STUDY - Technical - New Dacian's Medicine
Assessment
of Nutritional Status (2)
Translation Draft
Let's continue "discussing" the nutritional process! And, speaking of classical medicine (allopate), perhaps the most studied aspect of the history of nutrition status is the complex process by which nutritional and energy factors are absorbed.
I will continue my approach from the previous post by presenting the elements related to nutrient processing in the 3 main categories of patients: 1. Outpatient patients: all patients should be questioned about the process of assimilation of nutritional factors reflected by apatitis, chewing, swallowing, bolus size, table size and frequency, satiety, heartburn, dyspepsia, regurgitation, bloating, diarrhea, constipation, smelly, light or dark stools and/ or flatulence; 2. Patients with acute conditions: should be questioned if there are changes in the nutrition process of a. temporary, in relation to the disease or b. temporary, in connection with medication; and 3. Patients with chronic conditions: should be questioned as patients with acute conditions and, in addition, previous efforts are needed to solve existing problems such as a. reduction of ingestion of appetite-related medicines, b. improvement of teeth, c. choice of special foods such as smoothies, high-fibre foods, hypoacidic foods, d. improvement of meal schedules and e. control of gastrointestinal symptoms after meals.
The feeding process begins with appetite. Both anorexia and nausea can compromise the ability to maintain adequate ingestion. This is why patient perception elements should be taken into consideration of possible nutrition impairment through various queries. Is the taste of food metallic or unpleasant? Are there mechanical difficulties of chewing, such as a less adequate and/ or functional teeth? Are there chewing problems? Is early satiety present or, on the contrary, its absence? Is nutrition associated with gastrointestinal discomfort, such as vomiting or diarrhoea? Were there any changes in the consistency, smell and frequency of intestinal products? Questions about the eating process can reveal social problems, eating disorders, mechanical barriers to food intake and malabsorption, any of which can affect the state of nutrition.
There are associated conditions that increase the nutritional needs that need to be identified and that need to be taken into account. Pregnancy, lactation and, in children, periods of rapid growth cause an increase in metabolic demands and the need for specific nutritional factors. Many acute conditions, each of them self-limiting, can compromise, by cumulation, the state of nutrition if food intake is not adequately adjusted. A list of these events and their duration, as well as an assessment of their impact on health status, can help select patients at risk.
In addition, an important milestone is nutritional supplements and medication history. Assessing the amount and frequency of nutritional supplements along with excessive medication can tell if the intake of specific vitamins is overmeasure. These medicines affect the bioavailability of nutritional factors, and the use of these medicines should be promptly reported in order to track the ingestion of the affected nutrient factor.
From the point of view of physical examination, body weight should be recorded at each patient's consultation. The presence and severity of edema and ascites should be noted, since they affect the interpretation of body weight. Absolute body weight and its changes have prognostic implications. Diseases associated with weight loss of up to 10-20% over 6 months or less may cause damage to the functions of various systems and organs. if weight loss exceeds 20% during the course of the disease, energy and protein malnutrition may occur. Weight should be measured daily in hospitalized patients.
Absolute fasting results in a loss of about 0.4 kg/ day from body weight, a semi-starvation causes less loss of body weight. Most of the weight loss in starvation is initially achieved from fat deposits and then through catabolism of skeletal muscle proteins and liver proteins (proteins of other organs are spared until the weakening is extreme). Rapid weight gain in the case of hospitalization is rarely due to increased muscle or fat mass. Hydration rapidly increases the total amount of water and sodium, and renal compensation may be delayed. Rapid weight gain can occur when a malnourished patient is given carbohydrates because their glycogen deposits are restored and their liver content in the water increases.
Height must be measured annually and at each admission. This measurement is of particular importance for detecting height loss in patients with bone metabolic disorders and should be performed with the patient standing straight and looking straight ahead. When the drop in height is suspected and in patients who cannot stand without support, their maximum height can be estimated using the height at which the knees are located. The height at which the knees are found is the distance between the plant and an anterior surface at the thigh above the femoral condiments and in contact with the patella.
This measurement is done with the patient in the sitting or lying position. The height at which the knees are found is slightly affected by age or weight changes and is calculated as follows: 1. Height in men (in cm) = 64.19 - (0.04 x age) + (2.2 x height at which the knees are found) and 2. Height in women (also in cm) = 84.88 - (0.24 x age) + (1.83 x height at which the knees are found). Determination of body mass index (BMI) or weight relative to skeletal size shows whether an individual's current weight is adequate.
The BMI assessment (body weight divided by the height square) has the advantage that it is a simple and useful method for assessing both over and undernutrition. A normal BMI is between 18.5 and 24.9 kg/ m square. overweight is represented by a BMI between 25 and 29.9, obesity has a BMI between 30 and 39.9 (between 30-34.9 grade I obesity and between 35-39.9 grade II obesity), and morbid obesity has a BMI greater than 40. In contrast, the risk for protein-calorie malnutrition can be defined as average at a BMI of 17-18.4, moderate for 16-16.9 and severe for a BMI of less than 16. A BMI between 13 and 15 suggests that the body's total fat percentage is less than 5% by weight. BMI is a simple and widespread method used to estimate the energy balance, but does not take into account differences in height.
In many ways, weight is taken into account in relation to the size of the skeleton. The size of the skeleton is conventionally divided into three classes: small, medium and large. Large skeletons require greater muscle mass to move. Current classifications (made mainly by life insurance companies) divide weight to varying degrees, associated with lower mortality compared to skeletal size. While some databases use the circumference of the wrist to assess the size of the skeleton, the distance between the humeral epicondyls is a much more accurate indicator of the size of the skeleton because this distance is less influenced by the subcutan cell tissue.
Based on the size of the skeleton, height and sex, data can be obtained showing an individual's ideal weight and how far the individual's current weight is from the ideal weight. Corrections to the missing limb are required in patients with limb amputations before these values are interpreted. For example, 7.1% of body weight should be removed for lower limb amputation above the knee and 18.6% if the entire lower limb is amputated. Such data are interpreted with caution in pregnant women, for whom different tables are required.
In addition to weight, which provides data that assesses the energy balance in its entirety, it is often useful to take into account various specific aspects of the body's composition, referring in particular to fat and muscle mass (protein or nitrogen). The measurements of the skin fold made with the screw provide a useful indicator of the fat mass. The thickness of the skin fold at the triceps level varies depending on the size of the skeleton and the height. This assessment does not provide information in addition to BMI or weight in relation to skeletal size when assessing obese people, but is particularly useful in identifying those individuals who have dangerously lost their fat deposits. Much more discrete techniques for measuring the percentage of fat in the body, such as underwater weighing, X-ray absorption and nuclear magnetic resonance can also be used in certain situations.
Muscle mass may also be assessed by certain laboratory measurements or may be assessed directly in the physical examination. The circumference in the half of the arm is in relation to muscle mass, skin, subcutaneous cell tissue, bone and neuromuscular package of the arm and, related to these parameters, the amount of muscles, skin and fat is determined by the state of nutrition. A correction is made with regard to the skin and subcutaneous cell tissue by decreasing the previously calculated skin fold from the surface of the muscle mass. The surface of the muscle mass in the middle of the arm, with all measurements made in centimeters, is made using the formula (arm circumference - the square of the product between the constant pi and the skin fold)/ four times the constant pi (i.e. 3.14).
This measurement is useful for identifying protein malnutrition, which is a particular problem of old age. The muscle values of the arm come from various sources (governmental, medical, insurance companies). Comparing the values held with the control values (in the tables mentioned) some observations can be made. The circumference of the muscles in the half of the arm also measures the humerus and neurovascular structures that do not decrease in size with weight loss, and in certain tables, in terms of bone mass of the arm, a correction is made by various decreases for men and women, to somewhat estimate the size of the humerus (since these values are constant , this decrease is clinically unimportant). The atrophic muscle has more water, total lipids and collagen than the normal muscle and, as a result, functional muscle mass in patients with cashectic or severely in a serious condition is probably overestimated.
From the point of view of laboratory data, routine paraclinical examinations are not a sensitive indicator of nutrition status, as changes in serum protein concentration occur at an advanced stage of malnutrition, but may, in certain circumstances, be useful for assessing the effectiveness of nutritional intervention. For the ambulatory patient, paraclinical evaluation should be focused on potential deficits identified by anamnesis and objective examination. However, insufficient intake of protein and energy factors is not the only cause of decrease in serum protein levels in various diseases, as serum protein concentration may be influenced by various factors.
This problem is exemplified by serum albumin. Dehydration can lead to an increase in the concentration of all plasma components and may cause an apparent increase in albumin concentration. Exchanges from intravascular to extravascular space, in the case of surgical operations or burns, cause a decrease in serum albumin levels, while semi-starvation causes albumin to pass into the intravascular space and may increase serum albumin higher than the concentration of total proteins.
The synthesis of albumin may decrease during acute conditions, with increased synthesis of acute phase reactants, and physiological stress may increase albumin catabolism. The concentration of albumin may also decrease as a result of its large losses through the skin, kidneys or gastrointestinal tract. While dehydration and exchanges between intra and extravascular space cause early impairment of serum albumin levels, changes in albumin synthesis and catabolism affect its concentration over a few days, as the half-life of serum albumin is normally between 18 and 20 days.
Serum albumin concentration usually peaks 5-7 days after the onset of a self-limiting condition and it is normal for serum albumin to decrease to 5 g/l after surgery. Measuring serum protein concentration with a shorter half-life can provide us with a much more accurate assessment of protein status. Transferina has a half-life of 8-9 days, and prealbumin has a half-life of 2-3 days.
Unfortunately, the levels of these proteins in serum are influenced by the same factors that influence serum albumin levels. Measuring serum protein concentration may be useful in assessing prognosis. A low serum albumin concentration in chronic conditions is associated with a long duration of hospitalization, frequent re-admission for low wound healing and for various infections, and increased mortality. laboratory data can help monitor treatment.
If protein intake is responsible for their low serum concentration, serum prealbumin levels increase rapidly in response to an increased protein intake. As for microelements, serum vitamin levels do not reflect their deposits, with the exception of vitamin B12, folate and vitamin D, and the diagnosis of vitamin deficiency is usually based on a high degree of suspicion and by following the response to the specific administration of various vitamins.
Assessing the status of minerals and, in particular, phosphorus, magnesium, calcium, potassium and iron is much more useful clinically, although their serum levels do not always change in parallel with their deposits in the body.
And, to finish this long post with the presentation of some elements about the overall evaluation. The assessment of the state of nutrition is an important component of anamnesis, objective examination and laboratory data. The speed of this assessment should be made in relation to the severity of the diseases and the degree of malnutrition. For outpatients with an adequate nutritional status, we should focus on identifying potential factors that could alter nutritional status in the future, including changes in body weight and impaired food processing.
For patients hospitalized with acute or chronic conditions the problem is the identification of the subgroup of patients with severe impairment of nutritional status, where the restoration of a nutritional balance is an essential component of acute treatment. For example, in a patient who cannot swallow due to a stroke it is preferable to expect parenteral nutrition or assisted enteral nutrition for 7-10 days if the nutrition status is adequate, while banning nutritional support can have disastrous effects in a casy patient.
In acute, self-limiting conditions, we should focus on explaining the interaction between acute disease and the underlying nutrition status (weight, variety of diet and nutrient processing). The objective is to detect reversible factors, which could influence the course of the disease, and the risks for possible complications. In chronic conditions, the aim is to identify the effects of nutritional status impairment during diseases. Anthropometric and laboratory measurements can be useful in this respect, based on the assessment of the state of nutrition remaining anamnesis and objective examination.
I'm done with this part... Next time we move on to malnutrition...
Let's continue "discussing" the nutritional process! And, speaking of classical medicine (allopate), perhaps the most studied aspect of the history of nutrition status is the complex process by which nutritional and energy factors are absorbed.
I will continue my approach from the previous post by presenting the elements related to nutrient processing in the 3 main categories of patients: 1. Outpatient patients: all patients should be questioned about the process of assimilation of nutritional factors reflected by apatitis, chewing, swallowing, bolus size, table size and frequency, satiety, heartburn, dyspepsia, regurgitation, bloating, diarrhea, constipation, smelly, light or dark stools and/ or flatulence; 2. Patients with acute conditions: should be questioned if there are changes in the nutrition process of a. temporary, in relation to the disease or b. temporary, in connection with medication; and 3. Patients with chronic conditions: should be questioned as patients with acute conditions and, in addition, previous efforts are needed to solve existing problems such as a. reduction of ingestion of appetite-related medicines, b. improvement of teeth, c. choice of special foods such as smoothies, high-fibre foods, hypoacidic foods, d. improvement of meal schedules and e. control of gastrointestinal symptoms after meals.
The feeding process begins with appetite. Both anorexia and nausea can compromise the ability to maintain adequate ingestion. This is why patient perception elements should be taken into consideration of possible nutrition impairment through various queries. Is the taste of food metallic or unpleasant? Are there mechanical difficulties of chewing, such as a less adequate and/ or functional teeth? Are there chewing problems? Is early satiety present or, on the contrary, its absence? Is nutrition associated with gastrointestinal discomfort, such as vomiting or diarrhoea? Were there any changes in the consistency, smell and frequency of intestinal products? Questions about the eating process can reveal social problems, eating disorders, mechanical barriers to food intake and malabsorption, any of which can affect the state of nutrition.
There are associated conditions that increase the nutritional needs that need to be identified and that need to be taken into account. Pregnancy, lactation and, in children, periods of rapid growth cause an increase in metabolic demands and the need for specific nutritional factors. Many acute conditions, each of them self-limiting, can compromise, by cumulation, the state of nutrition if food intake is not adequately adjusted. A list of these events and their duration, as well as an assessment of their impact on health status, can help select patients at risk.
In addition, an important milestone is nutritional supplements and medication history. Assessing the amount and frequency of nutritional supplements along with excessive medication can tell if the intake of specific vitamins is overmeasure. These medicines affect the bioavailability of nutritional factors, and the use of these medicines should be promptly reported in order to track the ingestion of the affected nutrient factor.
From the point of view of physical examination, body weight should be recorded at each patient's consultation. The presence and severity of edema and ascites should be noted, since they affect the interpretation of body weight. Absolute body weight and its changes have prognostic implications. Diseases associated with weight loss of up to 10-20% over 6 months or less may cause damage to the functions of various systems and organs. if weight loss exceeds 20% during the course of the disease, energy and protein malnutrition may occur. Weight should be measured daily in hospitalized patients.
Absolute fasting results in a loss of about 0.4 kg/ day from body weight, a semi-starvation causes less loss of body weight. Most of the weight loss in starvation is initially achieved from fat deposits and then through catabolism of skeletal muscle proteins and liver proteins (proteins of other organs are spared until the weakening is extreme). Rapid weight gain in the case of hospitalization is rarely due to increased muscle or fat mass. Hydration rapidly increases the total amount of water and sodium, and renal compensation may be delayed. Rapid weight gain can occur when a malnourished patient is given carbohydrates because their glycogen deposits are restored and their liver content in the water increases.
Height must be measured annually and at each admission. This measurement is of particular importance for detecting height loss in patients with bone metabolic disorders and should be performed with the patient standing straight and looking straight ahead. When the drop in height is suspected and in patients who cannot stand without support, their maximum height can be estimated using the height at which the knees are located. The height at which the knees are found is the distance between the plant and an anterior surface at the thigh above the femoral condiments and in contact with the patella.
This measurement is done with the patient in the sitting or lying position. The height at which the knees are found is slightly affected by age or weight changes and is calculated as follows: 1. Height in men (in cm) = 64.19 - (0.04 x age) + (2.2 x height at which the knees are found) and 2. Height in women (also in cm) = 84.88 - (0.24 x age) + (1.83 x height at which the knees are found). Determination of body mass index (BMI) or weight relative to skeletal size shows whether an individual's current weight is adequate.
The BMI assessment (body weight divided by the height square) has the advantage that it is a simple and useful method for assessing both over and undernutrition. A normal BMI is between 18.5 and 24.9 kg/ m square. overweight is represented by a BMI between 25 and 29.9, obesity has a BMI between 30 and 39.9 (between 30-34.9 grade I obesity and between 35-39.9 grade II obesity), and morbid obesity has a BMI greater than 40. In contrast, the risk for protein-calorie malnutrition can be defined as average at a BMI of 17-18.4, moderate for 16-16.9 and severe for a BMI of less than 16. A BMI between 13 and 15 suggests that the body's total fat percentage is less than 5% by weight. BMI is a simple and widespread method used to estimate the energy balance, but does not take into account differences in height.
In many ways, weight is taken into account in relation to the size of the skeleton. The size of the skeleton is conventionally divided into three classes: small, medium and large. Large skeletons require greater muscle mass to move. Current classifications (made mainly by life insurance companies) divide weight to varying degrees, associated with lower mortality compared to skeletal size. While some databases use the circumference of the wrist to assess the size of the skeleton, the distance between the humeral epicondyls is a much more accurate indicator of the size of the skeleton because this distance is less influenced by the subcutan cell tissue.
Based on the size of the skeleton, height and sex, data can be obtained showing an individual's ideal weight and how far the individual's current weight is from the ideal weight. Corrections to the missing limb are required in patients with limb amputations before these values are interpreted. For example, 7.1% of body weight should be removed for lower limb amputation above the knee and 18.6% if the entire lower limb is amputated. Such data are interpreted with caution in pregnant women, for whom different tables are required.
In addition to weight, which provides data that assesses the energy balance in its entirety, it is often useful to take into account various specific aspects of the body's composition, referring in particular to fat and muscle mass (protein or nitrogen). The measurements of the skin fold made with the screw provide a useful indicator of the fat mass. The thickness of the skin fold at the triceps level varies depending on the size of the skeleton and the height. This assessment does not provide information in addition to BMI or weight in relation to skeletal size when assessing obese people, but is particularly useful in identifying those individuals who have dangerously lost their fat deposits. Much more discrete techniques for measuring the percentage of fat in the body, such as underwater weighing, X-ray absorption and nuclear magnetic resonance can also be used in certain situations.
Muscle mass may also be assessed by certain laboratory measurements or may be assessed directly in the physical examination. The circumference in the half of the arm is in relation to muscle mass, skin, subcutaneous cell tissue, bone and neuromuscular package of the arm and, related to these parameters, the amount of muscles, skin and fat is determined by the state of nutrition. A correction is made with regard to the skin and subcutaneous cell tissue by decreasing the previously calculated skin fold from the surface of the muscle mass. The surface of the muscle mass in the middle of the arm, with all measurements made in centimeters, is made using the formula (arm circumference - the square of the product between the constant pi and the skin fold)/ four times the constant pi (i.e. 3.14).
This measurement is useful for identifying protein malnutrition, which is a particular problem of old age. The muscle values of the arm come from various sources (governmental, medical, insurance companies). Comparing the values held with the control values (in the tables mentioned) some observations can be made. The circumference of the muscles in the half of the arm also measures the humerus and neurovascular structures that do not decrease in size with weight loss, and in certain tables, in terms of bone mass of the arm, a correction is made by various decreases for men and women, to somewhat estimate the size of the humerus (since these values are constant , this decrease is clinically unimportant). The atrophic muscle has more water, total lipids and collagen than the normal muscle and, as a result, functional muscle mass in patients with cashectic or severely in a serious condition is probably overestimated.
From the point of view of laboratory data, routine paraclinical examinations are not a sensitive indicator of nutrition status, as changes in serum protein concentration occur at an advanced stage of malnutrition, but may, in certain circumstances, be useful for assessing the effectiveness of nutritional intervention. For the ambulatory patient, paraclinical evaluation should be focused on potential deficits identified by anamnesis and objective examination. However, insufficient intake of protein and energy factors is not the only cause of decrease in serum protein levels in various diseases, as serum protein concentration may be influenced by various factors.
This problem is exemplified by serum albumin. Dehydration can lead to an increase in the concentration of all plasma components and may cause an apparent increase in albumin concentration. Exchanges from intravascular to extravascular space, in the case of surgical operations or burns, cause a decrease in serum albumin levels, while semi-starvation causes albumin to pass into the intravascular space and may increase serum albumin higher than the concentration of total proteins.
The synthesis of albumin may decrease during acute conditions, with increased synthesis of acute phase reactants, and physiological stress may increase albumin catabolism. The concentration of albumin may also decrease as a result of its large losses through the skin, kidneys or gastrointestinal tract. While dehydration and exchanges between intra and extravascular space cause early impairment of serum albumin levels, changes in albumin synthesis and catabolism affect its concentration over a few days, as the half-life of serum albumin is normally between 18 and 20 days.
Serum albumin concentration usually peaks 5-7 days after the onset of a self-limiting condition and it is normal for serum albumin to decrease to 5 g/l after surgery. Measuring serum protein concentration with a shorter half-life can provide us with a much more accurate assessment of protein status. Transferina has a half-life of 8-9 days, and prealbumin has a half-life of 2-3 days.
Unfortunately, the levels of these proteins in serum are influenced by the same factors that influence serum albumin levels. Measuring serum protein concentration may be useful in assessing prognosis. A low serum albumin concentration in chronic conditions is associated with a long duration of hospitalization, frequent re-admission for low wound healing and for various infections, and increased mortality. laboratory data can help monitor treatment.
If protein intake is responsible for their low serum concentration, serum prealbumin levels increase rapidly in response to an increased protein intake. As for microelements, serum vitamin levels do not reflect their deposits, with the exception of vitamin B12, folate and vitamin D, and the diagnosis of vitamin deficiency is usually based on a high degree of suspicion and by following the response to the specific administration of various vitamins.
Assessing the status of minerals and, in particular, phosphorus, magnesium, calcium, potassium and iron is much more useful clinically, although their serum levels do not always change in parallel with their deposits in the body.
And, to finish this long post with the presentation of some elements about the overall evaluation. The assessment of the state of nutrition is an important component of anamnesis, objective examination and laboratory data. The speed of this assessment should be made in relation to the severity of the diseases and the degree of malnutrition. For outpatients with an adequate nutritional status, we should focus on identifying potential factors that could alter nutritional status in the future, including changes in body weight and impaired food processing.
For patients hospitalized with acute or chronic conditions the problem is the identification of the subgroup of patients with severe impairment of nutritional status, where the restoration of a nutritional balance is an essential component of acute treatment. For example, in a patient who cannot swallow due to a stroke it is preferable to expect parenteral nutrition or assisted enteral nutrition for 7-10 days if the nutrition status is adequate, while banning nutritional support can have disastrous effects in a casy patient.
In acute, self-limiting conditions, we should focus on explaining the interaction between acute disease and the underlying nutrition status (weight, variety of diet and nutrient processing). The objective is to detect reversible factors, which could influence the course of the disease, and the risks for possible complications. In chronic conditions, the aim is to identify the effects of nutritional status impairment during diseases. Anthropometric and laboratory measurements can be useful in this respect, based on the assessment of the state of nutrition remaining anamnesis and objective examination.
I'm done with this part... Next time we move on to malnutrition...
Understanding, love and
gratitude!
Dorin, Merticaru