NUTRITION NUTRITION ASSESSMENTASSESSMENT

Barbara Fine RD, LDNBarbara Fine RD, LDN

Malnutrition in Hospitalized Malnutrition in Hospitalized PatientsPatients

Consequences:Consequences: Poor wound healingPoor wound healing Higher rate of infectionsHigher rate of infections Greater length of stay (readmission for Greater length of stay (readmission for

elderly)elderly) Increased costsIncreased costs Increased morbidity and mortalityIncreased morbidity and mortality Suboptimal surgical outcomeSuboptimal surgical outcome

Nutrition AssessmentNutrition Assessment

Collecting, integrating, and analyzing nutrition-Collecting, integrating, and analyzing nutrition-related datarelated data Including food-drug interactions, cultural, religious Including food-drug interactions, cultural, religious

and ethnic food preferences, age related nutrition and ethnic food preferences, age related nutrition issues and the need for diet counselingissues and the need for diet counseling

Dietitian to evaluate patient’s nutritional status Dietitian to evaluate patient’s nutritional status and the extent of any malnutritionand the extent of any malnutrition

Data gathered will provide the objective basis Data gathered will provide the objective basis for recommendations and evaluation of carefor recommendations and evaluation of care

Includes a chart review and patient interviewIncludes a chart review and patient interview

Purpose of Nutrition Purpose of Nutrition AssessmentAssessment

Estimates functional status, diet intake Estimates functional status, diet intake and body composition compared to and body composition compared to normal populationsnormal populations

Body composition reflects calorie and Body composition reflects calorie and protein needsprotein needs

Nutritional status predicts hospital Nutritional status predicts hospital morbidity, mortality, length of stay, costmorbidity, mortality, length of stay, cost

Baseline body composition and Baseline body composition and biochemical markers determine if biochemical markers determine if nutrition support is effectivenutrition support is effective

Nutrition ScreeningNutrition Screening Includes height, weight, unintentional Includes height, weight, unintentional

weight loss, change in appetite and serum weight loss, change in appetite and serum albuminalbumin

Data used to determine patients at Data used to determine patients at nutritional risk and the need for a detailed nutritional risk and the need for a detailed assessmentassessment

Nutrition care plan developed to reflect Nutrition care plan developed to reflect calorie, protein and other nutrient needs calorie, protein and other nutrient needs from the information collectedfrom the information collected

Implement planImplement plan Monitor and revise as neededMonitor and revise as needed

Screening: Nutrition Care Screening: Nutrition Care IndicatorsIndicators Nutritional historyNutritional history

AppetiteAppetite Nausea/vomiting (>3 days)Nausea/vomiting (>3 days) DiarrheaDiarrhea DysphagiaDysphagia Reduced food intake (<50% of normal for 5 days)Reduced food intake (<50% of normal for 5 days)

Feeding modalityFeeding modality TPN/PPNTPN/PPN TFTF Diet restrictionsDiet restrictions

Unintentional Weight LossUnintentional Weight Loss >10 lbs in past 3 months>10 lbs in past 3 months

Serum AlbuminSerum Albumin DiagnosisDiagnosis

Cachexia, end-stage liver or kidney disease, coma, malnutrition, Cachexia, end-stage liver or kidney disease, coma, malnutrition, decubitis ulcers, cancer of GI tract, Crohns, Cystic Fibrosis, new decubitis ulcers, cancer of GI tract, Crohns, Cystic Fibrosis, new onset diabetes, eating disorderonset diabetes, eating disorder

Above used to determine nutritional risk and need for Above used to determine nutritional risk and need for referral to RDreferral to RD

Components of Nutrition Components of Nutrition AssessmentAssessment

Medical and social historyMedical and social history Diet history and intakeDiet history and intake Clinical examinationClinical examination AnthropometricsAnthropometrics Biochemical dataBiochemical data

Medical and Social Medical and Social HistoryHistory

Gathered from chart review and patient Gathered from chart review and patient interviewinterview

Medical historyMedical history: diagnosis, past medical : diagnosis, past medical and surgical history, pertinent medications, and surgical history, pertinent medications, alcohol and drug use, bowel habitsalcohol and drug use, bowel habits

Psychosocial dataPsychosocial data: economic status, : economic status, occupation, education level, living and occupation, education level, living and cooking arrangements, mental statuscooking arrangements, mental status

Other:Other: age, sex, level of physical activity, age, sex, level of physical activity, daily living activitiesdaily living activities

Dietary History and Dietary History and IntakeIntake

Appetite and intakeAppetite and intake: taste changes, : taste changes, dentition, dysphagia, feeding independence, dentition, dysphagia, feeding independence, vitamin/mineral supplementsvitamin/mineral supplements

Eating patternsEating patterns: daily and weekend, diet : daily and weekend, diet restrictions, ethnicity, eating away from restrictions, ethnicity, eating away from home, fad dietshome, fad diets

Estimation of typical calorie and nutrient Estimation of typical calorie and nutrient intakeintake: RDAs, Food Guide Pyramid: RDAs, Food Guide Pyramid Obtain diet intake from 24-hour recall, food Obtain diet intake from 24-hour recall, food

frequency questionnaire, food diary, observation frequency questionnaire, food diary, observation of food intakeof food intake

Diet AssessmentDiet Assessment

Evaluate what and how much person is Evaluate what and how much person is eating, as well as habits, beliefs and eating, as well as habits, beliefs and social conditions that may put person at social conditions that may put person at riskrisk

Usual intakeUsual intake 24 hr recall: retrospective, easy24 hr recall: retrospective, easy Food logs: prospective, requires motivationFood logs: prospective, requires motivation Food frequency questionnaire: general Food frequency questionnaire: general

idea of how often foods are consumedidea of how often foods are consumed Compare to estimation of needsCompare to estimation of needs

Nutritional Questions for Nutritional Questions for the Review of Systemsthe Review of Systems

GeneralGeneral Usual adult weightUsual adult weight Current weightCurrent weight Maximum, minimum weightsMaximum, minimum weights Weight change 1 and 5 years priorWeight change 1 and 5 years prior Recent changes in weight and time periodRecent changes in weight and time period Recent changes in appetite or food toleranceRecent changes in appetite or food tolerance Presence of weakness, fatigue, fever, chills, Presence of weakness, fatigue, fever, chills,

night sweatsnight sweats Recent changes in sleep habits, daytime Recent changes in sleep habits, daytime

sleepinesssleepiness Edema and/or abnormal swellingEdema and/or abnormal swelling

Nutritional Questions for Nutritional Questions for the Review of Systemsthe Review of Systems

AlimentaryAlimentary Abdominal pain, nausea, vomitingAbdominal pain, nausea, vomiting Changes in bowel pattern (normal or baseline)Changes in bowel pattern (normal or baseline) Diarrhea (consistency, frequency, volume, color, Diarrhea (consistency, frequency, volume, color,

presence of cramps, food particles, fat drops)presence of cramps, food particles, fat drops) Difficulty swallowing (solids vs. liquids, intermittent Difficulty swallowing (solids vs. liquids, intermittent

vs. continuous)vs. continuous) Early satietyEarly satiety Indigestion or heartburnIndigestion or heartburn Food intolerance or preferencesFood intolerance or preferences Mouth sores (ulcers, tooth decay)Mouth sores (ulcers, tooth decay) Pain in swallowingPain in swallowing Sore tongue or gumsSore tongue or gums

Nutritional Questions for Nutritional Questions for the Review of Systemsthe Review of Systems

NeurologicNeurologic Confusion or memory lossConfusion or memory loss Difficulty with night visionDifficulty with night vision Gait disturbanceGait disturbance Loss of position senseLoss of position sense Numbness and/or weaknessNumbness and/or weakness

SkinSkin Appearance of a diagnostic rashAppearance of a diagnostic rash Breaking of nailsBreaking of nails Dry skinDry skin Hair loss, recent change in textureHair loss, recent change in texture

Clinical ExaminationClinical Examination

Identifies the physical signs of malnutrition Identifies the physical signs of malnutrition Temporal wastingTemporal wasting

Signs do not appear unless severe deficiencies Signs do not appear unless severe deficiencies existexist

Most signs/symptoms indicate two or more Most signs/symptoms indicate two or more deficienciesdeficiencies

Examples: see list attachedExamples: see list attached Hair: easily plucked, thin; protein or biotin Hair: easily plucked, thin; protein or biotin

deficiencydeficiency Mouth: tongue fissuring (niacin), decreased Mouth: tongue fissuring (niacin), decreased

taste/smell (zinc)taste/smell (zinc)

AnthropometricsAnthropometrics

Inexpensive, noninvasive, easy to Inexpensive, noninvasive, easy to obtain, valuable with other parametersobtain, valuable with other parameters

Height, weight and weight changesHeight, weight and weight changes Segmental lengths, fat folds and Segmental lengths, fat folds and

various body circumferences and areasvarious body circumferences and areas Repeated periodically to note changesRepeated periodically to note changes Individuals serve as own standardIndividuals serve as own standard Changes are not obvious for 3-4 weeksChanges are not obvious for 3-4 weeks

Disadvantages of Disadvantages of AnthropometricsAnthropometrics

Intra and interobserver errorIntra and interobserver error Changes in composition of patient’s Changes in composition of patient’s

tissuestissues Inaccurate application of raw dataInaccurate application of raw data Measurements are evaluated by Measurements are evaluated by

comparing them with predetermined comparing them with predetermined reference limits that allow for reference limits that allow for classification into risk categoriesclassification into risk categories

AnthropometricsAnthropometrics Height-measuredHeight-measured

Commonly overestimated in men and Commonly overestimated in men and underestimated in womenunderestimated in women

Estimates for bedridden or wheelchair boundEstimates for bedridden or wheelchair bound Arm span, recumbent lengthArm span, recumbent length Knee-height with calipersKnee-height with calipers

Weight-measuredWeight-measured Effect of fluid statusEffect of fluid status

Edema and ascites falsely elevate weightEdema and ascites falsely elevate weight

Weight historyWeight history Weight change over timeWeight change over time

AnthropometricsAnthropometrics

Ideal body weightIdeal body weight Males: 106 lbs + 6 lbs per inch over 5 ftMales: 106 lbs + 6 lbs per inch over 5 ft Females: 100 lbs + 5 lbs per inch over 5 ftFemales: 100 lbs + 5 lbs per inch over 5 ft Add 10% for large-framed and subtract 10% Add 10% for large-framed and subtract 10%

for small-framedfor small-framed %IBW = (current wt/IBW) X 100%IBW = (current wt/IBW) X 100

80-90% mild malnutrition80-90% mild malnutrition 70-79% moderate malnutrition70-79% moderate malnutrition 60-69% severe malnutrition60-69% severe malnutrition <60% non-survival<60% non-survival

AnthropometricsAnthropometrics %UBW: usual body weight%UBW: usual body weight

= (current wt/UBW) X 100= (current wt/UBW) X 100 85-95% mild malnutrition85-95% mild malnutrition 75-84% moderate malnutrition75-84% moderate malnutrition 0-74% severe malnutrition0-74% severe malnutrition

% weight change = usual weight – present % weight change = usual weight – present weight/usual weight X 100weight/usual weight X 100

Significant weight lossSignificant weight loss >5% in 1 month>5% in 1 month >10% in 6 months>10% in 6 months

Body Mass Index = BMIBody Mass Index = BMI

Evaluation of body weight independent of Evaluation of body weight independent of heightheight

BMI = weight (kg)/heightBMI = weight (kg)/height22 (m) (m) >40>40 obesity IIIobesity III 30-4030-40 obesity IIobesity II 25-3025-30 overweightoverweight 18.5-2518.5-25 normalnormal 17-18.417-18.4 PEM IPEM I 16-16.916-16.9 PEM IIPEM II <16<16 PEM IIIPEM III

Health Risk and Central Health Risk and Central ObesityObesity

Upper body obesity = increased riskUpper body obesity = increased risk Waist > 35 inches in femalesWaist > 35 inches in females Waist > 40 inches in malesWaist > 40 inches in males Clinically significant for BMI 25-35Clinically significant for BMI 25-35 BMI >35 health risk high and not BMI >35 health risk high and not

increased further by waist increased further by waist circumferencecircumference

Frame SizeFrame Size

Determined using wrist circumference and Determined using wrist circumference and elbow breadthelbow breadth

Determines the optimal weight for height Determines the optimal weight for height to be adjusted to a more accurate estimateto be adjusted to a more accurate estimate

Wrist circumference: measures the Wrist circumference: measures the smallest part of the wrist distal to the smallest part of the wrist distal to the styloid process of the ulna and radiusstyloid process of the ulna and radius

Elbow breadth: measures the distance Elbow breadth: measures the distance between the two prominent bones on between the two prominent bones on either side of the elboweither side of the elbow

Skinfold ThicknessSkinfold Thickness

Estimates subcutaneous fat stores to Estimates subcutaneous fat stores to estimate total body fatestimate total body fat

Compared with percentile standards from Compared with percentile standards from multiple body sites or collected over time multiple body sites or collected over time

Triceps, biceps, subscapular, and Triceps, biceps, subscapular, and suprailiac using calipers are most suprailiac using calipers are most commonly usedcommonly used

Disadvantages: total body fluid overload, Disadvantages: total body fluid overload, caliper calibration, inter-individual caliper calibration, inter-individual variabilityvariability

Body Circumferences Body Circumferences and Areasand Areas

Estimates skeletal muscle mass (somatic protein stores Estimates skeletal muscle mass (somatic protein stores and body fat storesand body fat stores

Midarm or upper arm circumference (MAC): on the Midarm or upper arm circumference (MAC): on the upper arm at the midpoint between the tip of the upper arm at the midpoint between the tip of the acromial process of the scapula and the olecranon acromial process of the scapula and the olecranon process of the ulnaprocess of the ulna

Midarm muscle or arm muscle circumference (MAMC): Midarm muscle or arm muscle circumference (MAMC): determined from the MAC and triceps skinfold (TSF)determined from the MAC and triceps skinfold (TSF)

MAMC = MAC – (3.14 X TSF)MAMC = MAC – (3.14 X TSF) Total upper arm area: determines upper arm fat storesTotal upper arm area: determines upper arm fat stores Upper arm muscle mass provides a good indication of Upper arm muscle mass provides a good indication of

lean body mass, used in the calculation of upper arm lean body mass, used in the calculation of upper arm fat areafat area

Upper arm fat area: calculation may be a better Upper arm fat area: calculation may be a better indicator of changes in fat stores than TSFindicator of changes in fat stores than TSF

Bioelectrical Impedance Bioelectrical Impedance Analysis (BIA)Analysis (BIA)

Measures electrical conductivity Measures electrical conductivity through water in difference body through water in difference body compartmentscompartments

Uses regression equations to Uses regression equations to determine fat and LBMdetermine fat and LBM

Serial measures can track changes Serial measures can track changes in body compositionin body composition Obesity treatmentsObesity treatments

DEXA: dual-energy X-ray DEXA: dual-energy X-ray absorptiometryabsorptiometry

Whole body scan with 2 x-rays of Whole body scan with 2 x-rays of different intensitydifferent intensity

Computer programs estimateComputer programs estimate Bone mineral densityBone mineral density Lean body massLean body mass Fat massFat mass ““Best estimate” for body composition of Best estimate” for body composition of

clinically available methodsclinically available methods

Anthropometrics: additional Anthropometrics: additional methodsmethods

Research methods: precise, but cost Research methods: precise, but cost prohibitiveprohibitive Total body potassiumTotal body potassium Underwater weight Underwater weight

(hydrodensitometry)(hydrodensitometry) Deuterated water dilutionDeuterated water dilution

Muscle strength and enduranceMuscle strength and endurance

Biochemical DataBiochemical Data

Used to assess body storesUsed to assess body stores Altered by lack of nutrients, medications, Altered by lack of nutrients, medications,

metabolic changes during illness or stressmetabolic changes during illness or stress Interpret results carefullyInterpret results carefully Fluid status distorts resultsFluid status distorts results ““Stressed” states (infection, surgery) Stressed” states (infection, surgery)

effects resultseffects results Use reference values established by Use reference values established by

individual labindividual lab

Visceral ProteinsVisceral Proteins

Produced by the liverProduced by the liver Affected by protein deficiency, but Affected by protein deficiency, but

also renal and hepatic disease, also renal and hepatic disease, wounds and burns, infections, zinc wounds and burns, infections, zinc and energy deficiency, cancer, and energy deficiency, cancer, inflammation, hydration status, and inflammation, hydration status, and stressstress

AlbuminAlbumin

Half life 14-21 daysHalf life 14-21 days Normal value 3.5-5.0 g/DLNormal value 3.5-5.0 g/DL Most widely used indicator of Most widely used indicator of

nutritional statusnutritional status Acute phase response: levels decrease Acute phase response: levels decrease

in response to stress (infection, injury)in response to stress (infection, injury) Affected by volumeAffected by volume

Increases with dehydration, decreases with Increases with dehydration, decreases with edema and overhydrationedema and overhydration

PrealbuminPrealbumin

Better measure of nutritional status Better measure of nutritional status due to shorter half-life, ~2 daysdue to shorter half-life, ~2 days

Normal value: 18-40 mg/DLNormal value: 18-40 mg/DL Responds within days to nutritional Responds within days to nutritional

repletionrepletion Levels affected by trauma, acute Levels affected by trauma, acute

infections, liver and kidney disease; infections, liver and kidney disease; highly sensitive to minor stress and highly sensitive to minor stress and inflammationinflammation

C-reactive proteinC-reactive protein

Positive acute phase respondentPositive acute phase respondent Increases early in acute stress as Increases early in acute stress as

much as 1000-foldmuch as 1000-fold Decreased correlates with end of Decreased correlates with end of

acute phase and beginning of acute phase and beginning of anabolic phase where nutritional anabolic phase where nutritional repletion is possiblerepletion is possible

Creatinine Height IndexCreatinine Height Index Estimates LBMEstimates LBM = = actual creat excretion (24 hour urine actual creat excretion (24 hour urine

collection)collection) expected creat excretionexpected creat excretion Males: IBW X 23 mg/kgMales: IBW X 23 mg/kg Females: IBW X 18 mg/kgFemales: IBW X 18 mg/kg >80% normal>80% normal 60-80% moderately depleted60-80% moderately depleted <60% severely depleted<60% severely depleted Accurate 24-hr urine collection is difficult to Accurate 24-hr urine collection is difficult to

obtain in acute-care settingobtain in acute-care setting

Hematological IndicesHematological Indices Determine nutritional anemiasDetermine nutritional anemias Transferrin: Fe transport proteinTransferrin: Fe transport protein TIBC: total Fe binding capacityTIBC: total Fe binding capacity

Indicates number of free binding cites on transferrinIndicates number of free binding cites on transferrin Fe deficiency: increased transferrin levels, Fe deficiency: increased transferrin levels,

decreased saturationdecreased saturation Ferritin: Fe storage protein, increases during Ferritin: Fe storage protein, increases during

inflammationinflammation Depressed hemoglobin is an indicator of Fe Depressed hemoglobin is an indicator of Fe

deficiency anemiadeficiency anemia

Nitrogen balanceNitrogen balance Goal for repletion is a positive nitrogen Goal for repletion is a positive nitrogen

balancebalance 24-hr record of protein intake and urine 24-hr record of protein intake and urine

collection is requiredcollection is required Done within 48 hr after initiation of Done within 48 hr after initiation of

nutrition therapynutrition therapy Results not valid in conditions with high Results not valid in conditions with high

protein losses (burns or high-output protein losses (burns or high-output fistulas)fistulas)

N balance = protein intake/6.25 – (urinary N balance = protein intake/6.25 – (urinary urea N + 3 or 4)urea N + 3 or 4)

Estimation of Nutrient Estimation of Nutrient NeedsNeeds

Predictive equation for energy (calorie) needsPredictive equation for energy (calorie) needs Harris Benedict uses age, height, and weight to Harris Benedict uses age, height, and weight to

estimate basal energy expenditure (BEE), the estimate basal energy expenditure (BEE), the minimum amount of energy needed by the body minimum amount of energy needed by the body at rest in fasting stateat rest in fasting state

In men: In men: BEE (kcal/day) = 66.5 + (13.8 X W) + (5.0 X H) – (6.8 X A)BEE (kcal/day) = 66.5 + (13.8 X W) + (5.0 X H) – (6.8 X A) In women:In women:BEE (kcal/day) = 655.1 + (9.6 X W) + (1.8 X H) – (4.7 X A)BEE (kcal/day) = 655.1 + (9.6 X W) + (1.8 X H) – (4.7 X A) Where W = weight in kilograms, H = height in Where W = weight in kilograms, H = height in

centimeters and A = age in yearscentimeters and A = age in years BEE is multiplied by an activity factor and injury BEE is multiplied by an activity factor and injury

factor to predict total daily energy expenditure factor to predict total daily energy expenditure

Activity CategoriesActivity Categories

Confined to bed = 1.0-1.2Confined to bed = 1.0-1.2 Out of bed = 1.3Out of bed = 1.3 Very light = 1.3Very light = 1.3 Light = 1.5 (women), 1.6 (men)Light = 1.5 (women), 1.6 (men) Moderate = 1.6 (women), 1.7 (men)Moderate = 1.6 (women), 1.7 (men) Heavy = 1.9 (women), 2.1 (men)Heavy = 1.9 (women), 2.1 (men)

Injury CategoriesInjury Categories SurgerySurgery

Minor = 1.0-1.1Minor = 1.0-1.1 Major = 1.1-1.2Major = 1.1-1.2

InfectionInfection Mild = 1.0-1.2Mild = 1.0-1.2 Moderate = 1.2-1.4Moderate = 1.2-1.4 Severe = 1.4-1.8Severe = 1.4-1.8

TraumaTrauma Skeletal = 1.2-1.35Skeletal = 1.2-1.35 Blunt = 1.15-1.35Blunt = 1.15-1.35 Head trauma treated with steroids = 1.6Head trauma treated with steroids = 1.6

BurnsBurns Up to 20% body surface area (BSA) = 1.0-1.5Up to 20% body surface area (BSA) = 1.0-1.5 20-40% BSA = 1.5-1.8520-40% BSA = 1.5-1.85 Over 40% BSA = 1.85-1.95Over 40% BSA = 1.85-1.95

Energy NeedsEnergy Needs

Quick rule of thumbQuick rule of thumb Also calculated based on weight in Also calculated based on weight in

kilograms and adjusted for activity kilograms and adjusted for activity levellevel 25-30 kcal/kg for acute illness, 25-30 kcal/kg for acute illness,

minimally active, overweight, >80minimally active, overweight, >80 Adjusted body weightAdjusted body weight 30-35 kcal/kg for young, active30-35 kcal/kg for young, active

Indirect Indirect calorimetry/Metabolic Cartcalorimetry/Metabolic Cart

Measures COMeasures CO22 produced and O produced and O22 consumed in consumed in critically ill patients on ventilatorscritically ill patients on ventilators

Calculates resting metabolic rate based on gas Calculates resting metabolic rate based on gas exchange exchange

Respiratory quotient calculatedRespiratory quotient calculated Corresponds to oxidation of nutrientsCorresponds to oxidation of nutrients CHO: 1:1 ratio of COCHO: 1:1 ratio of CO22 produced/O produced/O22 consumed consumed Lipid: 0.7:1 ratioLipid: 0.7:1 ratio Protein: 0.82:1 ratioProtein: 0.82:1 ratio Mixed diet: 0.85:1 ratioMixed diet: 0.85:1 ratio Overfeeding/lipogenesis: >1.0Overfeeding/lipogenesis: >1.0

Protein NeedsProtein Needs Determined based on clinical condition Determined based on clinical condition

and body weight in kilogramsand body weight in kilograms Normal - RDA: 0.8 g/kg for adult Normal - RDA: 0.8 g/kg for adult Fever, fracture, infection, wound Fever, fracture, infection, wound

healing: 1.5-2.0healing: 1.5-2.0 Protein repletion: 1.5-2.0Protein repletion: 1.5-2.0 Burns: 1.5-3.0Burns: 1.5-3.0 Typically use range of 1.1-1.4 g/kgTypically use range of 1.1-1.4 g/kg Decreased protein needs in acute renal Decreased protein needs in acute renal

failurefailure Comparison of intake to needs will Comparison of intake to needs will

indicate intervention requiredindicate intervention required

Subjective Global Subjective Global AssessmentAssessment

Alternative method to assess nutritional Alternative method to assess nutritional status of hospitalized patientsstatus of hospitalized patients

Combines information from the patient’s Combines information from the patient’s history with parts of a clinical examhistory with parts of a clinical exam

Subjective Global Subjective Global AssessmentAssessment

HistoryHistory Unintentional weight loss over the past 6 monthsUnintentional weight loss over the past 6 months Pattern and amount of weight loss is consideredPattern and amount of weight loss is considered Weight change in past 2 weeksWeight change in past 2 weeks Weight of <5% is small, loss >10% is significantWeight of <5% is small, loss >10% is significant Dietary intake change (relative to normal)Dietary intake change (relative to normal) GI symptoms >2 weeks (nausea, vomiting, GI symptoms >2 weeks (nausea, vomiting,

diarrhea, anorexia)diarrhea, anorexia) Functional capacity (energy level: daily activities, Functional capacity (energy level: daily activities,

bedridden)bedridden) Metabolic demands of primary condition notedMetabolic demands of primary condition noted

Subjective Global Subjective Global AssessmentAssessment

Physical ExamPhysical Exam Each feature is noted as normal, mild, Each feature is noted as normal, mild,

moderate, or severe based on clinician’s moderate, or severe based on clinician’s subjective impressionsubjective impression Loss of subcutaneous fat measures in the Loss of subcutaneous fat measures in the

triceps and the mid-axillary line at the triceps and the mid-axillary line at the lower ribslower ribs

Muscle wasting in the quadriceps and Muscle wasting in the quadriceps and deltoid areadeltoid area

Presence of edema in ankle or sacral regionPresence of edema in ankle or sacral region Presence of ascitesPresence of ascites

SGA RatingSGA Rating Determined by subjective weightingDetermined by subjective weighting May choose to place more emphasis on weight loss, poor May choose to place more emphasis on weight loss, poor

dietary intake, subcutaneous tissue loss, muscle wastingdietary intake, subcutaneous tissue loss, muscle wasting Must be trained in this technique to achieve consistency Must be trained in this technique to achieve consistency Scoring may predict development of infection more Scoring may predict development of infection more

accurately than other objective measures of nutritional accurately than other objective measures of nutritional status (albumin)status (albumin) A = well nourished (60% reduction in post-op complications)A = well nourished (60% reduction in post-op complications) B = moderately malnourished ( at least 5% wt loss with B = moderately malnourished ( at least 5% wt loss with

decreased intake and subcutaneous loss)decreased intake and subcutaneous loss) C = severely malnourished (4X more post op complications, C = severely malnourished (4X more post op complications,

10% wt loss and physical signs of malnutrition)10% wt loss and physical signs of malnutrition) Ascites and edema decrease significance of body weightAscites and edema decrease significance of body weight

Subjective Global Subjective Global AssessmentAssessment

AdvantagesAdvantages Predicts post-surgical complicationsPredicts post-surgical complications Does not require lab testingDoes not require lab testing Can be taught to a broad range of health professionalsCan be taught to a broad range of health professionals Compares favorably with objective measurementsCompares favorably with objective measurements Validated in liver transplant, dialysis, and HIV patientsValidated in liver transplant, dialysis, and HIV patients

DisadvantagesDisadvantages Subjective and dependent on the experience of the Subjective and dependent on the experience of the

observerobserver Not sensitive enough to use in following nutrition Not sensitive enough to use in following nutrition

progressprogress

Nutrition Screening Nutrition Screening InitiativeInitiative

From 1991, is a checklist for the elderly to use From 1991, is a checklist for the elderly to use in early identification of common nutrition in early identification of common nutrition problemsproblems

9 warning signs of poor nutritional status9 warning signs of poor nutritional status Disease, poor eating pattern, tooth loss/mouth pain, Disease, poor eating pattern, tooth loss/mouth pain,

economic hardship, reduced social contact, multiple economic hardship, reduced social contact, multiple medications, involuntary weight loss/gain, a need medications, involuntary weight loss/gain, a need for assistance in self care, and older than 80for assistance in self care, and older than 80

When concerns are identified, interventions are When concerns are identified, interventions are suggestedsuggested

Goal is to provide appropriate intervention Goal is to provide appropriate intervention before health and quality of life are seriously before health and quality of life are seriously impairedimpaired