Nutritional assessment in clinical practice. What to measure?
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1 Nutritional assessment in clinical practice. What to measure? Nicolette Wierdsma PhD RD Dietitian VU University medical center, specialized in gastroenterology diseases and nutritional diagnostics and consequences Hinke Kruizenga PhD RD Editor in chief Dutch Journal of Nutrition and Dietetics, Dietitian VU University medical center (malnutrition) Dutch Malnutrition Steering Group
2 What is nutritional assessment? 1. Food intake, consumption and losses 2. Body composition and nutrient reserves 3. Functional parameters 4. Disease state 2
3 Diagnostic components bit.ly/guidelinemalnutrition
4 Structuring: ICF flowchart or diagnostic toolkit
5 Critical Reasoning =.. Widen your view Remove your blinkers! PLEASE, HAVE DOUBTS!!! Is this LOGICAL? CSI Dietetics Did I expect this?
6 Critical Reasoning asks for: 1. Being analytical 2. Working methodically 3. Working systematically Aim: To produce an accurate diagnosis and identify the most appropriate treatment. Critical Reasoning is based on hypotheses Observations Interpretations Knowledge Experience
7 Dietetic diagnosis Treatment goals Evaluation Diagnostics in ICF Treatment plan Conclusion Learning point
8 Choice of outcomes: essential for diagnostics and critical reasoning Psychiatric status Body composition Functionality Disease Food intake Vitamin status Quality of life Age Social status Absorption Digestion Electrolyte state
9 Diagnostic toolkit All dietetic diagnostic measures in one pocket guide!
10 Casus: mr X, 37 yr Reason for consultation analyze unintentional weight loss abdominal discomfort, increased stools I eat enough Tired, works parttime Def: 9 x dd, abdominal cramps Sometimes undigested food particles ONS 3 dd 1 What is enough? Functionality? Absorption? Adverse effects? 2009 Colitis Ulcerosa 2010 Remission 2011 IPAA (pouch) Every day? Digestion? Med: vesicare, temazepam, cholestagel, vit B12 injections, levofloxacine 1x/3 mo.
11 Differential diagnoses mr X. Malnutrition? Inflammation? Side effects medication? Malabsorption? Hyperthyroidism? Psycho-social factor?
12 Diagnostic toolkit for nutritional status SOMATIC FACTORS Age, gender Diagnosis (or: diagnoses) and disease stage/characteristics Hospital admission / surgery / treatment Laboratory test results Gastrointestinal issues Appetite Chewing and swallowing issues Anthropometry (body weight and its fluctuations, length, BMI) Growth Body composition (lean BM / FFM Index) Energy expenditure [resting energy expenditure (REE) and total energy expenditure (TEE)] Food intake Medication PSYCHOLOGICAL FACTORS Motivation / stage of behavioural change Depression / psychological disorder Cognitive disorder / dementia Stress Coping with loss Insight into disease Quality of Life Loneliness FUNCTIONAL FACTORS Grip strength Gait speed Activity pattern Exercise / sport (I)ADL dependency SOCIAL FACTORS Financial difficulties Work Education level Activities / interests Extent of participation in society Personal and family situation / children Social network Informal care Transportation possibilities
13 Diagnostics - functionality Hand grip strength 38 kg = < P5 Short Physical Performanc Battery (SPPB) Walking speed
14 Diagnostics - malnutrition Fat Free Mass Index (FFMI by BIA) BMI Weight loss Inflammation (CRP, fecal calprotectic) Level of activity (Barthel index, ADL) Appetite (VAS) kg/m2 (<P5) 20.0 kg/m kg/ 6 mo (= -12%) CRP 8, Calpro VAS appetite FFMI percentiles Height Weight DEXA BIA
15 Malnourished! Intake Energy expenditure Losses 15
16 Intake more than enough? Nutritional intake: 4-d Diary: 3000 kcal (275 g fat, 75 g protein) REE (indirect calorimetry) 2050 kcal RQ 0.92, (VCO2 198; VO2 215) WHO-equation: 1700 kcal Increased REE TEE= 2050 x 1.3 = 2665 Intake 3000 kcal
17 Diagnostics - malabsorption No Endoscopy No fistulas, normal mucosa, no inflammation, celiac disease or cuffitis No Bacterial overgrowth? Side effects medication? No Bristol stool chart 5,6,7 Fecal analysis
18 Fecal measurements By To Volume (g/d) Collection Diarrhea? % dry matter Freeze drying Watery or solid? Small intestine or colon? Fat (g/d) Malabsorption? Nitrogen (g/d) X 6.25 = protein Malabsorption? Energy (kcal/d) Bomb calorimetry Malabsorption? Calprotecin Inflammation Alpha 1 antitrypsin Evt clearance PLE? Bile salts Cause of diarrhea? Elastase Pancreatic dysfunction 18
19 Fecal energy: Bombcalorimetry Intestinal absorption capacity = Intake - fecal loss x 100% Intake - Intake energy, fat, protein calculated from 4-d nutritional diary - 3-d fecal collection Wierdsma, J Hum Nutr Diet, 2013
20 Outcome Interpretation Volume (g/d) 805 % dry matter 9 Fat (g/d) 10 (abs 95%) Nitrogen (g/d) 3.1 (abs 75%) Energy (kcal/d) 453 (abs 85%) Normal absorption Malabsorption Moderate malabsorption Calprotecin 138 Slightly increased Alpha 1 antitrypsin Bile salts n.d. n.d. Elastase 300 Normal pancreatic function 20
21 Book keeping (per day): Intake: TEE: REE x 1.3 Fecal loss: Netto: kcal (high fat) kcal kcal kcal
22 In conclusion: Apparently high intake, but insufficient in total bookkeeping REE + 20% compared to WHO/ H&B equations (Unexpected) Slightly increased fecal losses and decreased intestinal absorption capacity (protein) Malnutrition (weight loss, HGS, FFMI) Most probably wasting (no inflammation) Psycho-social state? Coping problem?
23 Diet: Physiotherapy: Med: Extra energy and proteins Training, excercise Metamucil, dd IBS component / functional complaints? Monitoring / Follow up: Repeat Weight, FFMI, HGS, REE Repeat fecal analysis
24 Importance of critical reasoning in this case? Nutritional intake seemed to be sufficient Higher REE and fecal losses Recognising the pattern of the disease I eat enough Malabsorption can be present in CU Psychosocial, acceptance, compliance? Functional tired
25 DPG adults Nicolette Wierdsma PhD RD Hinke Kruizenga PhD RD Rebecca Stratton PhD RD RNutr DPG paediatrics Luise Marino PhD RD Rnutr Rosan Meyer PhD RD RNutr
26 Losses Reference tables Laboratory values Medication Refeeding syndrome Nutritional assessment Procedures Body composition Classification of organ failure and diseases RDA s, maximum safe upper limit, toxic dose GI transit time, quantity and functions of digestive juices, location of absorption of nutrients Equations com/calculations/
27 More information
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