🍽️Nutrition Assessment Unit 13 – Nutrition Assessment for Chronic Diseases

Key Concepts in Nutrition Assessment

• Nutrition assessment evaluates an individual's nutritional status using a systematic approach that includes dietary, anthropometric, biochemical, and clinical data
• Chronic diseases are long-term health conditions that often require ongoing management and can significantly impact nutritional status (cardiovascular disease, diabetes, cancer)
• Malnutrition is a common complication of chronic diseases that can lead to poor outcomes and increased healthcare costs
  • Malnutrition can manifest as undernutrition (inadequate intake) or overnutrition (excessive intake)
  • Malnutrition can impact immune function, wound healing, and overall quality of life
• Nutrition screening tools (Malnutrition Screening Tool, Mini Nutritional Assessment) help identify patients at risk for malnutrition who require further assessment
• Nutrition-focused physical examination assesses signs of nutrient deficiencies or excesses (skin changes, muscle wasting, edema)
• Biochemical data (albumin, prealbumin, transferrin) provide objective measures of nutritional status and can help monitor response to interventions
• Dietary assessment methods (24-hour recall, food frequency questionnaire) help evaluate nutrient intake and identify areas for improvement

Common Chronic Diseases and Their Nutritional Impact

• Cardiovascular disease is associated with dyslipidemia, hypertension, and inflammation, which can be influenced by dietary factors (saturated fat, sodium, antioxidants)
• Diabetes is characterized by impaired glucose metabolism and can lead to complications such as neuropathy and nephropathy
  • Glycemic control is a key goal in diabetes management and can be achieved through carbohydrate counting and portion control
  • Micronutrient deficiencies (vitamin D, magnesium) are common in diabetes and may require supplementation
• Cancer can cause metabolic changes that lead to cachexia, a complex syndrome characterized by muscle wasting and weight loss
  • Cancer treatment side effects (nausea, taste changes, mucositis) can impact nutrient intake and absorption
• Chronic kidney disease can lead to electrolyte imbalances, fluid retention, and metabolic acidosis, which require dietary modifications (potassium, phosphorus, protein restriction)
• Osteoporosis is characterized by low bone mineral density and increased fracture risk, which can be mitigated through adequate calcium and vitamin D intake
• Inflammatory bowel disease (Crohn's disease, ulcerative colitis) can cause malabsorption and nutrient deficiencies that require individualized nutrition support
• Neurological conditions (Alzheimer's disease, Parkinson's disease) can impact appetite, swallowing, and nutrient intake, leading to malnutrition risk

Assessment Methods for Chronic Disease Patients

• Dietary assessment methods evaluate nutrient intake and eating patterns to identify areas for improvement
  • 24-hour recall involves a detailed account of all foods and beverages consumed in the past 24 hours
  • Food frequency questionnaires assess usual intake over a longer period (weeks to months)
  • Food records or diaries provide a prospective account of intake over several days
• Anthropometric measurements assess body composition and can help monitor changes over time
  • Weight and height are used to calculate body mass index (BMI) as a measure of body fat
  • Waist circumference and waist-to-hip ratio assess abdominal obesity and cardiovascular risk
  • Skinfold thickness measurements estimate body fat percentage using calipers
• Biochemical data provide objective measures of nutritional status and can help monitor response to interventions
  • Albumin and prealbumin are markers of visceral protein status and can reflect recent dietary intake
  • Hemoglobin A1c measures average blood glucose control over the past 2-3 months in diabetes
  • Lipid profile (total cholesterol, LDL, HDL, triglycerides) assesses cardiovascular risk
• Nutrition-focused physical examination assesses signs of nutrient deficiencies or excesses
  • Skin changes (dryness, rashes, delayed wound healing) may indicate micronutrient deficiencies
  • Muscle wasting and loss of subcutaneous fat may indicate protein-energy malnutrition
  • Edema may indicate fluid imbalances or protein deficiency
• Functional status assessment evaluates the impact of nutritional status on daily activities and quality of life
  • Hand grip strength is a measure of muscle function and can reflect overall nutritional status
  • Gait speed and balance tests assess physical performance and fall risk

Interpreting Lab Values and Biomarkers

• Albumin is a marker of visceral protein status and can reflect recent dietary intake
  • Normal range: 3.5-5.0 g/dL
  • Low levels may indicate malnutrition, inflammation, or liver disease
• Prealbumin is a more sensitive marker of visceral protein status and can reflect changes in intake over a shorter period (2-3 days)
  • Normal range: 16-35 mg/dL
  • Low levels may indicate acute malnutrition or inflammation
• Transferrin is an iron-binding protein that can reflect iron status and visceral protein status
  • Normal range: 200-360 mg/dL
  • Low levels may indicate iron deficiency or malnutrition
• Hemoglobin A1c measures average blood glucose control over the past 2-3 months in diabetes
  • Normal range: <5.7%
  • Levels >6.5% indicate diabetes; levels 5.7-6.4% indicate prediabetes
• Lipid profile assesses cardiovascular risk
  • Total cholesterol: <200 mg/dL
  • LDL cholesterol: <100 mg/dL
  • HDL cholesterol: >40 mg/dL (men), >50 mg/dL (women)
  • Triglycerides: <150 mg/dL
• Vitamin D status is assessed by measuring 25-hydroxyvitamin D levels
  • Normal range: 30-100 ng/mL
  • Levels <20 ng/mL indicate deficiency; levels 20-29 ng/mL indicate insufficiency
• Electrolytes (sodium, potassium, chloride, bicarbonate) can reflect fluid balance and acid-base status
  • Abnormal levels may indicate dehydration, renal dysfunction, or metabolic acidosis

Dietary Analysis Techniques

• Nutrient analysis software (Food Processor, Nutritionist Pro) can calculate nutrient intake from dietary assessment data
  • Requires accurate portion size estimation and complete food descriptions
  • Can compare intake to recommended values (Dietary Reference Intakes) to identify deficiencies or excesses
• Food composition databases (USDA FoodData Central) provide nutrient information for a wide variety of foods
  • Can be used to estimate nutrient intake from food records or recalls
  • May not account for nutrient variability due to growing conditions, processing, or preparation methods
• Meal planning tools (MyPlate, exchange lists) can help patients plan balanced meals that meet nutrient needs
  • MyPlate emphasizes variety, portion control, and nutrient-dense food choices
  • Exchange lists group foods by macronutrient content and can be used for carbohydrate counting in diabetes
• Nutrient density analysis assesses the amount of nutrients provided per calorie of food
  • Nutrient-dense foods (fruits, vegetables, whole grains) provide high levels of nutrients relative to calories
  • Energy-dense foods (processed snacks, sugary drinks) provide calories with few essential nutrients
• Diet quality indices (Healthy Eating Index, Mediterranean Diet Score) assess overall diet quality based on adherence to dietary guidelines
  • Higher scores indicate greater consumption of nutrient-dense foods and lower consumption of added sugars and saturated fats
  • Can be used to monitor changes in diet quality over time and assess disease risk

Physical Examination and Anthropometric Measurements

• Body mass index (BMI) is calculated as weight (kg) divided by height (m) squared
  • Underweight: <18.5 kg/m^2
  • Normal weight: 18.5-24.9 kg/m^2
  • Overweight: 25.0-29.9 kg/m^2
  • Obesity: >30.0 kg/m^2
• Waist circumference measures abdominal obesity and is a predictor of cardiovascular risk
  • High risk: >40 inches (men), >35 inches (women)
• Waist-to-hip ratio assesses body fat distribution and is calculated as waist circumference divided by hip circumference
  • High risk: >0.9 (men), >0.85 (women)
• Skinfold thickness measurements estimate body fat percentage using calipers
  • Common sites: triceps, biceps, subscapular, suprailiac
  • Equations (Durnin-Womersley, Jackson-Pollock) convert skinfold measurements to body fat percentage
• Mid-arm muscle circumference estimates muscle mass and is calculated as mid-arm circumference minus $(3.14 \times \text{triceps skinfold thickness})$
  • Low values may indicate muscle wasting and malnutrition
• Handgrip strength is a measure of muscle function and can reflect overall nutritional status
  • Dynamometer is used to measure maximum grip strength in each hand
  • Low values may indicate sarcopenia or frailty
• Nutrition-focused physical exam assesses signs of nutrient deficiencies or excesses
  • Hair: thinning, loss of pigment, easy pluckability (protein, biotin, iron deficiency)
  • Eyes: pale conjunctiva (iron deficiency), night blindness (vitamin A deficiency)
  • Mouth: angular stomatitis (riboflavin deficiency), glossitis (folate, B12 deficiency)
  • Skin: petechiae (vitamin C deficiency), dermatitis (zinc, essential fatty acid deficiency)
  • Nails: koilonychia (iron deficiency), transverse ridging (protein deficiency)

Developing Nutrition Care Plans

• Nutrition diagnosis identifies the specific nutrition problem to be addressed
  • Examples: inadequate oral intake, altered gastrointestinal function, overweight/obesity
• Nutrition intervention outlines the specific actions to be taken to address the nutrition problem
  • Examples: nutrient supplementation, texture-modified diet, portion control strategies
• Nutrition monitoring and evaluation specifies the parameters to be measured to assess progress towards goals
  • Examples: weight change, biochemical markers, dietary intake
• SMART goals are specific, measurable, achievable, relevant, and time-bound
  • Example: "Increase fruit and vegetable intake to 5 servings per day within the next month"
• Interdisciplinary collaboration involves working with other healthcare professionals to address nutrition-related issues
  • Examples: speech therapist for swallowing difficulties, wound care specialist for pressure ulcers
• Patient education and counseling empowers patients to make informed decisions about their nutrition care
  • Includes information on nutrient needs, food sources, and strategies for behavior change
  • Motivational interviewing techniques explore and resolve ambivalence to change
• Documentation communicates nutrition care plans to other healthcare providers and tracks progress over time
  • Includes assessment data, diagnosis, intervention, and monitoring and evaluation plan
  • Electronic health records facilitate data sharing and care coordination

Challenges and Considerations in Chronic Disease Assessment

• Polypharmacy can impact nutrient absorption, metabolism, and excretion
  • Drug-nutrient interactions can lead to deficiencies or toxicities (warfarin and vitamin K, metformin and B12)
  • Medication side effects (dry mouth, constipation, nausea) can impact intake and nutritional status
• Cognitive impairment can affect ability to provide accurate dietary intake information
  • Caregiver input may be needed to assess intake and identify nutrition problems
  • Simplified assessment tools (Mini Nutritional Assessment) may be more appropriate
• Cultural and socioeconomic factors can influence dietary habits and access to nutritious foods
  • Cultural competency involves understanding and respecting diverse beliefs and practices related to food and health
  • Food insecurity screening (Hunger Vital Sign) can identify patients at risk for malnutrition due to limited access
• Ethical considerations arise when patients' values and preferences conflict with recommended nutrition care
  • Autonomy involves respecting patients' right to make informed decisions about their care
  • Beneficence involves promoting patients' well-being and minimizing harm
• Interprofessional communication is essential for coordinated nutrition care
  • Nutrition care process terminology standardizes language used to describe nutrition problems and interventions
  • Discharge planning ensures continuity of care and follow-up after hospitalization
• Reimbursement for nutrition services can be a barrier to comprehensive assessment and intervention
  • Medical nutrition therapy is a billable service for certain conditions (diabetes, renal disease)
  • Advocacy efforts aim to expand coverage for nutrition services in chronic disease management