1. 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
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2. How to Identify Declining Health Status
Body mass index (BMI)
Percent weight change
Percent usual body weight
Arm muscle area
Subjective global assessment

3. 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

4. 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

5. Category BMI Range kg/m2 Severe thinness <16 Moderate thinness
Mild thinness
Normal
Overweight
Obese Class I
Obese Class II
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:

6. BMI Online Resources
.aspx (for ages 2-19)
weight/assessing/bmi/adult_BMI/english_bmi_calculator/bmi_calculator.htm (ages 20+)

7. BMI Printable Chart

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

9. 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%

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.

11. 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.

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

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

14. % 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.

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

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

17. 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

18. 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):

19. 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).

20. 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

21. Mid-Upper Arm Muscle Circumference

22. Triceps Skinfold (TSF)
Technique: Use right side

23. 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

26. 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

27. 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
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

28. 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

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

30. 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):
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:

31. 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:

33. Questions?