essential nutrients, lactating women should consume at least 1800 calories per
I
day. These recommendations may need reevaluation according to current
researches [28], Tables 1, 2 & 3 show samples meals pattern for 1800, 2000,
,
and 2200 calories respectively.
g
in
CALCIUM
h
Many studies establish the importance of calcium during and after
is
lactation, due to its effect on bone mineralization, therefore adequate intake of
l
calcium must be achieved. Calcium rich foods must be introduced to women
who have lactose intolerance or a strong dislike of milk and milk products
b
(Table 6). The Institution of Medicine [29] suggests ways to encourage the
u
consumption of milk products ensuring an adequate intake of calcium in
women with lactose intolerance, because lactose intolerance often risks the
P
pregnancy. These suggestions include:
e
Try small serving 3 oz of whole milk several times daily.
 Try yogurt containing active, live cultures.
c
 Try aged cheese such as cheddar cheese.
n
 Try taking lactase tablets or drops when drinking milk.
 Try lactase – treated milk and milk products.
i e
 Try cultured buttermilk for drinking or baking.
S c OTHER MICRONUTRIENTS
a
Breast milk content of vitamins and minerals depends on current intake
and maternal stores. In some cases if a woman is vegetarian or has limited sun
v
exposure, has religious or cultural or self – imposed food restrictions, vitamin
o
specific supplementation may be recommended [30].
N
c .
I n
g ,
i n
Table 5. Key Nutrients in Each Food Group
h
Protein Vitamins Minerals
il s
A C D E B12 B6 Folic Acid Ca Fe Zn Mg
Protein foods
Animal ** ** ** ** **
Vegetable protein ** * ** ** ** ** **
b
Milk products ** * ** ** * ** *
Bread/cereals/grain
u
Whole grains * * ** ** * * **
enriched * *
Fruits/vegetables
P
Vitamin C Rich
Vitamin A Rich * ** * *
Others ** *
e
Unsaturated fats ** * **
Miscellaneous **
c
Table 6. Calcium Content of Food Sources Replacing Milk
n
Food equal to about 1-cup Food equal to about 1/2-cup of Food equal to about 1/3-cup of milk in Food that can be made
e
of milk in calcium content milk in calcium content calcium content high in calcium
i
 3 - oz of sardines with  3 – oz of canned salmon with  1 cup of cooked dried beans  Soups made from
 4 oz of kale
c
bone. bones bones cooked with
 8 – oz of calcium  4 – oz of tofu  4 oz of turnip green vinegar or tomato
fortified orange juice  4 oz of collards  1 medium square of corn  Macaroni and
S
 4 corn tortillas if processed with  2 pan cakes cheese
calcium salt  7-9 oysters
 3 oz of shrimps
va
N o
c .
I n
g ,
i n
Table 7. RDA for pregnant and lactating woman compared to RDA for non-pregnant, non-lactating woman
h
Non pregnant Pregnant Lactating
il s
Non lactating 0 - 6 months 6 -12 months
Protein (g) 45 -50 55 – 60 60 – 65 57 – 62
Vitamin C (mg) 60 70.0 95.0 90.0
b
Niacin (mg NE) 15 17.0 20.0 20.0
Thiamin (mg) 1.1 1.5 1.6 1.6
u
Riboflavin (mg) 1.3 1.6 1.8 1.7
Vit. B6 (mg) 1.6 2.2 2.1 2.1
P
Vit B12(µg) 2.0 2.2 2.6 2.6
Vit D (µg) 5 10 10 10
Vit. K (µg) 65 65 65 65
e
Vit. A (RE) 800 800 1200 1200
Vit E (mg-Ate) 8 10 12 11
c
Iron (mg) 15 30 15 15
n
Folic acid (µg) 180 400 280 260
Calcium (mg) 800 1200 1200 1200
e
Selenium (µg) 55 65 75 75
i
Magnesium (mg) 280 320 355 340
Zinc (mg) 12 15 19 16
c
Iodine (µg) 150 175 200 200
Phosphorus (mg) 800 1200 1200 1200
S
va
N o
.
WEIGHT LOSS
Weight loss is recommended for lactating women if prior to becoming
nc
I
pregnant they were overweight or obese. Prepregnancy obese women should
,
have 6.5 pounds per month weight loss once lactation is established while in
women with normal Body Mass Index prior to pregnancy a weight loss of 4.5
g
pounds per month is recommended [29]. Weight related problems during
in
lactation are shown in Table 8.
h
VEGETARIANISM
l is
Barth et al., 1985 [31], Dagnelie et al, 1992 [32] reported that protein,
b
vitamin B12, magnesium, calcium, iron, riboflavin, vitamin D, B6, zinc, and
carnitine are lower in breast milk of vegan or liberal macrobiotic women. The
u
high fiber content in the vegetarian diet of lactating women may be significant
in causing a decrease in the the bioavailability of some minerals (iron and
P
zinc) [33]. Exclusively breast fed infants by vegetarian women have been
reported to have vitamin B12 deficiency and nutritional rickets [34-36].
e
Table 8. Weight Related Problems during Lactation
n
All Breast Feeding Women
c Women with Normal Pre-Pregnancy Weight for
e
Height
i
Slow infant growth despite frequent weight loss > 4.5 Lb (~ 2 kg) per month after
c
feeding and other breastfeeding first six months postpartum
techniques weight loss < normal weight for height
S
weight loss > normal weight for height
Women with Low Pre - Pregnancy Weight for Height
a
Any weight loss after the weight returns to the pre pregnancy weight
Weight loss > 4.5 lb(~ 2 kg) per month after the first six months postpartum
v
Women With High or Very High Pre - Pregnancy Weight for Height
o
Weight loss in excess of 6.5 lb (~ 3 kg) per month after first month postpartum
Postpartum weight gain
Adopted from Institute of Medicine (IOM), National Academy of Science (1992),.
N
Nutrition during Pregnancy and Lactation- An Implementation Guide. Committee
on Nutritional Status during Pregnancy and Lactation. Washington, DC: National
Academy Press, p 86. Reprinted with permission.
.
Vegetarian women were found to have very low concentration of poly
c
unsaturated fatty acid (VLCPUFA) in their breast milk. Canola oil, safflower
n
oil, or sun flower oils consumption may be recommended to improve the
I
VLCPUFA content in their milk, or supplementation with a product containing
docosahexaenoic acid DHA can be considered [37].
REFERENCES
g ,
in
[1] Department of Health Directorate Nutrition: Guidelines on Maternal
h
Nutrition. South Africa: A manual for Health Care Personnel; 2008.
is
[2] Demissie T, Mekonen Y, Haider J: Agro-ecological comparison levels
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and correlate of nutritional status of women. Ethiop J Health Dev 2003,
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b
[3] Sylvia B, Mary Dowd S: The Nursing Mother’s Diet. The art of
u
Successful Breastfeeding: A Mother‟s Guide. 2002. http://www.
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P
[4] Gibson rs. Anthropometric measurement of body composition, in:
Gibson rs ed principals on nutritional assessment. New york: oxford
e
university press. 1990:187-208.
[5] Durnin JVG, Womersley J, Body fat assessed from total body density
c
and its estimation from skinfold thickness: measurements in 481 men
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and women aged from 16 to 72 years. Br J Nutr 1974: 32: 77 – 97.
[6] Siri WE. Body composition from fluid spaces and density:analysis of
i e
methods. In: Techniques for Measuring Body Composition. Washington,
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1961:223 – 224.
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[7] Roche AF, Siervogel RM, Chunlea WC, Webb P, Grading body fatness
fromlimited anthropometric data. Am J Clin Nutr 1981, 34:2831 – 2838.
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Med 1988, 5:11-40.
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[9] Shetty PS. Adaptationto low energy intakes: the responses and limits to
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[10] Butte, N.F., C. Garza, J.E. Stuff, E.O. Smith, and B.L, Nichols. 1984.
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Effect of maternal diet and body composition on lactational
performance. Am. J. Clin. Nutr.39: 296-306.
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[11] Sadurskis, A., N. Kabir, J. Wager, and E. Forsum. 1988. Energy
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metabolism, body composition, and milk production in health Swedish
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women during lactation. Am. J. Clin. Nutr. 48:44-49.
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[12] Dennis, K.J., and W. R. Bytheway. 1965. Changes in body weight after
delivery. J. Obster. Gynaecol. Br. Commonw. 72:94-102.
,
[13] Brewer, M.M, M.R. Bates, and L. P. Vannoy. 1989. Postpartum changes
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in maternal weight and body fat depots in lactating vs non lactating
women. Am. J. Clin. Nutr.49:259-265.
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[14] Greene, G. W., H. Smiccikklas, Wright, T. O. Scholl, and R. J.
Karp.1988. Postpartum weight change: how much of the weight gained
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in pregnancy will be lost after delivery? Ostet. Gyneocol. 71:701-707.
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[15] Heinig, M. J., L.A. Nommsen, and K. G. Dewey. 1990. Lactation and
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postpartum weight loss. FASEB J. 4:362 (abstract).
[16] Ohlin, A., and Rossner.1990. Maternal body weight development after
b
pregnancy. Int. J. Obes.14:159-173.
u
[17] Dugdale, A. E., and J. Eaton-Evans.1989. The effect of lactation and
other factors on post-partum changes in body – weight and triceps skin
P
fold thickness. Br. J. Nutr. 61:149-153.
[18] ACC/SCN. Fourth Report on the World Nutrition Situation. Nutrition
throughout the life cycles... Geneva: ACC/SCN in collaboration with
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IFPRI, 2000.
c
[19] Yip R, Iron deficiency. Contemporary scientific issue and international
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programmatic approaches. J Nutr 1994, 124: 1479S- 1490S.
[20] World Health Organization. Indicators for assessing vitamin A
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Deficiency and Their Application in Monitoring and Evaluating
i
Intervention Programmes. WHO/NUT/96.10 Geneva: WHO, 1996.
c
[21] Illingworth, P. J., R. T. Jung, P.W. Howie, P. Leslie, and T.E. Isles.1986.
Diminution in energy expenditure during lactation, Br. Med. J. 292:437-
S
441.
[22] Motil, K. J.,C.M. Montandon, D.L. Hachey, T. W. Boutton, P. D. Klein,
a
and C. Garza. 1989. Whole body proteinmetabolism in lactating and non
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lactating women. J. Appl. Physiol. 66:370-376.
[23] Motil, K. J., C.M. Montandon, M. Thotathuchery, and C. Garza. 1990.
o
Dietary protein and nitrogen balance in lactating and non lactating
women. Am J Clin Nutr. 51:378-384.
N
[24] Van., Der Elst, C. W., Dempster, D. L., Woods, and H. de V. Heese.
1986. Serum zinc and copper in thin mothers, their breast milk and their
infants. J. Trop. Pediatr. 32: 111-114.
.
[25] National Research Center (NCR) Food and Nutrition Board (1989).
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Recommendation Dietary Allowances, Report of the subcommittee on
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Tenth Edition of the RDAs, Commission on Life Sciences, Washington,
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DC: National Academy Press, 284.
[26] World Health Organization (WHO) (1985). Energy and Protein
,
Requirements. Report of the joint FAO/WHO/UNO meeting, WHO
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Tech Rep Ser, Geneva: WHO, 724:84-9.
[27] Thomson, AM, Hytten, FE, Billewicz, WZ(1970). The energy cost of
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lactation. Brit J Nutr, 24(2):565-72.
[28] Van Raaij, JM, Schonk, CM, Vermaat-Miedema, SH, Peek, ME,
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Hautvast, JG (1991). Energy cost of lactation and energy balances of
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well-nourished Dutch lactating women: reappraisal of the extra energy
l
requirements of lactation. Am J Clin Nutr, 53(3)612-9.
[29] Institute of Medicine (IOM) (1992b). Nutrition during Pregnancy and
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Lactation – An Implementation Guide. Committee on Nutritional Status
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during Pregnancy and Lactation, Food and Nutrition Board. Washington,
DC: National Academy Press, 44, 64-65, 86, 101-102.
P
[30] Institute of Medicine (IOM) (1991). Nutrition during Lactation
subcommittee on Nutritional During Lactation, Committee on
Nutritional Status During Pregnancy and Lactation, Food and Nutrition
e
Board. Washington, DC: National Academy Press, 22.
c
[31] Brath, CA, Roos, N, Nottbohn, B, et al. (1985). L-cartinine
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concentrations in milk from mothers on different diets. In: Schaub, J
(Ed), Composition and Physiological Properties of Human Milk.
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Amsterdam: Elsevier.
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[32] Dagnellie, PC,v anStaveren, WA, Roos, AH, Tuinstra, LGMT, Burema,
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J (1992). Nutrient and contaminants in human milk from mothers on
macrobiotic and omnivorous diets. Eur J Clin Nutr, 46:355-66.
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[33] Dagnellie, PC, vanStaveren, WA, Vergote, FJ, Dingjan, PG, van den
Berg, H, Hautvast, JG (1989). Increased risk of vitamin B12 deficiency
a
in infants on macrobiotic diets, Am J Clin Nutr, 50(4):818-24.
v
[34] Dagnellie, PC, Vergote, FJ, van Staveren, WA, van den Berg, H,
Dingjan, PG, Hautvast, JG (1990). High prevalence of rickets in infants
o
on macrobiotic diet, Am J Clin Nutr,51(2):202-8.
[35] Sills, IN, Skuza, KA, Horlick, MN, Schwartz, MS, Rapaport, R (1994).
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Vitamin D deficiency rickets: reports of its demise are exaggerated. Clin
Peditr, 33(8):491-3.
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[36] Specker, BL, Black, A, Allen, L, Morrow, F (1990). Vatamin B12: low
c
milk concentration in vegetarian women and methylmalonic aciduria in
n
their infants. Am J Clin Nutr, 52(6): 1073-6.
I
[37] Makrides, M, Neumann, MA, Gibson, RA (1996). Effect of maternal
docosahexaenoic acid (DHA) supplementation on breast milk
,
composition. Eur J Clin Nutr, 50:352-7.
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[38] Darmon N, Briend A, Drewnowski A. Energy-dense diets are associated
with lower diet costs: A community study of French adults. Public
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Health Nutr. 2004; 7:21–7.
is h
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No
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Chapter 3
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NUTRITIONAL ASSESSMENT OF INFANCY
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AND CHILDHOOD
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Low Birth Weight (LBW): is an infant who weighs less than 2500g (5 ½
lb).
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Very Low Birth Weight (VLBW): is an infant who weighs less than
1500g (3 1/3lb).
e
Extremely Low Birth Weight (ELBW): is an infant who weighs less
than 1000g (2 ¼ lb).
c
Infant: is referred for who born between 37th and 42nd weeks of gestation.
n
Premature: infant born before 37 weeks of gestation.
Post – term: infant born after 42 weeks of gestation.
i e
Small for Gestational Age (SGA): infant is defined as one who weighs
less than 10th percentile of the standard weight for that gestational age.
c
The appropriate for Gestational Age (AGA): infant has a birth weigh
between the 10th and 90th percentiles on the intrauterine growth chart.
S
Large for Gestational Age (LGA): is the infant whose birth weight is
above the 90th percentile. Figure 1 shows the classification of neonates based
a
on maturity and intrauterine growth [1].
v
Preterm infants who are born with more extracellular water lose some
weight after birth. However, postnatal weight loss should not be excessive.
o
Preterm infants who loss more than 15% to 20% of their birth weight may
become dehydrated as a result of inadequate fluid intake and may become
N
tissue wasting from poor energy intake, by the second or third week of life
birth weight should be regained. Weight progress is assessed by using Hall
growth chart, during the first 40 days of life. Figure 2 shows the Hall growth
chart during the first 40 days of life [2].
.
In addition to weight, measurements of length and head circumference are
c
important anthropometric parameters. To evaluate growth adequacy by all
n
three parameters, growth curves Figure 3 can be used. Infant growth can be
I
followed on one chart through the first year of age [3]. Anthropometry is the
measurement of body size, weight, height and proportions [4-6], it is consider
,
a method for estimating body composition in clinical settings [7]. It can be a
g
sensitive indicator for health, growth and development of infants and children
[5]. In addition it can be used to evaluate nutritional status and monitor the
in
effect of nutrition intervention for diseases [4-8]. To assess the growth rate and
nutritional status of premature infants, age should be corrected (or adjusted)
h
for prematurity [3] which is based on the national center for health statistics
is
curves for full- term infants from birth to 3 years of age. For example, an
l
infant born at 28 weeks of gestation is 12 weeks premature. At 4 months
postnatal age, it can be compared with those of 1- month – old infant born at
b
term (Table 1) [19].
P u
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va
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Figure 1. Classification of neonates based on maturity and intrauterine growth. SGA,
small for gestational age. AGA, appropriate for gestational age. LGA, large for
gestational age. (Adopted from Battaglia FC, Lubchenco LO. A practical classification
N
of newborn infants by weight and gestational age. J Pediatr 71: 159, 1967.)
c .
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Figure 2. Weight chart for premature infant based on actual growth data. (From Shaffer SG, et al. Postnatal weight changes in low –
birth weight infants. Pediatrics 79:702.1987).
va
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Figure 3. An example of a growth record of weight, length, and head circumference for infants from 26 weeks gestation to 1 year of age.
S
This chart has a built –in correction factor for prematurity.(From Babson SG, Benda GI. Growth graphs for the clinical assessment of
infants of varying gestational age. J Pediatric 89:814, 1976).
va
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Nutritional Assessment of Infancy and Childhood 31
.
Table 1. Steps of correcting or adjusting age for premature infants
1- Calculate the number of weeks the infant was premature.
nc
I
40 weeks (term) – birth gestation
2- Number of weeks early = the correction factor
,
3- Chronological age – correction factor = adjusted age for premature infant
g
Example:
1- 40 weeks – 28 weeks gestation = 12 weeks early
in
2- 12 weeks or 3 months is the correction factor
3- 4 months (chronological age) – 3 months corrected factor = 1 month
h
adjusted age.
LENGTH, STATURE, AND HEAD CIRCUMFERENCE
l is
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The most essential and easy anthropometric measurements are length,
stature (height), weight and head circumference. It is most sensitive and
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commonly used as health indicators among infants and children.
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NUTRITION ASSESSMENT DURING CHILDHOOD
n c
Periodic nutritional assessments of children allow the detection of any
problems and early treatment. Assessment of children´s nutritional status
i e
includes length or height, weight, weight for height and/or Body Mass Index
(BMI), all of which are plotted as percentiles on the national center for health
c
statistics (NCHS) growth charts. Upper Arm Circumference (UAC), triceps
and sub scapular fat fold are less commonly used to estimate of body
S
composition [9].
Statures for age, weight for age, weight for stature and BMI for age are
a
compared with standards obtained from large number of healthy, normal
v
children to assess child‟s growth and development. It also helps in estimating
basal energy expenditure [10].
o
Length is measured with the subject lying down, in a supine or face – up
position, for children up to 24 months of age or who cannot stand erectly
N
without assistance [5, 11]. Length measurement needs a special device with
stationary headboard and movable footboard that are perpendicular to the
backboard. This device has zero ends at the edge of the headboard, the child
.
length can be read from footboard (Figure 4) [5], and it scales (in millimeter or
c
inches).
Childs head should be against the headboard, child‟s shoulders and
I n
buttocks securely touching the backboard, shoulders and hips at right angles to
the long axis of the body. Childs legs should be straight and against the
,
backboard, footboard should be pressed firmly enough from the bottom of the
g
feet (without shoes or socks) to compress the soft tissues of the soles. Length
should be recorded to the nearest 0.1 cm or 1/8 in [5, 11].
in
Stature or standing height can be measured for children 2-3 years of age
and older, or those who are able to stand erectly without assistance, it can be
h
measured by a stadiometer such as a harpenden stadiometer. The child should
is
be barefoot and wear minimal clothing; stand with heels together, arms to the
l
side, legs straight, relaxed shoulders and head in the Frankfort horizontal plane
(look straight ahead) (Figure 5), this plane is represented by a line between the
b
lowest point on the margin of the orbit (the bony socket of the eye) and the
u
tragion (the notch above the tragus, cartilaginous projection just anterior to the
external opening of the ear) with the head in line with the spine, this plane
P
should be horizontal [11], back of the head should be against the vertical
surface of the stadio meter (Figure 6).
c e
en
c i
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va
No Figure 4. Special device for measuring the length of children who cannot stand erectly
without assistance, the device has a stationary headboard and movable footboard.
.
Moore WM. Roche AF. 1983. Pediatric Anthropometry, 2 nd ed. Columbus, OH: Ross
c
Laboratories.
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Figure 5. Length and stature are measured with the head in the Frankfort horizontal
plane Gordon CC, Chumlea WC, Roche AF. 1988. Stature, recumbent length, and
P
weight. In Lohman TG, Roche AF, Marturell R (eds.), Anthropometric Standardization
references manual. Champaign, IL: Human Kinetics Books.
c e
en
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va
No Figure 6. Body position when measure stature. (Moore WM and Roche AF. 1983.
Pediatric Anthropometry, 2 nd ed. Columbus, OH: Ross Laboratories.)
.
The headboard is lowered on the highest point of the head with gentle
c
pressure to compress the hair. The measurement read to the nearest 0.1 cm or
n
1/8 inch.
, I
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h in
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Figure 7. Head circumference measurement. The lower edge of the tape should be just
above the eyebrows and ears, around the occipital prominence of the head, tight
enough to compress the hair. (Moore WM and Roche AF. 1983. Pediatric
e
Anthropometry, 2nd ed. Columbus, OH: Ross Laboratories.)
n c
c i e
S
va Figure 8. adapted from Infant weighing on a pan – type pediatric electronic scale.
o
(Moore WM and Roche AF. 1983. Pediatric Antrhopometry, 2nd ed. Columbus, OH:
Ross Laboratories. Gordon CC, Chumlea WC, Roche AF. 1988. Stature, recumbent
N
length, and weight. In Lohman TG, Roche AF, Marturell R (eds.), Anthropometric
Standardization references manual. Champaign, IL: Human Kinetics Books.)
.
Head circumference increases rapidly during the first 12 months of life, it
c
is considered as an important procedure for head and brain growth, it can be
n
measured while the infant is sitting in the lap of its care giver or while
I
standing for older children. The lower edge of non stretchable, flexible
measuring tape should be positioned above the eyebrows, above the ears and
,
around the back of the head, in the same plane on both sides of the head and
g
pulled snug to compress the hair, this measurement is the maximum
circumference and should be read to the nearest 0.1 cm or 1/8 inch (Figure 7).
in
Head circumference – for – age can be evaluated using suitable pediatric
growth charts [12].
h
Weight measurement is the most important and commonly used parameter
is
in nutritional assessment due to its importance in predicting equations for
l
energy, protein and other nutrient´s estimation [13].
Infant should be weighed on a pan – type pediatric electronic scale (Figure
b
8), that is accurate to within at least 10 g (0.01 kg) [5, 11] the infant should be
u
lying down in the middle of the pan, average of two or three weighing can be
reported and then plotted on the graph chart.
P
c e
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Figure 9. Children who can stand without assistance cab be weighed by an electronic
platform scale. (Chumlen WC, Roche AF, Mukherjee D. 1987. Nutritional Assessment
o
of the elderly through anthropometry. Columbus, OH: Ross Laboratory. Moore WM
and Roche AF. 1983. Pediatric Antrhopometry, 2 nd ed. Columbus, OH: Ross
N
Laboratories. Gordon CC, Chumlea WC, Roche AF. 1988. Stature, recumbent length,
and weight. In Lohman TG, Roche AF, Marturell R (eds.), Anthropometric
Standardization references manual. Champaign, IL: Human Kinetics Books).
.
Children who can stand without assistance cab be weighed by an
c
electronic platform scale that is accurate to 100 g (0.1 kg) [4, 5, 11] (Figure 9),
n
to distribute the weight on both feet equally, the child should stand in the
I
middle of the scales platform without touching anything, in light underwear
clothing, then child weight can be plotted on the growth chart.
g ,
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No
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No Figure 10. Length – for - age, weight – for - age, weight – for – length (20).
c .
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No
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No Figure 11. Head Circumference – for – age and weight- for- length percentiles. Birth to
24 months for boys and girls (20).
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No Source: Developed by the National Center for Health Statistics in collaboration with the National
Center for Chronic Disease Prevention and Health Protection (2000).
http://www.cdc.gov/growthcharts.
Figure 12. Stature - for – age and weight for age 2 – to - 20 years for boys and girls.
c .
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Source: Developed by the National Center for Health Statistics in collaboration with the National
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Figure 13 A. Body Mass Index – for – age percentile 2 to 20 years, for boys.
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va Source: Developed by the National Center for Health Statistics in collaboration with the National
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Figure 13 B. Body Mass Index – for – age percentile 2 to 20 years, for girls.
.
CDC GROWTH CHARTS
Growth charts are essential tools for infants, children and adolescents´
nc
I
physical growth and development, as well as for nutritional status assessment
,
[12-15]. It can be used to determine whether a child is adequately nourished or
not and to monitor their dietary intake during medical treatment.
g
Two age intervals: birth to 24 months and 2 to 20 years growth charts
in
have been developed by CDC. Birth to 24 months age interval charts for age
give percentile curves for: length – for - age, weight – for - age, weight – for -
length (Figure 10) and head circumference – for – age (Figure 11), while for 2
h
to 20 years of age interval, the charts give percentile curves for stature – for
is
age, weight – for – age (Figure 12), Body Mass Index – for – age (Figure 13A
l
and B) for boys and girls respectively.
Length is measured in the recumbent position (lying down), when using
b
the birth – to – 24 months chart, while height (stature) is measured in the
u
standing position for a person 2 to 20 years old (Figures 4 & 6) respectively.
The growth charts for children´s assessment from birth to 24 months was
P
recently developed by the CDC and the American Academy of Pediatrics
using growth standard data collection by the World Health Organization
e
(WHO) in it Multicenter Growth Reference Study (MGRS) [12].
n
How Touse the Chart Properly
c
i e
For proper use of CDC growth charts be sure to select the chart that
correctly matches the child‟s age and sex. Measurement of length, weight and
c
head circumference must be done by following the standardized methods. Age
should be calculated to the nearest month [5].
S
Locate the child´s age on the chart´s horizontal axis, then locate child‟s
length, weight, or head circumference on the vertical axis, draw a small circle
a
on the chart where the lines that represent the two values intersect. Charts
v
show nine percentile curves: 2, 5, 10, 25, 50, 75, 90, 95 and 98. The 50th
percentile is considered for the average, or medi value for specific population
o
of interest. If the plotted length for age were on 75th percentile curve, this
means 75% of girls her age would be shorter than she is. If child‟s height for
N
age were at the 10th percentile, only 10% of children of the same age and sex
would be shorter values less than 2nd and greater than 98th percentile warrant
evaluation.
.
Charts for Age 2 to 20 Years
Compared to the charts for children from birth up to 24 months of age
nc
I
there are minor differences in how these charts are used. Stature (or standing
height) is used instead of length, and head circumference is not used as a
,
variable. Another difference is in the number of percentile curves. In the
g
stature - for - age and weight - for - age charts for both sexes, there are seven
percentile curves: 5, 10, 25, 50, 75, 90 and 95. In the weight - for - stature
in
charts for both sexes, there is an 85th percentile curve in addition to the other
seven curves.
h
Values less than 5th percentile and greater the 95th percentile warrant
is
evaluation. The Body Mass Index for age charts also has an additional 85th
l
percentile curve (Box 1).
b
Box 1. Defining overweight and obesity in the pediatric population
u
A child or adolescent age 2 to 20 years having a BMI – for – age ≥ 85th
P
percentile but ≤ 95th percentile is classified as “overweight‟‟ and a child or
adolescent is classified as obese when the BMI – for – age is ≥ 95th percentile or
the individual has a BMI ≥ 30 Kg/m2, whichever is smaller. The BMI of an
e
individual is classified as “obese” when it is ≥ 30 kg/m2 even if it is less than
c
the 95th percentile curve [16–18].
Percentile cut – off –value classification of BMI
n
< 5th percentile underweight
e
≥ 5th and < 85th percentile healthy weight
i
≥ 85th and < 95th percentile over weight
≥ 95th percentile or BMI ≥ 30 kg/m2 obese
c
(Whichever is smaller?)
S
Case Study 1
va John is 7- years- old, he is in the second grade, and his weight is 31 kg, height
127 cm. Johns was referred by pediatrician to dietetic clinic for nutritional
o
assessment.
N
 Calculate Johns BMI
 Assess John‟s weight-for-age, height- for- age, BMI-for-age percentile.
 Determine the ideal weight for John‟s age
.
Case Study 2
Tom is an eleven month old boy, on breast feeding and solid food, his
nc
I
birth weight was 2.8 kg, birth length 46cm, and his mother brought him to
dietetics clinic for nutritional assessment. Current weight is 7.5kg and current
,
length is 67cm.
g
1) Calculate Tom´s BMI,
in
2) Assess Tom‟s weight-for-age, height- for- age, BMI-for-age
percentile.
h
3) Determine the ideal weight forTom‟s‟ age.
4) Is Tom classified as malnourished?
l is
b
REFERENCES
u
[1] Ballard JL, et al. New Ballard Score expanded to included extremely
P
premature infants. J. Pediatr 119:417, 1991.
[2] Shaffer SG, et al. Postnatal Weight Changes in low birth weight infants.
Pediatrics 79:702, 1987.
e
[3] Babson SG, Benda GI. Growth graphs for the clinical assessment of
c
infants of varying gestational age. J Pediatr 89 (s):814, 1976.
[4] Chumlen WC, Roche AF, Mukherjee D. 1987. Nutritional Assessment
n
of the elderly through anthropometry. Columbus, OH: Ross Laboratory.
e
[5] Moore WM. Roche AF. 1983. Pediatric Antrhopometry, 2nd ed.
i
Columbus, OH: Ross Laboratories.
c
[6] Heymsfield SB, Casper K. 1987. Anthropometric Assessment of the
adult hospitalized patient. Journal of Parenteral and Enteral Nutrition
S
11 (Supp): 365-415.
[7] Pollock ML, Jackson AS. 1984. Research progress in validation of
a
clinical methods of assessing body composition. Medicine and Science
in sports and exercise 16:606-613.
v
[8] Brodie DA. 1988. Techniques of measurement of body composition.
o
Part I. Sports Medicine 5:11-40.
N
.
[9] Lohman TG, Roche AF. Maturell R (eds.) Anthropometric
c
Standardization reference manual. Champaign, IL: Human Kinetics
n
Book 1991.
I
[10] Chumlea WC, Roche AF, Steinbaugh ML. 1985. Estimating Stature
from knee height for persons 60 to 90 years of age. Journal of the
,
American Geriatrics Society 33:116-120.
g
[11] Gordon CC, Chumlea WC, Roche AF. 1988. Stature, recumbent length,
and weight. In Lohman TG, Roche AF, Marturell R (eds.),
in
Anthropometric Standardization references manual. Champaign, IL:
Human Kinetics Books.
h
[12] Center for Disease Control and Prevention. 2012. Use of World Health
is
Organization and CDC growth charts for children aged 0-59 months in
l
the United States. Morbidity and Mortality weekly report 59 (No. RR-
9): 1-15.
b
[13] Mei Z. Grummer –Strawn LM 2011. Comparison of Changes in growth
u
percentiles of US Children on CDC 2000 growth charts with
corresponding changes on WHO 2006 growth charts. Clinical
P
Pediatrics 50:402-407.
[14] Kucz Marski RJ, Ogden CL, Guo SS et al. 2002. 2000 CDC growth
charts for the United States: Methods and development. National Center
e
for Health Statistics, Series 11, Number 246.
c
[15] Parsons HG, George MA, Innis SM. 2011. Growth assessment in
n
clinical practice: whose growth curve? Current Gastroenterology
Reports 13: 286-292.
e
[16] Ogden CL, Fleel KM. 2010. Changes in terminology for childhood
i
overweight and obesity, National Health Statistics Reports No.25,
c
National Health Statistics. U.S. Centers for Disease Control and
Prevention, U.S. Department of Health and Human Services.
S
[17] Krebs NS, Himes JH. Jacobson D., Nicklas TA. Guilday P. 2007.
Assessment of Child and adolescent overweight and obesity. Pediatrics
a
120 (suppl 4): S 193-S228.
v
[18] Barlow SE, 2007. Expert Committee recommendations regarding the
prevention, assessment, and treatment of Child and Adolescent
o
overweight and obesity: Summary Report. Pediatrics 120 (supp 4): S
164-S192.
N
.
[19] Bernstein S et al. Approaching the management of the neonatal
c
intensive care unit graduate through history and physical assessment.
n
Pediatr Clin North Am 45(1): 79, 1998.
I
[20] WHO Child Growth Standards (http://www.who.int/childgrowth/en).
g ,
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Chapter 4
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IN ADOLESCENTS
b l
u
The most challenging period in human life is adolescence, due to the
sudden increase in growth; as a result, special nutritional needs are created.
P
Increased nutrient demands, life style and food habit changes, and special
nutrients needs make adolescents a vulnerable group [1]. Physical activity
e
level and maturation stage are main determinants of actual needs, the best
index to determine caloric needs is calorie per unit of height (kcal/cm) to
c
compensate the differences in growth by age. Table 1 summarizes the
n
recommended range of energy and protein for adolescence [2].
e
Table 1. Recommended Energy and Protein Allowances for Adolescence
c
Age (yrs)
i kcal/day kcal/kg kcal/cm

protein
g/day g/cm
S
Females
11-14 2200 47 14.0 46 0.29
15-18 2200 40 13.5 44 0.26
a
19-24 2200 38 13.4 46 0.28
v
Males
11-14 2500 55 16.0 45 0.28
o
15-18 3000 45 17.0 59 0.33
19-24 2900 40 16.4 58 0.33
From Recommended Dietary Allowances, 10th ed. 1989 by the National Academy of
N
Sciences,published by National Academy Press, Washington DC.
To determine whether individuals are maintaining the growth pattern or

growth channel, weight and height should be plotted on growth grids. Tables
.
of the National Center for Health Statistics (NCHS) can be used to evaluate
c
the relationship between weight and height (Figure 1). According to the age
and sex, the appropriate weight for height is between 25th and 75th percentile
I n
[3].
g ,
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No .
Nutritional Assessment in Adolescents 51
c .
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No Source: Developed by the National Center for Health Statistics in collaboration with the National
Figure 1. Stature - for – age and weight for age 2 – to - 20 years for boys and girls.
.
Table 2. Body Mass Index (BMI in kg/m2) for adolescents
c
at risk for overweight
I n
At risk of overweight obesity (≥95th percentile)
≥85th and ≤ 95th percentile
,
Age (years) Males Female Males Females
10 20 20 23 23
g
11 20 21 24 25
in
12 21 22 25 26
13 22 23 26 27
14 23 24 27 28
h
15 24 24 28 29
is
16 24 25 29 29
l
17 25 25 29 30
18 26 26 30 30
b
19 26 26 30 30
20-24 27 26 30 30
u
Adopted from Himes JH andDietz WH. Guidelines for overweight in adolescent preventive
services. Recommendations from an expert committee. Am j Clin Nutr 59:307, 1994.
P
Weight status can be indicated by Body Mass Index (BMI), which is
e
highly correlated with body fat. Adolescence BMI is calculated as body weight
in kilograms divided by height in square meters. BMI = weight (kg)/height
c
(m2). Table 2 is used to determine the adolescent weight status [4].
en
c i
S
va
No Figure 2. examples of commercially available skin fold calipers.
c .
I n
g ,
in
Figure 3. Subcutaneous fat. Adapted from Gibson J, Rosalind S. 2005, Principles of
h
nutritional assessment. New York: Oxford University Press.
l is
ub
P
c e
en
c i
A. Process at the shoulder and the olecranon B. Process at the elbow.
Figure 4. A. Mid arm point between the Acromion. B. Marking the mid-point.
S
Adolescents BMIs between 85th and 95th percentiles are at risk for
a
overweight and should be investigated to determine health risk through
nutritional assessment. While adolescents with BMI ≤ 5th percentile are
v
underweight and should be assessed for diseases or eating disorders.
o
Furthermore, those with BMIs ≥ 95th percentile for age and gender are obese
and should be medically assessed [5]. Another evaluation method for
N
overweight and obesity is skin fold measurement, an individual who is above
75th percentile in weight for height is being suggested that they are overweight
and, ≥90th percentile suggest obesity.
.
Skin fold thickness measurement is measured by skin fold caliper (Figure
c
2) [6], and used to assess an individual body fat (Figure 3) [7, 8], clinically it
n
is practical method, and its validity depends on the accuracy of the measuring
I
technique. To measure the triceps and biceps skin fold you should point the
proper site which is the mid arm point between the acromion process at the
,
shoulder and the olecranon process at the elbow (Figure 4 A and B).
g
Subcutaneous fat assumed to be 50% of body fat, as obesity increases the
accuracy of measurement decreases. There are four skinfold site that reflects
in
body fatness: biceps, triceps, below the scapula and above the iliac crest
(Supra iliac) (Figure 5 A, B, C, D).
is h
l
Triceps
b
Skinfold site is on the posterior aspect of the right arm, over the triceps
u
muscle, mid-way between the lateral projection of the acromion process of the
scapular and the inferior margin of the olecranon process of the ulna. The
P
skinfold site should be marked along the posterior mid line of the upper arm.
Measurer should stand behind the subject; skin grasped with the thumb &
e
index finger of the left hand about 1 cm to the skin fold site. Caliper is about 1
cm from the left thumb & forefingers, caliper is perpendicular to the long axis
c
of the skin fold, and the dial can be easily read (Figure 5 A, Appendix 1) [9,
n
10], shows the reference values of triceps for children and adolescence aged 2
months – 19 years.
Biceps
c i e
S
Skin fold measures the thickness of the vertical fold in the front upper left
arm (Figure 5 B). Sub scapular site is 1 cm below the interior border of the
a
scapula as shown in Figure (5 C). By gentle feeling for the inferior angle of the
v
scapula or by placing the subject right arm behind the back while subject
standing with relaxed arms to sides (Appendix 2) [9, 10] shows the reference
o
values of sub scapular for children and adolescence aged 2 months – 19 years.
Supra iliac is measured just above the iliac crest at the mid axillary line
N
(Figure 5D).
The subject should be standing erectly, with feet together hands hanging at
the sides, skin should be grasped about 1 cm posterior to the mid auxiliary line
and measured the skinfold at that site.
.
Appendices 3 and 4 [9, 10] shows the sum of triceps and subscapular skin
c
fold thickness in (mm) by age 2 – 90 years for males and females respectively.
n
Appendices 5 and 6 [9, 10] show the mid- upper arm muscle area (cm²) by age
I
2 – 90 years for male and females respectively.
g ,
h in
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A: Triceps skin fold measurements. B: Biceps skin fold measurements.
c e
en
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C: Measurement of the subscapular skin D: Measurement of the suprailiac skin
a
fold. fold.
v
Figure 5. Sites of skin fold measurements.
No
c .
I n
g ,
APPENDIX 1.
i n
h
Triceps skinfold thickness in millimeters for children and adolescents aged 2 months-19 years by sex and age,
by mean, standard error of the mean and select percentile: United States 2003-2006 [9, 10]
il s
Sex and Age Number Mean Standard Percentile
examined error 5th 10th 15th 25th 50th 75th 85th 90th 95th
b
Males Millimeters
2 months 11 * * * * * * * * * * *
3-5 months 128 11.0 0.25 * 8.4 8.7 9.0 10.5 12.0 13.9 14.5 *
u
6-8 months 128 10.6 0.26 * 7.3 8.0 8.9 10.1 12.3 13.0 13.4 *
9-11 months 122 10.2 0.30 * * 7.7 8.1 9.7 11.9 12.9 * *
P
1 year 336 9.8 0.19 6.4 7.2 7.4 8.0 9.4 11.0 12.0 12.5 14.3
2 years 260 9.6 0.13 6.3 6.8 7.2 8.0 9.5 11.1 12.0 12.7 13.2
3 years 195 9.3 0.21 * 6.4 6.9 7.3 9.0 10.7 11.4 12.0 *
4 years 199 9.1 0.26 * 6.2 6.5 7.0 8.3 10.4 11.5 12.3 *
e
5 years 197 10.0 0.32 * 6.1 6.5 7.2 8.7 11.0 12.9 15.8 *
6 years 173 9.8 0.25 * 6.0 6.3 7.1 8.9 11.9 13.0 14.6 *
c
7 years 176 10.5 0.53 * 6.2 6.6 7.4 8.9 12.1 13.7 15.4 *
8 years 146 11.7 0.69 * 6.2 6.4 7.2 10.0 14.5 17.7 20.6 *
n
9 years 173 12.6 0.51 * 6.4 6.9 7.6 11.4 16.2 19.3 20.3 *
10 years 169 14.4 0.54 * 7.4 8.1 8.8 12.2 18.9 21.2 24.1 *
e
11 years 147 15.3 0.93 * 7.6 8.0 9.3 13.1 19.3 24.2 26.6 *
i
12 years 265 15.4 0.56 6.1 7.4 8.4 9.5 12.9 20.4 23.4 26.5 28.9
13 years 277 14.6 0.58 6.3 6.8 7.4 8.2 12.3 18.7 23.9 26.2 28.7
c
14 years 253 13.4 0.62 * 6.4 6.8 7.8 10.4 17.7 22.6 24.9 *
15 years 263 12.6 0.45 6.4 6.7 7.3 8.0 9.9 15.4 19.2 22.4 26.4
16 years 290 13.6 0.47 5.8 6.2 6.8 7.4 9.9 19.1 24.5 26.3 29.1
S
17 years 259 12.7 0.56 5.2 6.0 6.5 7.3 10.1 17.2 19.8 22.4 26.4
18 years 266 13.1 0.88 5.4 6.2 6.5 7.2 9.9 1.8 20.8 24.7 28.7
19 years 254 13.6 0.72 * 5.9 6.9 7.9 11.0 16.2 22.9 26.6 *
va
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I n
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i n
h
Females Millimeters
il s
2 months 9 * * * * * * * * * * *
3-5 months 91 10.8 0.31 * * 8.0 8.9 10.6 11.9 13.4 * *
6-8 months 120 11.1 0.30 * * 7.6 8.8 11.3 12.8 13.9 * *
9-11 months 118 10.8 0.24 * * 8.0 8.9 10.9 12.3 12.9 * *
b
1 year 316 10.1 0.19 6.5 7.2 7.5 8.3 9.7 11.4 12.7 13.2 14.6
2 years 299 10.5 0.21 6.3 7.0 7.7 8.4 10.1 12.4 13.2 14.2 15.3
3 years 174 10.2 0.28 * 6.7 7.0 7.6 9.4 11.9 13.2 14.8 *
u
4 years 220 10.6 0.23 * 7.1 7.4 8.2 10.3 12.1 13.2 14.2 *
5 years 194 10.7 0.32 * 7.2 7.6 8.4 9.9 12.1 13.3 14.9 *
P
6 years 188 10.8 0.30 * 6.2 6.9 8.0 10.0 12.9 14.7 15.1 *
7 years 153 12.7 0.38 * 7.7 8.0 8.8 11.0 15.0 18.4 19.8 *
8 years 176 12.6 0.48 * 7.4 7.8 8.7 11.0 15.3 17.7 20.1 *
9 years 182 15.5 0.59 * 8.4 9.2 10.7 14.1 18.4 22.2 24.6 *
e
10 years 176 16.4 0.60 * 8.3 9.6 11.3 15.1 19.9 228 26.6 *
11 years 167 176 0.72 * 8.8 9.3 11.2 16.0 22.9 26.0 28.5 *
c
12 years 231 16.0 0.52 * 8.9 9.2 11.1 14.6 19.8 22.8 25.5 *
13 years 274 18.8 0.49 9.2 10.2 10.8 12.9 18.3 23.2 26.0 29.2 32.1
n
14 years 252 18.3 0.84 * 10.1 11.1 12.9 16.2 23.9 26.4 27.6 *
15 years 226 19.7 0.65 * 11.0 11.9 13.8 18.5 23.8 26.4 30.0 *
e
16 years 236 18.8 0.72 * 10.5 11.2 13.2 17.1 23.3 27.0 29.3 *
i
17 years 227 20.3 0.56 * 11.3 13.1 14.6 18.7 25.1 28.0 29.7 *
18 years 246 21.0 0.76 * 11.1 12.8 14.8 20.1 26.2 29.9 33.2 *
c
19 years 208 20.5 0.80 * 11.2 12.3 14.2 19.9 25.2 27.1 29.5 *
*Figure does not meet standards of reliability or precision.
*Age shown is age at time of examination.
S
Note: Pregnant females were excluded.
va
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c .
I n
g ,
APPENDIX 2.
i n
h
Subscapular skinfold thickness in millimeters for children and adolescents aged 2 months- 19 years by sex and age,
by mean. Standard error of the mean, and selected percentiles: United States 2003- 2006 [9, 10]
il s
b
Males Millimeters
2 months 12 * * * * * * * * * * *
u
3-5 months 126 8.3 0.20 * * 6.5 7.0 7.9 9.2 10.6 * *
6-8 months 126 7.6 0.18 * * 5.8 6.2 7.3 8.4 9.2 * *
9-11 months 121 7.6 0.26 * * 5.6 5.9 7.1 9.0 9.5 * *
P
1 year 333 6.8 0.11 4.8 5.0 5.2 5.7 6.5 7.5 8.2 8.5 9.7
2 years 255 6.5 0.10 * 4.8 4.9 5.2 6.0 7.1 8.2 8.5 *
3 years 196 6.7 0.18 * 4.4 4.7 5.2 6.2 7.7 8.4 9.1 *
4 years 197 6.1 0.19 * 4.1 4.3 4.8 5.4 6.3 7.3 8.4 *
e
5 years 196 7.3 0.46 * 4.3 4.5 4.9 5.9 7.3 9.1 11.9 *
6 years 170 7.0 0.20 * 4.3 4.5 4.9 5.9 7.9 9.2 10.5 *
c
7 years 174 7.1 0.35 * 4.3 4.5 4.9 5.9 7.5 9.0 10.4 *
8 years 140 7.9 0.53 * 4.2 4.4 4.8 5.9 8.7 11.3 15.0 *
9 years 164 8.8 0.50 * 4.4 4.9 5.4 6.7 9.7 14.3 16.5 *
n
10 years 165 10.4 0.65 * 4.9 5.1 5.9 7.4 13.4 17.1 20.4 *
11 years 141 10.7 0.59 * 5.2 5.4 5.9 7.8 14.8 17.3 20.5 *
e
12 years 258 11.5 0.61 4.9 5.1 5.5 6.0 8.5 14.6 18.1 21.9 29.3
i
13 years 272 12.0 0.64 5.0 5.6 6.1 6.6 9.3 15.2 19.8 22.4 25.8
14 years 242 10.6 0.46 * 5.7 6.1 6.7 8.5 13.4 15.8 19.3 *
c
15 years 257 11.2 0.41 6.0 6.5 6.9 7.2 9.0 12.9 15.2 20.1 24.5
16 years 285 12.7 0.38 6.4 6.7 7.2 7.8 9.6 16.3 20.8 23.6 26.5
17 years 256 12.7 0.60 6.2 7.1 7.5 8.2 10.1 14.4 20.5 24.2 27.8
S
18 years 257 13.9 0.69 7.1 7.4 8.0 8.7 10.5 17.4 21.7 24.5 28.4
19 years 240 14.5 0.62 * 7.8 8.2 9.1 12.4 18.0 21.4 26.1 *
va
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c .
I n
g ,
i n
h
il s
Females Millimeters
2 months 10 * * * * * * * * * * *
3-5 months 92 8.4 0.26 * * 5.9 6.4 8.1 9.6 10.4 * *
6-8 months 116 8.4 0.37 * * 5.9 6.3 7.8 9.6 10.8 * *
b
9-11 months 120 8.3 0.16 * 5.9 6.1 6.6 7.9 9.2 10.4 11.0 *
1 year 310 7.3 0.12 4.9 5.1 5.3 5.9 6.9 8.3 8.9 9.3 10.5
2 years 292 7.0 0.16 4.5 4.9 5.0 5.4 6.3 7.9 9.0 9.8 10.7
u
3 years 173 7.2 0.23 * 4.6 4.9 5.3 6.5 8.0 9.1 11.0 *
4 years 216 7.2 0.21 * 4.9 5.0 5.2 6.3 7.9 9.5 10.4 *
5 years 191 7.8 0.40 * 4.9 5.2 5.4 6.3 8.2 9.9 12.1 *
P
6 years 185 7.5 0.24 * 4.5 4.8 5.3 6.5 8.4 10.3 11.8 *
7 years 148 8.5 0.40 * 4.6 5.0 5.4 7.3 9.8 11.9 12.9 *
8 years 174 9.1 0.53 * 4.7 5.0 5.5 6.8 10.1 13.4 17.9 *
e
9 years 174 11.1 0.50 * 5.4 6.1 6.7 9.4 13.7 17.6 19.0 *
10 years 168 12.1 0.44 * 5.7 6.1 7.4 10.1 16.1 19.1 20.2 *
11 years 158 13.5 0.61 * 6.3 6.8 8.0 11.5 17.9 21.0 23.2 *
c
12 years 225 12.4 0.61 * 6.1 6.9 7.9 10.6 15.3 19.0 20.6 *
13 years 268 14.6 0.65 6.0 7.1 7.7 8.7 12.7 18.3 23.9 26.3 28.9
n
14 years 240 14.0 0.72 6.9 7.6 8.1 9.0 11.7 16.3 20.8 24.1 29.8
15 years 220 15.7 0.49 * 7.9 8.6 9.9 13.9 20.2 22.8 24.4 *
e
16 years 226 14.8 0.52 * 8.1 8.6 9.3 12.9 17.5 20.7 24.9 *
i
17 years 213 16.2 0.56 * 8.3 9.0 10.5 14.2 19.6 24.6 27.3 *
18 years 226 16.7 0.62 * 8.4 9.3 10.8 15.0 20.9 24.2 25.8 *
c
19 years 192 18.2 0.78 * 8.5 9.0 10.7 16.5 24.4 25.9 28.1 *
*
Figure does not meet standards of reliability or precision.
*
Age shown is age at time of examination.
S
va
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c .
I n
g ,
APPENDIX 3.
i n
h
Mean (m), standard deviation (SD), and percentiles of sum of triceps and subscapular skinfold thickness (mm)
by age for males and females 2 to 90 years [9, 10]
il s
Age Group Mean Age N M SD Percentile
(years) (years) 5th 10th 15th 25th 50th 75th 85th 90th 95th
Females
b
2.0-2.9 2.45 533 16.8 4.9 9.7 10.8 11.6 12.9 15.8 19.2 21.4 22.9 25.5
3.0-3.9 3.46 554 15.5 4.7 9.3 10.4 11.2 12.6 15.5 19.0 21.1 22.8 25.4
u
4.0-4.9 4.43 525 15.3 5.7 8.2 9.4 10.4 11.9 15.4 19.7 22.6 24.7 28.2
5.0-5.9 5.46 541 15.9 6.9 7.4 8.7 9.7 11.4 15.3 20.5 23.9 26.6 10.9
6.0-6.9 6.47 272 17.1 8.5 9.6 11.4 15.7 21.5 25.4 28.5 33.6
P
7.0-7.9 7.44 260 18.6 9.2 7.1 8.5 9.8 11.7 16.4 22.9 27.3 30.7 36.6
8.0-8.9 8.47 243 20.4 10.5 7.5 10.3 12.4 17.6 24.8 29.8 40.3
9.0-9.9 9.43 264 22.2 11.5 8.0 9.7 11.1 13.4 19.1 27.0 32.4 36.7 43.9
e
10.0-10.9 10.43 252 24.2 12.3 8.9 10.8 12.3 14.9 21.0 29.6 35.4 40.0 47.9
11.0-11.9 11.46 276 26.1 12.9 12.3 13.9 15.7 23.4 32.5 38.7 42.6 51.8
c
12.0-12.9 12.46 214 13.1 11.8 14.1 15.9 18.9 25.9 35.5 42.0 47.0 55.4
13.0-13.9 13.45 222 29.5 13.1 13.5 15.9 17.8 21.0 28.4 38.3 44.8 49.9 58.4
14.0-14.9 14.47 214 31.0 13.2 15.0 17.5 19.5 22.8 30.4 40.4 47.0 52.0 60.4
n
15.0-15.9 15.47 181 32.4 13.2 15.7 18.4 20.5 23.9 31.6 41.4 47.7 52.5 50.3
16.0-16.9 16.46 212 33.6 13.4 16.3 19.1 21.2 24.6 32.4 42.2 48.4 53.1 50.5
e
17.0-17.9 17.45 193 34.6 13.6 16.5 19.5 21.7 25.4 33.4 43.2 49.3 53.8 50.9
i
18.0-18.9 18.43 173 35.5 14.0 16.4 19.7 22.1 26.0 34.4 44.4 50.4 54.8 51.6
19.0-19.9 19.48 178 36.4 14.4 16.4 19.7 22.1 26.1 34.5 44.6 50.7 55.1 62.0
c
20.0-29.9 2491 1671 39.6 15.1 19.1 22.8 25.5 29.8 35.1 50.0 56.6 68.9
30.0-39.9 3485 1578 45.4 15.4 24.0 27.8 30.7 35.2 44.7 55.7 62.2 66.9 74.2
40.0-49.9 44.28 1137 50.6 15.5 25.9 31.2 34.8 40.3 50.6 61.2 66.9 70.9 76.7
S
50.0-59.9 5483 856 50.6 15.4 25.7 31.1 34.8 40.3 50.7 61.2 66.8 70.7 76.4
60.0-69.9 54.82 1010 47.2 14.4 21.9 29.0 32.4 37.6 47.2 57.0 62.3 65.9 71.3
70.0-79.9 74.46 831 42.1 14.0 19.3 24.2 27.5 41.8 51.3 56.4 59.9 65.1
80.0-89.9 8445 554 33.8 12.4 13.4 17.5 20.4 24.6 32.6 40.7 45.1 481 52.5
va
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I n
g ,
APPENDIX 4.
i n
h
Mean (m), standard deviation (SD), and percentiles of sum of triceps and subscapular skinfold thickness (mm)
by age for males and females 2 to 90 years [9, 10]
il s
Males
b
2.0-2.9 2.46 544 14.8 4.0 9.4 10.4 11.1 12.3 14.8 17.7 19.5 20.8 22.8
3.0-3.9 3.45 482 14.2 3.8 9.0 10.0 10.7 11.7 14.0 16.8 18.4 19.6 21.5
u
4.0-4.9 4.47 540 14.4 3.9 8.6 9.6 10.3 11.4 13.7 16.4 18.0 19.3 21.2
5.0-5.9 5.43 490 14.8 4.4 8.1 9.1 9.8 10.9 13.4 16.4 18.2 19.5 21.7
6.0-6.9 6.45 258 15.4 6.1 6.8 7.9 8.7 10.1 13.3 17.3 19.9 21.8 25.0
P
7.0-7.9 7.47 270 16.0 7.1 6.4 7.5 8.5 10.0 13.5 18.1 21.1 23.4 27.2
8.0-8.9 8.46 258 16.7 7.4 6.7 7.9 8.9 10.5 14.2 19.1 23.3 24.7 28.8
9.0-9.9 9.50 276 17.3 7.7 7.3 8.7 9.7 11.5 15.5 20.8 24.3 26.9 31.3
10.0-10.9 10.45 287 17.9 7.9 7.9 9.4 10.5 12.4 16.8 22.5 26.3 29.2 33.9
e
11.0-11.9 11.44 271 18.5 8.2 8.3 9.8 11.0 13.1 17.7 23.8 27.7 30.8 35.8
12.0-12.9 12.47 199 19.1 8.5 8.3 9.9 11.1 13.1 17.8 24.0 28.0 31.0 36.1
c
13.0-13.9 13.47 187 19.7 9.7 7.4 8.9 10.2 12.3 17.2 23.9 28.4 31.8 37.6
14.0-14.9 14.49 177 20.2 10.6 6.6 8.2 9.4 11.5 16.5 23.3 28.0 31.6 37.7
n
15.0-15.9 15.45 177 20.6 10.3 6.9 8.4 9.6 11.6 16.3 22.7 27.0 30.2 35.7
16.0-16.9 16.45 188 21.1 10.0 7.6 9.2 10.4 12.5 17.3 23.7 27.9 31.1 36.6
17.0-17.9 17.45 186 21.5 9.9 8.6 10.4 11.7 13.9 19.0 25.8 30.2 33.6 39.2
i e
18.0-18.9 18.45 167 22.0 9.5 9.7 11.5 12.8 15.1 20.3 27.0 31.4 34.7 40.2
19.0-19.9 19.43 153 22.4 9.4 10.0 12.0 13.3 15.6 20.9 27.6 32.0 35.3 40.7
20.0-29.9 24.96 1537 25.0 9.8 11.7 14.2 16.1 19.0 25.2 32.3 36.5 39.5 44.1
c
30.0-39.9 34.72 1355 30.0 10.9 13.2 16.5 18.8 22.3 29.2 36.5 40.7 43.5 47.8
40.0-49.9 44.35 1095 31.7 10.5 15.4 18.6 20.8 24.2 30.9 38.0 41.9 44.7 48.9
50.0-59.9 54.89 768 31.9 10.1 16.3 19.5 21.8 25.1 31.8 38.7 42.6 45.3 49.3
S
60.0-69.9 64.83 1059 31.8 10.1 16.4 19.6 21.9 25.3 32.0 39.0 42.8 45.5 49.6
70.0-79.9 74.16 753 30.9 9.9 15.5 18.7 20.8 24.2 30.6 37.3 41.0 43.6 47.5
80.0-89.9 84.09 535 27.5 8.6 14.0 156.8 18.7 21.6 27.2 32.9 36.1 38.3 41.6
va
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I n
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APPENDIX 5.
i n
h
Mean (M), standard deviation (SD), and percentiles of mid-upper arm muscle area (cm²) by age
for males and females of 2 to 90 years [9, 10]
il s
b
Males
2.0-2.9 2.46 548 14.7 2.2 11.4 12.0 12.5 13.2 14.5 16.0 16.9 17.5 18.5
u
3.0-3.9 3.45 481 16.4 2.5 12.4 13.1 13.7 14.5 16.1 17.9 18.9 19.6 20.7
4.0-4.9 4.47 542 17.4 2.8 13.0 13.8 14.3 15.2 16.9 18.8 19.9 20.7 21.9
5.0-5.9 5.43 492 18.2 3.1 13.6 14.5 15.1 16.1 18.1 20.3 21.6 22.5 23.9
P
6.0-6.9 6.45 258 19.3 3.6 14.6 15.6 16.3 17.4 19.8 22.4 23.9 25.0 26.7
7.0-7.9 7.47 271 20.8 3.9 15.8 16.9 17.7 19.0 21.5 24.4 26.2 27.4 29.3
8.0-8.9 8.46 257 22.8 4.3 17.0 18.2 19.1 20.5 23.2 26.4 28.2 29.5 31.6
9.0-9.9 9.50 282 25.6 5.0 18.2 19.6 20.5 22.0 25.1 28.6 30.7 32.2 34.5
e
10.0-10.9 10.45 287 28.6 5.9 19.3 20.9 22.0 23.7 27.2 31.3 33.7 35.5 38.2
11.0-11.9 11.44 272 32.1 7.2 20.8 22.6 23.9 25.9 30.2 35.0 38.0 40.1 43.4
c
12.0-12.9 12.47 201 36.1 8.0 23.1 25.2 26.7 29.1 34.1 40.0 43.5 46.0 50.1
13.0-13.9 13.47 188 40.0 9.4 26.3 28.6 30.3 33.0 38.7 45.3 49.2 52.1 56.6
14.0-14.9 14.49 179 44.1 9.8 30.3 32.9 34.7 37.7 43.7 50.7 54.9 58.0 62.7
n
15.0-15.9 15.45 177 47.9 9.5 64.3 37.0 38.9 42.0 48.3 55.6 59.9 63.0 67.8
16.0-16.9 16.45 191 51.6 10.4 37.6 40.5 42.6 45.8 52.5 60.1 64.6 67.9 72.9
e
17.0-17.9 17.45 188 55.0 11.2 40.0 43.1 45.3 48.8 56.0 64.2 69.0 72.5 78.0
i
18.0-18.9 18.45 167 58.0 11.7 42.0 45.2 47.5 51.2 58.6 67.1 72.2 75.8 81.5
19.0-19.9 19.43 154 60.6 12.2 42.6 45.8 48.2 51.8 59.4 68.0 73.1 76.7 82.5
c
20.0-29.9 24.96 1564 64.5 13.4 45.2 48.8 51.4 55.4 63.8 73.4 79.1 83.2 89.6
30.0-39.9 34.72 1405 66.6 13.5 48.7 52.4 55.2 59.4 68.1 78.1 84.0 88.3 95.0
40.0-49.9 44.35 1158 69.9 12.8 49.8 53.5 56.2 60.5 69.1 79.0 84.8 89.0 95.6
S
50.0-59.9 54.89 815 67.4 12.6 49.7 53.3 55.8 59.7 67.8 76.9 82.3 86.1 92.1
60.0-69.9 64.83 1122 64.8 12.4 46.8 50.2 52.7 56.5 64.4 73.3 78.6 82.4 88.3
70.0-79.9 74.16 820 59.5 11.1 43.5 46.5 48.8 52.2 59.2 67.2 71.8 75.2 80.4
80.0-89.9 84.09 635 52.7 10.1 38.1 40.9 42.9 46.0 52.4 59.6 63.9 66.9 71.7
va
N o
c .
I n
g ,
APPENDIX 6.
i n
h
Mean (M), standard deviation (SD), and percentiles of mid-upper arm muscle area (cm²) by age
for males and females of 2 to 90 years [9, 10]
il s
b
Females
2.0-2.9 2.45 534 15.0 2.2 10.9 11.5 12.0 12.6 14.0 15.5 16.4 17.0 18.0
3.0-3.9 3.46 554 14.7 2.4 11.9 12.6 13.1 13.9 15.5 17.2 18.3 19.0 20.1
u
4.0-4.9 4.43 526 15.3 2.6 12.7 13.5 14.0 15.0 16.8 18.9 20.1 20.9 22.2
5.0-5.9 5.46 540 10.8 3.1 13.2 14.1 14.7 15.7 17.8 20.1 21.5 22.5 24.0
6.0-6.9 6.47 272 18.8 3.6 13.6 14.6 15.4 16.5 18.8 21.4 22.9 24.0 25.8
P
7.0-7.9 7.44 263 20.9 4.2 14.0 15.1 15.8 17.1 19.6 22.4 24.1 25.3 27.3
8.0-8.9 8.47 245 23.2 4.5 14.6 15.7 16.6 17.9 20.7 23.8 25.7 27.1 29.2
9.0-9.9 9.43 266 25.4 5.6 15.7 17.0 17.9 19.4 22.5 26.1 28.2 29.7 32.2
e
10.0-10.9 10.43 254 27.6 5.5 17.7 19.2 20.3 21.9 25.5 29.5 32.0 33.7 36.5
11.0-11.9 11.46 281 29.7 6.5 20.2 21.9 23.2 25.1 29.1 33.8 36.6 38.6 41.8
12.0-12.9 12.46 216 31.5 6.9 22.6 24.5 25.9 28.0 32.5 37.7 40.8 43.1 46.6
c
13.0-13.9 13.45 224 33.1 7.3 24.3 26.3 27.8 30.1 35.0 40.5 43.9 46.3 50.1
14.0-14.9 14.47 218 34.5 7.6 25.1 27.2 28.7 31.1 36.1 41.9 45.3 47.8 51.8
n
15.0-15.9 15.47 187 35.6 8.0 25.1 27.2 28.7 31.2 36.2 42.1 45.6 48.2 52.2
16.0-16.9 16.46 216 36.6 8.2 24.9 27.1 28.6 31.0 36.1 41.9 45.4 48.0 52.0
e
17.0-17.9 17.45 202 37.4 8.6 24.7 26.8 28.4 30.9 36.1 42.1 45.8 48.4 52.6
i
18.0-18.9 18.43 178 38.0 8.7 24.9 27.0 18.6 31.1 36.3 42.4 46.0 48.7 52.9
19.0-19.9 19.48 182 38.5 8.8 25.3 27.5 29.1 31.6 36.9 43.0 46.7 49.4 53.6
c
20.0-29.9 24.91 1766 39.9 9.1 26.4 28.7 30.3 32.9 38.4 44.7 48.6 51.3 55.7
30.0-39.9 34.85 1698 42.3 10.5 27.4 30.0 31.9 34.9 41.3 48.8 53.4 56.7 62.0
40.0-49.9 44.28 1227 44.8 11.3 29.0 31.8 33.9 37.1 44.1 52.2 57.2 60.9 66.7
S
50.0-59.9 54.83 928 45.7 11.7 28.8 31.7 33.7 37.0 44.1 52.4 57.4 61.2 67.1
60.0-69.9 64.82 1092 45.1 11.7 28.1 30.9 32.9 36.2 43.1 51.2 56.2 59.9 65.7
70.0-79.9 74.46 899 43.7 11.3 27.5 30.2 32.2 35.3 42.1 50.1 54.9 58.5 64.2
80.0-89.9 84.45 696 41.0 10.5 26.2 28.8 30.7 33.7 40.1 47.6 52.2 55.6 61.0
va
N o
64 M. Mohamed Essa, Ghazi Dradkeh and Nejib Guizani
.
REFERENCES
[1] Spear BA. Adolescent Growth and Development In: Rickets VI (Ed.).
nc
I
Adolescent Nutrition: Assessment and Management. New York
,
Chapman and Hall, 1996, pp.3-24.
[2] From Recommended Dietary Allowances, 10th ed. 1989 by the National
g
Academy of Sciences. Published by National Academy Press,
in
Washington DC.
[3] Mahan LK, Rees JR, Nutrition in adolescence. St. Louis: Times/Mirror
Mosby, 1984.
h
[4] Himes JH, Dietz WH. Guidelines for overweight in adolescent
is
preventive services. Recommendations from an expert committee. Am j
l
Clin Nutr 59:307, 1994.
[5] World Health Organization (WHO). Physical status: The use and
b
interpretation of anthropometry. Report of a WHO Expert Committee.
u
WHO Tech Rep Ser 854:1 – 452, 1995.
[6] Johnston FE, Hamill PV, Lemeshow S. Skinfold thickness of children 6
P
– 11 years, United States. Vital health stat 11 1972: 120:33-46.
[7] Gibson, Rosalind S. 2005 Principles of nutritional assessment. New
e
York: Oxford University Press.
[8] Sarría, A; García-Llop, L A; Moreno, L A; Fleta, J; Morellón, M P;
c
Bueno, M (1998). ”Skinfold thickness measurements are better
n
predictors of body fat percentage than body mass index in male spanish
children and adolescents.” European Journal of Clinical Nutrition 52
i e
(8): 573–6. doi:10.1038/sj.ejcn.1600606. PMID 9725657.
[9] Lohman TG, 1988. Anthropometry and body composition. In Lohman
c
TG, Roche AF, Martorell R(eds), Anthropometric standardization
S
reference manual. Champaign, IL: Human Kinetics Books.
[10] The National Center for Health Statistics in collaboration with the
National Center for Chronic Disease Prevention and Health Promotion
a
2003-2006.
o v
N
c .
I n
Chapter 5
g ,
NUTRITIONAL ASSESSMENT IN ADULTS
h in
l is
b
Nutritional Assessment is a comprehensive approach, using medical,
social, nutritional, physical examination, anthropometric measurements and
u
laboratory data with the aim of defining the nutritional statusit is completed by
a registered dietitian [1].
P
Nutrition assessment consists of five categories: food/nutrition history,
medical history, laboratory data, anthropometric measurements and nutrition –
e
focused physical examination (Box 1) [2]. According to A.S.P.E.N Board of
c
Directors adult nutrition screening and assessment is illustrated in Figure 1 [3].
n
Box 1. Nutritional Assessment Categories
i e
Food/Nutrition History
c
- Meals and snack pattern
S
- Tolerance of food/nutrition
- Intake adequacy
- Availability of food
a
- Physical Activity pattern
v
Medical History
o
- Current Illness history
- Use of medication/supplements
N
- Medical/Surgical History
- Socioeconomic status
Anthropometric Data
- Weight (current, usual, ideal)
.
- Height
c
- Body Mass Index
- Waist-hip-ratio
I n
- Growth rate
- Weight change
,
Laboratory Data
g
- Electrolytes
in
- Glucose/Hemoglobin A1c
- Lipid profile
- Kidney function test
h
- Liver Function test
is
Nutrition – focused physical examination
l
- Adipose store
b
- Oral (lips, gums, tongue, mucus membrane)
- General appearance
P u
Nutritional assessment aims to: (1) identify patients at-risk-of malnutrition
(2) restore or maintain an individual´s nutritional status (3) Create proper
nutrition prescription (4) Monitor and evaluate the efficacy of nutritional care
e
plan. Weight loss has a strong association with adverse outcomes in some
c
patients, accurate weight measurement is vital [5, 6].
Evaluation of conditions that might alter digestion, absorption, and
n
excretion, as well as accurate estimation of recent intake are essential for
e
nutrtional deficiencies to be correctly diagnosed [7, 8, 9].
i
To evaluate whether the nutritional status is a contributing factor for the
c
worsening of a patient´s medical condition or not, nutritional assessment
should be done. Height, usual and current weight, diet history (eating habits,
S
changes in food intake) is the basic information that should be collected for
proper nutritional assessment.
a
More detailed dietary, laboratory, and anthropometric assessment should
be obtained for critically ill patients. Additional anthropometric measurements
v
such as skinfold measurements mainly triceps and subscapular, mid arm and
o
mid calf circumferences are recommended.
Additional biochemical measurements include: 24-hour urinary creatinine
N
(for creatinine-height index estimation), 24-hour urine urea nitrogen (for
nitrogen balance estimation), serum proteins are required for critically ill
patients.
Nutritional Assessment in Adults 67
.
NUTRITION SCREENING STABLE
FOR RISK OF PRESENCE OF
c
MALNUTRITION
1. Acute care: within 24 hours
n
2. Long-term care: on admission or within 14 days of admission
I
3. Home-care: on initial RD?visit
g ,
in
AT-RISK OF MALNUTRITION
Adults are at risk of malnutrition if any of the following is present:
[1] -Involuntary loss or gain of >10% of usual body weight, within 6 months or
h
>5% in 1 month or a weight is 20% over or under ideal body weight), presence
of Chronic disease or increased metabolic requirements
is
[2] Inadequate oral intake for > 7 days
[3] Altered diets (receiving Total Parenteral or Enteral Nutrition)
NOT AT-RISK
b l AT-RISK
u
RESCREEN AT: NUTRITION ASSESSMENT
P
4. Regular intervals  Nutrition history
 Assess the anthropometric data
5. When nutritional/ and Laboratory data
clinical status  Nutritional focused physical
e
changes exam
n c
e
STABLE NUTRITIONALLY AT RISK
c i
NUTRITION CARE PLAN BASED ON:
RE-ASSESSMENT BASED ON
 Nutrition care objectives, including
 Clinical status changes short and long term goals
S
 Nutritional status changes  Create nutrition prescription
 Tolerance of nutrition  Enteral and Parenteral Nutrition
prescription Support if needed
va
A.S.P.E.N. Board of Directors. Clinical Pathways and Algorithms for Delivery of
Parenteral and Enteral Nutrition Support in Adults. Silver Spring, MD:
o
A.S.P.E.N.: 1998: S. [4].
N
Figure 1. Adult Nutrition Screening and Assessment Algorithm.
Kcalorie counts (Figure 2), dietary intake, more extensive patient

interviewing are additional dietary assessments that can be carried out if
required.
.
DIETARY ASSESSMENT
Dietary assessment includes: patient‟s food preferences, food allergies,
nc
I
food intolerance, eating patterns (meals and snack frequency, timing, location
,
and food preparation).
Dietary intake can be assessed retrospectively or prospectively depending
g
on the purpose of the assessment.
in
Day:
Date:
Meal type Food Description Quantity
is hcalorie
b l
P u
c e
n
Figure 2. KCalorie Counting Chart.
i e
NUTRIENT INTAKE ANALYSIS (NIA)
c
NIA is a tool used to identify nutritional inadequacies before deficiencies
S
are developed by intake monitoring. Direct observation or inventory of food
eaten based on what remains on the individual‟s tray or plate is a method of
a
actual intake evaluation. NIA should be recorded for 72 hours to reflect an
average intake of an individual correctly.
o v FOOD DIARY
N
Is a tool to assess food intake by documenting dietary intake as it occurs,
usually for non-hospitalized patients. To estimate dietary intake accurately, the
record should be on the same day and intake calculated and averaged for 3 to 7
.
days and then compared to Recommended Dietary Allowance (RDAs)
c
(Figure 3).
I n
Day_______________________________
,
Meal Food List Amount Taken How Prepared Where
g
(home, work, etc.,)
Breakfast
in
Snack
Lunch
h
Snack
l is
Dinner
Snack
Figure 3. Food Diary.
ub
P
Meal Day1 Day2 Day3 Day4 Day5 Day6 Day7
Breakfast
e
Snack 1
c
Lunch
en
i
Snack 2
c
Dinner
S
Snack 3
a
Figure 4. 24 hours – Recall.
o v RETROSPECTIVE DATA
N
24-Hour Recall is a method of dietary intake estimation in the last 24-
hours, which then can be analyzed and evaluated. Reliability and validity of
dietary recall methods are important [10].
.
Retrospective methods of data collection have disadvantages which
c
include: memory lapses, underestimation and/or over estimation of the amount
n
consumed, inaccurate knowledge of portion sizes (Figure 4).
I
Food Frequency Questionnaire
,
2 – 4 per week
5 – 6 per week
Once per
per week
Once per 3
Once per
Never
month
months
Once
Daily
year
in
Milk, yoghurt, regular fat (1
h
cup)
is
Milk, yoghurt, lowfat (1 cup)
l
Spinac, kale, other green leafy
vegetables (1/2 cup)
b
Carrots (1medium)
u
Beef (3 oz)
P
Rice, White (1 cup)
e
Rice, brown (1 cup)
c
Cookies (2-2” diameter)
n
Ice cream, regular fat (1/2
e
cup)
i
47
c
Figure 5. Food Frequency Questionnaire.
S
FOOD FREQUENCY QUESTIONNAIRE (FFQ)
a
Is a retrospective review of intake frequency that is calculated by food
v
consumed per day, per week, per month? The food frequency chart organizes
o
foods into groups that have common nutrients, because the focus of the food
frequency is on the final group rather than the specific nutrientsthe information
N
gathered is general (Figure 5).
.
Table 1. Summarize the advantages and disadvantages
c
on dietary intake data [11]
I n
Method Advantages Disadvantages
Nutrient Intake -Allows actual -May yield inconsistent and subjective
,
Analysis observation of food estimates of food consumption
intake -possible variation in portion size
g
Daily Food -Provides daily record -Variable literacy skills of subjects
in
record/diary of food consumption -Requires ability to measure/judge
-Can provide portion sizes
information on -Actual food intake possibly influenced
h
quantity of food, how by the recording process
is
prepared, and timing -Questionable reliability of records
of meals and snacks
l
Food frequency -Easily standardized -Requires literacy skills
b
-Can be beneficial -Does not provide meal pattern data
when considered in -Requires knowledge of portion sizes
u
combination with
usual intake
P
24-hour recall -Provides overall -Relies on memory
picture of intake -Requires knowledge of portion sizes
-Quick -May not represent usual intake
e
-Easy -Requires interviewing skills
Complied from informationin Hopkins B. Assessment of nutritional status in: gottschlich MM,
c
Matarese LE, Shronts EP, (eds). Nutrition Support Dietetics,2nd ed. Silver Spring, MD:
n
American Society for Parenteral and Enteral Nutrition 1993. pp. 16-17.
c i e ANTHROPOMETRY
Anthropometric assessment is one of the components of nutritional
S
assessment, it deals with physical measurement of individuals and relates them
to standards for growth and development evaluation. The two most important
a
measurements are weight and height. Unintentional weight loss is an indicator
v
of serious disease [12]. Weight is important for energy expenditure estimation
and in Quetelet‟s Index (BMI) [13]. Height is essential for quetelets index
o
(QI), creatinine height index, and body surface area and energy expenditure
calculations [14].
N
Body weight gain may indicate fat and/or lean tissue repletion, fluid
retention or fluid overload as in edema, ascites, and pleural effusion; while
weight loss may indicate presence of a disease or nutritional impairment.
.
Weight loss may result from use of diuretics which increase renal excretion,
c
because of these changes body weight needs to be evaluated carefully.
n
Weight may be evaluated by comparing it with desirable or reference
I
weight, it can be expressed as a percent of desirable body weight as:
,
% desirable body weight = current weight/desirable weight X 100
g
% DBW of ≤80% is considered as substandard [15]. 80% DBW means the
in
patient is 20% below the desirable body weight. Nutritional status may be
indicated by using recent body weight changes than the static weight
h
measurement [16]. Changes in body weight can be assessed by calculation of
is
percentage of usual weight by using the following equation:
l
% Usual weight= current weight/usual weight x 100
ub
Usual weight can be obtained by patient or his relatives or from patient
medical record.
P
Percent weight change is another approach to assess recent changes in
body weight using the following formula [16, 17]:
e
% Weight change = usual weight - current weight/usual weight * 100
n c
Weight loss can be classified as in Box 2.
e
Box 2. Classification of weight loss
< 5%
c i
5% - 10%
- Small
- Potentially significant
S
> 10% - Definitely significant
Corish CA, Kennedy NP.2000. Protein – energy undernutrition in hospital in - patients.
a
British Journal of Nutrition 83:575-591. Detsky AS, Smalley PS, Chage J.1994. Is
this patient malnourished? Journal of the American medical association,
v
271:54-58.
No
.
Case Study 1
nc
Mrs. Jee is 46 years old, female, white, married with 3 children, working eight
I
hours daily as a secretary, was admitted to orthopedic surgery unit, she is unable
to stand because of hip fracture, mid arm circumference 32 cm and knee height
,
46 cm, calculate the estimated weight for Mrs. Jee.
From table 3 below the suitable equation for Mrs. Jee weight estimation is:
g
Weight = (KH X 1.01) + (MAC X 2.81) - 66.04
in
Weight = (46 X 1.01) + (32 X 2.81) – 66.04
Weight = 46.46 + 89.92 – 66.04
h
Weight = 70.34 kg
is
Table 2. Equations for Estimating Body Weight from Knee Height (KH)
l
and mid arm Circumference (MAC) for Various Groups
b
Age* Race Equation** Accuracy
u
Females
6 – 18 Black Weight = (KH x 0.71) + (MACx2.59) - 50.43 ±7.65 kg
P
6 – 18 White Weight = (KH x 0.77) + (MACx2.47) - 50.16 ±7.20 kg
19 - 59 Black Weight = (KH x 1.24) + (MACx2.97) - 82.48 ±11.98 kg
19 - 59 White Weight = (KH x 1.01) + (MACx2.81) - 66.04 ±10.60 kg
e
c
Males
6 – 18
n
Black Weight = (KH x 0.59) + (MACx2.73) - 48.32 ±7.50 kg
6 – 18 White Weight = (KH x 0.68) + (MACx2.64) - 50.08 ±7.82 kg
e
i
19 - 59 White Weight = (KH x 1.19) + (MACx3.21) – 86.82 ±11.42 kg
c
Adapted from Chumlea WC, Guo S, Roche AF, Steinbaugh ML.1988. Prediction of
S
body weight for the no ambulatory elderly from anthropometry. Journal of the
American dietetic association 88:564-568.
a
*Age (in years) is rounded to the nearest year.
**Weight is in kg: lb÷2.2 = kg, kg x 2.2 = lb, Knee Height is in cm: in. x 2.54 = cm,
v
cm ÷ 2.54 = in.
o
Body weight change > 0.5 kg/day indicates an accumulation or loss of
water and not loss or gain of fat or lean tissue, this means body fluid level
N
changes is the main cause of rapid weight change. Metric measures such as
subscapular skin fold, Knee height (KH), mid arm circumference and calf
circumference can be used for ambulatory patient‟s weight estimation [18].
Table 2 summarizes the equations that can be used for weight estimation.
.
Patient age and the anthropometric measures that are available are the main
c
determinants of which equation to use.
ESTIMATED WEIGHT FOR AMPUTATED BODY PARTS

I n
The patient‟s current weight can be adjusted to account for the weight of
g ,
in
the amputated body part, if the patient has had an amputation. The following
equation can be used to calculate adjusted body weight [15, 32].
h
Adjusted weight = Current weight/100 - % of amputation x 100
l is
Table 3 shows the percent of total body weight contributed by amputated
body parts of individual.
ub
Table 3. Percent of total body weight contributed by individual body parts
P
Body part (%) contribution to
Entire arm 6.5
e
Upper arm 3.5
Forearm 2.3
c
Hand 0.8
Entire leg 18.5
n
Upper leg 11.6
e
Lower leg 5.3
i
Foot 1.8
Adapted from Brunnstrom S. 1983, clinical kinesiology, 4th ed. Philadelphia: Davis.
S c
Case Study 2
Mr. x is a 58 years old type 2 diabetic patient, his current weight is 72 kg, he
a
has amputated at the left knee (left lower leg and foot removed). Calculate the
v
adjusted weight for Mr. X
From Table 3 above leg and foot contribute approximately 7.1% of total body.
o
Adjusted wt. = 72/(100-7.1) x 100 = 77.5 kg
N
The adjusted weight of Mr. X is approximately 77.5 kg without amputation.
c .
I n
g ,
in
Adapted from Chumlea WC, Guo SS, Steinbaugh ML.1994. Prediction of stature from
h
knee height for black and white adults and children with application to mobility –
is
impaired or handicapped persons. Journal of the American Dietetic Association
94:1385-1388.
b l
Figure 6. Knee height measurement.
P u
c e
n
Knee height measurement, Knee height was defined as the distance from the sole of
the foot to the most anterior surface of the femoral condyles of the thigh (medial
i e
being more anterior), with the ankle and knee each flexed to a 90° angle. Teichtahl
et al. BMC Musculoskeletal Disorders 2012 13:19 doi: 10.1186/1471-2474-13-19.
c
Figure 7. Knee Height Measurements by Boardable Sliding Caliper.
S
Knee Height
va Knee height can be used for height estimation for patients who cannot
stand or with skeletal deformities, severe arthritis paralysis and amputation
o
[14, 18], knee height is the most common approach for height estimation
because it has been shown to correlate highly with height [14, 19, 20]. The
N
Quetelet‟s index (BMI) can be calculated and compared with various
standards. Knee height measurement, using large, boardable sliding calipers
[23] while the subject in the supine position (lying facing up) [14, 18, 21, 22].
.
Knee and ankle of left leg are positioned are at 90º degree angle (Figures 6
c
and 7).
I n
Table 4. Equations for Estimating Height from Knee Height
for Various Groups
Age
Black Females
Equation Error
g ,
in
> 60 H = 58.72 + (1.96 KH) 8.26cm
19 – 60 H = 68.10 + (1.86 KH) - (0.06 A) 7.60cm
h
6 – 18 H = 46.59 + (2.02 KH) 8.78cm
White Females
is
> 60 H = 75.00 + (1.91 KH) – (0.17A) 8.82 cm
l
19 – 60 H = 70.25 + (1.87 KH) -(0.06 A) 7.20 cm
6 – 18 H = 43.21 + (2.14 KH) 7.80 cm
b
Black Males
> 60 H = 95.79 + (1.37 KH) 8.44 cm
u
19 – 60 H = 73.42 + (1.79 KH) 7.20 cm
6 – 18 H = 39.60 + (2.18 KH) 9.16 cm
P
White Males
> 60 H = 59.01 + (2.08 KH) 7.84 cm
19 – 60 H = 71.85 + (1.88 KH) 7.94 cm
e
6 – 18 H = 40.54 + (2.22 KH) 8.42 cm
c
Adapted from Chumlea WC, Guo SS, Steinbaugh ML.1994. Prediction of stature from
knee height for black and white adults and children with application to mobility –
n
impaired or handicapped persons. Journal of the American Dietetic Association
94:1385-1388.
i e
* Age in years rounded to the nearest year.
H = height KH = Knee height A = age in years.
c
Estimated height will be within this value of 95% of persons within each age, sex, race
group.
S Researchers developed the equations that can be used for height
a
estimation. Table 4 [14] shows the sex-age and race-specific equations for
v
height estimation of children, adults and older persons. Knee height for
persons 60 to 90 years old can be estimated by using the nomogram.
No IDEAL WEIGHT ESTIMATION

Ideal body weight can be determined by variety of approaches, Hamawi
equations is one of the most used equation:
.
IBW Male = 48.8 kg for the first 150 cm + 1.1 kg for each cm over 150 cm
c
or (- 1.1) for each cm under 150cm
I n
IBW Female = 45.5 kg for the first 150 cm + 0.91 kg for each cm over 150
cm or (- 0.91) for each cm under 150 cm
MEASURING FRAME SIZE
g ,
in
Frame size can be measured by several methods including the ratio of
h
height to wrist circumference [34]. The frame size can be calculated by using
is
the following formula, and classified as small, medium and large (Table 5).
l
r = ht/c
b
r: The ratio of body height to wrist circumference
u
ht: Body height in (cm)
c: Circumference of the right wrist in (cm).
P
e
WRIST CIRCUMFERENCE
c
Wrist circumference is measured just distal to the styloid process at the
n
wrist crease on the right arm using measurement tape (Figure 8). To measure
e
the wrist circumference, the arm should be flexed at the elbow, and the hand
i
muscles relaxed. The tape should be perpendicular to the long axis of the
c
forearm. The tape should be touching the skin but not compressing the soft
tissues, measurement is recorded to the nearest 0.1cm [35].
S
Table 5. Determining frame size for males and females
a
r - Value
v
Frame size Women Men
Small > 10.9 >10.4
o
Medium 10.9 – 9.9 10.4 – 9.6
Large < 9.9 < 9.6
N
Grant JP, Custer PB, Thurlow J. 1981. Current techniques of nutritional assessment.
Surgical Clinics of North America 61:437-463.
c .
I n
g ,
h in
l is
ub
P
Adapted from Grant JP, Custer PB, Thurlow J. 1981. Current techniques of nutritional
assessment. Surgical Clinics of North America 61:437-463.
e
Figure 8. Measurement of Wrist Circumference.
n c
BODY FAT DISTRIBUTION
i e
Body fat distribution is an important concern of health implications of
c
obesity [37-39]. Fat distribution within the body is more important than
quantity of body fat, it can be classified in to two types: (1) upper body, or
S
male type (android) and (2) lower body, or female type (gynoid) [38].
Table 6. Waist – Hip Ratio and health risk
va Male
WHR
Female
Health Risk
Men
o
≤ 0.95 ≤ 0.8 Low
0.96 – 1.0 0.81 – 0.85 Moderate
N
> 1.0 > 0.85 High
.
Table 7. Height -Weight Table for Persons Ages 25 to 59 Years
c
(Height without shoes, Weight without Clothing*)
I n
Height Small Frame Medium Frame Large frame
In. cm Ib kg Ib kg Ib kg
,
Men
61 155 123-129 56-59 126-136 57-62 133-145 60-66
g
62 157 125-131 57-60 128-138 58-63 135-148 61-67
63 160 127-133 58-60 130-140 59-64 137-151 62-69
in
64 163 129-135 59-61 132-143 60-65 139-155 63-70
65 165 131-137 60-62 134-146 61-66 141-159 64-72
66 168 133-140 60-64 137-149 62-68 144-163 65-74
h
67 170 135-143 -61-65 140-152 64-69 147-167 67-76
68 173 137-146 6-2-66 143-155 65-70 150-171 68-78
is
69 175 139-149 63-68 146-158 66-72 153-175 70-80
70 178 141-152 64-69 149-161 68-73 156-179 71-81
l
71 180 144-155 65-70 152-165 69-75 159-183 72-83
72 183 147-159 67-72 155-169 70-77 163-187 74-85
b
73 185 150-163 68-74 159-173 72-79 167-192 76-87
74 188 153-167 70-76 162-177 74-80 171-197 78-90
u
75 191 157-171 71-78 166-182 75-83 176-202 80-92
Women
57 145 99-108 45-49 106-118 48-54 115-128 52-58
P
58 157 100-110 45-50 108-120 49-55 117-131 53-60
59 150 101-112 46-51 110-123 50-56 119-134 54-61
60 152 103-115 47-52 112-126 51-57 122-137 55-62
e
61 155 105-118 48-54 115-129 52-59 125-140 57-64
62 157 108-121 49-55 118-132 55-61 128-144 58-65
c
63 160 111-124 50-56 121-135 55-61 131-148 60-67
64 163 114-127 52-58 124-138 56-63 134-152 61-69
n
65 165 117-130 53-59 127-141 58-64 137-156 62-71
66 168 120-133 55-60 130-144 59-65 140-160 64-73
e
67 170 123-136 56-62 133-147 60-67 143-164 65-75
i
68 173 126-139 57-63 136-150 62-68 146-167 66-76
c
69 175 129-142 59-65 139-153 63-70 149-170 68-77
70 178 132-145 60-66 142-156 65-71 152-173 69-79
71 180 135-148 61-67 145-159 66-72 155-176 70-80
S
Adapted from 1983 Metropolitan height and weight tables. 1983. Statistical bulletin of the metropolitan
life insurance company 64 (jam-Jun):3 [36]. Height without shoes obtained by subtracting 1 in.
from heights with shoes for males and females weight without clothes obtained by subtracting 5
a
lb and 3 lb from weight with clothes for males and females, respectively.
o v
N
.
Case Study 3
Peter is 21 years old white man admitted to accident and emergency
nc
I
department because of car accident, he is unable to stand due to multi
fractures, his weight 72 kg, and knee height was 51 cm, wrist
,
circumference 22cm
g
1. Estimate his height.
in
2. Calculate his ideal body weight.
3. determine his frame size
is h
Numerous studies have shown that person with android obesity are at
l
more risk for insulin resistance, hyper insulinemia, and pre - diabetes, type 2
diabetes mellitus, hypertension, hyperlipidemia and stroke as well as risk for
b
death [38-39, 40 - 42].
u
Total abdominal fat or adipose tissue present in three regions:
Subcutaneous (just under the skin), Visceral (surrounding the organs within
P
the peritoneal cavity), and retroperitoneal (outside of and posterior to the
peritoneal cavity). Total abdominal fat can be assessed by two approaches that
e
are relatively easy to practice in clinical setting:
Waist – to- hip ratio (WHR) and waist circumference WC is calculated by
c
dividing the waist circumference by the hip (gluteal) circumference (Table 6).
n
Height -Weight with relation to frame size for Persons Ages 25 to 59
Years can be predicted from reference Tables (Table 7).
c i e
S
va
No Figure 9. Waist Measurement.
c .
I n
g ,
h in
l is
Figure 10. Measurement of Arm Circumference.
WAIST CIRCUMFERENCE MEASUREMENT
ub
P
To measure waist circumference, locate the upper hipbone at the top of the
right iliac crest, measuring tape is placed horizontal around the abdomen at the
e
level of the iliac crest at fixed position, sung the tape but does not compress
the skin, take the measurement at the end of normal expiration [39].
n c
ARM MUSCLE CIRCUMFERENCE
i e
Arm Muscle Circumference (AMC) is estimated from Arm Circumference
c
(AC) and Triceps Skin Fold Thickness (TSF) [18, 25, 26], it is accepted as
S
measure of nutritional status as it is an indicator of muscle and subcutaneous
adipose tissue. A non-stretchable measuring tape is placed around the arm,
while the arm is relaxed, perpendicular to the long axis of the arm at the level
a
of triceps skinfold site (Figure 10). Measurement must without compression of
v
soft tissue and should be recorded to the nearest 0.1cm. Arm circumference
o
can be measured in the supine position, either with the right or left side [18,
27].
N
AMC (cm) = AC (cm) - [π X TSF (cm)] [28]
.
ARM MUSCLE AREA (AMA)
Arm muscle area is an important indicator of nutritional status and used as
nc
I
index of lean tissue or muscle in body [18, 28], Arm muscle area (AMA) is an
,
estimation of the area of the bone and muscle portions of the upper arm [29], it
is calculated from triceps skinfold measurement and the mid arm
g
circumference. AMA is correlated with creatinine excretion in children [30],
in
and with total body muscle mass in adult [24]. It can be calculated by the
standard equation below. Table 8 shows the guidelines for interpretation of
age/sex percentile values for arm muscle area [28]. Appendix 1 and Appendix
h
2 show mid – upper arm muscle area (cm²) by age for males and females
is
respectively:
l
AMA (cm)2 = [MAC (cm) – (π X TSF(cm))] 2/4 π
b
AMA: arm muscle area in mm2,
u
MAC: mid arm circumference in mm, and
TSF: triceps skinfold thickness in mm.
P
Table 8. Show the guidelines for interpretation of age/sex percentile values
e
for arm muscle area
c
Percentile Category
n
< 5th Wasted
th th
>5 but ≤ 15 Below average
i e
>15th but < 85th Average
>85th but ≤ 95th Above average
c
th
>95 High muscle
Adapted from Frisancho AR. Anthropometric standards for the assessment of growth
S
and nutritional status. Ann Arbor: University of Michigan Press.
a
The Corrected Arm Muscle Area (CAMA) is an estimation of the area of
v
the muscle portions of the upper arm, attempting to eliminate the area due to
bone [29]. To correct the overestimation of AMA, Heymsfield and coworkers
o
[24] developed the following revised equations by subtracting a constant that
represent bone, nervous tissue, and vascular tissue in the upper arm:
N CAMA (cm)² for males = [MAC (cm) – (π X TSF(cm))]²/4 π] - 10
CAMA (cm)² for females = [MAC (cm) – (π X TSF(cm))]²/4 π] – 6.5

.
Where cAMA: corrected arm muscle area in cm², MAC: mid arm
c
circumference in cm and TSF: triceps skinfold thickness in cm.
n
The Mid-Upper Arm Fat Area (MUAFA) is an estimation of the area of
I
the fat portions of the upper arm, and is simply the difference between the
MUAA and the MUAMA [31].
MUAFA = MUAA - MUAMA
g ,
in
Arm Fat Index (AFI), a percentage of the arm that is fat, using the
following formula [31].
AFI = 100 X MUAFA/MUAA
is h
CALF CIRCUMFERENCE (CC)
b l
u
Measure the largest part of the calf. You may need to search for the largest
P
part of the calf by measuring above and below the middle of the calf
c e
en
c i
S
va
No Figure 11. Calf measurement, measure the largest part of the calf by measuring above and below the
middle of the calf.
c .
I n
g ,
APPENDIX 1 (36).
i n
h
Mean (M), standard deviation (SD), and percentiles of mid-upper arm muscle area (cm²) by age for males
of 2 to 90 years
il s
b
Males
2.0-2.9 2.46 548 14.7 2.2 11.4 12.0 12.5 13.2 14.5 16.0 16.9 17.5 18.5
3.0-3.9 3.45 481 16.4 2.5 12.4 13.1 13.7 14.5 16.1 17.9 18.9 19.6 20.7
u
4.0-4.9 4.47 542 17.4 2.8 13.0 13.8 14.3 15.2 16.9 18.8 19.9 20.7 21.9
5.0-5.9 5.43 492 18.2 3.1 13.6 14.5 15.1 16.1 18.1 20.3 21.6 22.5 23.9
6.0-6.9 6.45 258 19.3 3.6 14.6 15.6 16.3 17.4 19.8 22.4 23.9 25.0 26.7
P
7.0-7.9 7.47 271 20.8 3.9 15.8 16.9 17.7 19.0 21.5 24.4 26.2 27.4 29.3
8.0-8.9 8.46 257 22.8 4.3 17.0 18.2 19.1 20.5 23.2 26.4 28.2 29.5 31.6
9.0-9.9 9.50 282 25.6 5.0 18.2 19.6 20.5 22.0 25.1 28.6 30.7 32.2 34.5
10.0-10.9 10.45 287 28.6 5.9 19.3 20.9 22.0 23.7 27.2 31.3 33.7 35.5 38.2
e
11.0-11.9 11.44 272 32.1 7.2 20.8 22.6 23.9 25.9 30.2 35.0 38.0 40.1 43.4
12.0-12.9 12.47 201 36.1 8.0 23.1 25.2 26.7 29.1 34.1 40.0 43.5 46.0 50.1
c
13.0-13.9 13.47 188 40.0 9.4 26.3 28.6 30.3 33.0 38.7 45.3 49.2 52.1 56.6
14.0-14.9 14.49 179 44.1 9.8 30.3 32.9 34.7 37.7 43.7 50.7 54.9 58.0 62.7
15.0-15.9 15.45 177 47.9 9.5 64.3 37.0 38.9 42.0 48.3 55.6 59.9 63.0 67.8
n
16.0-16.9 16.45 191 51.6 10.4 37.6 40.5 42.6 45.8 52.5 60.1 64.6 67.9 72.9
17.0-17.9 17.45 188 55.0 11.2 40.0 43.1 45.3 48.8 56.0 64.2 69.0 72.5 78.0
e
18.0-18.9 18.45 167 58.0 11.7 42.0 45.2 47.5 51.2 58.6 67.1 72.2 75.8 81.5
i
19.0-19.9 19.43 154 60.6 12.2 42.6 45.8 48.2 51.8 59.4 68.0 73.1 76.7 82.5
20.0-29.9 24.96 1564 64.5 13.4 45.2 48.8 51.4 55.4 63.8 73.4 79.1 83.2 89.6
c
30.0-39.9 34.72 1405 66.6 13.5 48.7 52.4 55.2 59.4 68.1 78.1 84.0 88.3 95.0
40.0-49.9 44.35 1158 69.9 12.8 49.8 53.5 56.2 60.5 69.1 79.0 84.8 89.0 95.6
50.0-59.9 54.89 815 67.4 12.6 49.7 53.3 55.8 59.7 67.8 76.9 82.3 86.1 92.1
S
60.0-69.9 64.83 1122 64.8 12.4 46.8 50.2 52.7 56.5 64.4 73.3 78.6 82.4 88.3
70.0-79.9 74.16 820 59.5 11.1 43.5 46.5 48.8 52.2 59.2 67.2 71.8 75.2 80.4
80.0-89.9 84.09 635 52.7 10.1 38.1 40.9 42.9 46.0 52.4 59.6 63.9 66.9 71.7
va
N o
c .
I n
g ,
APPENDIX 2.
i n
h
Mean (M), standard deviation (SD), and percentiles of mid-upper arm muscle area (cm²) by age for females
of 2 to 90 years
il s
b
Females
2.0-2.9 2.45 534 15.0 2.2 10.9 11.5 12.0 12.6 14.0 15.5 16.4 17.0 18.0
u
3.0-3.9 3.46 554 14.7 2.4 11.9 12.6 13.1 13.9 15.5 17.2 18.3 19.0 20.1
4.0-4.9 4.43 526 15.3 2.6 12.7 13.5 14.0 15.0 16.8 18.9 20.1 20.9 22.2
5.0-5.9 5.46 540 10.8 3.1 13.2 14.1 14.7 15.7 17.8 20.1 21.5 22.5 24.0
P
6.0-6.9 6.47 272 18.8 3.6 13.6 14.6 15.4 16.5 18.8 21.4 22.9 24.0 25.8
7.0-7.9 7.44 263 20.9 4.2 14.0 15.1 15.8 17.1 19.6 22.4 24.1 25.3 27.3
8.0-8.9 8.47 245 23.2 4.5 14.6 15.7 16.6 17.9 20.7 23.8 25.7 27.1 29.2
9.0-9.9 9.43 266 25.4 5.6 15.7 17.0 17.9 19.4 22.5 26.1 28.2 29.7 32.2
e
10.0-10.9 10.43 254 27.6 5.5 17.7 19.2 20.3 21.9 25.5 29.5 32.0 33.7 36.5
11.0-11.9 11.46 281 29.7 6.5 20.2 21.9 23.2 25.1 29.1 33.8 36.6 38.6 41.8
c
12.0-12.9 12.46 216 31.5 6.9 22.6 24.5 25.9 28.0 32.5 37.7 40.8 43.1 46.6
13.0-13.9 13.45 224 33.1 7.3 24.3 26.3 27.8 30.1 35.0 40.5 43.9 46.3 50.1
14.0-14.9 14.47 218 34.5 7.6 25.1 27.2 28.7 31.1 36.1 41.9 45.3 47.8 51.8
n
15.0-15.9 15.47 187 35.6 8.0 25.1 27.2 28.7 31.2 36.2 42.1 45.6 48.2 52.2
16.0-16.9 16.46 216 36.6 8.2 24.9 27.1 28.6 31.0 36.1 41.9 45.4 48.0 52.0
e
17.0-17.9 17.45 202 37.4 8.6 24.7 26.8 28.4 30.9 36.1 42.1 45.8 48.4 52.6
i
18.0-18.9 18.43 178 38.0 8.7 24.9 27.0 18.6 31.1 36.3 42.4 46.0 48.7 52.9
19.0-19.9 19.48 182 38.5 8.8 25.3 27.5 29.1 31.6 36.9 43.0 46.7 49.4 53.6
c
20.0-29.9 24.91 1766 39.9 9.1 26.4 28.7 30.3 32.9 38.4 44.7 48.6 51.3 55.7
30.0-39.9 34.85 1698 42.3 10.5 27.4 30.0 31.9 34.9 41.3 48.8 53.4 56.7 62.0
40.0-49.9 44.28 1227 44.8 11.3 29.0 31.8 33.9 37.1 44.1 52.2 57.2 60.9 66.7
S
50.0-59.9 54.83 928 45.7 11.7 28.8 31.7 33.7 37.0 44.1 52.4 57.4 61.2 67.1
60.0-69.9 64.82 1092 45.1 11.7 28.1 30.9 32.9 36.2 43.1 51.2 56.2 59.9 65.7
70.0-79.9 74.46 899 43.7 11.3 27.5 30.2 32.2 35.3 42.1 50.1 54.9 58.5 64.2
80.0-89.9 84.45 696 41.0 10.5 26.2 28.8 30.7 33.7 40.1 47.6 52.2 55.6 61.0
va
N o
.
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assessment. Surgical Clinics of North America 61:437-463.
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n c
c i e
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No
c .
I n
g ,
hin
lis
ub
P
c e
en
c i
S
va
No
c .
I n
Chapter 6
g ,
NUTRITIONAL ASSESSMENT OF ELDERLY
h in
l is
b
Nutrition care has a strong focus on disease prevention through healthy
life styles in the elderly. Health promotion and disease prevention can be
u
achieved by proper nutrition, independence, improving self-care behaviors and
P
good quality of life education programs and strategies are necessary for elderly
to teach them how to eat healthier, do exercise safely and stay motivated.
e
Aging is a normal biologic process, organs change with age, some
physiological functions may decline and they do differently between
c
individuals and within organs. These changes can happen as a result of the
n
aging process or as caused by chronic disease such as atherosclerosis.
Body composition changes with age, fat mass and visceral fat increase,
i e
while lean muscle mass decreases. Loss of muscle mass, strength and function
(sarcopenia) are age – related, which lead to alteration of metabolic rate,
c
decrease mobilization and increase risk for falls and quality of life
S
significantly affected [1]. As the number of older adults (65 years of age or
older) is increasing worldwide rapidly, poor appetite, low food intake, low
a
food variety among elderly people may expose them to risk of malnutrition
v
[2]. Malnutrition is defined as an imbalance of energy, protein and other
nutrient intake that may causes negative effect on body forms, function and
o
clinical outcomes [3]. Malnutrition is more common in the older population. It
is usually associated with impaired muscle function, decreased bone mass,
N
impaired status, anemia, decrease cognitive function, immune dysfunction,
poor and delayed wound healing, delay of post surgery recovery, increase
hospital length of stay, increased hospital readmission rate, increase mortality
.
rate and increase cost [4]. Different age related changes in older ages cause
c
reduce in appetite and energy intake has been termed as "anorexia of aging"
n
(Figure 1) [5].
I
Early nutrition assessment of malnutrition or risk of malnutrition provide
,
the opportunity to start early treatment and reduce the risk of morbidity and
mortality, length of hospital stay and cost in this population [6].
g
in
MINI NUTRITIONAL ASSESSMENT (MNA)
is h
Mini nutritional assessment (MNA) was recommended by European
l
Society of Parenteral and Enteral Nutrition (ESPEN) guidelines for detection
of elderly people (>65 years) who are malnourished or at risk of malnutrition
b
[7]. MNA is 18 – items questionnaire published by Guigoz et al. [8], it consist
u
of 6 questions on food intake, weight loss, mobility, psychological stress or
acute disease, presence of dementia or depression, and Body Mass Index
P
(BMI). Alternate measurements such as calf circumference may be used when
height and/or weight cannot be assessed for BMI calculation scoring.
e
MNA categorizes the nutritional status of elderly into 3 – categories
c
according to scores as: 12 – 14 are normal nutritional status, 8 – 11 indicate at
risk of malnutrition, 0 – 7 indicate malnutrition. No laboratory data are needed
n
for MNA (Figure 2).
c i e ANTHROPOMETRIC MEASUREMENTS
S
Calf Circumference (CC)
va
Measure the largest part of the calf. You may need to search for the largest
part of the calf by measuring above and below the middle of the calf, see
o
Figure 11, Chapter 3.
N
c .
I n
g ,
Energy Expenditure
i n
Physiological changes with Aging
h
1. Hormonal
il s
2. Cytokines
3. Taste & smell
4. Changes in GI tract
b
Anorexia of Aging
P u
e
Exercise Pathological changes with Aging
c
 Medical
n
 Drugs
 Psychological
e

i
Social
Figure 1. A depletion of the “anorexia of aging.”
Sc
va
N o
94 Ghazi Dradkeh, M. Mohamed Essaand Nejib Guizani
.
Mini Nutritional Assessment MNA
Last name: First name:
nc
I
Sex: Age: Weight, kg: Height, cm:
Date:
,
Complete the screen by filling in the boxes with the appropriate numbers. Total the
g
numbers for the final screening score.
Screening
in
A
Has food intake declined over the past 3 months due to loss of appetite, digestive
problems, chewing or swallowing difficulties?
h
0 = severe decrease in food intake
is
1 = moderate decrease in food intake
2 = no decrease in food intake
l
B
Weight loss during the last 3 months
b
0 = weight loss greater than 3 kg (6.6 lbs)
1 = does not know
u
2 = weight loss between 1 and 3 kg (2.2 and 6.6 lbs)
3 = no weight loss
P
C Mobility
0 = bed or chair bound
1 = able to get out of bed/chair but does not go out
e
2 = goes out
D Has suffered psychological stress or acute disease in the past 3 months
c
0 = yes 2 = no
E Neuropsychological problems
n
0 = severe dementia or depression
1 = mild dementia
i e
2 = no psychological problems
F1 Body Mass Index (BMI) (weight in kg)/(height in m2)
c
0 = BMI less than 19
1 = BMI 19 to less than 21
S
2 = BMI 21 to less than 23
3 = BMI 23 or greater
IF BMI IS NOT AVAILABLE, REPLACE QUESTION F1 WITH QUESTION F2.
a
DO NOT ANSWER QUESTION F2 IF QUESTION F1 IS ALREADY
COMPLETED.
v
F2 Calf circumference (CC) in cm
0 = CC less than 31
o
3 = CC 31 or greater
Screening score (max. 14 points)
N
12-14 points: Normal nutritional status
8-11 points: At risk of malnutrition
0-7: Malnourished
Figure 2. Mini Nutritional Assessment (MNA) (8).

Nutritional Assessment of Elderly 95
.
MID – UPPER – ARM CIRCUMFERENCE
Arm muscle circumference (AMC) is estimated from arm circumference
nc
I
(AC) and Triceps Skin Fold Thickness (TSF) [9, 10, and 11]; it is accepted as
,
measure of nutritional status as it is an indicator of muscle and subcutaneous
adipose tissue. A non-stretchable measuring tape is placed around the arm,
g
while the arm is relaxed, perpendicular to the long axis of the arm at the level
of triceps skinfold site (see Figure 10, chapter 3). Measurement must without
in
compression of soft tissue and should be recorded to the nearest 0.1cm. Arm
circumference can be measured in the supine position, either with the right or
h
left side [9, 12].
is
AMC (cm) = AC (cm) - [π X TSF (cm)] [13]
b l
u
HEIGHT ESTIMATION
P
1. Knee Height
e
Knee height can be used for height estimation for patients who cannot
stand or with skeletal deformities, severe arthritis paralysis and amputation
c
[9, 14], knee height is the most common approach for height estimation
n
because it has been shown to correlate highly with height [14, 15, 16] (see
Figures 6 and 7 in chapter 3). Table 1 shows height estimation by using knee
e
height. The Quetelet‟s index (BMI) can be calculated and compared with
i
various standards (Table 2).
S c
2. Demi Span
a
Demi span is the distance from the midline at the sternal notch to the web
v
between the middle and ring fingers along outstretched arm (Figure 3). Height
is then calculated from a standard formula.
No 1. Locate and mark the midpoint of the sterna notch with the pen.
2. Ask the patient to place the left arm in a horizontal position.
3. Check that the patient‟s arm is horizontal and in line with shoulders.
.
Table 1. Height Estimation from Knee Height
nc
Knee height Men height (m) Women height (m)
I
(cm) 18-59 60-90 18-59 60-90
43.0 1.53 1.48 1.47 1.44
,
43.5 1.54 1.49 1.49 1.45
44.0 1.55 1.51 1.50 1.46
44.5 1.55 1.52 1.51 1.47
g
45.0 1.56 1.53 1.52 1.48
45.5 1.57 1.54 1.53 1.49
in
46.0 1.58 1.55 1.54 1.50
46.5 1.59 1.56 1.55 1.51
h
47.0 1.60 1.57 1.56 1.52
47.5 1.61 1.58 1.57 1.53
is
48.0 1.62 1.59 1.58 1.54
48.5 1.63 1.60 1.59 1.55
l
49.0 1.64 1.61 1.58 1.56
49.5 1.65 1.62 1.60 1.57
b
50.0 1.66 1.63 1.61 1.58
50.5 1.67 1.64 1.62 1.59
u
51.0 1.68 1.65 1.63 1.60
51.5 1.69 1.66 1.64 1.61
52.0 1.70 1.67 1.65 1.62
P
52.5 1.70 1.68 1.66 1.62
53.0 1.71 1.69 1.67 1.63
53.5 1.72 1.70 1.68 1.64
e
54.0 1.73 1.71 1.69 1.65
54.5 1.74 1.72 1.70 1.66
c
55.0 1.75 1.73 1.71 1.67
55.5 1.76 1.74 1.72 1.68
n
56.0 1.77 1.76 1.73 1.69
56.5 1.78 1.77 1.73 1.70
e
57.0 1.79 1.78 1.74 1.71
i
57.5 1.80 1.79 1.75 1.72
58.0 1.81 1.80 1.76 1.73
c
58.5 1.82 1.81 1.77 1.74
59.0 1.83 1.82 1.78 1.75
S
59.5 1.84 1.83 1.79 1.76
60.0 1.85 1.84 1.80 1.77
60.5 1.86 1.85 1.81 1.78
a
61.0 1.86 1.86 1.82 1.79
61.5 1.87 1.87 1.83 1.80
v
62.0 1.88 1.88 1.84 1.81
62.5 1.89 1.89 1.85 1.82
o
63.0 1.90 1.90 1.86 1.83
63.5 1.91 1.91 1.87 1.83
64.0 1.92 1.92 1.87 1.84
N
64.5 1.93 1.93 1.88 1.85
65.0 1.94 1.94 1.89 1.86
.
4. Using the tape measure, measure distance from mark on the midline at
c
the sterna notch to the web between the middle and ring fingers.
n
5. Check that arm is flat and wrist is straight. Take reading in cm [17]
I
Females: height (cm) = [(1.35 x demi-span in cm)] + 60.1
Males: height (cm) = [(1.40 x demi – span (cm)] + 57.8
g ,
h in
l is
b
Adapted from BAPEN (British Association for Parenteral and Enteral Nutrition) from
u
the „MUST‟ Explanatory Booklet. For further information see www.bapen.org.uk
(http://www.bapen.org.uk/pdfs/must/must_explan.pdf).
P
Figure 3. Measurement of Demi – Span.
3. Half - Arm – Span
c e
n
Half arm-span is the distance from the midline at the sternal notch to the
e
tip of the middle finger (Figure 4). Height is calculated by doubling the half
i
arm-span.
c
1. Locate and mark the edge of the right collar bone (in the sternal notch)
S
with the pen.
2. Ask the patient to place the non-dominant arm in a horizontal position.
a
3. Check that the patient‟s arm is horizontal and in line with shoulders.
v
4. Using the tape measure, measure distance from mark on the midline at
the sternal notch to the tip of the middle finger.
o
5. Check that arm is flat and wrist is straight. Take reading in cm [18].
N
Height = half arm span x 2
c .
I n
Adapted from http://www.rxkinetics.com/height_estimate.html. Accessed January 15,
2011.
g ,
in
Figure 4. Measurement of half arm span.
4. Ulna Length (UL)
is h
l
Ulna length is the distance between the point of the elbow and the
b
midpoint of the prominent bone of the wrist (Figure 5). This value is then
u
compared with a standardized height conversion chart (Table 3). Arm should
be bended (left side if possible), palm across chest, fingers pointing to opposite
P
shoulder, measure the length in centimeters (cm) to the nearest 0.5 cm between
the point of the elbow (olecranon) and the mid-point of the prominent bone of
e
the wrist (styloid process) [19].
n c
c i e
S
a
Adapted from, British Association of Parenteral and Enteral Nutrition. October 2008.
v
Malnutrition Universal Screening Tool. The Malnutrition Universal Screening
Tool (MUST) is reproduced here with the kind permission of BAPEN.
o
Figure 5. Measurement of Ulna Length.
N
Triceps skinfold site is on the posterior aspect of the right arm, over the
triceps muscle, mid-way between the lateral projection of the acromion
process of the scapular and the inferior margin of the olecranon process of the
.
ulna. The skinfold site should be marked along the posterior mid line of the
c
upper arm. Measurer should be stand behind the subject; skin grasped with the
n
thumb & index finger of the left hand about 1 cm to the skin fold site. Caliper
I
is about 1 cm from the left thumb & forefingers, caliper is perpendicular to the
long axis of the skin fold, and the dial can be easily read see Figure 17 A in
,
chapter 2. Appendix 1 and 2 show the reference values of triceps for males and
g
females 20 years of age and older respectively.
Ritz et al. (2004) [20] showed that knee height is accurately sufficient for
in
height estimation in French elderly patients. Estimated height by using knee
height and age was calculated by chulmea et al. [21] by the following
h
equation.
l is
For men: height (cm) = [2.02 x KH (cm)] - [0.04 x Age (y)] + 64.19 (1)
b
For women: height (cm) = [1.83 x KH (cm)] - [0.24 x Age (y)] + 84.88 (2)
u
Ideal weight for elderly people can be calculated by using Lorentz
P
equations (WLO) (22) as follows:
For men: H – 100 - [(H – 150)/4] (3)
c e
For women: H – 100 - [(H – 150)/2.5] (4)
n
Body Mass Index can be calculated as:
e
BMI = weight (kg)/height (m²)
i
Sub scapular site is 1 cm below the interior border of the scapula, by
c
gentle feeling for the inferior angle of the scapula or by placing the subject
right arm behind the back while subject standing with relaxed arms to sides
S
Appendix 3 shows the reference values of sub scapular for females 20 years
and.
a
Table 2. Classification of Body Mass Index for Elderly
o v Body Mass Index

Under weight
> 65 years
< 23
N
Normal 23 - 29
Overweight & obesity >29
c .
I n
g ,
i n
Table 3. Height estimation from ulna length
h
Men (>65 years) 1.94 1.93 1.91 1.89 1.87 1.85 1.84 1.82 1.80 1.78 1.76 1.75 1.73 1.71
il s
Height
(m)
Men (<65 years) 1.87 1.86 1.84 1.82 1.81 1.79 1.78 1.76 1.75 1.73 1.71 1.70 1.68 1.67
Ulna length (cm) 32.0 31.5 31.0 30.5 30.0 29.5 29.0 28.5 28.0 27.5 27.0 26.5 26.0 25.5
b
Height
Women (>65 years) 1.84 1.83 1.81 1.80 1.79 1.77 1.76 1.75 1.73 1.72 1.70 1.69 1.68 1.66
(m)
u
Women (<65years) 1.84 1.83 1.81 1.79 1.78 1.76 1.75 1.73 1.71 1.70 1.68 1.66 1.65 1.63
P
Height
Men (>65 years) 1.69 1.67 1.66 1.64 1.62 1.60 1.58 1.57 1.55 1.53 1.51 1.49 1.48 1.46
(m)
Men (<65years) 1.65 1.63 1.62 1.60 1.59 1.57 1.56 1.54 1.52 1.51 1.49 1.48 1.46 1.45
e
Ulna length (cm) 25.0 24.5 24.0 23.5 23.0 22.5 22.0 21.5 21.0 20.5 20.0 19.5 19.0 18.5
c
Height
Women (>65years)
(m)
1.65 1.63 1.62 1.61 1.59 1.58 1.56 1.55 1.54 1.52 1.51 1.50 1.48 1.47
Women (<65years) 1.61 1.60 1.58 1.56 1.55 1.53 1.52 1.50 1.48 1.47 1.45 1.44 1.42 1.40
en
c i
S
va
N o
.
Table 3. Geriatric Nutritional Risk Index Classification (23)
nc
GNRI Nutrition Risk
I
< 82 Major risk
82 – 92 Moderate risk
,
92 - ≤ 98 Low risk
>98 No risk
g
in
Table 4. Clinical Signs and Nutritional Deficiencies (52)
h
System Signs or symptoms Nutrient deficiency
Skin Dry scaly skin Zinc/essential fatty acids
is
Folicular hyperkeratosis Vitamin A, C
l
Petechiae Vitamin C, k
Photosensitive Niacin
b
Dermatitis
Poor wound healing Zinc, Vitamin C
u
Scrotal dermatitis Riboflavin
Hair Thin/depigmentd Protein
Easy pluckability Protein, Zinc
P
Nail Transverse Albumin
Depigmentation
Spooned Iron
e
Eyes Night blindness Vitamin A, zinc
c
Conjunctival Riboflacin
Inflammation
n
Keratomalacia Vitamin A
Mouth Bleeding gums Vitamin C, riboflaxin
e
Glositis Niacin, piridoxin, riboflavin
i
Atrophic papillae Iron
Hypogeusia Zinc, vitamin A
c
Neck Thyroid enlargement Iodine
Parotid enlargement Protein
S
Abdomen Diarrhea Niacin, folate, vitamin B 12
Hepatomegaly Protein
Extremities Bone tenderness Vitamin D
a
Joint pain Vitamin C
v
Muscle tenderness Thiamine
Muscle wasting Protein, selenium vitamin D
o
Edema Protein
Nuerological Ataxia Vitamin B12
Tetany Calcium, magnesium
N
Parasthesia Thiamine, vitamin B12
Ataxia Vitamin B12
Dementia Vitamin B, niacin
Hyporeflexia Thiamine12
.
GERIATRIC NUTRITIONAL RISK INDEX (GNRI)
Geriatric nutritional risk index is a new index for predicting the risk of
nc
I
nutrition – related complications. It can be assessed through the equation of
,
Bouillanne et al. [22].
g
GNRI = [(1.489 X albumin (g/l)] + [41.7 x (weight/Wlo)]
in
GNRI is defined four grades of nutrition – related risk (Table 3).
h
Weight loss of 5% or 10% and albumin concentration of 38, 35, and 30 g/l
is
were used for determination of GNRI.
CLINICAL ASSESSMENT
b l
u
Clinical signs can develop as a result of nutritional deficiencies; each
P
clinical sign is related to a specific nutrient deficiency. Table 4 summarizes the
clinical signs and nutritional deficiencies.
e
The assessment of biological and social determinants of nutritional
c
problems for elderly has been developed by using the DETERMINE checklist
which focuses on Disease, Eating problems, Tooth loss and swallowing
n
difficulties, Economic hardship, Reduced social contact, Multiple medications,
Involuntary weight loss or gain, Need for assistance in self – care, and Elders
i e
at a very advanced age (Table 5) [23].
S c HYDRATION
a
Hydration is the most common cause of fluid imbalance in older people.
Poor hydration is clinically important because inadequate hydration is
v
associated with many adverse consequences including poor oral health, poor
o
skin integrity, constipation, urinary tract infection and confusion. Poor
hydration itself can also contribute to reduced food intake and malnutrition.
N
Dehydration, is a well known nutritional problem, can be defined as
depletion in total body water content due to pathologic fluid losses, diminished
fluid intake, or combination of both, institutionalized elderly patients are most
particularly at risk of dehydration related danger [24]. Due to age related
.
changes in total body water, renal concentrating ability, decrease thirst, and
c
medication relate hypodypsia [25, 26], confusion, disorientation, weak spells,
n
infection, coronary artery disease, impaired or delayed wound healing, and
I
death are dangerous side effect of dehydration [27-32]. There are different
forms of dehydration (Table 6).
Table 5. Determine Your Nutritional Health (23)
g ,
in
The warning signs of poor nutritional health are often overlooked. Use this checklist to
find out if you or someone you know is at risk.
h
Read the statements below. Circle the number in the yes column for those that apply to
you or someone you know. For each yes answer, score the number in the box. Total
is
your nutritional score.
l
YES
b
I have an illness or condition that made me change the kind and/or amount 2
of food I eat.
u
I eat fewer than two meals per day. 3
I eat few fruits, vegetables or milk products. 2
P
I have three or more drinks of beer, liquor or wine almost every day 2
I have tooth or mouth problems that make it hard for me to eat. 2
I don‟t always have enough money to buy the food I need. 4
e
I eat alone most of the time. 1
I take three or more different prescribed or over the counter drugs a day. 1
c
Without wanting to, I have lost or gained 10 pound in the last six months. 2
I am not always physically able to shop, cook and/or feed myself. 2
n
Total:
i e
Total Your Nutritional Score
0-2 Good! Recheck your nutritional score in six months.
c
3-5 You are at moderate nutritional risk. See what can be done to improve your eating
habits and lifestyle. Your local health center, senior nutrition program, senior citizens
S
counter or health department can help. Recheck your nutritional score in three months.
≥6 You are at high nutritional risk. Bring your nutritional this checklist the next time
a
you see your doctor, dietitian or other qualified health or social service professional.
v
Talk with him/her about any problem you may have. Ask for help to improve your
nutritional health.
o
Remember that warning signs suggest risk, but do not represent diagnosis of any
condition.
Adapted from: The Nutrition Screening Initiative- A project of: The American of Family
N
Physicians: The American Dietetic Association: and the National Council on the Aging.
.
Table 6. Dehydration forms
nc
Dehydration form Definition
I
Hypertonic dehydration is depletion in total body water
(TBW) owing to pathologic fluid losses, diminished water
,
intake, or a combination of both [29–33]
hypotonic dehydration a fluid depletion in which more
g
sodium than water is lost and extracellular fluid becomes
in
depleted [29, 31–34]
Isotonic dehydration a balanced depletion of both water and sodium, also leads to
a loss of extracellular fluid.
Table 7. Assessment of hydration status
is h
l
Hydration status Criteria
b
Dehydration Serum osmolarity > 295miliosmolls
Intravascular volume a BUN(Blood Urea Nitrogen)-creatinine ratio above 20 or a
u
depletion level of serum sodium above 145 mg per deciliter
hypovolemia a serum osmolarity above 295 milliosmols and a BUN-
P
creatinine ratio above 20 [30].
e
ASSESSMENT OF HYDRATION STATUS
n c
Hydration status should be assessed at time of admission, as part of
comprehensive.
e
Physical assessment, and as deemed appropriate when acute situations
i
occur [35]. Assessment of hydration status includes:
c
a. Urine specific gravity
S
b. Urine color
c. serum osmolarity
a
d. BUN: creatinine ratio
o v a. Urine Specific Gravity (USG)
N
Testing USG has been shown to be a reliable and an important indicator of
the body absolute hydration status [36] that can be used as a single measure,
which is non-invasive, easy and quick to conduct in the field work [37].
.
Australian Pathology Association criteria defined a dehydrated state as a
c
USG > 1.030. USG < 1.020 was the recommended cut-off point for
n
euhydration by Armstrong et al. [38] and Shirreffs and Maughan [39]. Based
I
on USG, hydration status were categories as Table 8 [40].
,
Table 8. Hydration status according to urine specific gravity
g
Urine Specific Gravity (USG) Hydration Status
in
≤ 1.015 Optimal (euhydrated).
1.016–1.020 marginally adequate hydration
h
1.021–1.025 hypohydrated.
1.026–1.030 severely hypohydrated
is
> 1.030 clinically dehydrated state
b. Urine Color
b l
u
Urine color has also been used with reasonable accuracy when laboratory
P
analysis is not available or when a quick estimate of hydration is necessary.
Some data indicate that urine color is as good indicator of hydration as plasma
or urine osmolality or urine specific gravity [41].
e
Good hydration can be detected when urine is plentiful, odorless and pale
c
in color. Dark, strong-smelling urine could be a sign of dehydration. Certain
n
foods, medications and vitamin supplements may cause the color of urine to
change even though you are hydrated.
i e
Note: Use of a urine color chart is suggested for people with adequate
c
renal function and not by people who wear incontinence pads.
S
c. Serum Osmolarity
va
A common simplified formula for serum osmolarityis:
o
Calculated osmolarity = 2 x serum sodium + serum glucose + serum urea
(all in mmol/L) [43].
N
c .
I n
g ,
h in
l is
b
Figure 6. Simple urine color chart to assess the hydration status [42].
u
Adapted from Armstrong, L.E., Soto, J.A., Hacker, F.T., Casa, D.J., Kavouiras, S.A.,
Maresh, C.M. (1998). „Urinary indices during dehydration, exercise, and rehydration.‟
P
Int. J. Sport Nutr. 8: 345-355.
Table 9. Conditions that affect the osmolality [44]
Serum:
c e
Conditions that increase osmolality Conditions that decrease osmolality
Serum:
n
 Dehydration/sepsis/fever/sweating/burns  Excess hydration
e
 Diabetes mellitus (hyperglycemia)  Hyponatremia
i
 Diabetes insipidus  Syndrome of Inappropriate
c
 Uremia ADH secretion (SIADH)
Urine: Urine:
 Diabetes insipidus
S
 Dehydration
 Syndrome Inappropriate ADH secretion  Excess fluid intake
(SIADH)  Acute renal insufficiency
a
 Adrenal insufficiency  Glomerulonephritis
v
 Glycosuria
 Hypernatremia
o
 High protein diet
Adapted from Family Practice Notebook.com. Serum http://www.fpnotebook.
N
com/Renal/Lab/SrmOsmlty.htm.Urine http://www.fpnotebook.com/Urology/Lab/Urn
Osmlty. htm Accessed 5/27/10.
.
Osmolality can also be measure by an osmometer. The difference between
c
the calculated value and measured value is known as the osmoticgap. Serum
n
osmolality: 282 - 295 mOsm/kg water; a serum osmolality of 285 mOsm
I
usually correlates with a urine specific gravity of 1.0 Osmolality may be
affected by different conditions (Table 9).
,
For serum osmolality values of less than 240 mOsm or greater than 321
g
mOsm are considered to be risky. A serum osmolality of 384 mOsm produces
stupor. If the serum osmolality rises over 400 mOsm, the patient may have
in
grand mal seizures. Values greater than 420 mOsm are fatal. When the serum
osmolality is normal or increased, the kidneys are conserving water. As the
h
serum osmolality rises, the urine osmolality should also rise.
d. BUN: Creatinine Ratio
l is
ub
Elevated blood urea nitrogen (BUN) level with a normal or low serum
creatinine level, may indicate under – hydration. A BUN: creatinine ratio
P
greater than 20:1 is a sign of dehydration [45].
Dehydration is the loss of body water with or without salt, at a rate greater
e
than the body can replace it [46]. Dehydration is common in the elderly and
can lead to constipation, increased risk of infections, and medication toxicity.
c
Risk factors for dehydration [47] as well as for over hydration [48] are
n
summarized in Table 10.
Each person considered at risk for over hydration or under hydration
i e
should have an individualized goal for daily fluid intake determined by a
documented standard for daily fluid intake [47, 49].
c
The daily fluid intake can be calculated as follows:
S
A. 100 mL/kg for first 10 kg weight
B. 50 mL/kg for next 10 kg weight
a
C. 15 mL/kg of remaining kg weight
v
For people receiving a diet consisting of food and fluids:
o
The number calculated for the standard fluid intake represents fluids from
all sources (Food plus liquids).
N
.
Table 10. Risk factors of dehydration and over hydration
Risk factors of dehydration [33] Risk factors of over hydration [34]
nc
I
 Acute situation:  People with diagnosis of:
a. Vomiting a. Congestive heart failure
,
b. Diarrhea b. Renal disease
g
c. Febrile episodes c. Major psychiatric disorders
d. Repeated NPO episode schizophrenia
in
 People with the following diseases:  People taking lithium
a. Alzheimer‟s and other dementia  People receiving excessive
h
b. Depression intravenous fluid therapy for
c. Stroke correction of dehydration
is
d. Diabetes
l
e. Malnutrition
f. Dysphagia
b
g. Reflux
h. Four or more chronic conditions
u
 Chronic cognitive impairment
 Functional status: semi-dependent
P
 Inadequate nutrition including the
use of hyperosmolar or high protein
e
enteral feeding
c
Example:
en
An individual weighs 95 pounds or 43 kilograms (2.2 pounds per kilogram)
c i
100 mL/first 10 kg weight 100 X 10 = 1,000 mL
50 mL/kg for next 10 kg weight 50 X 10 = 500 mL
S
15 mL/kg for remaining 23 kg weight 15 X 23 = 345 mL
Total fluid intake need from all sources 1,845 mL
a
Multiplied by 0.75 x 0.75
v
Intake needs from liquids alone 1383.75 or 1,385 mL
o
Figure 7. Required liquid fluid intake for those on a diet consisting of food and fluids.
N
.
Table 11. Recommended daily fluid intake by weight
Body weight Body weight Recommended total Recommended fluid
nc
I
(kg) (pounds) fluid intake per day intake from liquids
(ml) per day (ml)
,
10 22.0 1000 750
12 26.4 1100 825
g
14 30.8 1200 900
16 35.2 1300 975
in
18 39.6 1400 1050
20 44.0 1500 1125
h
22 48.4 1530 1148
24 52.8 1560 1170
is
26 57.2 1590 1193
l
28 61.6 1620 1215
30 66.0 1650 1238
b
32 70.4 1680 1260
34 74.8 1710 1283
u
36 79.2 1740 1305
38 83.6 1770 1328
P
40 88.0 1800 1350
42 92.4 1830 1373
e
44 96.8 1860 1395
46 101.2 1890 1418
c
48 105.6 1920 1440
50 110.0 1950 1463
n
52 114.4 1980 1485
e
54 118.8 2010 1508
i
56 123.2 2040 1530
58 127.6 2070 1553
c
60 132.0 2100 1575
62 136.4 2130 1598
S
64 140.8 2160 1620
66 145.2 2190 1643
68 149.6 2220 1665
a
70 154.0 2250 1688
v
72 158.4 2280 1710
74 162.8 2310 1733
o
76 167.2 2340 1755
For each additional 2 kg body weight (approximately 4.5 pounds) add 30 ml total fluid
N
intake of which 22 ml should be from liquids.
.
Table 12. Relative Strength of Different Signs of Hydration Status in
c
Elderly [47, 48]
I n
Parameter Physical Sign Dehydration Over hydration
47,48 48
,
Vital signs Rapid pulse ++
Orthostatic +/-
g
hypotension
Weight Acute increase +++
in
Acute increase +++
Oral mucous Dry, pale, decrease +++
h
membranes saliva
Tongue Longitudinal furrows +++
is
Dry +++
l
Skin turgor Decrease -
eyes Sunken +
b
Axillary sweat Decreased +++
Speech Difficulties ++
u
Confusion Acute onset +++
Upper body control Muscle weakness
P
Lower extremities Pitting edema +++
Neck veins Distended in supine +++
position
e
(Note): (+) = some relationship, (+++) = strong relationship, (-) = no relationship.
c
a. Up to seventy-five percent (75%) of total body fluids are consumed
n
from liquids [33].
b. Therefore, total daily fluid intake needs to be multiplied by 0.75 to
i e
determine amount needed from liquids alone.
c. Figure 7 provides an example of how to calculate required fluid intake
c
needs from fluids alone when a person is on a diet of foods and fluids.
S
For people receiving entire diet from tube feedings alone:
a
As a general rule:
v
A. 1 calorie/mL formulas are approximately 80%-85% water
o
(e.g., 800 - 850 mL water per 1000 mL formula).
B. 1.5 calorie/mL formulas are approximately 75%-80% water
N
(e.g, 750 - 800 mL water per 1000 mL formula).
C. 2.0 calorie/mL formulas are approximately 70%-75% water
(e.g., 700-750 mL water per 1000 mL formula).
.
D. Additional water can come from orally consumed food and liquids,
c
water used to irrigate feeding tubes, and IV solutions. Hydration
n
status is correlated with different clinical signs (Table 12).
I
Depending on the basis of the percentage of body weight loss dehydration
,
is classified as mild, marked, severe and fatal (Table 13) [51].
g
Table 13. Degree of dehydration [51]
in
Degree of % of weight Symptoms
h
dehydration loss
is
Mild 2% Thirst
l
Marked 5% Marked thirst
Dry mucous membrane
b
Dryness and wrinkling of skin
u
Low grade temperature elevation
Tachycardia
P
Respiration 28 or greater
Decrease (10-15mmHg) in systolic blood
pressure standing position
e
Urinary output < 25ml/hr (oliguria)
c
Increased specific gravity (> 1.030)
Elevated Hct
n
Elevated Hgb
e
Elevated BUN
i
Body weight loss
c
Severe 8% Symptoms of marked dehydration plus:
Flushed skin
S
Systolic blood pressure drop(60mmHg or
below)
Behavioral changes (restlessness, irritability,
a
disorientation, delirium)
v
Fatal 22-30% of Anuria
total body Coma leading to death
o
water loss can
prove fatal
N
.
Case Study 1
Mrs. X is 81 years old, she has had Parkinson‟s disease for 5 years,
nc
I
weighing 95 pounds (43 kg) is being fed a 1 calorie/mL formula at 75
mL/hour by Nasogastric Tube(NGT)
,
Over 24 hours (1800 mL, or 1.8L per day).
1. Estimated daily water needs:
g
a. 100 mL/first 10 kg weight 100 X 10 = 1,000 mL
in
b. 50 mL/kg for next 10 kg weight 50 X 10 = 500 mL
c. 15 mL/kg for remaining 23 kg weight 15 X 23 = 345 mL
Total fluid intake need from all sources 1,845 mL
h
2. Water provided by tube feeding formula (1 cal/mL formula)
is
a. 800 mL water per 1000 mL formula
l
b. The person received 1.8 liters per day
c. 800 mL/L x 1.8 liters = 1440mL
b
Water provided by tube feeding formula 1,440 mL
3. Additional water required:
u
Total fluid needed from all sources 1,845 mL
(minus) Water provided by tube feeding formula 1,440 mL
P
Additional water required 445 mL/day
e
Figure 8. Required liquid fluid intake for those on a diet from tube feedings alone [50].
c
Case Study 2
en
Mary is 73 years old, female, known case of type 2 diabetes on oral
i
medications 12 years ago, hypertension on medication 3 years ago, admitted
c
to orthopedic ward since last month because of a femur fracture, she is still
unable to stand, her current weight is 75 kg, and knee height 51cm, her lab
S
results are:
FBS 8.9 mmol/l urine specific gravity 1.1 albumin 28g/l sodium
a
145mmol/l
BUN 9.1 mmol/l creatinine 128mmol/l
o v 1.
2.
Calculate her fluid requirement
Calculate BMI& IBwt
N
3. Assess her hydration status
4. Assess her nutritional risk
c .
I n
g ,
APPENDIX 1.
i n
h
Triceps skinfold thickness in millimeters for males 20 years of age and older by race and ethnicity and age, by mean, standard error
of the mean, and selected percentiles; United States 2003-2006
il s
Race and ethnicity and age Number Mean Standard Percentile
Millimeters
b
All race and ethnicity groups
20 years and over 4152 15.0 0.19 6.1 7.3 8.3 10.1 13.8 18.8 21.9 24.2 28.1
u
20-29 years 755 14.3 0.35 5.0 6.2 7.1 8.8 12.7 18.9 21.7 25.4 29.4
30-39 years 690 14.7 0.28 5.8 7.1 8.2 10.0 13.6 18.3 21.4 23.4 27.0
40-49 years 705 15.3 0.35 6.6 7.6 8.7 10.4 13.9 19.2 22.3 24.1 27.9
P
50-59 years 542 15.1 0.41 6.2 7.4 8.9 10.8 14.1 18.5 21.5 23.2 26.7
60-69 years 618 16.1 0.43 7.3 8.3 9.4 11.2 14.9 19.7 22.5 25.2 30.3
70 -79 years 520 15.6 0.33 7.1 8.7 9.5 11.0 14.0 19.2 22.5 25.0 29.1
80 years and over 322 13.9 0.26 6.8 7.6 8.3 9.7 12.7 16.2 19.8 21.6 24.4
e
Non-Hispanic white
20 years and over 2177 15.2 0.21 6.1 7.4 8.6 10.3 13.9 19.1 22.1 24.4 28.5
20-39 years 639 14.5 0.33 5.4 6.4 7.5 9.2 13.1 18.7 21.4 24.0 28.5
c
40-59 years 651 15.5 0.38 6.4 7.6 9.1 10.9 14.1 19.3 22.5 24.3 28.0
60 years and over 887 15.9 0.31 7.3 8.6 9.4 11.1 14.4 19.1 22.4 24.9 29.7
n
Non-Hispanic black
20 years and over 838 14.3 0.22 4.9 6.1 7.0 8.7 12.8 18.4 21.8 24.1 28.1
20-39 years 318 14.4 0.39 4.7 5.3 6.3 8.4 12.8 18.9 22.4 24.8 30.8
e
40-59 years 274 13.7 0.36 5.4 6.5 7.1 8.7 12.2 17.4 20.3 22.0 24.7
i
60 years and over 246 15.5 0.42 4.8 6.9 7.9 10.0 14.0 20.4 24.0 26.2 29.9
Mexican American
c
20 years and over 848 14.2 0.40 6.2 7.4 8.5 9.8 13.0 17.1 20.1 22.9 26.3
20-39 years 348 14.8 0.59 6.0 7.2 8.5 10.0 13.4 18.0 21.8 24.4 27.3
40-59 years 238 13.3 0.33 * 7.7 8.2 9.1 12.0 15.9 18.0 19.7 *
S
60 years and over 262 13.7 0.45 * 8.1 8.6 9.7 12.5 6.0 19.6 21.1 *
*
Figure does not meet standards of reliability and precision.
*
Persons of other races and unknown race and ethnicity are included.
va
N o
c .
I n
g ,
APPENDIX 2.
i n
h
Triceps skinfold thickness in millimeters for females 20 years of age and older by race and ethnicity and age,
by mean, standard error of the mean, and selected percentiles; United States 2003-2006
il s
Millimeters
b
20 years and over 3552 24.1 0.22 11.6 13.9 15.5 18.3 24.0 29.9 32.4 34.2 36.4
u
20-29 years 599 21.8 0.44 10.4 11.9 13.2 15.5 21.1 27.3 30.3 32.4 34.7
30-39 years 538 24.3 0.54 12.1 14.7 15.8 18.2 23.9 30.2 32.9 35.3 37.4
40-49 years 617 25.1 0.44 12.1 14.1 15.9 19.5 25.6 30.9 33.6 35.2 36.9
P
50-59 years 477 25.6 0.36 13.3 16.1 17.5 20.5 25.9 31.0 33.2 34.9 36.5
60-69 years 570 25.3 0.42 13.4 16.6 18.1 20.3 25.4 30.2 32.8 24.2 36.0
70 -79 years 408 23.2 0.41 11.2 14.2 15.7 17.9 22.9 28.7 31.1 32.7 36.0
80 years and over 343 20.2 0.41 10.1 11.3 12.7 14.7 19.0 25.0 28.5 30.1 32.7
e
Non-Hispanic white
20 years and over 1909 23.9 0.26 11.6 13.7 15.3 18.0 23.8 29.8 32.3 34.0 36.1
c
20-39 years 540 22.8 0.50 11.1 13.1 14.1 16.8 22.1 28.5 31.6 33.2 36.4
40-59 years 565 25.1 0.40 12.3 14.7 16.3 19.8 25.5 31.0 33.1 24.4 36.7
60 years and over 804 23.5 0.34 11.2 13.9 15.6 18.0 23.5 28.8 31.8 32.9 35.2
n
Non-Hispanic black
20 years and over 686 25.4 0.37 10.6 14.1 16.0 19.5 25.9 31.6 34.5 35.9 37.3
e
20-39 years 242 24.1 0.61 10.1 12.4 14.4 18.1 24.2 30.3 33.1 35.0 37.2
40-59 years 231 27.1 0.45 10.6 16.1 18.2 22.0 28.0 33.8 35.7 36.8 38.2
i
60 years and over 213 24.9 0.44 11.2 14.4 16.3 18.9 25.1 30.8 33.1 34.7 36.2
Mexican American
c
20 years and over 676 24.9 0.53 13.3 15.9 17.2 19.9 24.3 30.1 32.6 34.6 36.3
20-39 years 244 24.6 0.62 13.0 14.8 16.8 19.2 23.5 30.2 32.5 34.7 36.3
40-59 years 196 26.0 0.64 * 17.0 18.6 21.2 26.1 30.1 33.5 34.9 *
S
60 years and over 236 23.0 0.35 * 14.4 15.6 18.9 22.2 27.3 30.4 32.3 *
*
*
va
N o
c .
I n
g ,
APPENDIX 3.
i n
h
Subscapular skinfold thickness in millimeters for females 20 years of age and older by race and ethnicity and age,
by mean, standard error of the mean, and selected percentiles; United States 2003-2006
il s
Millimeters
b
20 years and over 3186 20.8 0.24 8.4 10.0 11.3 13.9 20.3 26.8 30.4 32.6 35.1
u
20-29 years 526 18.3 0.49 7.6 8.9 10.0 11.7 16.3 24.1 27.3 30.5 33.9
30-39 years 492 21.1 0.50 9.2 10.6 11.8 14.3 20.2 27.4 30.9 32.2 35.3
40-49 years 521 22.2 0.46 9.1 10.7 12.3 15.2 22.7 28.5 31.8 33.9 35.6
P
50-59 years 406 22.6 0.41 8.8 11.6 13.0 16.5 22.6 28.9 31.7 34.1 36.2
60-69 years 534 22.3 0.41 9.1 10.9 13.5 16.7 21.8 28.0 32.0 33.0 34.9
70 -79 years 375 19.3 0.54 7.4 9.3 10.5 13.8 19.3 23.9 27.0 29.5 32.4
80 years and over 333 16.1 0.36 6.9 8.1 8.8 10.4 14.4 21.3 24.4 25.4 28.2
e
Non-Hispanic white
20 years and over 1904 20.1 0.26 8.1 9.6 10.8 13.2 19.4 25.8 29.9 31.7 24.8
c
20-39 years 516 18.8 0.45 7.8 9.2 10.3 12.1 16.8 24.4 28.5 31.0 33.8
40-59 years 513 21.7 0.39 8.7 10.4 12.1 14.8 21.9 28.3 30.9 33.3 35.6
60 years and over 775 19.4 0.37 7.6 9.2 10.2 12.9 19.3 24.8 27.8 30.2 33.0
n
Non-Hispanic black
20 years and over 571 24.0 0.54 9.5 12.0 13.4 17.5 24.3 30.8 33.8 34.6 36.8
e
20-39 years 210 22.4 0.81 * 10.7 12.0 15.0 22.4 29.4 32.5 34.0 *
40-59 years 182 26.1 0.66 * 15.1 17.0 20.6 26.5 32.6 24.2 35.3 *
i
60 years and over 179 24.0 0.71 * 12.6 13.9 17.6 23.6 30.2 32.5 35.1 *
Mexican American
c
20 years and over 569 23.2 0.59 10.9 13.6 14.6 17.2 23.2 28.2 31.2 33.5 35.7
20-39 years 200 23.0 0.99 * 11.9 13.9 16.3 23.2 28.7 31.9 34.0 *
40-59 years 145 24.1 0.50 * 15.1 16.2 18.8 24.0 28.3 31.14 33.2 *
S
60 years and over 224 21.6 0.50 * 13.2 14.1 17.1 20.6 25.7 29.4 31.2 *
*
*
va
N o
.
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[44] Family Practice Notebook.com. Serum http://www.fpnotebook.com/
Renal/Lab/SrmOsmlty.htmUrinehttp://www.fpnotebook.com/Urology/L
e
ab/UrnOsmlty.htm Accessed 5/27/10.
i
[45] Weinberg AD, Maniker KL. Dehydration: Evaluation and management
c
in older adults. JAMA. 1995, 274(19):1552 – 1556.
[46] David R. Thomas et al. understanding clinical dehydration and its
S
treatment. Journal of the American medical directors association vol.9,
issue 5, 2008. 292- 301.
a
[47] Mentes, J.C. & Iowa Veterans Affairs Nursing Research Consortium
v
(2004, February). Hydration Management Evidenced-Based Guideline.
The University of Iowa Gerontological Nursing Interventions Research
o
Center, Research Translation and Dissemination Core. Iowa City, IA:
University of Iowa.
N
[48] Mentes, J.C. & Iowa Veterans Affairs Nursing Research Consortium
(1998, September). Hydration Management Research - Based
Guideline. The University of Iowa Gerontological Nursing Interventions
.
Research Center, Research Translation and Dissemination Core. Iowa
c
City, IA: University of Iowa.
n
[49] Chidester, J. & Spangler, A. (1997). Fluid intake in the institutionalized
I
elderly. Journal of the American Dietetic Association, 97, 23-28.
[50] Campbell, S.M. (1998). Inquire here. Support Line, 20(1), 17.
,
[51] Kee, J. L, & Paulanka, B. J. (2000). Fluids and electrolytes with clinical
g
application: A programmed Approach. (6th Ed.). Albany, NY: Delmar.
[52] Christakis G (ed). Nutritional assessmen in health programs.
in
Washington, DC: American Public Health Association, 1973,pp.26-27.
is h
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P u
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No
c .
I n
g ,
GLOSSARY
h in
l is
MEDICAL TERMINOLOGY
b
Allergy: Hypersensitivity to physical or chemical agents.
u
Alveoli: Rounded cavities present in the breast (singular = alveolus).
P
Amenorrhea: Absence of menstrual cycle.
Amylophagia: Compulsive consumption of laundry starch or cornstarch.
Anaphylaxis: Sudden onset of a reaction with mild to severe symptoms.
e
Anencephaly: Condition initiated early in gestation of the central nervous
c
system in which the brain is not formed correctly, resulting in neonatal
death.
n
Anovulatory cycles: Menstrual cycles in which ovulation does not occur.
e
Anthropometry: The science of measuring the human body and its parts.
i
Appropriate gestational age (AGA): Weight, length, and head circumference
c
are between the 10th and 90th percentiles for gestational age.
Arteriosclerosis: Age – related thickening and hardening of the artery walls.
S
Asthma: Condition in which the lungs are unable to exchange air due to lack
of expansion of air sacs.
a
Atherosclerosis: A type of hardening of arteries in which cholesterol id
deposited in the arteries.
v
Athetosis: Uncontrolled movement of the large muscle groups as a result of
o
damage to the central nervous system.
Atrial fibrillation: Degeneration of the heart muscle, causing irregular
N
contractions.
Attention Deficit Hyperactivity Disorder (ADHD): Condition characterized
by low impulse control and short attention span, with and without a high
level of overall activity.
122 Glossary
.
Autoimmune disease: A disease related to the destruction of body‟s own cells
c
by substances produced by the immune system that mistakenly recognize
n
certain cell components as harmful.
I
Autism: Condition of deficit in communication and social interaction with
onset generally before age 3 years.
,
Bioactive food components: Constituents in food or dietary supplements,
g
other than those needed to meet basic human nutritional needs, that are
responsible for changes in health status. Binge-eating disorder (BED):
in
An eating disorder characterized by periodic binge eating, which normally
is not followed by vomiting or the use of laxatives.
h
Bone age: Bone maturation, correlates well with stage of pubertal
is
development.
l
Bronchopulmonary dysplasia (BPD): Condition in which the
underdeveloped lungs in preterm infant are damaged so that breathing
b
requires extra efforts.
u
Bulimia nervosa: Disorder characterized by repeated bouts of uncontrolled,
rapid ingestion of large quantities of food followed by self-induced
P
vomiting, laxatives or diuretic use, fasting or vigorous exercise in order to
prevent weight gain.
Cachexia: Profound physical wasting and malnutrition usually associated with
e
chronic disease, advanced acquired immune deficiency syndrome,
c
alcoholism, or drug abuse.
n
Carotenemia: A condition, caused by ingestion of high amounts of
carotenoids(or carotene) from plant foods, in which the skin turns
e
yellowish color.
i
Carotid artery disease: Condition in which the arteries that supply blood to
c
the brain and neck become damaged.
Catch-up growth: Period of time shortly after a slow period when the rate of
S
weight and height gains is likely to be faster than expected for age and
gender.
a
Celiac-disease: An autoimmune disease characterized by inflammation of the
v
small intestine lining resulting from a genetically based intolerance to a
component of gluten. The inflammation produces diarrhea, fatty stool,
o
weight loss, and vitamins and minerals deficiencies. Also called tropical
sprue and gluten - sensitive enteropathy.
N
Cerebral palsy: A group of disorders characterized by impaired muscle
activity and coordination present at birth or developed during early
childhood.
Glossary 123
.
Cerebral spine atrophy: Condition in which muscle control declines over
c
time as a result of nerve loss, causing death in childhood.
n
Cerebrovascular disease: A group of disorders, characterized by decreased
I
blood supply to the brain, resulting from hemorrhage of or atherosclerosis
within the cerebral arteries.
,
Chronic disease: Slow – developing, long lasting disease that are not
g
contagious. They can be treated but not always cured.
Chronic inflammation: Low – grade inflammation that lasts weeks, months,
in
or years. Inflammation is the first response of the body‟s immune system
to infection or irritation.
h
Clift lip and palate: Condition in which the upper lip and roof of the mouth
is
are not formed completely and are surgically corrected, resulting in
l
feeding, speaking, and hearing difficulties in childhood.
Cognitive function: The process of thinking.
b
Colic: A condition marked by a sudden onset of irritability, fussiness, or
u
crying in a young infant between 2 weeks and 3 months of age who is
otherwise growing and healthy.
P
Congenital abnormality: A structural, functional, or metabolic abnormality
present at birth. Also called congenital anomalies.
Congenital anomaly: Condition evident in a newborn that is diagnosed at or
e
near birth, usually as a genetic or chronic condition, such as spina bifida
c
or cleft lip and palate.
n
Coronary Heart Disease (CHD): A disease of the heart resulting from
inadequate circulation of blood to local areas of the heart muscle. The
e
disease is almost always a consequence of focal narrowing of the coronary
i
arteries by atherosclerosis and is known as ischemic heart disease or
c
coronary artery disease.
Cystic fibrosis: Condition in which a genetically changed chromosome 7
S
interferes with all the exocrine functions in the body, but particularly
pulmonary complications, causing chronic illness.
a
Dementia: General term for a decline in mental ability severe enough to
v
interfere with daily life.
Depression: A state of low mood and aversion to activity that can affect a
o
person's thoughts, behavior, feelings and sense of well-being.
Diaphragmatic hernia: Displacement of the intestines up into the lung area
N
due to incomplete formation of the diagram in utero.
DiGeorge syndrome: Condition, in which chromosome 22 has a small
deletion, resulting in a wide range of heart, speech, and learning
difficulties.
124 Glossary
.
Diplegia: Condition, in which the part of the brain controlling movement of
c
the legs is damaged, interfering with muscle control and ambulation.
Diverticulitis: Infected: pockets” within the large intestine.
I n
Down syndrome: condition in which three copies of chromosome 21 occur,
resulting in lower muscle strength, lower intelligence, and greater risk for
,
overweight.
g
Dumping syndrome: A condition characterized by weakness, dizziness,
flushing, and warmth, nausea, and palpitation immediately or shortly after
in
eating and produced by abnormal rapid emptying of the stomach,
especially in individuals who have had part of the stomach removed.
h
Dysmenorrhea: Painful menstruation due to abnormal cramps, back pain,
is
headache, and/or other symptoms.
l
Dysphagia: Difficulty in swallowing.
Edema: Swelling due to an accumulation of extracellular fluid.
b
Embryo: The developing organism from conception through 8 weeks.
u
Endocrine: A system of ductless glands, such as thyroid, adrenal gland,
ovaries, and testes, that produce secretions that affect body functions.
P
Endothelium: The layer of cells lining the inside of blood vessels.
Epididymis: Tissue on top of the testes that store sperm.
Epithelial cells: Cells that line the surface of the body.
e
Faddism is an eating regime that focuses on a particular food or food group.
c
Failure to thrive (FTT): Condition of inadequate weight or height gain
n
thought to result from a calorie deficit.
Febrile seizure, is an epileptic seizure associated with a high body
e
temperature but without any serious underlying health issue.
i
Fever is defined as a body temperature above the normal range due to an
c
increase in the temperature.
Fecundity: Biological ability to bear children.
S
Galactosemia: A rare genetic condition of carbohydrate metabolism in which
a blocked or inactive enzyme does not allow breakdown of galactose.
a
Gastroesophageal reflux Disease (GERD): Movement of the stomach
v
contents backward into the esophagus, due to stomach muscle
contractions.
o
Geophagia: Compulsive consumption of clay or dirt.
Gestational diabetes: Carbohydrate intolerance with onset or first recognition
N
in pregnancy.
Glossitis is a problem in which the tongue is swollen and changes color, often
making the surface of the ton.
Glossary 125
.
Glomerulonephritis is inflammation of the tiny filters in your kidneys
c
(glomeruli).
n
Glycosuria or glucosuria is the excretion of glucose into the urine.
I
Gravida: Number of pregnancies a woman has experienced.
Gynecological age: Defined as chronological age minus age at menarche. For
,
example, a female with the chronological age of 14 years minus age at
g
first menstrual cycle of 12 equals a gynecological age of 2.
Hyperinsulinemia: Means the amount of insulin in your blood is higher than
in
what's considered normal.
Hyper lipidemia: Excessively high levels of lipids in the blood.
h
Hyper metabolism: An increased rate of energy and protein metabolism
is
trauma, infection, burns, or surgery.
l
Hypertonic: Refers to a greater concentration.
Hyper vitaminosis A: An excessive consumption of vitamin A.
b
Hyperbilirubinemia: Elevated blood levels of bilirubin, a yellow pigment
that is a by – product of the breakdown of fetal hemoglobin.
u
Hypertension: High blood pressure (typically exceed 140/90mmHg).
P
Hypertonia: Condition characterized by high muscle tone, stiffness, or
spasticity.
Hypocalcemia: Condition in which body pools of calcium are unbalanced,
e
and low levels in blood.
c
Hypogonadism: Atrophy or reduced development of testes or ovaries. Results
n
in immature development of secondary sexual characteristics.
Hypothyroidism: Condition characterized by growth impairment and mental
e
retardation and deafness when caused by inadequate maternal intake of
i
iodine during pregnancy. Used to be called cretinism.
c
Hypotonia: Condition characterized by low muscle tone, floppiness, or
muscle weakness.
S
Hypotonic: Solution that has a lower osmotic pressure than another solution.
Infectious disease: Any disease caused by the invasion and multiplication of
a
microorganisms, such as bacteria, fungi, or viruses.
v
Insulin resistance (IR): A physiological condition in which cells fail to
respond to the normal actions of insulin.
o
Klinefelter’s syndrome: A congenital abnormality in which testes are small
and firm, legs abnormally long, and intelligence generally subnormal.
N
Kwashiorkor: A severe form of protein energy malnutrition in young
children. It is characterized by swelling, fatty liver, susceptibility to
infection, profound apathy, and poor appetite. The cause of kwashiorkor is
unclear.
126 Glossary
.
Macrocephaly: Large head size for age and gender as measured by
c
centimeters (or inches) of head circumference.
n
Macrophages: A white blood cell that acts mainly through phagocytosis.
I
Maple syrup urine disease: Rare genetic condition of protein metabolism in
which breakdown by-products build up in blood and urine, causing coma
,
and death if untreated.
g
Menarche: The occurrence of the first menstrual cycle.
Menopause: Cessation of the menstrual cycle and reproductive capacity in
in
females.
Menses: The process of menstruation.
h
Microcephaly: Small head size for age and gender as measured by
is
centimeters (or inches) of head circumference.
l
Miscarriage: Loss of conceptus in the first 20 weeks of pregnancy.
Osteoblasts: Bone cells involved with bone formation, bone – building cells.
b
Osteoclasts: Bone cells that absorb and remove unwanted tissue.
u
Osteoporosis: Condition in which low bone density or weak bone structure
leads to an increased risk of bone fracture.
P
Oxytocin: A hormone produced during letdown that causes milk to be ejected
into the ducts.
Pagophagia: Compulsive consumption of ice or freezer frost.
e
Parity: The number of previous deliveries experienced by a woman.
c
Periconceptional period: Around the time of conception, generally defined as
n
the month before and the month after conception.
Pica: An eating disorder characterized by the compulsion to eat substances
e
that are not food.
i
Pitting edema: Observable swelling of body tissues due to fluid accumulation
c
that may be demonstrated by applying pressure to the swollen area.
Pleural effusion: Excess fluid that accumulates in the pleural cavity, the fluid-
S
filled space that surrounds the lungs.
Polycystic ovary syndrome (PCOS): (Abnormal sacs with membranous
a
lining). A condition in females characterized by insulin resistance, high
v
blood insulin and testosterone levels, obesity, menstrual dysfunction,
amenorrhea, infertility, hirsutism (excess body hair), and acne.
o
Postictal state: Time after a seizure of altered consciousness, appears like a
deep sleep.
N
Post-partum: The period beginning immediately after the birth of a child and
extending for about six weeks e.
Post- term: Infant who born after 42 weeks of gestation.
Glossary 127
.
Prader-willi syndrome: Condition in which partial deletion of chromosome
c
15 interfere with control of appetite, muscle development, and cognition.
Preeclampsia: A pregnancy – specific condition that usually occurs after 20
I n
weeks of pregnancy (but may occur earlier). It is characterized by increase
blood pressure and protein in the urine and is associated with decreased
,
blood flow to maternal organs and through the placenta.
g
Pre-diabetes: A term used to represent impaired fasting glucose (IFG) or
impaired glucose tolerance (IGT) based on the observation that most
in
people have either IFG or IGT before they are diagnosed with type 2
diabetes.
h
Premature: Infant who born before 37 weeks of gestation.
is
Pre term delivery: Birth of a baby of less than 37 weeks gestational age.
l
Prolactin: A hormone that stimulates milk production.
Rett syndrome: Condition in which a genetic change on the X chromosome
b
results in severe neurological delays, causing children to be short, thin
u
appearing, and unable to talk.
Sarcopenia: Degenerative loss of skeletal muscle mass.
P
Sepsis: Is a potentially life-threatening complication of an infection.
Schizophrenia: A severe brain disorder in which people interpret reality
abnormally.
e
Small for gestational age: Infant who weighs less than 10th percentile of the
c
standard weight for that gestational age.
n
Shoulder dystocia: Blockage or difficulty of delivery due to obstruction of
the birth canal by the infant‟s shoulders.
e
Stature: Standing height.
i
Sunken: Situated beneath the surface; submerged.
c
Stunting: A decreased height-for-age. It is generally seen in long-term, mild
to moderate protein-energy malnutrition.
S
Suckle: A reflexive movement of the tongue moving forward and backward.
Supine: The position in which one is lying on his or her back.
a
Testes: Male reproductive glands located in the scrotum. Also called testicles.
v
Venous thromboembolism: A blood clot in a vein.
Xerostomia: Dry mouth.
No
128 Glossary
.
GLOSSARY
Accuracy: The degree to which a measured value represents the real or true,
nc
I
value.
,
Acromion process: The spine of the scapula (shoulder blade) extending
toward the outside of the body. The acromion process, or tip, is used as an
g
anatomic landmark in arm anthropometric measurements (e.g., mid arm
in
circumference and triceps skinfold measurement).
Adequate intake: The recommended daily dietary intake level assumed to be
adequate and based on experimentally determined approximations of
h
nutrient intake by a group of healthy people. It is an observational
is
standard used when there are insufficient data available to determine a
l
Recommended Dietary Allowances. One of four nutrient reference intakes
included in the Dietary References.
b
Adjusted body weight: Is a weight which used to calculate calories
u
requirements when BMI ≥ 30 kg/m² by using the following equation:
Actual Body Weight: Ideal Body Weight x 0.25 + Ideal Body Weight.
P
Adolescence: Is a transitional stage of physical and psychological
development that generally occurs during the period from puberty to
e
adulthood.
Aging: The process of becoming older, a process that is genetically
c
determined and environmentally modulated.
n
Albumin: A serum protein, produced by the liver, used as an indicator of
nutritional status.
i e
Amputated body parts: Removal of body part partially or totally that is
enclosed by skin.
c
Android obesity: Excess body fat that is predominantly within the abdomen
S
and upper body, as opposed to hips and thighs. This is the typical pattern
of male obesity.
Anemia: A hemoglobin level below the normal reference range for individuals
a
of the same sex and age.
v
Anorexia nervosa: A condition of disturbed or disordered eating behavior
characterized by a refusal to maintain a minimally normal body weight, an
o
intense fear of gaining weight, and distorted perception of body shape or
size in which a person feels overweight (either globally or in certain body
N
areas), despite being markedly underweight.
Glossary 129
.
Anorexia of aging: A loss of appetite and/or reduced food intake affects a
c
significant number of elderly people and is far more prevalent among frail
n
individuals.
I
Anthropometry: Measurement of body (weight, height, circumferences, and
skinfold thickness).
,
Arm circumference: Is an estimation of the area of the arm.
g
Arm fat index: Is the quotient of triceps skinfold thickness (in mm) and the
olecranon-acromial distance (in cm) squared.
in
Arm muscle area: An indicator of total body muscle calculated from the
triceps skinfold thickness and mid arm circumference.
h
Arm muscle circumference: Is an estimation of the muscle area of the upper
is
arm, calculated from triceps skinfold thickness and arm circumference.
l
Ascites: An accumulation of fluid in the peritoneal cavity.
Basal energy expenditure: Is the rate of energy expenditure by humans at rest
b
Basal metabolic rate (BMR): An individual‟s energy expenditure measured
u
in the post absorptive state (no food consumed during the previous 12
hours) after resting quietly for 30 minutes in a thermally neutral
P
environment.
Behavior modification: A behavioral change theory that attempts to alter
previously learned behavior or to encourage the learning of new behavior
e
through a variety of action-oriented methods, as opposed to changing
c
feelings or thoughts.
n
Biceps: A muscle that has two heads.
Blood urea nitrogen (BUN): Test measures the amount of nitrogen in your
e
blood that comes from the waste product urea.
i
Body Mass Index (BMI): Body Mass Index. See Quetelteʼs index.
c
Body surface area: Is the measurement surface area of a human body.
Bulimia nervosa: An eating disorder characterized by episodes of binge
S
eating followed by some behavior to prevent weight gain, such as purging,
fasting, or exercising excessively.
a
Calf circumference: Is the measurement of the underlying musculature and
v
adipose tissue at the widest point of the calf.
Calorie count: Calculation of the energy and nutrient value of foods eaten by
o
a subject, such as hospitalized patient.
Cancer: A group of diseases characterizes by abnormal growth of cells that,
N
when uncontrolled, invade other tissues or organs, interfering with their
normal function and nutrition.
Catabolism: The breakdown of more complex compounds into simple
biological substances, generally resulting in energy release.
130 Glossary
.
CHI: Creatinine-height index.
c
Cholesterol: A fatlike sterol found in animal products and normally produced
n
by the body. it serves as a precursor for bile acids and steroid hormones
I
and is an essential component of the plasma membrane and the myelin
sheaths of nerves. Serum cholesterol levels are causally related to risk for
,
coronary artery disease.
g
Chronic diseases: A disease progressing over a long period of time, such as
coronary heart disease, certain cancers, stroke, diabetes mellitus, and
in
atherosclerosis.
Creatine: A nitrogen-containing compound, 98% of which is found in muscle
h
in the form of creatine phosphate. Creatine spontaneously dehydrates to
is
form creatinine, which is then excreted unaltered in the urine.
l
Creatinine: The end product of creatine metabolism. Twenty-four hour
urinary creatinine excretion is used as an index of body muscle mass.
b
Creatinine – height index (CHI): An index or a ratio sometimes used to
u
assess body protein status. CHI = 24-hour urinary creatinine excretion ÷
expected creatinine excretion of a reference adult of the same sex and
P
stature x 100.
Current weight: Someone‟s body weight at the mean time or at the moment.
Daily Reference Value: A dietary reference value serving as a basis for the
e
Daily Values. DRVs are for nutrients (e.g., total fat, cholesterol, total
c
carbohydrate, and dietary fiber) for which no set of standards existed
before passage of the Nutrition Labeling and Education Act of 1990. 24 –
n
Hour urinary creatinine: A test measures the amount of creatinine in
e
urine collected in 24 hour.
i
Daily Value (DV): A dietary reference value appearing on the nutrition labels
c
of foods regulated by the FDA and the USDA as part of the Nutrition
Labeling and Education Act of 1990. It is derived from the Daily
S
Reference Values (DRVs) and the Reference Daily Intakes (RDIs). The
daily value on food labels shows the percent of the DRVs or RDIs that a
a
serving of food provides.
Deciliter (dl): A unit of volume in the metric system. One deciliter equals 10-1
v
liter, 1/10 of a liter, or 100 milliliters.
o
Deficiency diseases: Disease caused by a lack of adequate dietary nutrients,
vitamins, or minerals (e.g., rickets, pellagra, beriberi, xerophthalmia, and
N
goiter).
Dehydration: Excessive loss of body water, with an accompanying disruption
of metabolic processes.
Glossary 131
.
Demi span: Distance from the midline at the sternal notch to the web between
c
the middle and ring fingers along outstretched arm.
n
Density: See body density.
I
Diabetes mellitus: A metabolic disorder characterized by inadequate insulin
secretion by the pancreas or the inability of certain cells to use insulin and
,
resulting in abnormality high serum glucose levels. Diabetes mellitus can
g
be classified as type 1 diabetes, type 2 diabetes, or gestational diabetes
(GDM).
in
Desirable body weight: The best body weight according to someone‟s height.
Diet history: An approach to assessing an individual‟s usual dietary intake
h
over an extended period of time (e.g., past month or year). This typically
is
involves Burke‟s four assessment steps: collecting general information
about the subject‟s health habits, questioning the subject about his or her
l
usual eating pattern, performing a “cross check” on the data given in step
b
2, and having the subject complete a 3-day food record.
u
Dietary intake: Amount of food or drink that is taken into your body during a
day.
P
Dietary fiber: Non digestible carbohydrate and lignin that are naturally
present in plant foods and that are consumed in their natural, intact state as
part of an unrefined food.
e
Dietary Reference Intake: Reference values that are quantitative estimates of
c
nutrient intakes to be used for planning and assessing diets for apparently
n
healthy people in various life-stage and gender groups in the United States
and Canada. The dietary Reference Intakes include the Estimated Average
e
Requirement, the Recommended Dietary Allowance, the Adequate Intake,
i
and the Tolerable Upper Intake Level.
c
DV: Daily Value.
Edema: Swelling caused by fluid accumulation in body tissues. It usually
S
occurs in the feet, ankles and legs, but it can involve your entire body.
Elderly: Being past middle age and approaching old age; rather old.
a
Electrolyte: An electrically charged particle (anion or cation), present in
v
solution within the body, that is capable of conducting an electrical
charge. Sodium, chloride, potassium, and bicarbonate are electrolytes
o
commonly found in the body.
Enteral nutrition: The delivery of food or nutrients into the esophagus,
N
stomach, or small intestine through tubes to improve nutritional status.
Erythrocyte: Red blood cell, or RBC.
132 Glossary
.
Essential lipid: The small amount of lipid (constituting about 1.5% to 3% of
c
lean body weight), serving as a structural component of cell membranes
n
and the nervous system, that is necessary for life.
I
Estimated of Average Requirement: The daily dietary intake level estimated
to meet the nutrient requirement of 50% of healthy individuals in a
,
particular life stage and gender group. One of four nutrient reference
g
intakes included in the Dietary Reference Intakes.
Estimated food record: A method of recording individual food intake in
in
which the amounts and types of all food and beverages are recorded for a
specific period of time, usually ranging from 1 to 7 days. Portion sizes are
h
estimated using household measures (e.g., cups, tablespoons, and
is
teaspoons), a ruler, or containers (e.g., coffee cups, bowls, and glasses).
l
Certain items (e.g., eggs, apples, 12-ounce cans of soda) are counted as
units.
b
Estimated Energy Requirement: The average dietary energy intake that is
u
predicted to maintain energy balance in a healthy adult of a defined age,
gender, weight, height, and level of physical activity, consistent with good
P
health. In children and pregnant and lactating women, it includes the
needs associated with the deposition of tissues or the secretion of milk
consistent with good health.
e
Eating disorder: Abnormal attitude towards food that causes someone to
c
change their eating habits and behavior.
n
Etiology: The cause of a disease or an abnormal condition.
Extremely low birth weight: Is an infant who weighs less than 1000 g
e
(2¼Ib).
i
Fat mass: Portion of the human body that is composed strictly of fat.
c
FDA: Food and Drug Administration.
Ferritin: The combination of the protein Apo ferritin and iron that functions
S
as the primary storage form for body iron. It is primarily found in liver,
spleen, and bone marrow.
a
Fetus is the term used to refer to a prenatal mammal between its embryonic
v
state and its birth.
Food allergy: An immune system reaction that occurs soon after eating a
o
certain food.
Food balance sheet: See balance sheet approach.
N
Food diary: A powerful tool to help you become more aware of your eating
habits and activity levels.
Glossary 133
.
Food exchange system: A meal planning method, originally developed for
c
diabetic diet, that simplifies control of energy consumption, helps ensure
n
adequate nutrient intake, and allows considerable variety in food selection.
I
Food frequency questionnaire: A questionnaire listing food on which
individuals indicate how often they consume each listed item during
,
certain time intervals (daily, weekly, or monthly). Standard portion sizes
g
are used and an estimate of nutrient intake is provided on the
questionnaire. Sometimes referred to as the semi-quantitative food
in
frequency or listed-based diet history approach.
Food intolerance: A detrimental reaction, often delayed, to a food, beverage,
h
food additive, or compound found in foods that produce symptoms in one
is
or more body organs and systems, but it is not a true food allergy.
l
Food preferences: Process in which other like or dislike food items.
Food inventory record: An approach to household food consumption
b
measurement in which total household food use in calculated by
u
subtracting food on hand at the end of the survey period (ending
inventory) from the sum of food on hand at the start of the survey period
P
(beginning inventory) and food brought into the household during the
survey.
Fortified food: Process of adding micronutrients (essential trace elements and
e
vitamins) to food.
c
Frankfort horizontal plane: An imaginary plane intersecting the lowest point
n
on the margin of the orbit (the bony socket of the eye) and the tragion (the
notch above the tragus, the cartilaginous projection just anterior to the
e
external opening of the ear). This plane should be horizontal with the head
i
and in line with the spine.
c
Frame size: Frame size is determined by a person's wrist circumference in
relation to his height.
S
Geriatric nutritional risk index: Index for evaluating at-risk elderly medical
patients.
a
Gestational diabetes: Is a condition in which women without previously
v
diagnosed diabetes exhibit high blood glucose.
Glycolated hemoglobin: Hemoglobin that has glucose bound to it. Also
o
referred to as hemoglobin A1C or simply as A1C test, it reflects average
blood glucose levels during the past 8 to 12 weeks.
N
Gram: A unit of mass in the metric system. One gram equals 10-3 kilogram, 1
pound equals 453.5924 grams, and 1 ounce equals 28.350 grams.
134 Glossary
.
Gynoid obesity: Excess body fat that is predominantly within the hips and
c
thighs, as opposed to within the abdomen and upper body. This is the
n
usual pattern of female obesity.
I
Half arm span: Distance from sternal notch to the tip of the middle finger of
the hand.
,
Head circumference: A measurement of a child's head around its largest area.
g
Healthy eating index: An instrument developed by the U.S. department of
agriculture to provide a single summary measure of overall dietary
in
quality.
Height – weight indices: Various ratios or indices expressing body weight in
h
terms of height. Among these are Quetelet‟s index and Benn‟s index.
is
Hemoglobin: The iron containing protein pigment of red blood cells that
l
carries oxygen to body cells. Blood hemoglobin levels can reflect iron
status (e.g, abnormally low hemoglobin may mean anemia).
b
Hemoglobin A1C: See glycated hemoglobin.
u
Haemorrhaging is blood escaping from the circulatory system.
High density lipoprotein (HDL): A serum lipoprotein synthesized by the
P
liver and intestine that transports cholesterol within the bloodstream. As
the serum level of HDL increases, risk of coronary artery disease
decreases.
e
24 – Hour urine urea nitrogen: A test is performed by collecting a 24-hour
c
urine sample.
n
Hydration: A term used to indicate that a substance contains water; Hydration
fluid, a liquid substance that supplies the body with water.
e
Ideal body weight: Comparing a person‟s current (actual) weight against a
i
recommended weight based on height.
c
Illiac crest: The crest. Or top, of the ileum (the largest of three bones making
up the outer half of the pelvis). The crest is the bony spine located just
S
below the waist. Used as an anatomic landmark in skin fold measurement
sites.
a
Incidence: The number of new cases of a disease divided by the total number
v
of persons at risk of the disease within a specific time period, usually one
year. It indicates a person‟s risk or changes of developing the disease per
o
year.
Index of nutritional quality (INQ): A concept related to nutrient density that
N
allows the quantity of a nutrient per 1000 kcal in a food, meal, or diet to
be compared with a nutrient standard.
Infant: Referred for who born between 37th and 42nd weeks of gestation.
Glossary 135
.
Infant mortality: Infant mortality is the death of a child less than one year of
c
age.
n
Iodine deficiency disorder: Occurs when the soil is poor in iodine, causing a
I
low concentration in food products and insufficient iodine intake in the
population.
,
Iron deficiency: The depletion of body iron stores, corresponding to the
g
second and third stages in the development of iron deficiency.
Iron deficiency anemia: A low hemoglobin value found in association with
in
iron deficiency. Theoretically, anemia corresponding to the third stage of
iron deficiency.
h
IU: international unit.
is
Kat/L: The SI unit of enzyme activity. One katal per liter is the amount of
l
enzyme necessary to catalyze a reaction at the rate of 1 mole of substrate
per second per liter (mol, s – 1, L – 1).
b
Kcal: Kilocalorie. The amount of energy required to raise the temperature of 1
u
liter of water 1C. A unit of heat equal to 1000 calories. Also known as a
large calorie. One kcal equals 0.239 kilojoules.
P
Kilogram (kg): Kilogram. A unit of mass in the metric system. One kilogram
equals 1000 grams, or 2.2046 pounds.
Knee height: Is correlated with stature and, until recently, was the preferred
e
method for estimating height in bedridden patients.
c
Kwashiorkor: A protein deficiency, generally seen in children, characterized
n
by edema, growth failure, and muscle wasting.
Lactation: Describes the secretion of milk from the mammary glands and the
e
period of time that a mother lactates to feed her young.
i
Lapse: A single or temporary recurrence of an unwanted habit or behavior that
c
one has become or has turned from for a period of time.
Large for gestational age: Infant whose birth weight is above the 90th
S
percentile.
Length: The distance from one end of something to the other end.
a
LDL: Low-density lipoprotein.
v
LDL receptors: Molecules on the surface of plasma membranes of hepatic
and peripheral cells that recognize and remove low-density lipoprotein
o
from the blood.
Lean muscle mass: Fat-free mass represents the weight of your muscles,
N
bones, connective tissue and internal organs.
Low birth weight: Is an infant who weighs less than 2500 gm (5½ Ib).
Low-density lipoprotein: A serum lipoprotein whose primary role is
transporting cholesterol to the various cells of the body. LDL contains
136 Glossary
.
approximately 70% of the serum's total cholesterol, is considered the most
c
atherogenic (atherosclerosis-producing) lipoprotein, and is the prime
n
target of attempts to lower serum cholesterol. Low serum levels of LDL
I
cholesterol are desirable.
M: meter.
,
Malnutrition: This can mean any nutrition disorder but usually refers to
g
failing health caused by long-term nutritional inadequacies.
Marasmic Kwashiorkor: A combination of chronic energy deficiency and
in
chronic or acute protein deficiency.
Marasmus: Predominantly an energy (kilocalorie) deficiency presenting with
h
significant loss of body weight, skeletal muscle, and adipose tissue mass,
is
but with serum protein concentrations relatively intact.
l
Maternal nutrition: Nutritional status during any stage of her reproductive
age that eventually can affect fetus health and infant.
b
Maternal mortality: Death of a woman while pregnant or within 42 days of
u
termination of pregnancy, irrespective of the duration and the site of the
pregnancy, from any cause related to or aggravated by the pregnancy or its
P
management, but not from accidental or incidental causes.
MCV: Mean corpuscular (red blood cell) volume.
MCV model: A model for assessing the prevalence of iron deficiency that
e
requires abnormal values for at least two of the following measurements:
c
mean corpuscular volume, transferrin saturation, or erythrocyte
n
protoporphyrin level.
Mean: A value calculated by summing all the observations in a sample and
e
dividing the sum by the number of observations. Also referred to as the
i
arithmetic mean or, simply, average. One of three measures of central
c
tendency, along with median and mode.
Median: The observation that divides the distribution into equal halves, with
S
50% of the observations above and 50% of the observations below this
point. Also known as the 50th percentile. One of the three measures of
a
central tendency, along with mean and mode.
v
Memory lapses: Is a momentary inability to remember a piece of information.
Mg: Milligram.
o
MI: Myocardial infraction.
Mid axillary time: An imaginary line running vertically through the middle of
N
the axilla, used as an anatomic landmark in skin fold measurement.
Mid arm circumference: The measurement of the circumference of the non-
dominant (left) arm, at the midpoint between the tip of the shoulder and
the tip of the elbow.
Glossary 137
.
Mid upper arm muscle area: An estimation of the muscle area of the upper
c
arm.
n
Mid upper arm fat area: An estimation of the fat area of the upper arm.
I
Milligram (mg): A unit of mass in the metric system 10-3 gram, or one-
thousandth of a gram.
,
Millimeter (mm): A unit of distance in the metric system. 10-3 meter, or
g
1/1000 of a meter.
Millimole (mmol): 10-3 mole. Or 1/1000 of a gram.
in
Mini nutritional assessment: A screening tool used to identify older adults (>
65 years) who are malnourished or at risk of malnutrition.
h
Morbidity: Illness or sickness.
is
Mortality: Death.
l
National health and nutrition examination survey (NHANES): A
continuous, annual cross-sectional survey, conducted by the U.S.
b
department of health and human services, that assesses food intake,
u
height, weight, blood pressure, vitamin and mineral levels, and a number
of other health parameters in a statistically selected group of Americans.
P
Negative nitrogen balance: A condition in which nitrogen loss from the body
exceeds nitrogen intake. Negative nitrogen balance is often seen in the
case of illness, trauma, burns, or recovery from major surgery.
e
Neonatal mortality: Number of neonates dying before reaching 28 days of
c
age.
n
Nitrogen balance: A condition in which nitrogen losses from the body are
equal to nitrogen intake. Nitrogen balance is the expected state of the
e
healthy adult.
i
Nomogram: A graphic device with several vertical scales allowing calculation
c
of certain values when a straightedge is connected between two scales and
the desired value is read from a third scale.
S
Non-quantitative food frequency questionnaire: A food frequency
questionnaire assessing frequency of food consumption but not the size of
a
food servings.
v
Nutrient density: The nutritional composition of foods expressed in terms of
nutrient quantity per 1000 kcal. If the quantity of nutrients per 1000 kcal is
o
great enough, then the nutrient needs of a person will be met when his or
her energy needs are met.
N
Nutrient intake analysis: Calculation of a resident's food and beverage intake
for calories and protein for 72 hours.
Nutritional assessment: The measurement of indicators of dietary status and
nutrition-related health status of individuals or populations to identify the
138 Glossary
.
possible occurrence, nature, and extent of impaired nutritional status
c
(ranging from deficiency to toxicity).
n
Nutritional epidemiology: The application of epidemiologic principles to the
I
study of how diet and nutrition influence the occurrence of disease.
Nutritional monitoring: The assessment of dietary or nutritional status at
,
intermittent times with the aim of detecting changes in the dietary or
g
nutritional status of a population.
Nutritional quality of the diet: How much the consumed food items are good
in
or bad to human body depends on its contents.
Nutritional screening: The process of identifying characteristics known to be
h
associated with nutrition problems in order to pinpoint individuals who are
is
malnourished or at risk for malnutrition.
l
Obesity: An excessive accumulation of body fat.
Osmolarity: Concentration of osmotically active particles in solution, which
b
may be quantitatively expressed in osmoles of solute per liter of solution.
u
Osteopenia: A condition in which bone mineral density is decreased but not to
the point that a diagnosis of osteoporosis can be made. According to
P
WHO criteria, osteopenia occurs when the T-score is between -1.0 and -
2.5.
Osteoporosis: A condition in which there is a marked decrease in bone
e
mineral density and deterioration of bone micro architecture,
c
compromised bone strength, and an increased susceptibility to fracture and
n
painful morbidity. According to WHO criteria, osteoporosis occurs when
the T-score is less than -2.5.
e
Over estimation: To estimate at too high a value, rate comparing to what it
i
should be.
c
Over nutrition: The condition resulting from the excessive intake of foods in
general or particular food components.
S
Overweight: Body weight in excess of a particular standard and sometimes
used as an index of obesity.
a
Parenteral nutrition: The process of administering nutrients directly into
v
veins to improve nutritional status.
Parity: The number of times a female has given birth.
o
PEM: Protein-energy malnutrition.
Percentiles: Divisions of a distribution into equal, ordered subgroups of
N
hundredths. The 50th percentile is the median. The 90th percentile, for
example, is an observation whose value exceeds by only 10%.
Plasma: The liquid component of blood that has not clotted. An anticoagulant
added to the glass tube used to draw blood from a subject's vein prevents
Glossary 139
.
clotting of the blood. This tube is then centrifuged, leaving the blood cells
c
at the bottom of the tube and the plasma at the top. Unlike serum, plasma
n
contains the clotting factors.
I
Positive nitrogen balance: Nitrogen intake exceeds nitrogen loss from the
body. This is commonly seen during growth, pregnancy, and recovery
,
from trauma, surgery, or illness.
g
Post natal age: Period beginning immediately after the birth of a child.
Postprandial: After a meal.
in
Pregnant adolescence: Intended pregnancy during adolescence.
Prenatal care: Health care you get while you are pregnant. It includes your
h
checkups and prenatal testing.
is
Pre-pregnancy BMI: Body Mass Index value for women before being
l
pregnant.
Prevalence: The number of existing cases of a disease or condition divided by
b
the total number of people in a given population at a designated time. It
u
indicates the burden of a disease or how common it is.
Protein-energy malnutrition (PEM): An inadequate consumption of protein
P
and energy, resulting in a gradual body wasting and increased
susceptibility to infection.
Quantitative food frequency questionnaire: See semi-quantitative food
e
frequency questionnaire.
c
Quetelet's index: Weight in kilograms divided by height in meters sequare
(kg/m2). The most widely used weight-height or power-type index.
n
RDA: Recommended dietary allowance.
e
RDIs: Reference daily intakes.
i
Recommended dietary allowance: The average daily dietary intake level
c
sufficient to meet the nutrient requirement of nearly all (97% to 98%)
healthy individuals in a particular life stage or gender group. One of four
S
nutrient reference intakes included in the dietary reference intakes.
REE: Resting energy expenditure.
a
(Reference daily intakes( RDIs): A set of dietary references that serves as the
v
basis for the daily values and are based on the recommended dietary
allowances (RDAs) for essential vitamins and minerals and, in selected
o
groups, protein. The RDIs replace the U.S.
Relative weight: A subject‟s actual body weight divided by the midpoint value
N
of weight range for a given height and then multiplied by 100. See also
metropolitan relative weight.
Reliability: See reproducibility.
Retinol: A form of vitamin A.
140 Glossary
.
Retrospective methods: A method of looking backwards and examines
c
exposures to suspected risk or protection factors in relation to an outcome
n
that is established at the start of the study.
I
Resting energy expe (REE): Amount of energy needed by individual in
awake, resting, and post absorptive.
,
Semi-quantitative food frequency questionnaire: A food frequency
g
questionnaire that assesses both frequency and portion size of food
consumption. See also food frequency questionnaire.
in
Sensitivity: A test‟s ability to indicate an abnormality where there is one.
Serum: The liquid component of blood that has clotted. A plain glass tube is
h
used to draw blood from a subject‟s vein, and after several minutes the
is
blood clots. This tube is then centrifuged, leaving the blood cells at the
bottom of the tube and the serum at the top. Unlike plasma, serum doesn‟t
l
contain the clotting factors.
b
Serum osmolarity: A measure of the different solutes in plasma.
u
Serum proteins: Proteins present in serum (the liquid portion of clotted
blood) that are often regarded as indicators of the body‟s visceral protein
P
status (e.g., albumin).
Skin fold thickness: A double fold of skin that is measured with skin folds
calipers at various body sites.
e
Somatic protein: Protein contained in the body‟s skeletal muscles.
c
Specificity: A test‟s ability to indicate normalcy where there is no
n
abnormality.
Stadio meter: A device capable of measuring stature in children over 2 years
e
of age and in adults. This measure is taken in a standing position.
i
Standard deviation (SD): A measure of how much a frequency distribution
c
varies from the mean.
Stroke: A blockage or rupture of a blood vessel supplying the brain, with
S
resulting loss of consciousness, paralysis, or other symptoms.
Subjective global assessment: A clinical approach to assessing the nutritional
a
status of a patient using information gained from the patient‟s history and
v
physical examination.
Subscapular: Is a large triangular muscle which fills the subscapular fossa
o
and inserts into the lesser tubercle of the humerus and the front of the
capsule of the shoulder-joint.
N
Suprailliac: Measurement of the area on the side of the waist, just above the
point of the hipbone and a inch or so forward.
Symptoms: Disease manifestations that the patient is usually aware of and
often complains of.
Glossary 141
.
Thermic effect of food (TEF): Also known as diet-induced thermogenesis or
c
the specific dynamic action of food. TEF is the increased energy
n
expenditure following food consumption or administration of parenteral or
I
enteral nutrition caused by absorption and metabolism of food and
nutrients.
,
Total fiber: The sum of dietary fiber and functional fiber. See dietary fiber
g
and functional fiber.
Total water: The total number of water a person consumes which includes
in
drinking water, water in other beverages, and water or moisture in food.
Transferrin: The form in which iron is transported within the blood.
h
24- Hour recall: A method of dietary recall in which a trained interviewer
is
asks the subject to remember in detail all foods and beverages consumed
l
during the past 24 hours. This information is recorded by the interviewer
for later coding and analysis.
b
Triceps: Is the large muscle on the back of the upper limb of many
u
vertebrates.
Triglyceride: A lipid composed of a glycerol molecule to which are attached
P
three fatty acid molecules and the chemical form of most fat in food and in
the body. Triglyceride is also found in the blood, primarily in very low-
density lipoprotein particles and chylomicrons.
e
Ulna: The larger, inner bone of the forearm. Used as an anatomic landmark in
c
arm anthropometry.
n
Under estimation: To estimate at too low a value, rate comparing to normal
level.
e
Under nutrition: A condition resulting from the inadequate intake of food in
i
general or particular food components.
c
Unintentional weight: Losing weight without dieting or increasing physical
activity.
S
Upper arm circumference: The estimation of the amount of upper arm
muscle.
a
Urine specific gravity: A measure of the concentration of solutes in the urine.
v
Usual weight: Person's most frequent body weight.
U.S recommended daily allowance (USRDA): A set of nutrition standards
o
developed by the FDA for use in regulating the nutrition labeling of food.
They were replaced by the reference daily intakes.
N
Validity: The ability of an instrument to measure what it is intended to
measure. Validating a method of measuring dietary intake, for example,
involves comparing measurements of intake obtained by that method with
intake measurements obtained by some other accepted approach.
142 Glossary
.
Very low birth weight: Is an infant who weighs less than 1500 gm. (31/3 Ib).
c
Very- low density lipoprotein (VLDL): A lipoprotein, present in blood, that
n
is synthesized by the liver and primarily carries triglyceride to cells for
I
storage and metabolism.
Viscera: Organs of the body (such as liver, kidneys, heart).
,
Visceral fat: Fat tissues located inside the abdominal cavity, packed between
g
the organs.
nietsrp arecsiV protein found in the body‟s organs or viscera, as well as that
in
in the serum and in blood cells.
nVLV: Very low density lipoprotein.
h
Waist circumference: The distance around the horizontal plane through the
is
abdomen at the level of the iliac crest of a standing subject. This
l
measurement is used as an index of abdominal fat content.
Waist – to - hip ratio: A ratio of the circumference of the waist to that of the
b
hips.
u
Wasting: A decreased weight for age. It is generally seen in severe protein-
energy malnutrition.
P
Wrist circumference: Is a simple check to tell how much body fat and where
it is placed around someone‟s body Calculate r value: ht(cm)/wrist circ.
(cm).
e
Weight food record: A method of recording individual food intake in which
c
the amounts and types of all food and beverages are recorded for a specific
n
period of time, usually ranging from 1 to 7 days. Portion sizes are
determined by accurate weighing.
e
Weight-height indices: See height-weight indices.
c i
S
va
No
c .
I n
g ,
ABOUT THE AUTHORS
h in
l is
Ghazi Daradkeh
b
Research Scholar
Dr. M. Mohamed Essa
u
Associate Professor
P
Professor Nejib Guizani
Professor and Head
Department of Food Science and Nutrition, CAMS,
e
Sultan Qaboos University, Muscat, Oman
n c
Ghazi Daradkeh is Research scholar (PhD candidate) of Nutrition and
e
food science at Sultan Qaboos University, Oman. He is an expert in the field
i
of clinical nutrition and dietetics, has 25 years of experience in clinical
c
nutrition and dietetics field, published 12 papers, 1 book chapter. He is holding
memberships in various international bodies including Linnean Society FLS
S
UK, International Society for Neurochemistry (ISN) , etc.., He has so many
TV interviews about nutritional counseling and diet therapy , he wrote a
chapter in “Food and Brain health” book which was awarded as best book in
a
the world by GOURMAND Cook Book Awards. He has received so many
v
awards from local and international bodies
Email: ghaziffff@gmail.com
No Dr. M. Mohamed Essa, PhD, is an Associate Professor of Nutrition at

Sultan Qaboos University, Oman and holding visiting A/Prof position in
Neuropharmacology group, ASAM, Macquarie University, Sydney, Australia.
He is an editor-in-chief for International Journal of Nutrition, Pharmacology,
144 About the Authors
.
Neurological Diseases published by Wolters & Kluwer, USA and an involved
c
in editor/reviewer board of various well known journals such as Frontiers in
n
Neuroscience, Biochemie, PLOS one, etc. He is an expert in the field of
I
Nutritional Neuroscience and published 84 papers, 31 book chapters and 7
books (4 published and 3 in press). He has strong international collaborations
,
with institutes in USA, Australia and India. Recently he founded a new
g
foundation named “Food and Brain Research Foundation” to support research
in nutritional neuroscience. He is holding memberships in various international
in
bodies including American Society for Neurochemistry (ASN), International
Society for Neurochemistry (ISN), etc. He has received so many awards from
h
local and international bodies and this year one of his book titled “Food and
is
Brain health” was awarded as best book in the World by GOURMAND Cook
l
Book Awards. He has received many research grants from local and
international agencies.
b
Email: drmdessa@gmail.com; drmdessa@squ.edu.om
P u
Dr. N. Guizani obtained his PhD in Food Science from the University of
Florida, USA. He presently works as professor in the Department of Food
Science and Nutrition at Sultan Qaboos University, Oman. During his
e
academic career, Dr. Guizani has developed a research program based on a
c
multidisciplinary approach combining food chemistry, processing, and
microbiology using local commodities such as dates, fish and fermented
n
products. This program has generated a valuable scientific data base and
e
permitted the development of methods to safely manufacture traditional foods
i
and incorporate new products and ingredients in local processed food. His
c
most current research deals with the study of the functional properties of plant
foods and their impact on health. Specific interests of this research include the
S
antioxidant and anti-inflammatory effects of phenolics and flavonoids and
related compounds. He has published more than 68 research papers in peer
a
reviewed journals, 24 conference proceedings and 11 book chapters. In
addition, he has presented more than 50 papers in international and national
v
conferences and serves in the editorial board of 3 international journals.
o
Email: guizani@squ.edu.om
N
c .
I n
g ,
h in
INDEX
l is
ub
Body Mass Index (BMI), xiii, 5, 6, 7, 10,
P
13, 25, 36, 47, 48, 49, 50, 51, 58, 59, 73,
A 80, 84, 102, 104, 105, 109, 110, 124,
e
140, 141, 151
adolescence, vii, 49, 52, 54, 128, 139 body composition, vii, 15, 28, 31, 91
c
adulthood, vii, 128
age group, xi, 60, 61, 62, 63, 84, 85
n
anthropometric, vii, xi, 6, 15, 16, 28, 31, 33, C
64, 65, 74, 92, 128
e
anthropometric assessment, vii, 15, 66, 71 Calf Circumference (CC), xiii, 38, 39, 40,
i
Approprate for Getational Age (AGA), xiii, 52, 92, 102, 104
c
31, 32, 133 carbohydrate (CHO), 10, 136, 142, 143
Arm Circumference (AC), xiii, xiv, xv, 7, childhood, vii, 27, 31, 122, 123
S
36, 90, 91, 97, 105, 130 clinical assessment(s), xi, 30, 102
Arm Fat Index (AFI), xiii, 92 comprehensive treatment plan, xi, 145
Arm Muscle Area (AMA), xiii, xv, 91, 92 Corrected Arm Muscle Area (CAMA), xiii,
a
Attention Deficit Hyperactivity (ADH), xiii, 92
117, 134
v
D
o
B
Desirable Body Weight (DBW), xiii, 80
N
biochemical, 16, 66 dietary, 11
biochemical assessment, vii, xi, 16 dietary, vii, xi, 9, 10, 11, 12, 13, 43, 64, 65,
Blood Urea Nitrogen (BUN), xiii, 9, 115, 66, 67, 69, 84, 86, 120, 126, 128, 129,
118, 122, 124, 141 130, 131, 135, 137, 139
dietary history, vii, 13
146 Index
.
dietary intake, 9, 43, 65, 66, 67, 69, 84, Institute of Medicine (IOM), xiv, 6, 10, 25,
c
126, 129, 137, 139 28
Intelligence Qutenet (IQ), xiv
n
dietary intervention, vii
intervention(s), vii, xi, 4, 15, 28
I
dietary plan/dietary planning, xi
Intra Venous (IV), xiv, 122
dietitian(s), vii, xi, 12, 73, 98, 114
,
Iodine Deficiency Disorder (IDD), xiv, 2
doctors, xii Iron Deficiency Anemia (IDA), xiv, 2
g
E K
in
European Society of Parenteral and Enteral Knee Height (KH), xiv, 81, 82, 84, 85, 105,
h
Nutrition (ESPEN), xiii, 102, 128 106, 109
Extremely Low Body Weight (ELBW), xiii,
is
31
l
L
F
b
Large for Gestational Age (LGA), xiv, 31,
32
u
Food Frequency Questionnaire (FFQ), xiii, life cycle, xi
78 Low Birth Weight (LBW), xiv, xv, 7, 31
P
Low Density Lipoprotein (LDL), xiv, 10,
G 147, 148
e
Gastrointestinal Tract (GIT), xiii M
c
Geriatric Nutrition Risk Index (GNRI), xiv,
112, 113
n
malnourished, xi, 1, 15, 45, 70, 85, 90, 114,
135, 136
e
H malnutrition, xi, 1, 2, 4, 6, 64, 89, 90, 92,
i
100, 114, 120, 123, 125, 135, 136, 137,
c
health care providers, xi, xii, 4 140
Hematocrit (Htc), vii, xiv, 7, 115, 116, 117, medical team, xi
S
124, 130, 131 Mid Arm Circumference (MAC), xiv, 81,
Hemoglobin (Hgb), xiv, 7, 9, 18, 73, 122, 91, 92
145, 146 Mid Upper Arm Area (MUAA), xiv, 92
a
High Density Lipoprotein (HDL), xiv, 10, Mid Upper Arm Circumference (MUAC),
xv, 7
v
146
hydration status, vii, 104, 105, 106, 110, Mid Upper Arm Fat Area (MUAFA), xiv,
o
111, 112 92
Mid Upper Arm Muscle Area (MUAMA),
xv, 92
N
I Mini Nutritional Assessment (MNA), xiv,
102, 104, 105, 128
Ideal Body Weight (IBW), xiv, 85, 140 Multicenter Growth Reference Study
infancy, 27 (MGRS), xiv, 49
Index 147
.
patient records, xi
N
c
pharmacists, xii
physical activity, 6, 130, 139
n
National Center for Health Statistics
physical assessment, vii, 46
I
(NCHS), xv, 46, 47, 48, 52, 56, 57, 71
pregnancy, vii, xi, 1, 2, 4, 5, 6, 9, 11, 12, 15,
National Center for Health Statistics
,
16, 19, 22, 24, 122, 123, 124, 125, 134,
(NCHS), xv, 36, 56
136, 137
Non lactating (NL), xv, 23
g
premature infant, 28, 29, 31, 45
Non pregnant (NP), xv, 23, 80, 98
prematurity, 28, 30
in
Non pregnant non lactating (NPNL), xv, 20
Protein Energy Malnutrition (PEM), xv, 2,
Nothing Per Os (NPO), xv, 119
151
nurses, xii
h
nutrient, vii, 1, 5, 11, 15, 35, 47, 89, 100,
Q
is
126, 127, 129, 130, 132, 135, 137
nutrient deficiencies, vii
l
Nutrient Intake Analysis (NIA), xv, 76, 79 quality of life, xi, 89
nutrients, vii, 10, 11, 15, 19, 47, 68, 128, Quetelets Index (QI), xv, 80
b
129, 135, 136, 138
u
nutrients estimations, vii
nutrition, vii, xi, 1, 3, 4, 14, 15, 16, 28, 63, R
P
64, 83, 84, 85, 86, 87, 89, 90, 100, 101,
106, 114, 115, 127, 128, 129, 133, 134, Recommended Dietary Allowance (RDA),
135, 136, 138, 139 xv, 21, 23, 55, 71, 77, 140, 143, 151
e
nutritional assessment, vii, xi, 2, 3, 5, 15, Registered Nurse (RN), xv, 98, 129
23, 31, 35, 44, 45, 51, 62, 64, 69, 75, 76, requirements, xi, 15, 18, 25, 110, 126, 129,
c
85, 86, 90, 114, 135 137
nutritional assessment guidance, vii risk of malnutrition, xi, 89, 90, 92, 135
n
nutritional assessment tools, xi
e
nutritional care, vii S
i
nutritional deficiencies, 6, 100
nutritional diagnosis, xi
c
Small for Gestational Age (SGA), xv, 31,
nutritional status, 1, 2, 4, 11, 12, 23, 28, 31, 32
43, 63, 64, 69, 79, 80, 84, 85, 86, 90, 92,
S
Standard Deviation (SD), xv, 13, 66, 67, 68,
93, 114, 115, 126, 129, 135, 136, 138 69, 94, 95, 152
nutritional care, 74
a
T
v
O
Triceps Skin Fold (TSF), xv, 90, 91, 92, 105
o
obesity, 12, 44, 46, 50, 51, 52, 76, 78, 86,
87, 97, 124, 126, 131, 136
U
N
old age, vii, xi, 129
Upper Arm Circumference (UAC), xv, 7, 36

P
patient care, vii

148 Index
.
V W
Very Low Birth Weight (VLBW), xv, 31 Waist Circumference (WC), xv, 14, 26, 38,
nc
I
Vitamin A Deficiency (VAD), xv, 2 39, 40, 51, 52, 82, 83, 85, 89, 90, 98, 99,
100, 128, 129
,
Waist Hip Ratio (WHR), xv, 87, 89
World Health Organization (WHO), xv, 7,
g
27, 52, 53, 150
h in
l is
ub
P
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Handbook for Nutritional Assessment through Life Cycle

Book · April 2016

Ghazi Daradkeh Mohamed Essa Musthafa

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c i NEED FOR THE BOOK

The main purpose of the maternal nutritional assessment is to support

va NUTRITIONAL ASSESSMENT FOR PREGNANCY

No Pregnant females who are in general at risk for nutritional problems at

2. Anthropometric Measurements [12]

Pre-pregnancy BMI categories

MUAC is a good indicator of the protein reserves of a body, and a thinner

Pregnant women (all trimesters)

Non-pregnant 1st trimester 2nd trimester 3rd trimester

Tests Non-pregnant 1st trimester 2nd trimester 3rd trimester

4. Dietary Intake/Needs [1]

c i e Box 1. Classification of Iron Store Depletion

Table 3. Sample Meal Pattern 2200 Calories

va Meal Milk Fruit Vegetables Bread Meat Fat

Vitamin A Rich Food

b l Vitamin– B6 – Rich Foods

1- Calculate the number of weeks the infant was premature.

LENGTH, STATURE, AND HEAD CIRCUMFERENCE

Compared to the charts for children from birth up to 24 months of age

i kcal/day kcal/kg kcal/cm

To determine whether individuals are maintaining the growth pattern or

Kcalorie counts (Figure 2), dietary intake, more extensive patient

Meal type Food Description Quantity

Figure 3. Food Diary.

ESTIMATED WEIGHT FOR AMPUTATED BODY PARTS

S Researchers developed the equations that can be used for height

No IDEAL WEIGHT ESTIMATION

MEASURING FRAME SIZE

Table 6. Waist – Hip Ratio and health risk

Peter is 21 years old white man admitted to accident and emergency

WAIST CIRCUMFERENCE MEASUREMENT

N CAMA (cm)² for males = [MAC (cm) – (π X TSF(cm))]²/4 π] - 10

CAMA (cm)² for females = [MAC (cm) – (π X TSF(cm))]²/4 π] – 6.5

MUAFA = MUAA - MUAMA

AFI = 100 X MUAFA/MUAA

Figure 1. A depletion of the “anorexia of aging.”

Last name: First name:

Figure 2. Mini Nutritional Assessment (MNA) (8).

Males: height (cm) = [(1.40 x demi – span (cm)] + 57.8

3. Half - Arm – Span

4. Ulna Length (UL)

For men: H – 100 - [(H – 150)/4] (3)

o v Body Mass Index

Table 5. Determine Your Nutritional Health (23)

Table 7. Assessment of hydration status

o v a. Urine Specific Gravity (USG)

Table 9. Conditions that affect the osmolality [44]

d. BUN: Creatinine Ratio

Risk factors of dehydration [33] Risk factors of over hydration [34]

Total fluid intake need from all sources 1,845 mL

Body weight Body weight Recommended total Recommended fluid

No Dr. M. Mohamed Essa, PhD, is an Associate Professor of Nutrition at

Upper Arm Circumference (UAC), xv, 7, 36

patient care, vii