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Nutrition Screening and Assessment Nutrition 526: 2010
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Steps to Evaluating Pediatric Nutrition Problems
Screening Assessment Data collection Evaluation and interpretation Intervention Monitor reassessment
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Nutrition Screening: Purpose
To identify individuals who appear to have or be at risk for nutrition problems To identify individuals who require further assessment or evaluation 3
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Screening: Definition
Process of identifying characteristics known to be associated with nutrition problems ASPEN, Nutri in Clin Practice 1996 (5): Simplest level of nutritional care (level 1) Baer et al, J Am Diet Assoc 1997 (10) S2: 4
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Examples of Screening risk factors
Anthropometrics: weight, length/height, BMI Growth measures < than 5th %ile Growth measures > than 90th %ile Alterations in growth patterns Change in Z-scores Change 1-2 SD Change percentiles Medical and developmental Conditions Medications Improper or inappropriate food/formula choices or preparation Psychosocial Laboratory Values
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Examples of Screening risk factors
Jayden: PG Weight gain Nutritional Practices Barbara: Breastfeeding Weight changes Dietary practices Infant feeding practices Mark Newborn Weight loss Breastfeeding Jake 10 month old Hct: 29
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Assessment Systematic process Uses information gathered in screening
Adds more in depth, comprehensive data Links information Interprets data Develops care plan monitor Reassess 7
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Process Identify Problem or risk Identify Etiology
Determine intervention Monitor and Reevaluate
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Goals of Nutrition Assessment
To collect information necessary to document adequacy of nutritional status or identify deficits To develop a nutritional care plan that is realistic and within family context To establish an appropriate plan for monitoring and/or reassessment
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NCP: Nutrition Care Process
Provides a framework for critical thinking 4 Steps Assessment Diagnosis Intervention Monitoring/Evaluation
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NCP Assessment Obtain, verify, interpret information
Data used might vary according to setting, individual case etc… Questions to ask Is there a problem? Define the problem? Is more information needed?
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NCP Diagnosis Identification or labling of problem that is within RD practice to treat Examples: Inadequate intake Inadequate growth
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Examples of Nutrition Diagnosis Options
Altered GI Function Altered nutrition related laboratory values Decreased nutrient needs Evident malnutrition Inadequate protein-energy intake Excessive oral intake Increased energy expenditure Increased nutrient needs Involuntary weight loss Overweight/obesity Limited adherence to nutrition related recommendations (vs food and nutrition related knowledge) Underweight Food and medication interactions
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NCP: Diagnosis written as a PES statement
Problem/Etiology/Signs and symptoms “Must be clear and concise. 1 problem one etiology”
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Examples of Screening risk factors
Jayden: PG Weight gain Nutritional Practices Barbara: Breastfeeding Weight changes Dietary practices Infant feeding practices Mark Newborn Weight loss Breastfeeding Emma 12 months 95th percentile Diet information Jake 10 month old Hct: 29
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Jayden, Barbara, Mark, Emma, Jake
NCP Process Jayden, Barbara, Mark, Emma, Jake
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NCP Intervention Monitoring and Evaluation
Etiology drives the intervention Monitoring and Evaluation
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Challenges and Pitfalls
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Challenges Nutrient needs influenced by:
genetics, activity, body composition, medical conditions and medications Individuals anthropometric date influenced by: genetics, body composition, development, history 19
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Challenges Identification of etiology Weighing risk vs benefit
Supportive of: Family Individual Development/temperament 20
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Challenges Information Availability Accurate Representative complete
Goals and expectations Available Evidence bases applicable
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Comprehensive Nutrition Assessment
Collection of Nutritional data Interpretation of data Linking information Goals and expectations Individual data evidence Asking questions individualized intervention monitoring outcomes of intervention 22
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Potential Pitfalls Excuses Assumptions Faulty reasoning
Incorrect or inaccurate information Not evidence based Biased
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Information Collected: Current and Historical
Growth Dietary Medical history Diagnosis Feeding and developmental information Psychosocial and environmental information Clinical information and appearance (hair, skin, nails, eyes) Other (laboratory) 24
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Assessment Tools
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Nutrition Assessment Tools of Assessment Intake Additional information
Growth Measurements Growth charts Absolute size (percentile) Pattern Body composition Water, bone, muscle, fat Intake Additional information Intake Food record, food recall, analysis Additional information Medical, Development Social Laboratory Other anthropometrics etc
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Who is the regulator of growth?
Who regulates Intake? What do measurements mean? Weight Weight gain Lab values Intake information
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Growth
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Growth Growth is a dynamic process defined as an increase in the physical size of the body as a whole or any of its parts associated with increase in cell number and/or cell size Reflects changes in absolute size, mass, body composition
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Growth A normal, healthy child grows at a genetically predetermined rate that can be compromised by imbalanced nutrient intake
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Growth Assessment Progress in physical growth is one of the criteria used to assess the nutritional status of individuals
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Absolute size Absolute size Body composition Growth/changes over time
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Absolute size
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Other Anthropometrics
Upper arm circumference, triceps skinfolds Arm muscle area, arm fat area Sitting height, crown-rump length Arm span Segmental lengths (arm, leg) All have limitations for CSHCN, but can be additional information for individual child
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Body Mass Index for Age Body mass index or BMI: wt/ht2
Provides a guideline based on weight, height & age to assess overweight or underweight Provides a reference for adolescents that was not previously available Tracks childhood overweight into adulthood BMI is most conventionally expressed in kg/m2
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Guidelines to Interpretation of BMI
Underweight BMI-for-age <5th percentile At risk of overweight BMI-for-age 85th percentile Overweight BMI-for age 95th percentile Underweight guideline is from: WHO paper Overweight guidelines are from: Dietz’ work At risk is the critical term! Much more data for overweight risk factors than for underweight Some controversy re: the use of BMI to interpret underweight
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Interpretation of BMI BMI is useful for BMI is not useful for
screening monitoring BMI is not useful for diagnosis
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Who might be misclassified?
BMI does not distinguish fat from muscle Highly muscular children may have a ‘high’ BMI & be classified as overweight Children with a high percentage of body fat & low muscle mass may have a ‘healthy’ BMI Some CSHCN may have reduced muscle mass or atypical body composition
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Nutrient Analysis Fluid Energy Protein Calcium/Phosphorus Iron
Vitamin D Other 39
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Nutrient Needs Recommendations established for over 43 essential and conditionally essential nutrients
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Basis of recommendations
Physiology GI Renal Growth and Development Preventing deficiencies Meeting nutrient needs Water Energy Vitamin D Iron
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Dietary Information Collect data Nutrient Analysis
Comparison with recommendations, guidelines, evidence Link with additional information Interpret 42
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Dietary Information Family Food Usage 24 hour recall Diet history
3-7 day food record or diary Food frequency Other Information Food preparation, history, feeding observation, feeding problems, likes/dislikes, feeding environment
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Approaches to Estimating Nutrient Requirements
Direct experimental evidence (ie protein and amino acids) extrapolation from experimental evidence relating to human subjects of other age groups or animal models ie thiamin--related to energy intake mg/1000 kcal Breast milk as gold standard (average [] X usual intake) Metabolic balance studies (ie protein, minerals) Clinical Observation (eg: manufacturing errors B6, Cl) Factorial approach Population studies
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Dietary Reference Intakes (DRI) (including RDA, UL, and AI) are the periodically revised recommendations (or guidelines) of the National Academy of Sciences
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DRI: Dietary Reference Intakes AI: Adequate Intake
Comparison of individual intake data to a reference or estimate of nutrient needs DRI: Dietary Reference Intakes expands and replaces RDA’s reference values that are quantitative estimates of nutrient intakes for planning and assessing diets for healthy people AI: Adequate Intake UL: Tolerable Upper Intake Level EER: Estimated Energy Requirement
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DRI Estimated Average Requirement (EAR): expected to satisfy the needs of 50% of the people in that age group based on review of scientific literature. Recommended Dietary Allowance (RDA): Daily dietary intake level considered sufficient by the FNB to meet the requirement of nearly all (97-98%) healthy individuals. Calculated from EAR and is usually 20% higher Adequate intake (AI): where no RDA has been established. Tolerable upper limit (UL): Caution agains’t excess
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DRI Nutrition Recommendations from the Institute of Medicine (IOM) of the U.S> National Academy of Sciences for general public and health professionals. Hx: WWII, to investigate issues that might “affect national defense” Population/institutional guidelines Application to individuals.
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DRI’s for infants Macronutrients based on average intake of breast milk Protein less than earlier RDA AAP Recommendations Vitamin D: 200 IU supplement for breastfed infants and infants taking <500 cc infant formula Iron: Iron fortified formula (4-12 mg/L), Breastfed Infants supplemented 1mg/kg/d by 4-6 months
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Other Guidelines AAP Bright Futures
Educational or Professional teaching Public Policy Guidelines Consider source Consider Purpose ? How apply to individual
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Examples Baby cereal at 6 months Juice
Introduction of Cows milk to infants Weight gain in pregnancy Family meals
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Factors that alter Energy needs
Body composition Body size Gender Growth Genetics Ethnicity Environment Adaptation and accommodation Activity/work Illness/Medical conditions
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Energy Correlate individual intake with growth 53
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Medical Information
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Medical Information and History
Conditions that may impact growth, nutritional status, feeding Medications that may impact nutrient needs, absorbtion, utilization, or tolerance Illness, treatments, proceedures
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Medical Conditions Congenital Heart Disease Cystic Fibrosis Liver disorders Short gut syndrome or other conditions of malabsorbtion Respiratory disorders Neuromuscular Renal Prematurity Recent illness Others
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Drug-Nutrient Interaction
Altered absorbtion Altered synthesis Altered appetite Altered excretion Nutrient antagonists Tolerance
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Feeding and Developmental Information
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Feeding and development
Feeding Interactions Feeding Relationship Feeding Skills Feeding Development Feeding Behaviors
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What factors influence food choices, eating behaviors, and acceptance?
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Feeding Delays in feeding skills Feeding intolerance Behavioral
Medical/physiological limitations Other 61
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Sociology of Food Hunger Social Status Social Norms Religion/Tradition
Nutrition/Health
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Psychosocial and environmental information
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Psychosocial and Environmental Information
Family Constellation Dynamics Views Resources other Socioeconomic status employment/education/income/other Beliefs Religious/cultural/other
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Clinical and Laboratory assessment
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Clinical Assessment General appearance Temperature Color
Respiratory/WOB Skin/hair/nails/membranes Output (urine and stool) Other
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Clinical signs of Nutrient deficiency
Energy FTT, cacexia Protein Slow growth, edema, impaired wound healing Calcium Seizures, rickets, decreased bone density, tetany Phosphorus Seizures, decreased bone density, rickets, bone pain, decreased cardiac fx Vitamin D Decreased bone density, osteopenia, rickets Vitamin A Dry scaly skin, FTT, xeropthalmia,, dry mucus membranes Zinc FTT, edema, impaired wound healing, alopecia, acrodermatitis enteropathica Iron Pallor, tachycardia, FTT Essential fatty acid Scaly dermatitis, poor growth, alopecia Vitamin C Swollen joints, impaired wound healing, swollen bleeding gums, loose teeth, petechia fluid Weight loss, decreased UOP, dry mucus membranes, altered skin turgor, sunken fontanel, tachycardia, altered BP
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Laboratory Assessmet Laboratory tests can be specific and may detect deficiencies or excess prior to clinical symptomotology. Useful for assess status, response to tx, tolerance Validity effected by handling, lab method, technician accuracy, disease state, medical therapies Complements other components of process
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Examples of Laboratory Tests
Iron Hct, HgB, ferritin*, ZPPH* Protein/Energy Albumin, Transthyretin, RBP, other Bone Ca, Ph, Alk Pho, Vit D Vitamins Minerals Fluid Electrolytes, BUN, urine/serum osm, spec gravity
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Linking Information
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Assessment Process Linking information collected with:
Goals/expectations Reference data/standards Evidence individual Asking questions 71
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Case Examples Yes No Not sure or don’t know growth diet
Medical, developmental, feeding Social, environmental clinical laboratory
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Interpretation: Asking Questions
Is there a problem? Was there a problem? Does information make sense? What are goals and expectations? What is etiology of the problem? 73
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Intervention Identify etiology Identify contributing factors
Support feeding relationship Consider psychosocial factors, family choice and input Weigh risk v.s. benefit 74
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Etiology: Contributing factors
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Adequate intake vs feeding relationship
Concentrating formula vs fluid status impact on tolerance, compliance, errors, cost solution to problem vs exacerbating problem
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Summary: Screening Assessment Diagnosis Intervention
Monitoring and reevaluation 78
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Summary Identify Problem or risk Identify Etiology
Determine intervention Monitor and Reevaluate
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Summary: Assessment Process
Collect data Interpret data Link information Compare to references, standards, expectations Ask questions 80
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