Biochemical and Clinical Assessment

Nutrition Screening Tools

Chris Lai
Diet, Health & Disease
Elements of Nutritional Assessment
 Anthropometry
 Dimension and composition of the human body
 Biochemical data
 Reflect the nutrient intake or it’s impact
 Clinical Data
 Ascertains the clinical consequences of improper nutrition
 Dietary Assessment
 Collection of information on food and beverages consumed
Biochemical Assessment
 Substance that can be objectively measured and evaluated
as an indicator of normal biological process
 In contrast, physical signs are subjective measurements

Specimens includes:
Plasma, serum Adipose tissues
(Erythrocytes, leukocytes ) (fat soluble vitamins and fatty acids)
Urine Liver and bones
(water soluble vitamins, Cr, I, Se) (Fe, Ca)
Saliva Nails
(Zn) (Se, Cu, Zn)
Breast milk Hair

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Biochemical Assessment
Assessing dietary intake Assessing nutritional status

 To predict dietary intake  To distinguish between

or to check accuracy of adequacy, overload and
dietary intake data sub clinical deficiency for a
nutrient or to confirm a
diagnosis
Biochemical Assessment
Common biomarkers of overall status for a nutrients
 Serum ferritin
 Most sensitive indicator
of iron stores in the body
 Serum hemoglobin
 Simple measurement
 Not specific to iron
deficiency
 Serum albumin
 Indicate visceral protein
status

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Biochemical Assessment
Common biomarkers of food/ nutrients’ intakes
 Urinary nitrogen
 Assess total protein intake
 Urinary sodium excretion
 Reliable measure of sodium intake
 Serum vitamin C & ß-carotene
 Commonly used for total fruits and vegetable
Considerations in Biomarkers
 Many micronutrients are homeostatically regulated
 (e.g. Calcium) blood and urine test does not indicate status but
requires measurements of bone mineral

 Instability of the nutrient in vitro

 For vitamin C, plasma sample should be acidified and
analysed the same day or kept for a few days at −80°C
Considerations in Biomarkers
 Plasma level and intake of certain nutrients (e.g. vit. C) is
proportional only up to a certain threshold
Considerations in Biomarkers
Strengths
 Objective indicator of status/intake
 Nutrient specific, unlike clinical signs

Limitations
 Expensive , time consuming
 Need trained staff and facilities
 Not available for some nutrients
 Temporal effect of the biomarkers
 Indicate short-term/long term intake
Considerations in Biomarkers
Limitations (con’t)
 Biomarkers are not on the same metric as the food being
assessed
 Beta-carotene is commonly used for total fruits and vegetable

 Factors influencing interpretation of biochemical test

 e.g. infections, smoking, sample contaminations, physical
exercise, genetic factors, physiological state, stress and etc
 Serum zinc is affected by age, gender, acute inflammation, time
of day, fasting status, oral contraceptives, storage, haemolysis,
zinc contamination of collecting tube or anticoagulant.
Common Biomarkers in Body Check

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Blood Lipid Profile
 Major risk factors for cardiovascular diseases
 Development of atherosclerosis
Blood Lipid Profile
Examples of available biomarkers:
1. Total cholesterol (TC)
2. High-density-lipoprotein cholesterol (HDL-C)
3. Low-density-lipoprotein cholesterol (LDL-C)
4. Triglyceride (TG)

 Dyslipidemia may be indicated if:

 Abnormal high in TC, LDL-C, TG
 Abnormal low in HDL-C
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Renal Function
Examples of available biomarkers:
 Glomerular filtration rate (GFR)
 Removal of waste products
 Serum urea (Ur): creatinine (Cr) ratio
 Removal of waste products
 Potassium (K)
 Control of heart beat
 Phosphate (P)
 Accumulation may cause pruritus
Hydration
Examples of available biomarkers:
1. Serum sodium (Na)
2. Serum urea (Ur)

Dehydration may be indicated if:

 Serum sodium above the normal range (145mmol/l)
 Serum urea above the normal range with renal (kidney)
function appeared normal
 Clinical Data

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Clinical Data
1. Medical history
 Personal info
 The main complaint and symptoms by organ systems
 Past medical history
 Family history
 Medications

2. Physical examination
 Investigate the body of a patient for signs of disease
 Signs: what a physician or health professional detects
 Symptoms: what a patient experiences

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Medical history
Examples of indicators of potential nutrition problems:
 Weight loss
 Swallowing difficulties
 Poor fitting dentures
 Diabetes
 Family history
 Weight status

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Clinical Data
Blood pressure
 It is the pressure exerted by circulating blood upon the
walls of blood vessels
 A major risk factor for various cardiovascular diseases

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Physical signs example: Dehydration
Symptoms includes:
 Dry, sticky mouth
 Dry skin
 Headache and dizziness
 Tiredness and sleepiness
 Constipation
 Concentrate urine (dark colour)

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Physical signs example: Goiter
Thyroid gland
 Goiter is a reliable sign of
iodine deficiency
 Especially in mountainous
areas and far from sea
places

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Physical signs of nutrition deficiency

Sign Possible Deficiency

Nail
Spooning Iron deficiency, protein deficiency
White spots on nails Almost any mineral deficiency but typically zinc

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Physical signs of nutrition deficiency

Sign Possible Deficiency

Mouth
Bleeding gums Vitamin C deficiency
Angular cheilosis Vitamin B2 deficiency

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Physical signs of nutrition deficiency
Sign Possible Deficiency
Skin
Dry scaly skin Essential fatty acids or multiple nutritional
deficiencies
Follicular hyperkeratosis Essential fatty acid, vitamin A deficiency
Easy bruising Vitamin C, Vitamin K
Hair
Easy to pull out Protein deficiency
Hair loss Protein-energy deficiency , iron deficiency

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Clinical Data
Advantages
 Fast & Easy to perform
 Inexpensive
 Non-invasive

Limitations
 Did not detect early cases
 Lack of specificity
 Quantification
 Between observer variation
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Nutritional Assessment
4 elements of nutritional assessment:
1. Anthropometry
2. Biochemical data
3. Clinical Data
4. Dietary Assessment

• In the end, all information from history, examination and

results of investigation should considered together
• Help establish an overall picture of nutritional status

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1. Calculate BMI for a 40 year old
Chinese lady who weighs 149lb with
a height of 168cm? Comment on it

2. Which additional information would

you take into consideration when:
1. Assessing risk of heart disease?

2. Assessing renal disease progress?

 Nutritional Screening

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Malnutrition
 About 30% of all patients in hospital are undernourished.
A large part of these patients are undernourished when
admitted to hospital and in the majority of these,
undernutrition develops further while in Hospital
(McWhirter& Pennington 1994)

 In a study in China, 41.6% of surgical patients were

identified to be malnourished (Yu & Chen. 1999)
Malnutrition
 Malnourished patients stay in hospital for much longer,
3 times as likely to develop complications during surgery
and have a higher mortality rate
 Inappropriate identification can be counterproductive

 Nutrition screening tools

 Developed for use in many health care settings
 e.g. hospitals/community/other settings
 Identify people at nutrition risk on admission or those who
become malnourished overtime
Nutritional screening v.s. assessment
 Nutritional screening
 A simple, quick, and general procedure to detect significant risk
of nutritional problems
 Used by nursing, medical or other staff
 Often at the first contact of patient

 Nutrition assessment
 A more detailed and specific evaluation of a patient’s
nutritional status
 Usually undertaken by an expert in nutrition (e.g. dietitian,
clinician, nutrition nurse specialist)
 Allow development of specific nutritional care plan
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Nutrition screening tools
 Largely developed to detect protein-energy malnutrition,
rather than specific nutrient deficiencies

 70+ nutritional screening tools were developed for

different aims, applications and setting:
 Some for specific clinical conditions
 Some for members of public
 Some for elderly or specific subgroups
Subjective Global Assessment (SGA)
 Originally developed by a group of clinicians in 1980s
 Aimed to predict clinical outcome

 An analysis of a brief set of history and physical

assessment items to identify
 Middle aged subjects rather than elderly who are
malnourished or risk of malnutrition
 Although it has been used to assess elderly
Subjective Global Assessment (SGA)
 NOT a numerical scoring system

 An overall SGA score corresponded to a subjective

opinion of the patient’s nutritional status
 “One of the major criticisms of the method is that its accuracy
depends on the observer’s experience
 The only one evaluates function capacity
 It better identifies established undernourished than nutritional
risk.”(Barbosa-Silva& Barros. 2006)
Subjective Global Assessment (SGA)
Limitation
 Objective criteria
 Requires a trained
clinician to perform
 Requires that the subject
is undressed and able to
be turned
 More commonly used in
hospital setting
Mini Nutritional Assessment (MNA)
 Developed in the early 1990s

 A validated nutrition screening tool to identify

 Geriatric subjects age 65 and above, who are
malnourished or risk of malnutrition
 Can be used in hospitals, community and other care settings
 Take considerable time to complete 18 items
Mini Nutritional Assessment –Short Form
(MNA -SF)
Malnutrition Universal Screening Tool
(MUST)
 Developed by British Association for Parenteral and
Enteral Nutrition (BAPEN) in 2003
 The most widely used nutritional screening tool in the UK &
commonly used in other countries worldwide

 A validated five-step screening tool to identify

 Adults, who are malnourished, at risk or obese
 Can be used in hospitals, community and other care settings
 With clear guidance to a care plan
Malnutrition Universal Screening Tool
(MUST)
Nutritional Screening Initiative (NSI)
 Established in 1990s, with questions mostly based on self-
observation
 Requires specific information about dietary intake
 Weight measurement is NOT required
 Clinical professional is NOT required

 A self-rated questionnaire designed for

 Older adults who are malnourished or risk of
malnutrition
Nutritional Screening Initiative (NSI)
Choosing the right screening tools
 Consideration
 Intension of design?
 Target population?
 Conscious? Confused?
 Staff required?
 Applicability?
 Portable?

Case Study - Which tool would you used if:

 To assess nutritional status of a 55 year old lady who
joins a health talk in community center?
References
 Barbosa-SilvaMC, BarrosAJ. (2006) Indications and limitations of the use of
subjective global assessment in clinical practice: an update. Current Opinion in Clinical
Nutrition and Metabolic Care;9(3):263–269
 British Association for Parenteral and Enteral Nutrition (2003) Malnutrition
Universal Screening Tool: 'MUST', Redditch: BAPEN.Griffith CDM, Clark RG. (1984)
A comparison of the ‘Sheffield’ prognostic index with forearm muscle dynamometry
in patients from Sheffield undergoing major abdominal and urological surgery.
Clinical Nutrition; 3: 147-151
 BAPEN.(2008) 'Malnutrition Universal Screening Tool'. Available from:
http://www.bapen.org.uk/pdfs/must/must_full.pdf
 Chumlea WC, Guo S. (1992) Equations for predicting stature in white and black
elderly individuals. Journal of Gerontology; 47 (6): M197-M203
 Cole RE (June 2008). "Improving clinical decisions for women at risk of
osteoporosis: dual-femur bone mineral density testing". J Am Osteopath Assoc 108
(6): 289–95
References
 Green SM, Watson R. (2005) Nutritional screening and assessment tools for use by
nurses: literature review. J Adv Nurs 50:69–83.
 Gibson RS (2005). Principles of Nutritional Assessment (2nd ed.). Oxford University
Press
 Gibney MJ et al (2004), Public Health Nutrition, 1st ed., Wiley-Blackwell
 McWhirter J P, Pennington C R. (1994) Incidence and recognition of malnutrition in
hospital. BMJ;308: 945–948
 Shum NC, Hui WW, Chu FCS, ChaiJ, Chow TW. (2005) Prevalence of malnutrition
and risk factors in geriatric patients of a convalescent and rehabilitation hospital.
Hong Kong Med J; 11:234-42.
 Thomas B & Bishop J. (2007) Manual of Dietetic Practice, Fourth Edition. Blackwell
Publishing.
 Yu K & Chen W. (1999) The Nutritional Assessment of Surgical Elderly Inpatients.
ActaNutrimentaSinica21, 212-215.