Nutritional assessment

1. Nutritional assessment

2. Major goals in the assessment of nutritional status include: • identification of malnutrition, and its effects on an individual’s health status • identification of patterns of overconsumption, and their link with the development of obesity, diabetes, hypertension cardiovascular disease, and cancer • identification of nutritional parameters for optimal health and fitness

3. For being well nourished individuals should have 3-5 meals a day (every 4-6 hours except for the night time when the break should be 12 hours long) of caloric value adjusted to individual needs(depending on sex, age, health status) with right proportion of proteins (9-13%), fats (29-33%) and carbohydrates (57-61% of caloric value).

4. Malnutrition • Malnutrition is basically defined as a lack of essential nutrients at the cellular level resulting from psychological, personal, social, educational, economic, cultural, or political factors in the individual’s environment.

5. Malnutrition may exist in the form of • primary deficiency, which occurs when a specific essential nutrient is lacking in the diet. • secondary deficiency disease due to the body’s inability to digest, absorb, metabolize, or use a specific nutrient properly or because the body has an increased requirement for or increased excretion of a specific nutrient.

6. Malnutrition • acute, a result of temporary conditions and reversible without long-term side effects • chronic, existing over a long period with possible irreversible consequences.

7. Malnutrition can be classified as follows • Marasmus- protein calorie malnutrition, evidenced by a client who exhibits weight loss, fat loss, and muscle wasting due to overall calorie-protein deprivation. • Kwashiorkor-protein malnutrition, evidenced by a client who has adequate fat reserves but, on testing, reveals significant deficits in protein status. • Kwashiorkor-marasmus mix.

8. Components of nutritional assesment are: • antropometric measurement (height, weight, BMI,WHR, skinfold thickness, circumference of head, chest, mid-arm), • biochemical measurement (total lymphocyte count, serum albumin, total iron binding capacity, creatinine height index, nitrogen balance, haemoglobin and hematocrit, serum glucose), • clinical examination • dietary analysis (estimated calorie and protein needs).

9. BMI (body mass index) • BMI ( body mass index) is calculated according to the following formula • BMI= weight in kilograms/ (height in meters)2

10. In developed countries recommended BMI for healthy adult individuals is 20-25kg/m2. • For developing countries it is 18,5 kg/m2. • If BMI is > than the recommended it is defined as overweight and obesity • 1degree obesity (overweight) BMI=25-30 kg/m2. • 2 degree obesity BMI=30-40 kg/m2. • 3 degree obesity BMI>40 kg/m2.

11. WHR (waist to hip ratio) • WHR (waist to hip ratio) is calculated according to the formula: • WHR=waist circumference/ hip circumference

12. Apple-shape obesity • WHR in women >0,8 and in men >1 (in obese individuals) shows the male type of obesity (typical for males, apple-like shape).

13. Pear-shape obesity • WHR in women <0,8 and in men <1 (in obese patients)shows the female (feminine, pear) obesity.

14. Possible incorrect supplementation of particular nutrients: Excessive supply of animal protein- it provides 2-3 times more methionine amino acid than needed, if insufficient supply of vitamins B2, B6, B12, and folic acid coexist it leads to elevated levels of homocystein in the blood serum thus causing arteriosclerosis.

15. Excessive supply of mono-and dicarbohydrates- it leads to weight gain. With lack of proper regulatory hormones (insulin, adrenaline) it may lead to diabetes, hypo- or hyperglycaemia. Overconsumption of sucrose may cause vitamin B1,B2, B6 deficiency, whilst these vitamins are needed for its’ metabolism. Simple sugars age good fuel for bacteria on tooth enamel, thus encourage development of caries. They irritate the mucous membrane of digestive tract and cause excessive excretion of gastric juice.

16. Excessive supply of fats- especially of cholesterol and saturated fatty acids-together with low dietary fibre consumption it causes elevated levels of LDL in the blood serum ( lipoproteins of low density), what is detrimental to the blood vessels. Saturated fatty acids elevate blood pressure, increase platelet aggregation, elevate factor VII level( causing clots). In smokers it quickly leads to formation of plaques in the arteries.

17. Polyunsaturated fatty acids ώ-6 and ώ-3 lower the blood pressure. • ώ-6 polyunsaturated fatty acids lower cholesterol levels in the blood serum and in LDL-s, they decreases the aggregation ability of platelets and decreases tromboxane synthesis. • ώ-3 polyunsaturated fatty acids lower VLDL level in the blood serum , but impair resistance to infections, glucose tolerance, may cause poor clotting ability of the blood and bleeding.

18. Monounsaturated fatty acids (e. g. linoleic- present in olive oil, rape oil)-lower cholesterol content in LDLs. They should be 10-15 % of total calorie supply. • Overuse of fats causes bile acids excretion; their metabolites are cracinogenic. Fats increase microsomal oxydation in enterocytes, what encourages growth of Clostridium and Enterobacter bacteria in the intestine. The bacteria cause excessive production of steroid sex hormones precursors out of cholesterol (e.g. excessive prolactine excretion, the hormone induces breast cancer).

19. Excessive supply of salt • causes hypertention, gastritis atrophicans, and stomach cancer. The recommended salt consumption is 3g/day.

20. Insufficient supply of dietary fibre • causes constipation, colon cancer, obesity, cholecystolithiasis (bile stones), atheromatosis.

21. Insufficient supply of calcium • causes bone demineralization, osteoporosis, colon cancer, angina pectoris. Recommended daily consumption of calcium is 1500mg/day. Wrong Ca/P proportion in meals may handicap Ca absorption. Recommended Ca/P ratio should be 2:1 in children and 1:1 in adults.

22. Insufficient supply of iodine iodine is necessary for thyroid hormones production ( T3, T4) . The recommended daily consumption of J is 200mg in pregnant women, 90-120mg in newborn children and toddlers, young children 50-100mg, teenagers 100-150mg, healthy adults 150mg/day. Kitchen salt is enriched in J, other good sources of this element are: garlic, onion, strawberry, seafood. Lack of iodine causes goitre, hypothyroidism, cretinism in children.

23. Insufficient supply of iron the recommended daily consumption is 8mg/100kcal. Insufficient iron supply affects usually • teenage girls who start menstruating, • young women (as they loose iron during menstruation), • elderly people (due to poor absorption, digestive tract diseases, interactions with medicines) • intestinal parasites (tapeworms) may ‘steal’ iron which leads to anemia and koilonychia (spoon-shaped nails) As a result of iron deficiency microcyticanaemia ( with too mall erythrocytes) develops (clinical symptom-fatigue).

24. Calorie • A unit of energy obtained from food. The calorie is a measure of heat energy. One calorie is the amount of heat needed to raise the temperature of 1g of water by 1◦C. • The common unit of energy measurement in food is the Calorie, with a capital C, which is 1000calories (small c) or 1 kilocalorie (kcal). The International System of Units of heat energy uses the Joule (J) instead of the Calorie as the measurement for the energy content of food. The Joule equals roughly 250calories or 0,25Calories.

25. Classification of carbohydrates The term carbohydrate comes from its chemical nature. It is composed of the elements carbon, hydrogen and oxygen. They are classified according to the number of basic sugar units making up their structure.

26. Monosaccharides • Glucose • Fructose • Galactose

27. Disaccharides • Sucrose • Lactose • Maltose

28. Polysaccharides • Starch • Glycogen • Dextrins

29. Oligosaccharides • Dietary fiber • Cellulose • Noncellulose polysaccharides • Lignin

30. Fructose is the sweetest of simple sugars. It is found in fruits and other substances, such as honey, high-fructose corn syrup. In human metabolism , fructose is converted to glucose and burned for energy. • Galactose is not found free in foods but is produced in human digestion from lactose (milk sugar) and is then changed to glucose for energy. This reaction is reversible and during lactation glucose may be reconverted to galactose for use in milk production.

31. Disaccharides The disaccharides are double sugars composed of two monosaccharides linked together. Sucrose = glucose + fructose Lactose = glucose + galactose Maltose = glucose + glucose

32. Sucrose is the common ‘table sugar’ made commercially from sugar cane and beets . It is the most prevalent disaccharide . It contributes some 30% to 40% of the total kilocalories in the American diet. • Lactose is the sugar in the milk. It is the least sweet of the disaccharides. When milk sours, as in the initial stages of cheese making, the lactose changes its form and separates out the liquid whey from the solid curd. The curd is then processed for cheese. Thus cheese has very little sugars or none. • Maltose occurs in commercial malt products of starch breakdown and in germinating cereal grains.

33. Polysaccharides are made up of many single sugar (saccharide) units. The most important polysaccharide in human diet is starch. other forms are glycogen and dextrins. The nondigestable forms of dietary fiber, cellulose and other noncelluose polysaccharides, provide important bulk in the diet.

34. Starch is the most significant poysaccharide.It is a large complex compound made up of many coiled or branching chains of simple sugar (glucose) units. It yields only glucose on digestion. It is the most important source of dietary carbohydrate worldwide. • Glycogen-the animal storage compound comparable to starch in plants is glycogen. It is formed during cell metabolism and stored in relatively small amounts in the liver and muscle tissues.

35. Physiological effect of dietary fiber • water absorption (laxative effect) • binding effect (influence blood lipid levels) • colon bacteria effect (fermentation substrates for bacterial action).

36. Functions of carbohydrates • Energy source. The daily dietary supply of carbohydrates should be sufficient to provide 50-55% of the total kilocalories. Carbohydrate foods must be eaten regularly and at moderate frequent intervals to meet the constant energy demands of the body. • Glycogen reserves. The liver and muscle glycogen reserves provide a constant interchange with the body’s overall energy balance system. Thus these reserves protect cells from depressed metabolic function and injury.

37. Protein-sparing action. • Antiketogenic effect. • Heart and Central Nervous System function. Fatty acids are the preferred regular fuel for the heart muscle, the glycogen reserve in cardiac muscle is an important emergency source of energy. In a damaged heart, poor glycogen stores or low carbohydrate intake may cause cardiac symptoms and angina. A constant supply of carbohydrate is necessary for the proper functioning of the central nervous system. The brain contains no stored supply of glucose and is therefore especially dependent on constant supply of glucose from the blood. Profound hypoglycemic shock may cause irreversible brain damage

38. Foods rich in carbohydrates • bread • cereals • pasta • rice • bananas • potatoes

39. Lipids Lipids are organic compounds soluble in chloroform, ether and other organic solvents but usually insoluble in water. They are esters of glycerol and fatty acids.

40. Lipids • Saturated (animal) • Unsaturated (vegetable)

41. Foods rich in lipids are: • egg yolk • butter • margarine • vegetable oil • fatty meat • fried foods contain 10-40% of fat (as they soak)

42. Protein • The protein molecule is a complex structure made up of one or more chains of amino acids, which are linked by peptide bonds. Proteins are essential constituents of the body; they form the structural material of mussles, tissues, organs and are equally important as regulators of function as enzymes and hormones. Proteins are synthesized in the body from amino acids.

43. Classification of amino acids • There is a group of essential amino acids (histidine, isoleucine, leucine, lysine, methionine, phyenylalanine,threonine, tryptophan, valine)- they are the only ones we cannot make. • The remaining amino acids, which we can syntesize are nonessential amino acids (alanine, aspargine, aspartic acid, cystine, glutamic acid, glutamine, glycine, hydrxylysine, hydroxyproline, proline, serine, tyrosine)

44. Major minerals • calcium • phosphorus • magnesium • sodium • potassium • chloride • sulfur

45. Trace elements • iron • iodine • zinc • copper • manganese • chromium • cobalt • selenium • molybdenum • fluoride

46. Iron deficiency-microcytic anaemia, • Iodine deficiency- goitre, hypothyroidism, cretinism • Fluoride deficiency-dental caries • Calcium deficiency-rickets, osteomalatia, osteoporosis

47. Water-soluble vitamin C the B vitamins (thiamin-B1, riboflavin-B2, niacin, folate, biotin, pyridoxine-B6, cobalamin-B12, pantothenic acid) Fat-soluble vitamin A vitamin D vitamin E vitamin K Vitamins

48. Vitamin A • (retinol) ia a fat-soluble vitamin that occurs preformed in foods of animal origin (especially milk products, egg yolk and liver) and is formed in the body from the pigment beta-carotene, present in cabbage, lettuce, and carrots. Retinol is essential for growth, vision in dim light, and the maintenance of soft mucous tissue. A deficiency causes stunted growth, night blindness, xerophthalmia, keratomalacia, and eventually blindness. The RDI is 750 microgram retinol equivalents for an adult ( 1 microgram ret inolequivalent=1microggam retinol or 6 microgram beta-carotene)

49. Vitamin B1 • (thiamine, aneurine) is a vitamin of the B complex that is active in he form of thiamine pyrophosphate, a coenzyme in decarboxylation reaction in carbohydrate metabolism. A deficiency of vitamin B1 leads to beriberi. Good sources of the vitamin are cereals, beans, meat, potatoes, and nuts. The RDI is 1 mg for an adult.

50. Vitamin B2 • (riboflavin) is a constituent of the coenzymes FAD ( flavine adenine dinucleotide) and FMN (flavine mononucleotide). Riboflavin is therefore important in tissue respiration. A deficiency of riboflavin causes ariboflavinosis. Good sources of riboflavin are liver, milk, and eggs. The RDI for an adult is 1.3-1.6mg.