Western Mindanao State University

COLLEGE OF HOME ECONOMICS

Zamboanga City

NAME:

DATE:

SCHEDULE:

SUBJECT: ND 104-LAB

TOPIC: Direct Methods of Nutritional Assessment/ Interpreting Biochemical Assessment

WEEK NUMBER: 5

Activity 4
Direct Methods of Nutritional Assessment Part 2
Interpreting Biochemical Assessment

I. Introduction

Biochemical Assessment is an estimation of tissue saturation, enzyme activity or blood levels of

nutrients, it is used to identify the stage of nutritional deficiency and can be carried out in a variety of
tissues but field surveys are confined to blood and urine.

The objectives of biochemical assessment is to: detect marginal nutritional deficiency in

individuals, particularly when dietary histories are questionable or unavailable; their use is especially
important before over clinical signs of disease appear, thus permitting the initiation of appropriate remedial
steps and to supplement or enhance other studies such as dietary or community assessment among specific
population groups in order to pinpoint nutritional problems that these modalities may have suggested or
failed to reveal.

II. Objectives

At the end of this activity, you can:

1. Define the relevant terms used in biochemical assessment.

2. Elaborate the purpose of biochemical assessment.
3. Interpret hypothetically generated biochemical data.

III. Concepts Explanation

TWO TYPES OF TESTS EMPLOYED IN LABORATORY SURVEYS TO ASSESS SUBCLINICAL

DEFICIENCY STATES

1. Static Biochemical Tests

 Involves measurement of levels of a nutrient or a metabolite in a preselected biopsy material
that reflects either the total body content of the nutrient or the size of the tissue store most
sensitive to depletions are measured.
 Categories
 Measurement of a nutrient in biological fluids or tissues (biological fluids or tissues used are
blood, urine, hair, saliva, semen, amniotic fluid, fingernails, skin and buccal mucosa)
2. Functional Tests
 Defined as “diagnostic tests to determine the sufficiency of host nutriture to permit cells,
tissues, organs, anatomical systems, or the host to perform optimally the intended, nutrient-
dependent biological function (Solomons and Allen 1993). Indicates severity of deficiency;
measures the effect of lack thereof on the enzymes by which the body makes use of its
nutrient intake.
Categories
1. Enzymatic tests which measures the activity of an enzyme which requires the vitamin as a
coenzyme added in vitro.

2. Metabolic test which measures the rise in concentration of metabolite in blood or urine after
administering a load of an appropriate precursor.

APPROPRIATE BIOCHEMICAL TESTS TO DETECT SUBCLINICAL NUTRIENT

DEFICIENCIES AND ITS INTERPRETATION

Protein Status

 Laboratory indices of protein status measure somatic protein status, visceral protein status,
metabolic changes, muscle function and immune function.
a. Urinary Creatinine Excretion
 Urinary creatinine is used to assess the degree of depletion of muscle mass in marasmic patients,
and degree of depletion after long term intervention, provided that 72-hour urine collections are
made. Frequently expressed as creatinine height index
Guidelines for the Interpretation of Creatinine Height Index
Less than acceptable Acceptable
Deficient (High Risk) Low ( medium risk) (Low risk)
Creatinine height index (3
months to < 0.5 0.5-0.9 > 0.9
17years of age)

b. Serum Protein
 An index of visceral protein status; easily measured but a rather insensitive index of protein
status.
Guidelines for the Interpretation of Total Serum Protein Concentrations (g/dL)

Less Than Acceptable

Acceptable
Subjects Deficient (high risk)
Low (medium risk) (low risk)
Infants 0 to 11 months - < 5.0 ≥ 5.0
Children 1 to 5 years old - < 5.5 ≥ 5.5
Children 6 to 17 years old - < 6.0 ≥ 6.0
Adults < 6.0 6.0 to 6.4 ≥ 6.5
Pregnant, 2nd and 3rd trimester < 5.5 5.5 to 5.9 ≥ 6.0
 c. Serum Albumin
 Reflects changes occurring within the intravascular space and not the total visceral protein
pool; not very sensitive to short-term changes in protein status; has a long half-life of 14 to
20 days.

Interpretative guidelines for serum albumin concentrations, g/dL

Less than acceptable

Acceptable
Subjects Deficient (high risk)
Low (medium risk) (Low risk)

Infants 0 to 11 months - < 2.5 ≥ 2.5

Children 1 to 5 years < 2.8 < 3.0 ≥ 3.0
Children 6 to 17 years < 2.8 <3.5 ≥ 3.5
Adults < 2.8 2.8 to 3.4 ≥ 3.5
Pregnant 1st trimester < 3.0 3.0 to 3.9 ≥ 4.0
Pregnant, 2nd and 3rd trimester
< 3.0 3.0 to 3.4 ≥ 3.5

d. Serum Transferrin
 Transferrin is a serum beta-globulin protein synthesized primarily in the liver and is located
almost totally intravascularly; serves as the iron transport protein; it is also bacteriostatic (it
binds with free iron and prevents the growth of gram negative bacteria which require iron for
growth).
Interpretative Guidelines for Serum Transferrin

Parameter Protein Deficit

None Mild Moderate Severe

Transferrin > 200 150-200 100-150 < 100

e. Urinary Urea Nitrogen: Creatinine Ratios

 Urea is the largest source of urinary nitrogen and is synthesized in the liver. Urinary urea
nitrogen: creatinine ratios are used as an index of dietary protein intake but not an index of
long-term protein status.

Guidelines for the Interpretation of Urinary Urea Nitrogen: Creatinine Ratios

Less than acceptable Acceptable (Low risk)

Deficient (high risk) Low (medium risk)
Urea nitrogen:
< 6.0 6.0-12.0 > 12.0
creatinine ratio
Functional tests of protein status include muscle function and immunological tests. Muscle function
measure changes in muscle contractility, relaxation rate, endurance, and hand grip strength. Immunological
tests include lymphocyte count, delayed cutaneous hypersensitivity, measurement of thymus-dependent
lymphocytes, and lymphocyte nitrogen assays.

Vitamin A Status
 a. Serum vitamin A

Low: 10-20 ug/dL

Deficient: <10 ug/dL
A prevalence rate of 10% for “deficient” serum levels and 15% of “low” serum levels indicate the
existence of a public health problem in the community

b. Serum Carotene
Low ≤ 39 ug/dL
low serum carotene levels per se are not indicative of VAD but reflect current intake of carotene
which is a precursor of the vitamin

Serum Vitamin A – it can predict Vit. A status when then body reserves are depleted or overfilled.

For individual:
– Deficient - <10 ug/dL ( 0.35 umol/dL)
– Low - < 20 ug/dL ( 0.70 umol/dL)
– Adequate - > 30 ug/dL ( 1.05 umol/dL)
– Hypervitaminosis - > 100 ug/dL

THE WHO (1996) STATES THAT:

A. There is SEVERE VAD Public Health Problem when 20 % or more of the population has Serum
Values < 0.70 mmol/l;

B. A MODERATE public health problem when the prevalence is at least 10 % to < 20

% and a MILD problem when the prevalence is < 10 %;

C. Serum Retinyl Ester Concentrations

 Elevated concentrations of serum retinyl esters observed after chronic ingestion of high
levels of vitamin A and in liver disease.

D. Serum Carotenoids Concentrations

 Reflect the current dietary intake of carotenoids such as beta-carotene, lycopene, and various
hydroxylated carotenoids

E. Relative Dose Response

 A test used in the estimation of liver stores of Vitamin A and can be used to identify those
individuals with marginal vitamin A deficiency.
F. Rapid Dark Adaptation Test
 Used to assess nightblindness
G. Conjunctival Impression Cytology
 Detects early physiological changes occurring in VAD

Relative Dose Response

  RDR and modified relative dose response are based on the principle that when retinol is
high, the concentration in the blood is not altered of oral vitamin A;
RDR:
 50 % is indicative of acute deficiency
 Values between 20 % to 50 % indicates marginal status
 Values < 20 % suggest adequate intake

Dark Adaptation
 It is the best defined function of Vitamin A. When there is short supply of vitamin A, the
process of regenerating the visual purple is delayed leading to delayed adaptation of the eye
during night or dark vision.

Thiamine Status

a. Erythrocyte Transketolase Activity (ETKA)

 Transketolase is a thiamine pyrophosphate-dependent enzyme. Measurement of the activity of
this enzyme is used as an index of thiamine nutritional status as the erythrocytes are among the
first tissues to be affected by thiamine depletion.

b. Urinary Thiamine Excretion

 Thiamine levels in the urine do not adequately reflect body stores but provides an index of the
dietary intake. A thiamine load test has also been used as an index of thiamine status.
Excretion of thiamine in a four-hour period after the parenteral administration of 5 mg of
thiamine is measured. If subjects are deficient in thiamine, usually less than 20 ug of the 5 mg
thiamine load during the four-hour period is excreted.

Riboflavin Status

a. Erythrocyte Glutathione Reductase Activity Coefficient

 A useful and sensitive measure of impaired riboflavin status. Glutathione reductase is a
nicotinamide adenine dinucleotide phosphate and FAD-dependent enzyme, and is the major
flavoprotein in erythrocytes. It catalyzes the oxidative cleavage of the disulfide bond of
oxidized glutathione to form reduced glutathione.
Coefficient (EGR-AC)
• Normal value: 1.0-1.3
• Higher values indicate riboflavin deficiency
b. Urinary Riboflavin Excretion
 Reflects recent dietary intake rather than body stores.

Ascorbic Acid Status

Serum Ascorbic Acid

• Acceptable or Good: 0.8 mg/dL
• lower levels indicate ascorbic acid deficiency
Iron Status

a. Hemoglobin
• values below which anemia is said to exist:

Normal Hemoglobin levels, WHO Cut--Off:

Age & Sex Normal Hb Level (g/dL)
Infants and children, 6 mos--6 yrs. 11.0
Children & adolescents, 6--14 yrs. 12.0
Adult males 13.0
Adult female non pregnant/non -lactating 12.0
Adult females, pregnant 11.0
Adult females, lactating 12.0

b. Hematocrit
Normal values: Females: 37-47%
Males 45-52%

c. Total Iron Binding Capacity (TIBC)

Normal value: 250-425 mg/dL

d. Transferrin saturation
Normal value: 20-50%

e. Ferritin
Normal value: 30-250 mg/dL

Iodine Status

 The criteria below is used to classify IDD problem into different degrees of public health
significance. The indicator of iodine deficiency “elimination” is a median value of iodine
concentration of 100 ug/L, i.e. 50% of the samples should be above 100 ug/L and not more than
20% of the samples should be below 50 ug/L

 Epidemiological criteria for assessing iodine nutrition based on median urinary iodine
concentrations in school-aged children (WHO/UNICEF/ICCID, 2001)

Median Value, ug/L Severity of IDD Problem

< 20 severe
20-49 moderate
50-99 mild
≥ 100 No deficiency
 CLINICAL DIAGNOSIS OF GOITER AT ALL AGES
GRADE DESCRIPTION
1a Palpable goiter
Cannot be seen. It can only be felt by experienced health worker. It must be at least
the size of the outer half of the thumb of the patient
1b Very small goiter
It can be seen only when the neck is extended
2 It can be seen when the neck is in normal position
3 Goiter is visible at about 10 meters

Suggested Interpretation Guide for Endemic Goiter

Endemic Goiter can be said to exist as a significant public health problem where:
A. At least 5 % of adolescents or pre-adolescents have Goiter 1 or above, OR
B. At least 30 % of adults have goiter of Grade 0b or above

Folate Serum Status

 Folate concentration-levels fluctuate with recent dietary intake:
< 3 mg/mL - low serum folate concentration
3.0-6.0 - borderline
>6.0 - high
Zinc Serum Status
 Serum/plasma zinc concentration –most widely used index of zinc status; factors that modify zinc
levels are acute infection or inflammation, alcoholic cirrhosis, and PEM.
 Serum values of <70 µ/L used to assess risk of zinc deficiency.

CASTILLO, REA JANE C.

BSND-II
 Laboratory Exercise 4
Direct Methods of Nutritional Assessment Part 2
Interpreting Biochemical Assessment

Work Exercise No. 1. Biochemical assessment is used in nutrition assessment (clinical sign supporting
nutrition diagnosis) like during in monitoring and evaluation. What do you think is the purpose of
conducting biochemical assessments? How does it help in detecting nutritional deficiencies? (Your
answer will be categorized according to the types of test.)

TYPES OF TEST DESCRIPTION

STATIC BIOCHEMICAL TEST Static biochemical tests measure levels of the nutrients in biological
specimens.

Functional biochemical tests determine the changes in the activities

FUNCTIONAL TEST
of enzymes dependent on a specific nutrient, or in the
concentrations of specific blood components dependent on a given
nutrient.

Work Exercise No. 2. Identify the normal values and the appropriate test it is being used for of the
following nutrients:

USED FOR THE TEST OF:

NUTRIENTS NORMAL VALUE

SERUM PROTEIN
Creatinine 6 to 8 g/dl
Serum albumin

Retinol 20 to 60 micrograms per deciliter

Thiamin 2.5-7.5 μg/dL

Riboflavin
 Ascorbic Acid 0.6-2 mg/dL

240 to 300 μg/day for men and 190

Iodine
to 210 μg/day for women.

Iron 60 to 170 micrograms per deciliter

Work Exercise No. 3. Enumerate the specific type of malnutrition in terms of toxicities and deficiencies.

NUTRIENTS TOXICITY/IES DEFICIENCY/IES

SERUM PROTEIN
Creatinine
Serum albumin

Dry Skin
skin irritation, notably erythema Dry Eyes
Retinol
and peeling Night Blindness
Infertility and Trouble Conceiving

fatigue, irritability, poor memory,

body will absorb less of the nutrient
loss of appetite, sleep disturbances,
Thiamin and flush out any excess amount
abdominal discomfort, and weight
through the urine
loss

toxic level of riboflavin has not been

fatigue, swollen throat, blurred
Riboflavin observed from food sources and
vision, and depression
supplements

nausea and diarrhea, interfere with fatigue, depression, and connective

the healthy antioxidant-prooxidant
balance in the body, and, in patients
Ascorbic Acid
with thalassemia or
hemochromatosis, promote iron
overload
tissue defects (eg, gingivitis,
petechiae, rash, internal bleeding,
impaired wound healing). In infants
and children, bone growth may be
impaired.

thyroiditis, hypothyroidism,
Iodine hyperthyroidism, and thyroid goiter, hypothyroidism
papillary cancer
 nausea, vomiting, abdominal pain,
Iron anemia, tired and short of breath
hematemesis, and diarrhea

CONCLUSION:

At the end of this activity, I learned the 2 types of test which are the static biochemical and
functional test as well as their description. And in addition to this, I already had an idea about the
normal values and the appropriate test that is being used for the given nutrients and their specific
type of malnutrition in terms of toxicities and deficiencies.