Assessment of Declining Health Status Provided Courtesy of Nutrition411.com Assessment of Declining Health Status Contributed by Shawna Gornick-Ilagan, MS, RD, CWPC, CHES Updated by Nutrition411.com staff Review Date 4/14 G-1223

How to Identify Declining Health Status Body mass index (BMI) Percent weight change Percent usual body weight Arm muscle area Subjective global assessment

How to Identify Declining Health Status (cont’d) Body mass index (BMI) Percent weight change Percent usual body weight Arm muscle area Subjective global assessment

BMI 2.2 lb in 1 kg 2.54 cm in 1″ 100 cm in 1 m Because BMI is dependent only upon weight and height, it makes simplistic assumptions about distribution of muscle and bone mass, and thus may overestimate adiposity on those with more lean body mass (eg, athletes), while underestimating adiposity on those with less lean body mass (eg, the elderly). cm=centimeter, kg=kilogram, lb=pound, m=meter

Category BMI Range kg/m2 Severe thinness <16 Moderate thinness 16-16.99 Mild thinness 17-18.49 Normal 18.5-24.99 Overweight 25-29.99 Obese Class I 30-34.99 Obese Class II 35-39.99 Obese Class III 40+ A noted decline in BMI over a period of time or a very low BMI can indicate poor health status. Source: http://www.who.int/en/

BMI Online Resources http://www.nhlbi.nih.gov/guidelines/obesity/BMI/bmicalc.htm http://www.consumer.gov/weightloss/bmi.htm http://apps.nccd.cdc.gov/dnpabmi/Calculator .aspx (for ages 2-19) http://www.cdc.gov/nccdphp/dnpa/healthy weight/assessing/bmi/adult_BMI/english_bmi_calculator/bmi_calculator.htm (ages 20+)

BMI Printable Chart www.nhlbi.nih.gov/guidelines/obesity/bmi_tbl.pdf

Anthropometrics BMI Percent weight change Percent usual body weight Arm muscle area Subjective global assessment

Percent Weight Change Percent recent weight change= Usual Weight – Actual Weight Usual Weight Mary Jane was 150 lb last time you saw her 3 weeks ago Today you visit her and she is 135 lb What is her percent weight change? X 100 = 10%

Percent Weight Change (cont’d) Percent recent weight change= Usual Weight (150) – Actual Weight (135) Usual Weight (150) Mary Jane was 150 lb last time you saw her 3 weeks ago Today you visit her and she is 135 lb What is her percent weight change? X 100 Percent weight change is one of the most effective ways to measure declining health status. However, weight changes sometimes are because of factors other than weight loss, such as changes in fluid balance, amputation, or weighing errors.

Percent Weight Change (cont’d) Significant weight loss: 5% loss over 1 month or 7.5% loss over 3 months 10% loss over 6 months Severe weight loss: >7.5% loss over 3 months These are the guidelines used by the Centers of Medicare and Medicaid Services to identify significant weight loss in long-term care patients. These standards are widely used in all age groups to identify significant weight loss. Source: Blackburn et al, 1977.

Declining Weight Status BMI Percent weight change Percent usual body weight Arm muscle area Subjective global assessment

Usual Body Weight The stable body weight of the person during the past 6 to 12 months

% Usual Body Weight (cont’d) Actual Body Weight Usual Body Weight  100 Change in arm-muscle area (AMA) is greater than the change in mid-arm circumference. Consequently, changes in upper-arm musculature are not as easily detected by measurement of mid-arm circumference as by AMA.

% Usual Body Weight (cont’d) Mildly malnourished 85%-90% Moderately malnourished 75%-84% Severely malnourished <74% Absolute minimum weight for survival 48%-55%

Declining Health Status BMI Percent weight change Percent usual body weight Arm muscle area Subjective global assessment

Arm Muscle Area (AMA) AMA is an estimate of overall muscle mass The National Health and Nutritional Examination Survey (NHANES) data indicate a depletion of lean body mass (ie, malnutrition and/or declining health status) Assumptions: Arm, muscle, bone are circular TSF is 2 the thickness of fat Bone area is constant Arm muscle area is estimated using a mathematical formula that relies on a measurement of the mid-arm muscle circumference and triceps skinfold measurements. Arm muscle area is sometimes referred to as mid-arm muscle area (MAMA). TSF=triceps skinfold

AMA (cont’d) AMA is a better predictor of mortality than BMI in chronic obstructive pulmonary disease patients Source: Soler-Cataluña JJ. Chest. 2005;128(4):2108-2115.

What You Need to Calculate AMA The equation: [MAC – (π x TSF)]2 4π Where π=3.14 MAC—mid-arm circumference (cm) TSF—triceps skinfold (cm) Calculator Chart to interpret results (MAC [in centimeters] – 3.14 × tricipital skinfold thickness [in mm])2/(4 × 3.14). TSF=triceps skinfold (cm) Measure is in millimeters, so move decimal point to the left to find centimeters (33.0 mm Hg=3.3 cm).

Finding the Point to Measure the MUAC or MAC Conduct on the nondominant arm Bend elbow 90 degrees Measure the distance from the boney protrusion on the shoulder (acromion) and the point of the elbow (olecranon process) Mark the midpoint MAC=mid-arm circumference, MUAC=mid-upper arm circumference

Mid-Upper Arm Muscle Circumference

Triceps Skinfold (TSF) Technique: Use right side

Final Step Put results into AMA equation AMA=[MAC – (π x TSF)]2 4π Use Appendix R from Lee and Nieman’s Nutritional Assessment book to calculate results by finding the closest number in the appropriate category

Guidelines for Interpreting Percentile Values for Arm Muscle Area Category Percentile Wasted <5th percentile Below average 5th-15th percentile Average 15th-85th percentile Above average 85th-95th percentile High muscle >95th percentile

Practice Example (make everything cm) Age 51 If the MAC=12.5″ x 2.54=31.75 cm If the TSF=30 mm Hg=3 cm AMA=[MAC – (π x TSF)]2 4π AMA=31.75 cm – (3.14 x 3 cm)=22.33=squared 498.62 12.56 Individual is in the 10th percentile [(MAC − π x TSF)2/4 π] AMA=[(MAC − (3.14 x TSF)]2 / (4 x 3.14) AMA=arm muscle area (cm2) MAC=mid-arm circumference (cm) TSF=triceps skinfold thickness (cm) Or units of AMA, MAC, TSF all in mm To convert mm2 to cm2, divide mm2 by 100 =39.69 cm2 mm Hg=millimeters of mercury

Result Patient is at increased nutritional risk secondary to AMA results of 10%, categorized as below average One negative: AMA not validated in people who are older than 75 years of age Category Percentile Below average 5th-15th percentile

Declining Weight Status BMI Percent weight change Percent usual body weight Arm muscle area Subjective global assessment

Subjective Global Assessment (SGA) Is truly a subjective means of assessing nutritional status, which corresponds to the subjective opinion of the patient’s nutritional status Classifies the patient as A, B, or C, which is based on the subjective ratings in two broad areas: Medical history Physical examination SGA is truly a subjective means of assessing nutritional status. SGA classifies the patient as: A=well-nourished, B=moderately malnourished, or C=severely malnourished. Patients are placed into one of these categories based on their subjective rating in two broad areas—medical history and physical examination. The clinician rates each medical history and physical examination parameter as A, B, or C on the SGA Scoring Sheet. Using the ratings of the parameters as a guide, an overall SGA score is given, which corresponds to the subjective opinion of the patient’s nutritional status. Sources Detsky AS, Baker JP, Mendelson RA, Wolman SL, Wesson DE, Jeejeebhoy KN. Evaluating the accuracy of nutritional assessment techniques applied to hospitalized patients: methodology and comparisons. JPEN J Parenter Enteral Nutr. 1984;8(2):153-159. Detsky AS, McLaughlin JR, Baker JP, et al. What is subjective global assessment of nutritional status? JPEN J Parenter Enteral Nutr. 1987;11(1):8-13. Jeejeebhoy KN. Clinical and functional assessments. In: Shils ME, Olson JA, Shike M, eds. Modern Nutrition in Health and Disease. 8th ed. Philadelphia, PA: Lea and Febiger; 1994:805-811.

SGA (cont’d) SGA is not a scoring system—not appropriate to score or add the number of A, B, and C ratings to arrive at the overall SGA classification If a patient has more B and C ratings, malnutrition is more likely A well-nourished patient will have ratings on the left-hand side of the SGA scoring sheet SGA is not a numerical scoring system. Therefore, it is inappropriate to score or add the number of A, B, and C ratings to arrive at the overall SGA classification. The items on the form are used by the nutritionist to obtain a general feel for the patient’s status. If a patient has more B or C ratings, malnutrition is more likely. A well-nourished patient will have ratings on the left-hand side of the SGA scoring sheet. Sources Detsky AS, Baker JP, Mendelson RA, Wolman SL, Wesson DE, Jeejeebhoy KN. Evaluating the accuracy of nutritional assessment techniques applied to hospitalized patients: methodology and comparisons. J Parenter Enteral Nutr. 1984;8(3):153. Detsky AS, McLaughlin JR, Baker JP, et al. What is subjective global assessment of nutritional status? JPEN J Parenter Enteral Nutr. 1987;11(a):8-13. Jeejeebhoy KN. Clinical and functional assessments. In: Shils ME, Olson JA, Shike M, eds. Modern Nutrition in Health and Disease. 8th ed. Philadelphia, PA: Lea and Febiger; 1994:805-811.

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