C:\WINDOWS\Profiles\tom\Plocha\LOGOSUPP.PCX Nutritional Status Assessment Assoc. Prof. Jindřich Fiala 1 Department of Public Health Faculty of Medicine, Masaryk University Outline, main points 2 nBackground, basics, definitions, objectives, indications nMalnutrition Techniques (in assessing nutritional status): nAnthropometry n nPhysical (clinical) examination - general appearance n nHistory nBiochemical and immunological examinations n nDynamometry tests (muscle strength) n nValidated screening tools n nChildren (specifics) n Definitions, scope 3 nNutritional status: - Nutritional status assessment - Dietary assessment, (Food consumption, Dietary habits …) nMalnutrition - The resulting status of health and nutrition given and influenced by diet, dietary intake and uptake, factors influencing uptake (including malfunctions and diseases), energy output, heredity, environmental factors, lifestyle (physical activity, smoking, alcohol…) nNutritional assessment – differentiate: - Nutritional status, which is characterized by a deficit or excess of energy or individual nutrients - This imbalance results in measurable changes in the tissues, the body's form, the functions of the organism, and the clinical condition of the individual v.s. Malnutrition 4 Malnutrition by deficiency - undernutrition Malnutritions by excess, overnutrition nEnergy, energy-protein deficiency malnutritions: nSpecific deficiencies ÞUnderweight ÞCachexia ÞMarasmus ÞKwashiorkor ÞMarasmic kwashiorkor ÞIodine deficiency - endemic goitre (Struma) ÞVit. A deficiency - xeroftalmia ÞNutritional anaemia ÞNutritional osteopenia ÞB1 (Thiamine) deficiency - Beri beri ÞB2 (Riboflavin) deficiency ÞB3 (Niacin, vit. PP) - Pellagra ÞVit C deficiency) - Scurvy ÞSarcopenia ÞOverweight ÞObesity ÞMicronutrient excess 5 C:\Users\jfiala\Pictures\Beze jména.jpg Burden of malnutrition 6 qMalnutrition affects people in every country. qAround 1.9 billion adults worldwide are overweight, while 462 million are underweight. q qAn estimated 41 million children under the age of 5 years are overweight or obese, while some 159 million are stunted and 50 million are wasted. q q Adding to this burden are the 528 million or 29% of women of reproductive age around the world affected by anaemia, for which approximately half would be amenable to iron supplementation. q qMany families cannot afford or access enough nutritious foods like fresh fruit and vegetables, legumes, meat and milk, while foods and drinks high in fat, sugar and salt are cheaper and more readily available, leading to a rapid rise in the number of children and adults who are overweight and obese, in poor as well as rich countries. q qIt is quite common to find undernutrition and overweight within the same community, household or even individual – it is possible to be both overweight and micronutrient deficient, for example. - 7 C:\Users\jfiala\Desktop\Media Gallery\Beze jména.jpg 8 http://www.who.int/entity/nutrition/double-burden-malnutrition/doubleburdenmalnutrition_infographic _WHAT.png Types of Protein-Energy Malnutrition (PEM) 9 nUnderweight - adults low BMI, children low weight for age nWasting – gradual loss of body mass (getting thinner). In children: Low weight for height. nStunting – low height for age nKwashiorkor – edematous PEM by protein deficiency nMarasmus – severe wasting due to energy deficiency nMarasmic kwashiorkor nCachexia –associated with inflammatory or neoplastic condition nSarcopenia - skeletal muscle wasting by ageing nStarvation – pure caloric deficiency, conserve lean mass, increase fat metabolism The most common: For infants – Marasmus , for older infants: Kwashiorkor For elderly: Sarcopenia and cachexia (regarding undernutrition) 10 http://www.validnutrition.org/wp-content/uploads/2017/07/malnutrition-Chart.jpg Marasmus vs Kwashiorkor 11 nMarasmus nKwashiorkor Marasmus is caused by a severe deficiency of nearly all nutrients, especially protein, carbohydrates, and lipids. Sufficient calorie intake, but with insufficient protein consumption. C:\Users\jfiala\Desktop\Media Gallery\marasmus vs kwashiorkor.jpg 12 Výsledek obrázku pro kwashiorkor edema pathogenesis Malnutrition - symptoms 13 nLack of appetite or interest in food or drink nTiredness and irritability nInability to concentrate nAlways feeling cold nLoss of fat, muscle mass, and body tissue nHigher risk of getting sick and taking longer to heal nLonger healing time for wounds nHigher risk of complications after surgery nDepression nReduced sex drive and problems with fertility nBreathing becomes difficult nSkin may become thin, dry, inelastic, pale, and cold nThe cheeks appear hollow and the eyes sunken, as fat disappears from the face nHair becomes dry and sparse, falling out easily n Malnutrition - causes 14 nLow intake of food nMental health problems nDigestive disorders and stomach conditions nAlcoholism nLack of breastfeeding This may be caused by symptoms of an illness, for example, dysphagia, when it is difficult to swallow. Badly fitting dentures may contribute. Conditions such as depression, dementia, schizophrenia, anorexia nervosa, and bulimia can lead to malnutrition Some people cannot leave the house to buy food or find it physically difficult to prepare meals. Those who live alone and are isolated are more at risk. Some people do not have enough money to spend on food, and others have limited cooking skills. Alcohol can lead to gastritis or damage to the pancreas. These can make it hard to digest food, absorb certain vitamins, and produce hormones that regulate metabolism. Alcohol contains calories, so the person may not feel hungry. They may not eat enough proper food to supply the body with essential nutrients. Not breastfeeding, especially in the developing world, can lead to malnutrition in infants and children. nSocial and mobility problems If the body does not absorb nutrients efficiently, even a healthful diet may not prevent malnutrition. People with Crohn's disease or ulcerative colitis may need to have part of the small intestine removed to enable them to absorb nutrients. Celiac disease may result in damage to the lining of the intestines and poor food absorption. Persistent diarrhea, vomiting, or both can lead to a loss of vital nutrients Worldwide most frequent micronutrient deficiencies 15 nIron deficiency nIodine nVitamin A deficiency ØThe world's most widespread micronutrient deficit (2 billion people) ØAnaemia, reduced mental and physical performance, susceptibility to infections ØIn adult individual pool for 2 years ØIn developing countries, babies are born with small supplies and do not receive vitamin A by breastfeeding either ØFirst, reversible night blindness ØLater, irreversible blindness (annually 1.5 million children) ØDecrease in immune functions, pneumonias, infectious diarrhea, death Ø Ø ØThe second most common deficit, very serious manifestations for the population ØThe world’s most prevalent, yet easily preventable, cause of brain damage Ø"Iodine Deficiency Disorders" (IDD) - goiter, hypothyroidism, retardation of psychomotor development, cretinism ØThe best prevention: iodised salt ØNatural content in food outside marine products depends on the geological basement - mountain deficiency ØThe urinary excretion shows the saturation (<100 ug / l = deficiency) The spectrum of iodine deficiency disorders, IDD 16 Fetus Miscarriage Stillbirths Congenital anomalies Increased perinatal morbidity and mortality Endemic cretinism Neonate Neonatal goiter Neonatal hypothyroidism Endemic neurocognitive impairment Increased susceptibility of the thyroid gland to nuclear radiation Child and adolescent Goiter (Subclinical) hypothyroidism Impaired mental function Retarded physical development Increased susceptibility of the thyroid gland to nuclear radiation Adult Goiter with its complications Hypothyroidism Impaired mental function Spontaneous hyperthyroidism in the elderly Iodine-induced hyperthyroidism Increased susceptibility of the thyroid gland to nuclear radiation 17 METHODS Methods, techniques 18 nAnthropometry nPhysical, (clinical) examination – general appearance nLaboratory – biochemical and immunological examinations nDynamometry tests (muscle strength)* nHistory nValidated screening tests nChildren *Rather rare use History and Physical Examination 19 nComprehensive nutritional assessment begins with a history and physical examination. History should consist of medical diagnoses, hospitalizations, changes in appetite, availability and preparation of food, medications, and details regarding weight change. Weight loss is perhaps the most validated parameter of nutritional status. nFollowing the history, a thorough physical examination may be performed. Attention should be directed toward findings of soft-tissue wasting, hydration status, evidence of vitamin and mineral deficiencies, height, weight, and body mass index (BMI). See table for a description of physical examination findings and related nutrient deficiencies. History 20 nChronic and current diseases of the examined person nDietary habits, possible alternative diets, social status.. nLifestyle – physical activity, alcohol… n To a large extent, it overlaps with the „Dietary assessment" , or "Nutritional history". Directly within the Nutritional Status assessment,we focus especially on the factors that can influence the nutritional status: ÞFocus on gastrointestinal problems ÞUsing drugs that can interact with the digestion and uptake of nutrients Symptoms and signs of undernutrition and micronutrient deficiency 21 C:\Users\jfiala\Pictures\Beze jména.jpg •Nails oAnémie z nedostatku železa – suché, lomivé, ploché až lžičkovitého tvaru (koilonychie) oNedostatek bílkovin – příčné bílé proužky Výsledek obrázku pro koilonychie https://classconnection.s3.amazonaws.com/639/flashcards/1040639/png/screen_shot_2012-09-29_at_73928 _pm1348962057890.png Close-up view of 4 fingers. White horizontal bands https://img.medscapestatic.com/pi/meds/ckb/41/28841tn.jpg Nails Eyes •Oči oBlefaritis – nedostatek riboflavinu, příp. vitamínu A oXeróza spojivek – nedostatek vitamínu A oKorneální skleróza, keratomalacie – nedostatek vitamínu A oBitotovy skvrny – nedostatek vitamínu A oKorneální vaskularizace – nedostatek riboflavinu nebo vitamínu A oAngulární palpebritis – nedostatek riboflavinu, pyridoxinu, železa oŠeroslepost – nedostatek vitaminu A, retinolu a β-karotenu Související obrázek https://upload.wikimedia.org/wikipedia/commons/thumb/3/34/Blepharitis.JPG/220px-Blepharitis.JPG Výsledek obrázku pro xerosis conjunctival https://webeye.ophth.uiowa.edu/eyeforum/atlas/photos-earlier/xerosis-conjunctivae.jpg Výsledek obrázku pro corneal xerosis https://image.slidesharecdn.com/problemsolvingexercise-vita-copy-160505054605/95/vitamin-a-and-its- deficiency-19-638.jpg?cb=1462427304 Související obrázek https://openi.nlm.nih.gov/imgs/512/100/2873666/PMC2873666_jceh_23_72_004_f18.png?keywords=vitamin+a +deficiencies,bitot%27s+spots http://3.bp.blogspot.com/-xl6WLqTk1uI/TriLOUllM6I/AAAAAAAAAJw/rU2PltJiqsc/s1600/corneal_neovascular ization.jpg Mouth, lips •Rty oAngulární stomatitis – nedostatek riboflavinu, pyridoxinu, železa oAngulární jizvy – nedostatek riboflavinu, pyridoxinu oCheilitis – nedostatek riboflavinu Výsledek obrázku pro cheilitis http://healthlifemedia.com/healthy/wp-content/uploads/2017/09/types-of-cheilitis.jpg Teeth, gums •Dásně oGingivitis – nedostatek vitamínu C •Jazyk oNedostatek riboflavinu, k. nikotinové, pyridoxinu, kobalaminu, k. listové a železa – akutní zánět, glossodynie, pukliny, vyhlazení povrchu jazyka •Zuby oZubní kaz •Nedostatek fluoru – zvýšená kazivost oSkvrnitá sklovina •Nadbytek fluoru o Výsledek obrázku pro gingivitis https://images.onhealth.com/images/slideshow/dental-problems-s6-gingivitis.jpg Související obrázek https://upload.wikimedia.org/wikipedia/commons/thumb/4/4e/Dental_fluorosis_%28mild%29.png/300px-Den tal_fluorosis_%28mild%29.png Skin •Kůže oFolikulární hyperkeratóza – nedostatek vitamínu A, nedostatek esenciálních mastných kyselin, nedostatek pyridoxinu oXeroderma – nedostatek vitamínu A oNasolabiální seborrhoea – nedostatek riboflavinu oFolikulární petechie – avitaminóza C oPetechiální hemorrhagie – avitaminózy C, K Výsledek obrázku pro follicular hyperkeratosis https://jamanetwork.com/data/Journals/DERM/4687/dsk50017f2.png Seborrheic Dermatitis on Face https://noskinproblems.com/wp-content/uploads/2015/06/seborrheic-dermatitis-face.jpg Výsledek obrázku pro follicular petechiae http://slideplayer.com/1718407/7/images/10/Case+One%3A+Skin+Exam+Perifollicular+petechiae.jpg Výsledek obrázku pro petechial hemorrhaging http://www.uaz.edu.mx/histo/pathology/ed/ch_7/c7_rmsf_hand.jpg Skin •Kůže oZměny pigmentace •Špinavě hnědé skvrny – chronická podvýživa •Depigmentace – kwashiorkor •Erytém, svědění, pálení – puchýřky – hrubnutí kůže – pelagra •Bledá kůže - chudokrevnost Výsledek obrázku pro kwashiorkor skin https://www.med.uottawa.ca/sim/data/Images/Kwashiorkor.jpg Výsledek obrázku pro pellagra skin https://niacinreviews.com/wp-content/uploads/2016/10/Pellagra-300x209.jpg •Kostra – nedostatek vitamínu D oCraniotabes oCaput quadratum oPozdní uzávěr velké fontanely oRachitický růženec oPectus carinatum oHarrisonova rýha oDeformace dlouhých kostí oNohy do „X“ nebo do „O“ Výsledek obrázku pro craniotabes https://usercontent2.hubstatic.com/8761643_f520.jpg Související obrázek http://slideplayer.com/10592260/36/images/20/caput+quadratum.jpg Výsledek obrázku pro rachitic rosary https://image.slidesharecdn.com/bonedemineralizationpblariff-150108110339-conversion-gate02/95/bone -demineralization-10-638.jpg?cb=1420720388 Výsledek obrázku pro pectus carinatum Související obrázek https://lh3.googleusercontent.com/-j4DAMWNSi1E/VyuFmVjt3BI/AAAAAAAABis/ww3CnqYmfno/s640/blogger-ima ge-2107067516.jpg Bones, skeleton Thyroid - goitre •Žlázy oZvětšení příušních žláz – nedostatek kvalitních bílkovin oStruma – nedostatek jódu Výsledek obrázku pro struma https://i.iinfo.cz/images/414/struma-vole-zvetsena-stitna-zlaza-2-thumb.jpg Výsledek obrázku pro parotitis https://www.wikidoc.org/images/a/aa/Parotitis01.jpg 30 ANTHROPOMETRY Anthropometric (somatometric) measurements used in nutritional status assessment 31 nDirectly measured simple parameters: n ÞHeight ÞWeight ÞWaist ÞHip ÞArm (MUAC) ÞSkinfolds nAnthropometric indexes: n nBody composition analysis: n ÞBMI ÞWHR ÞBIA ÞHydrodensitometry (hydrostatic weighing) ÞDEXA ÞMRI ÞPlethysmography (BodPod) (whole body air displacement plethysmography) Þ3D-scanning Height 32 C:\Users\jfiala\Desktop\Media Gallery\výška - měření.jpg C:\Users\jfiala\Desktop\Media Gallery\seca.jpg C:\Users\jfiala\Desktop\Media Gallery\seca staiometer.jpg C:\Users\jfiala\Desktop\VÝUKA\20 - Výuka jaro 2018\OPZ II\Beze jména.jpg C:\Users\jfiala\Desktop\VÝUKA\20 - Výuka jaro 2018\OPZ II\Beze jména.jpg Weight 33 C:\Users\jfiala\Desktop\Media Gallery\váha.jpg C:\Users\jfiala\Desktop\Media Gallery\Beze jména.jpg nAlternatives to weighing patients: C:\Users\jfiala\Pictures\personal-floor-scale.jpg C:\Users\jfiala\Desktop\VÝUKA\20 - Výuka jaro 2018\OPZ II\Beze jména.jpg C:\Users\jfiala\Desktop\VÝUKA\20 - Výuka jaro 2018\OPZ II\Beze jména.jpg BMI 34 Classification: Underweight Normal range Overweight Obesity BMI < 18.5 18.5 – 24.9 25.0 -29.9 ≥ 30.0 nBMI = weight (kg) / height2 (m2) n BMI – Diagnostic criteria (cut-offs) 35 Circumferences 36 nWaist n nHip n nArm n C:\Users\jfiala\Desktop\Media Gallery\Beze jména.jpg nCalf n Possible circumferences in nutritional status assessment: Circumferences – measuring sites: 37 nWaist – taken in level of the umbilicus (navel) n nArm – mid upper arm, relaxed n C:\Users\jfiala\Desktop\Media Gallery\měření obvidu gluteálníhp.jpg C:\Users\jfiala\Desktop\Media Gallery\měření obvodu paže.jpg nHip - measurement is taken at the widest lateral extension of the hips n C:\Users\jfiala\Desktop\Media Gallery\Beze jména.jpg C:\Users\jfiala\Desktop\Media Gallery\Beze jména.jpg Cover Waist circumference – diagnostic criteria 38 OK Risk increased Substantially increased Men < 94 94.1 - 102 > 102 Women < 80 80.1 - 88 > 88 nWHO – risk of metabolic complications: n 39 C:\Users\jfiala\Desktop\VÝUKA\20 - Výuka jaro 2018\00 - příprava OPZ II\hodnocení výživového stavu\Media Gallery\zzz.jpg Waist circumference – correlation with abdominal fat 40 Després J P, Lemieux I, Prud'homme D: Treatment of obesity: need to focus on high risk abdominally obese patients. BMJ. 2001 Mar 24;322(7288):716-20. C:\Users\jfiala\Desktop\VÝUKA\13 - výuka podzim 2014\13 - obezitologie\obr.2.jpg 41 Výsledek obrázku pro WHR Výsledek obrázku pro WHR Výsledek obrázku pro WHR - apple pear Výsledek obrázku pro WHR - apple pear WHR – Waist to Hip Ratio WHR – diagnostic criteria 42 Low risk Moderate risk High risk Men < 0.95 0.95 - 1.00 > 1.00 Women < 0.80 0.81 - 0.85 > 0.85 C:\Users\jfiala\Desktop\VÝUKA\13 - výuka podzim 2014\13 - obezitologie\obr 5.jpg Ideal value (health and fertility): Men 0.9, Women 0.7 WHR interpretation pitfalls 43 Després J P, Lemieux I, Prud'homme D: Treatment of obesity: need to focus on high risk abdominally obese patients. BMJ. 2001 Mar 24;322(7288):716-20. C:\Users\jfiala\Desktop\VÝUKA\13 - výuka podzim 2014\13 - obezitologie\obr 1.jpg WHR 44 C:\Users\jfiala\Desktop\VÝUKA\13 - výuka podzim 2014\13 - obezitologie\Beze jména.jpg Výsledek obrázku pro WHR Výsledek obrázku pro WHR - waist to hip, masculine - feminine Související obrázek The most desirable between 0.6 – 0.75 Diagnostická kritéria - WHR 45 C:\Users\jfiala\Desktop\VÝUKA\13 - výuka podzim 2014\13 - obezitologie\Beze jména.jpg Classification of obesity developed by the National Heart, Lung and Blood Institute task force, along with the associated disease risk with increasing BMI, waist circumference and waist to hip ratio. 46 Oliveros E, Somers V, Sochor O, Goel K, Lopez-Jimenez F: The concept of normal weight obesity. Progress in cardiovascular diseases, 2014, 56, 426-433 C:\Users\jfiala\Desktop\VÝUKA\13 - výuka podzim 2014\13 - obezitologie\obr. 6.jpg 47 METABOLIC SYNDROM Metabolic syndrome 48 nMetabolic syndrome, sometimes known by other names, is a clustering of at least three of the five following medical conditions: abdominal obesity, high blood pressure, high blood sugar, high serum triglycerides and low high-density lipoprotein (HDL) levels. n nMetabolic syndrome is associated with the risk of developing cardiovascular disease and type 2 diabetes. n nInsulin resistance, metabolic syndrome, and prediabetes are closely related to one another and have overlapping aspects. n nThe syndrome is thought to be caused by an underlying disorder of energy utilization and storage. 49 C:\Users\jfiala\Desktop\VÝUKA\20 - Výuka jaro 2018\00 - příprava OPZ II\hodnocení výživového stavu\Matabolic synsrom\mrtabolic syndrom criteria.jpg 50 C:\Users\jfiala\Desktop\VÝUKA\20 - Výuka jaro 2018\00 - příprava OPZ II\hodnocení výživového stavu\Matabolic synsrom\waist circumference.jpg 51 BODY FAT AND BODY COMPOSITION MAEASUREMENT 52 SKINFOLDS Skinfolds measurement 53 nSeveral types od calipers C:\Users\jfiala\Desktop\VÝUKA\20 - Výuka jaro 2018\00 - příprava OPZ II\hodnocení výživového stavu\Media Gallery\26883.jpg C:\Users\jfiala\Desktop\VÝUKA\20 - Výuka jaro 2018\00 - příprava OPZ II\hodnocení výživového stavu\Media Gallery\06.jpg C:\Users\jfiala\Desktop\VÝUKA\20 - Výuka jaro 2018\00 - příprava OPZ II\hodnocení výživového stavu\Media Gallery\07.jpg C:\Users\jfiala\Desktop\VÝUKA\20 - Výuka jaro 2018\00 - příprava OPZ II\hodnocení výživového stavu\Media Gallery\kaliper best.jpg Best: Harpenden: Skinfolds measurement 54 C:\Users\jfiala\Desktop\VÝUKA\20 - Výuka jaro 2018\00 - příprava OPZ II\hodnocení výživového stavu\Media Gallery\řasy - měření - best.jpg nMeasuring with Best caliper: C:\Users\jfiala\Desktop\VÝUKA\20 - Výuka jaro 2018\00 - příprava OPZ II\hodnocení výživového stavu\Media Gallery\zzz.jpg C:\Users\jfiala\Desktop\VÝUKA\20 - Výuka jaro 2018\00 - příprava OPZ II\hodnocení výživového stavu\Media Gallery\zz.jpg C:\Users\jfiala\Desktop\VÝUKA\20 - Výuka jaro 2018\00 - příprava OPZ II\hodnocení výživového stavu\Media Gallery\zzz.jpg nTriceps nSupraspinal nSubscapular 55 BIA - Bioelectrical impedance analysis BIA – Bioelectrical impedance analysis 56 nBIA actually determines the electrical impedance, or opposition to the flow of an electric current through body tissues which can then be used to estimate total body water (TBW), which can be used to estimate fat-free body mass and, by difference with body weight, body fat. n n Výsledek obrázku pro Bioelectrical impedance analysis C:\Users\jfiala\Desktop\VÝUKA\20 - Výuka jaro 2018\00 - příprava OPZ II\hodnocení výživového stavu\Media Gallery\zzz.jpg C:\Users\jfiala\Desktop\VÝUKA\20 - Výuka jaro 2018\00 - příprava OPZ II\hodnocení výživového stavu\Media Gallery\zzz.jpg C:\Users\jfiala\Desktop\VÝUKA\20 - Výuka jaro 2018\00 - příprava OPZ II\hodnocení výživového stavu\Media Gallery\zzz.jpg C:\Users\jfiala\Desktop\VÝUKA\20 - Výuka jaro 2018\00 - příprava OPZ II\hodnocení výživového stavu\Media Gallery\zzz.jpg C:\Users\jfiala\Desktop\VÝUKA\20 - Výuka jaro 2018\00 - příprava OPZ II\hodnocení výživového stavu\Media Gallery\zzz.jpg Výsledek obrázku pro BIA measurement bodystat Inbody S10 57 C:\Users\jfiala\Desktop\VÝUKA\20 - Výuka jaro 2018\00 - příprava OPZ II\hodnocení výživového stavu\obrázky\inbodys10_seeingabove.jpg C:\Users\jfiala\Desktop\VÝUKA\20 - Výuka jaro 2018\00 - příprava OPZ II\hodnocení výživového stavu\obrázky\inbody s10.jpg Inbody S10 58 C:\Users\jfiala\Desktop\VÝUKA\20 - Výuka jaro 2018\00 - příprava OPZ II\hodnocení výživového stavu\obrázky\inbodys10_posture2.jpg 59 C:\Users\jfiala\Desktop\VÝUKA\20 - Výuka jaro 2018\00 - příprava OPZ II\hodnocení výživového stavu\obrázky\inbodys10_foot.jpg C:\Users\jfiala\Desktop\VÝUKA\20 - Výuka jaro 2018\00 - příprava OPZ II\hodnocení výživového stavu\obrázky\inbodys10_hand.jpg 60 nBody Composition Analysis C:\Users\jfiala\Desktop\VÝUKA\20 - Výuka jaro 2018\00 - příprava OPZ II\hodnocení výživového stavu\obrázky\Global_s10_result.jpg nMuscle-Fat Analysis nSegmental Lean Analysis nResearch Items 61 C:\Users\jfiala\Desktop\VÝUKA\20 - Výuka jaro 2018\00 - příprava OPZ II\hodnocení výživového stavu\obrázky\Inbody - Body composition analysis.jpg C:\Users\jfiala\Desktop\VÝUKA\20 - Výuka jaro 2018\00 - příprava OPZ II\hodnocení výživového stavu\obrázky\Inbody - Muscle fat analysis.jpg C:\Users\jfiala\Desktop\VÝUKA\20 - Výuka jaro 2018\00 - příprava OPZ II\hodnocení výživového stavu\obrázky\Inbody Segmental lean analysis.jpg Inbody S10 62 C:\Users\jfiala\Desktop\VÝUKA\20 - Výuka jaro 2018\00 - příprava OPZ II\hodnocení výživového stavu\obrázky\Beze jména.jpg 63 OTHER TECHNIQUES Underwater weighing - hydrodensitometry 64 C:\Users\jfiala\Desktop\Media Gallery\08.jpg DEXA – Dual Energy X-ray Absorptiometry 65 Související obrázek Scan2 DEXA – Dual Energy X-ray Absorptiometry - principle 66 C:\Users\jfiala\Desktop\Media Gallery\DEXA principle.jpg DEXA – Dual Energy X-ray Absorptiometry 67 C:\Users\jfiala\Desktop\Media Gallery\Beze jména.jpg BodPod –Air displacement plethysmography 68 C:\Users\jfiala\Desktop\Media Gallery\09.jpg C:\Users\jfiala\Desktop\Media Gallery\bod-pod.png Body fat - diagnostic criteria 69 Oliveros E, Somers V, Sochor O, Goel K, Lopez-Jimenez F: The concept of normal weight obesity. Progress in cardiovascular diseases, 2014, 56, 426-433 Men Women Normal < 20 < 30 Overfat 20 - 25 30 - 35 Obesity > 25 > 35 Biospace: Standard body fat percent is 15 % (range 10 - 20) for men and 23 % (range 18 - 28) for women C:\Users\jfiala\Desktop\VÝUKA\13 - výuka podzim 2014\13 - obezitologie\obr 3.jpg Category OK Overweight Obesity BMI < 25 25 – 30 > 30 PBF males < 20 % 20 – 25 % > 25 % PBF females < 32 % 32 – 38 % > 38 % Measured PBF corresponding to BMI cut-offs: (Galagher et al.) C:\Users\jfiala\Desktop\VÝUKA\20 - Výuka jaro 2018\00 - příprava OPZ II\hodnocení výživového stavu\Media Gallery\zzz.jpg C:\Users\jfiala\Desktop\VÝUKA\20 - Výuka jaro 2018\00 - příprava OPZ II\hodnocení výživového stavu\Media Gallery\zzz.jpg The health impact of obesity, NWO 70 nCondition „fit fat“ is better (healthier) than „unfit unfat“ n nThe most important is the ratio between fat and muscle tissue n nNWO (Normal Weight Obesity) – increased fat in normal BMI, it poses metabolic and health risk. Diagnosis is often missed! n 71 LABORATORY Hxx 72 C:\Users\jfiala\Desktop\Media Gallery\Beze jména.jpg Biochemical examinations – serum proteins 73 Normal [g/l] Heavy deficiency [g/l] Halftime Albumin > 32 < 21 20 days Transferin > 2 < 1 8-10 days Prealbumin > 0.2 < 0.1 2 days 74 C:\Users\jfiala\Desktop\Media Gallery\Beze jména.jpg Pros and cons of serum nutritional markers 75 C:\Users\jfiala\Desktop\Media Gallery\Beze jména.jpg ccc 76 C:\Users\jfiala\Desktop\Media Gallery\Beze jména.jpg Nitrogen balance/ 77 C:\Users\jfiala\Desktop\Media Gallery\Beze jména.jpg 78 CHILDREN Children types of malnutrition 79 nStunting – low height for age nMarasmus – severe deficiency in almost all nutrients nWasting – low weight for height nKwashiorkor – low proteins intake, adequate calories Þ oedemas nOverweight 80 http://www.validnutrition.org/wp-content/uploads/2017/07/malnutrition-Chart.jpg Definitions 81 Nutritional status assessment in children – BMI percentiles 82 C:\Users\jfiala\Desktop\VÝUKA\20 - Výuka jaro 2018\00 - příprava OPZ II\hodnocení výživového stavu\obrázky\děti - BMI 0-18r - chlapci.jpg C:\Users\jfiala\Desktop\VÝUKA\20 - Výuka jaro 2018\00 - příprava OPZ II\hodnocení výživového stavu\obrázky\děti BMI 0-18 r - dívky.jpg Hodnocení výživového stav dětí 83 C:\Users\jfiala\Desktop\VÝUKA\20 - Výuka jaro 2018\00 - příprava OPZ II\hodnocení výživového stavu\obrázky\děti - BMI - percentilové grafy - hodnocení.jpg Application Rust.cz 84 C:\Users\jfiala\Desktop\VÝUKA\20 - Výuka jaro 2018\00 - příprava OPZ II\hodnocení výživového stavu\obrázky\Beze jména.jpg Hodnocení výživového stav dětí 85 C:\Users\jfiala\Desktop\VÝUKA\20 - Výuka jaro 2018\00 - příprava OPZ II\hodnocení výživového stavu\obrázky\Beze jména.jpg Z - score 86 nThe difference between the measured value and the 50. percentile, expressed in units of SD. n Z - score (WHO) 87 n There are three different systems by which a child or a group of children can be compared to the reference population: Z-scores (standard deviation scores), percentiles, and percent of median. For population-based assessment—including surveys and nutritional surveillance—the Z-score is widely recognized as the best system for analysis and presentation of anthropometric data because of its advantages compared to the other methods (5). At the individual level, however, although there is substantial recognition that Z-score is the most appropriate descriptor of malnutrition, health and nutrition centers (e.g. supplementary feeding programmes in refugee camps) have been in practice reluctant to adopt its use for individual assessment. A detailed description of the three systems, including a discussion of their strengths and weaknesses, can be found elsewhere (5, 14). n nIn this database, weight-for-height, height-for-age and weight-for-age are interpreted by using the Z-score classification system. The Z-score system expresses the anthropometric value as a number of standard deviations or Z-scores below or above the reference mean or median value. A fixed Z-score interval implies a fixed height or weight difference for children of a given age. For population-based uses, a major advantage is that a group of Z-scores can be subjected to summary statistics such as the mean and standard deviation. The formula for calculating the Z-score is (5): n nZ-score (or SD-score) = (observed value - median value of the reference population) / standard deviation value of reference population n nInterpreting the results in terms of Z-scores has several advantages: nThe Z-score scale is linear and therefore a fixed interval of Z-scores has a fixed height difference in cm, or weight difference in kg, for all children of the same age. For example, on the height-for-age distribution for a 36-month-old boy, the distance from a Z-score of -2 to a Z-score of -1 is 3.8 cm. The same difference is found between a Z-score of 0 and a Z-score of +1 on the same distribution. In other words, Z-scores have the same statistical relation to the distribution of the reference around the mean at all ages, which makes results comparable across ages groups and indicators. nZ-scores are also sex-independent, thus permitting the evaluation of children's growth status by combining sex and age groups. nThese characteristics of Z-scores allow further computation of summary statistics such as means, standard deviations, and standard error to classify a population's growth status. MID-UPPER ARM CIRCUMFERENCE (MUAC) MEASURING TAPES 88 An accurate way to measure fat-free mass is to measure the Mid Upper Arm Circumference (MUAC). The MUAC is the circumference of the upper arm at the midway between the shoulder tip and the elbow tip on the left arm. A low reading indicates a loss of muscle mass. MUAC is a good screening tool in determining the risk of mortality among children, and people living with HIV/AIDS. MUAC is the only anthropometric measure for assessing nutritional status among pregnant women. It is also very simple for use in screening a large number of people, especially during community level screening for community-based nutrition interventions or during emergency situations. MUAC is therefore used as a screening tool for community based nutrition programmes. MUAC is also used for screening target children and pregnant women for severe acute malnutrition (SAM) and moderate acute malnutrition (MAM). MID-UPPER ARM CIRCUMFERENCE (MUAC) MEASURING TAPES 89 C:\Users\jfiala\Desktop\Media Gallery\Beze jména.jpg C:\Users\jfiala\Desktop\Media Gallery\Beze jména.jpg MUAC in children 90 Arm and Calf circumferences cut-offs 91 Arm (AC, MAC, MUAC): nChildren: Mid-arm and calf circumferences (MAC and CC) are better than body mass index (BMI) in predicting health status and mortality risk in institutionalized elderly Taiwanese. Arch Gerontol Geriatr. 2012 May-Jun;54(3):443-7. Ø<11.5 cm – severe malnutrition (severe wasting) Ø11.5 – 12.5 – yelow range Mid-arm and calf circumferences are stronger mortality predictors than body mass index for patients with chronic obstructive pulmonary diseaseInt J Chron Obstruct Pulmon Dis. 2016; 11: 2075–2080. nAdults: Ø< 21 cm – red Ø21 – 23 – yelow Calf (CC): Ø< 31 cm – manutrition Ø> 31 - OK ØLOW MAC = < 24 UNICEF: 92 Screening tests Validated screening test 93 nMNA – Mini Nutritional Assessment nSGA – Subjective Global Assessment nMNA-SF (Short Form) nNottingham questionnaire nPG-SGA (Patient Generated) nNRS – Nutritional Risk Screening nMUST – Malnutrition Universal Screening Tool Validated screening test 94 C:\Users\jfiala\Desktop\Media Gallery\Beze jména.jpg MNA – Mini Nutritional assessment 95 nSensitivity: 98.9 % nSpecifity: 94.3 % nDiagnostic accuracy: 97.2 % 96 97 98 MNA – Mini Nutritional Assessment 99 Screening: §Food intake decline over the past 3 months due to loss of appetite, digestive problems §Weight loss during the last 3 months §Mobility §Psychological stress or acute disease in the past 3 months §Neuropsychological problems (dementia or depression) §BMI (<19, 19-20.9, 21-22.9, ≥23) --------------------------------------------------------------------------------------------------- --------------------------- Assessment: Generally: §Self-sufficiency – lives independently? §Drugs – more than 3 prescription drugs per day §Skin defects – pressure sores or skin ulcers Diet: §How many full meals daily §Markers for protein intake §Fruits or vegetable – two or more servings per day? §How much fluid per day? §Mode of feeding – self-sufficiency?) Self view: §Self view of nutritional status §Self view of his/her nutritional status in comparison with other people Anthropometry – 2 circumference: §Arm circumferences (<21, 21-21.9, ≥22) §Calf circumference (<31, ≥31) Screening score: 0-7: Malnourished 8-11: At risk of malnutrition 12-14: Normal nutritional status Total assessment – Malnutrition Indicator Score (Screening score + Assessment score): <17: Malnourished 17-23.5: At risk of malnutrition 24-30: Normal nutritional status MNA - SF 100 C:\Users\jfiala\Desktop\Media Gallery\Beze jména.jpg MNA - SF 101 C:\Users\jfiala\Desktop\Media Gallery\Beze jména.jpg 102 C:\Users\jfiala\Desktop\Media Gallery\Beze jména.jpg SGA – Subjective Global Assessment 103 It covers 3 areas: nMedical History ØWeight change ØDietary intake change ØGastrointestinal symptoms ØFunctional capacity n nPhysical examination ØLoss of subcutaneous fat ØLoss of muscle mass ØPresence of oedema, ascites nSubjective global assessment ØA – Well nourished ØB - Mildly/Moderately Malnourished ØC - Severely Malnourished Ø The individual items are not point scored as the assessment is subjective. The results of the medical history and physical examination are summarized in the „Subjective Global Assessment“ Ø 104 C:\Users\jfiala\Desktop\Media Gallery\Beze jména.jpg SGA – Subjective Global Assessment Guidance for Body Composition 105 Subcutaneous fat Muscle wasting C:\Users\jfiala\Pictures\Beze jména.jpg SGA – Subjective Global Assessment 106 A - Well-nourished B - Mildly/moderately malnourished C- Severely malnourished nNo decrease in food/nutrient intake; n< 5% weight loss; nNo/minimal symptoms affecting food intake; nNo deficit in function; nNo deficit in fat or muscle mass nDefinite decrease in food/nutrient intake; n5% - 10% weight loss without stabilization or gain; nMild/some symptoms affecting food intake; nModerate functional deficit or recent deterioration; nMild/moderate loss of fat and/or muscle mass nSevere deficit in food/nutrient intake; n> 10% weight loss which is ongoing; nSignificant symptoms affecting food/ nutrient intake; nSevere functional deficit nOR *recent significant deterioration obvious signs of fat and/or muscle loss Fluid retention Subjective Global Assessment NRS 2002 - Nutritional Risk Screening 107 MUST – Malnutrition Universal Screening Tool 108 C:\Users\jfiala\Desktop\Media Gallery\Beze jména.jpg 109 C:\Users\jfiala\Desktop\Media Gallery\Beze jména.jpg