Assessment
Notes from lecture by professor Betty Cohen as of 3/14/2001 recorded by Michael D.
When we are performing nutrition assessment we are trying to determine how
well clients needs are met. To do that, we are looking at four categories
a) A-anthropometric information
b) B-biochemical information
c) C-clinical information
d) D-dietary which is actually historical information
We will start with historical information. It consists of
a) Health history
b) Drug history
c) Socioeconomic history
d) diet history
a) health history-within this category the most important factor is appetite and
any changes associated with it. There are various factors that can
influence our appetite.
They include -illness- we are looking at its association with digestion,
absorption, metabolism and excretion. Whenever there is
illness present all the above will be affected.
Example: anybody with protein kcal malnutrition will have
problem with absorption because there will not be enough
protein for regeneration of epithelial cells in our
gastrointestinal tract.
There are certain illnesses such as HIV/AIDS, Cancer,
Thyroid conditions ,to name the major ones that cause
hyper metabolism and cachexia may result.
Excretion has also significant effect on pt's. health
status. Any presence of diarrhea, constipation, intestinal
blockage, kidney problem resulting in over or under excretion
of urine. All these are factors that can result in deficiency
or excess of certain nutrients and need to be taken into
account.
b) Drugs People also usually don’t have only one single condition . They may have
other medical conditions and thus may be taking other medication that
may pose certain effect on them.
For example- some medication may cause constipation or make the patient
very tired.
c) Mental health- This is also brought by illness. For example high levels of
uremia in the blood as a result of kidney or liver disease may
cause dramatic changes in pt personality. He may not be able to
concentrate and may have no inhibition. Here you have to
evaluate whether this patient is able to
- follow your instructions
- to shop for himself atc.
d) Social -It is very important to find out about patients abilities to follow our
recommendations. Thus you need to find out:
- where are they eating their food
- where do they live
- do they have kitchen facilities
- are they or have they ever been on food stamps
- do they need meals to be delivered to them
- is there food pantry around their house
- is there a "road block" due to financial support- (that’s a risk for
malnutrition. If they don’t have money or kitchen
facilities all your counseling is of no use.)
e) Dietary- we recognize several methods to collect information on patients eating
habits:
a) Food frequency-Here you are asking pt if they are consuming food from
certain food groups, and how often are they doing so.
It is mainly used for verification of other tools.
b) Usual intake- It provides us with information on usual eating habits.
-what are they eating on usual basis
b) 24 hour food recall- It is information about pt food intake specific to
those 24 hours. It's purpose is to find out about
intake of specific amount of nutrient within specific
amount of time. For instance how many kcal is the
patient getting within 24 hours. It's main feature is
that it is very specific information.
c) Food record - It is basically dairy where patient records his intake of food
for certain period of time. We do not use this, however, in
the hospital setting.
2) Analysis
After compiling the above information, we are ready to analyze our
findings. Her you will find out how much kcal and grams of protein they are consuming.
One of the fastest way of doing analysis is comparing it to food guide pyramid, or to
exchange system. If you see ,however, that the patient has lost tremendous amount of
weight, and is visibly malnourished, spare yourself doing all this work. They haven’t been
eating and you can see that without any analysis of nutrition intake.
Food guide pyramid (FGP)
It says that if you follow this pattern, you will have variety in your diet. In
general FGP provides 1600-2200kcal. When we are talking about choosing food that is
healthy we mean food that is as close to its natural state as possible. In the FGP the
most kcal are coming from the it's upper part- meat, milk, and sweets & fats.
The reasons we are using FGP, is because it is the best teaching tool. Most people
are familiar with it, since it is displayed on most of our food items packaging.
Energy Calculation
In order to determine total kcal need, we need to look at
a) BMR-basal metabolic rate
b) activity factor
c) TEF- thermic effect of food-energy required for digesting food 10%
We also need to take into account height, weight and age.
By calculating this total energy need you can determine, based on your food intake,
what your weight is going to be.
a) If your intake = your total energy need (BMR + activity + TEF)
you will maintain your weight
b) If your intake > then your total energy need- you will gain wt
c) if your intake < then your total energy need - you will loose wt
And this is basic principle for weight management.
How to determine kcal and protein need
We can - use various tables- listed in your textbook in chapter8
- estimate energy expenditure
To estimate energy expenditure we count for male 1kcal/hour= 24 kcal/day x wt(kg)
female 0.9kcal/hour= 21.6 kcal/day x wt(kg)
The weight that we are using, is actual weight, if you are within normal weight (your ideal BW)
If somebody is obese, we use adjusted body wt. This is because only 25% of adipose cells
are metabolically active. This is based on the content of mitochondria within cells.
Muscle cells have larger amount, and thus are more metabolically active.
To calculate adjusted body wt: (actual BW - ideal BW) x .25 = adjusted BW
How do we calculate ideal body weight (IBW)
We can use:
A) Metropolitan life insurance table that lists three numbers. Difference is
based on our body frame. Use lover number
for small body frame, use upper number for large
body frame.
b)Calculation - male -we start with 5 feet=60 inches. at 5 feet male will weigh 106lb
Afterwards we add 6 lb for each inch over 5 feet.
- female -we start with 100lb and for each inch over 5 feet we add 5 lb.
If they are bellow 5 feet, then we need to subtract.
This method is indirect calorimetry, it is only estimation. To do direct calorimetry,
we need to perform this operation in a laboratory setting on special equipment.
Formula M 106 + 6 -10%/+10%
F 100 + 5 +10%/-10%
Example M 5'9" 106 + 9 x 6 = 160 +/- 10% = 144-160-176
Haris Benedict Formula
This formula is used to calculate patient's BMR
M 66 + (13.7 x wt(kg)) + (5 x ht(cm)) - (6.8 x age)
F 655 + (9.6 x wt(kg)) + ( 1.8 x ht(cm)) - (4.7 x age )
ht(cm) = inch x 2.54
ht(m) = inch x 0.25
wt= lb : 2.2 = wt(kg)
To calculate the total energy need, we need to add
-activity factor - in the hospital everybody is 20% (1.2)
-IF injury factor - this is determined by condition of the patient.
- It is on average 1.2 and should never go over 1.7
-TEF we do not use this factor for hospital settings
Total energy need is then calculated HB-BMR x activity factor(1.2) x IF(given
For more detailed formulas used in assesment click here
