HN 450 Nutritional Assessment Exam 1

Diet History

"usual" intake over a specified time Usual protocol: 1. Assess health habits plus a 24-hr recall 2. Assess usual eating pattern 3. Ask for detailed eating pattern 4. Complete a 3 day food record or food frequency questionnaire

Formula to calculate % of kcal for a macronutrient

# gm of _____ x kcal per gm (4, 7 or 9) / kcal per serving

Formula to determine Nutrient Adequacy Ratio (NAR)

% RDA/DRI. (Ave Daily Total divided by DRI x 100) Example: Total PRO eaten is 85 gms., RDA is 46 gms 85 / 46 = 1.85

Calculate % of calories from gms. of Cho, Pro, or fat

(# grams per serving x calories per gram of fat, carbs or pro) divided by the total calories per serving. Then move the decimal or multiply by 100 to get a percentage. Example: 8 gms. protein and 200 calories per serving 8 x 4 / 200 = 0.16 x 100 = 16%

Exchanges - Meat, med. fat (1 oz.) CHO, PRO, FAT, KCAL

***REMEMBER: This is for ONE OUNCE of meat and most servings are several ounces!!*** Carb (g) - 0 Pro (g) - 7 Fat (g) - 5 kcal - 75

Milk exchanges - by type of milk

- 1 milk exchange is skim milk. - 8 oz 2% milk = 1 milk exchange and 1 fat exchange - use whole milk = 1 milk + 2 fat exchanges

Approaches used to assess energy expenditure (athletes)

- Field observation - Indirect calorimetry - Factoral approach (calc. REE, physical cativities

Food Record

- Subject writes down what he/she ate for longer period of time - client needs training ahead of time - determine if the client or a surrogate will record the food - determine how many days should be recorded (usually 1-7 days and should include a weekend day)

Diet History - Strengths

- assesses usual nutrient intake - can detect seasonal changes - correlates well with biochemical markers - low investigator cost - does not affect eating behavior

Food Frequency Questionnaire - Strengths

- can be self-administered - machine readable - estimates "usual intake of foods" - easy for subjects - relatively inexpensive for large populations - used to study diet-disease relationships - does not influence eating behavior

Food Record - Strengths

- can provide detailed, accurate intake - not reliant on memory - more representative of usual intake

24-hr Recall - Strengths

- fast - cheap - easy to administer - low repsondent burden - can be used with illiterate persons - does not affect eating behavior - can be used on most large populations, thus less potential for nonresponse bias

24-hr Recall

- food intake over a 24-hr period - requires trained interviewer - prompting aids: memory guides, food models, measurement tools - method: multiple pass (2-5 passes)

Diet History - Limitations

- lengthy interview process - not realistic for large populations - needs highly trained interviewer - subject needs to be able to recall usual diet - difficult cognitive task for respondent - can have high investigative burden - intake often misreported

Food Frequency Questionnaire

- list of foods provided to client - list of approximately 150 or fewer foods or food groups - respondents indicate how many times a day/week/month/year that they consume the foods - Simple format: how many times a year, month, week, or day a person eats ice cream - Quantitiave format: how many times a year, month, week, or day a person eats 1/2 cup of ice cream

Food Frequency Questionnaire - Limitations

- need to use a validated food frequency list - may not represent usual portions used by clients - clients may have problems with multiple foods grouped into single listings - may be a difficult cognitive task for respondent - intake often misreported

24-hr Recall - Limitations

- tendency to under/overestimate -relies on memory - data entry can be labor intensive - one recall is usually not representataive of a person's usual intake

Food Record - Limitations

- time consuming - labor intensive - commitment of subject - requires literacy - could enhance self-monitoring for weight control or other behavior change resulting in non-normal eating

nutritional requirements of an "athlete" most likely to differ from those of average individuals with respect to:

1) calories (due to greater activity) 2) fluid/water (depending on sweat losses) and sometimes 3) electrolytes (also depending on sweat losses). Additionally athletes may have other goals that impact on dietary intake such as reaching a desirable body composition or weight, gaining muscle, or maximizing glycogen stores.

One pound of sweat loss is equivalent to

16 oz., or a pint

Components of Nutritional Assessment

A - Anthropometrics B - Biochemistry C - Clinical D - Dietary

Dietary (food and nutrient intake)

A. Data collection examples: 1. 24 hr recall 2. food record 3. food frequency 4. diet history B. Compare to standards or goals Examples: - dietary reference intakes/recommended dietary allowances (DRI/RDA) - MyPlate - Dietary Guidelines for Americans 2010 C. Classification of Nutritional Status Classify as: meets standards/goals (adequate nutritional status overnutrition (overweight, obesity) undernutrition (nutrient deficiencies)

Most nutrients for infants are expressed as ________ instead of _______ because _________

AI's instead of RDAs because the types of studies necessary to determine nutrient requirements of infants cannot be ethically done.

Healthy Eating Index Scores

Above 80 = good diet 51-80 = diet needs improvement below 51 = poor diet

When RDA is not available for a nutrient (because there is no EAR), the ________ can be used as the goal for an individual's intake.

Adequate Intake (AI)

How is the Recommended Dietary Allowance (RDA) used?

As a recommended intake when planning the diets of individuals, not groups. Because the RDA is associated with a very low risk of inadequacy (2-3%) to an individual.

Recommended Dietary Allowance (RDA)

Average daily dietary intake level that is sufficient to meet the nutrient requirement of nearly all (97-98%) healthy individuals in a particular life stage and gender group. RDA thus exceeds the requirements of nearly all members of the life stage and gender group. Has a safety margin built in of a nutrient to compensate for its incomplete use by the body and to account for variations in levels of the nutrient provided by various food sources.

Exchanges - Fat CHO, PRO, FAT, KCAL

Carb (g) - 0 Pro (g) - 0 Fat (g) - 5 kcal - 45

Exchanges - Milk, skim CHO, PRO, FAT, KCAL

Carb (g) - 12 Pro (g) - 8 Fat (g) - 0 kcal - 90

Exchanges - Milk, low-fat 1% CHO, PRO, FAT, KCAL

Carb (g) - 12 Pro (g) - 8 Fat (g) - 5 kcal - 120

Exchanges - Milk, whole CHO, PRO, FAT, KCAL

Carb (g) - 12 Pro (g) - 8 Fat (g) - 8 kcal - 150

Exchanges - Fruit CHO, PRO, FAT, KCAL

Carb (g) - 15 Pro (g) - 0 Fat (g) - 1 kcal - 60

Exchanges - Starch/Bread

Carb (g) - 15 Pro (g) - 3 Fat (g) -1 kcal - 80

Exchanges - vegetable CHO, PRO, FAT, KCAL

Carb (g) - 5 Pro (g) - 2 Fat (g) - 0 kcal - 25

Exchanges - Free CHO, PRO, FAT, KCAL

Carb (g) - <5 Pro (g) - 0 Fat (g) - 0 kcal - <20

Case-control studies

Compare the levels of past exposure to some factor of interest (nutrient or dietary component) in two groups of participants to determine how past exposure relates to a currently existing disease. Researchers use dietary methods that measure past dietary intake, therefore the 24 hr recall is not useful. Methods used are food frequency questionnaires and diet histories, both of which assess diet in the past. The respondent is not asked to recall specific memories of eating occasions but to respond on the basis of general perceptions of how frequently he or she ate a food. Typically, the relevant period asked about is often the year before diagnosis of disease or onset of symptoms, or at a particular life stage such s adolescence and childhood.

Nutrition Labeling / Daily Values is made up of two sets of references __________

Daily Reference Values (DRVs) Reference Daily Intakes (RDIs)

Nutrition Labeling / Daily Values

Daily values are dietary reference values intended to help consumers use food label information to plan healthy diets.

________ serves as the basis for Federal food and nutrition education programs.

Dietary Guidelines 2010

The DRI's consists of:

Estimated Average Requirement (EAR) Recommended Dietary Allowance (RDA) Tolerable Upper Intake Level (UL) Estimated Energy Requirements (EER)

Exchanges note regarding cheese

Falls under meat exchange!

Performing nutrient analysis on athletes

First question to ask is what point of time you want to really want to assess and study- because it may change rapidly. Ideally, assessment should be a multi-day food record intended to capture the point in time that you have targeted - recorded by cooperative subjects that you have trained ahead of time. if using diet analysis software to analyze an athlete's diet, database should be expandable because of the widespread supplement use in this group (vitamin/mineral supplements, sports drinks, weight gain powders, calorie-replacement drinks, etc).

The only index used by US to determine overall diet quality of Americans

Healthy Eating Index - used in US to monitor changes in food consumption patterns, to identify target areas for nutrition education and health promotion programs, and to evaluate those programs

Adequate Intake (AI)

If sufficient scientific evidence is not available to establish and EAR and set an RDA, an AI is derived instead.

EAR uses - Planning Intakes

Individual: Do not use Group: to plan for an acceptably low prevalence of inadequate intakes within a group

AI uses - Planning intakes

Individual: Plan for this intake; usual intake at or above this level has a low probability of inadequacy Group: Plan for mean intake at this level

UL uses - Planning intakes

Individual: Plan for usual intake below this level Group: Use in planning to minimize the proportion of the population at potential risk of excessive nutrient intake

UL uses - Assessing Intakes

Individual: Usual intake above this level may place an individual at risk of adverse effects from excessive nutrient intake Group: Mean usual intake at or above this level implies a low prevalence of inadequate intakes

RDA uses - Planning intakes

Individual: plan for this intake; usual intake at or above this level has a low probability of inadequacy. Group: Do not use

EAR Uses - Assessing Intakes

Individual: to examine the probability that usual intake is adequate Group: to estimate the prevalence of inadequate intakes within a group

AI uses - Assessing Intakes

Individual: usual intake at or above this level has a low probability of inadequacy Group: Mean usual intake at or above this level implies a low prevalence of inadequate intakes

RDA uses - Assessing Intakes

Individual: usual intake at or above this level has a low probablility of inadequacey Group: Do not use

Who is at risk for malnutrition and why?

Infants and Children: at risk due to rapid development, immature immune system, and potential for inadequate food resources. Pregnant Women: at risk due to depressed immune system and additional nutrient requirements for growth of fetus Low income families: at risk due to limited access to food and other resources Hospitalized patients: at risk due to illness, compromised immune systems, and exposure to hospital acquired infections. Aging Adults: at risk due to decreasing immune system function; changes in body composition, organ functions, adequate energy intake, and ability to eat or access foods. Depression and sadness also play a role.

How is the Estimated Average Requirement (EAR) used?

It's an intake goal for groups, not for individuals. Particularly useful for evaluating adequacy of population group.

Clinical (symptoms, visuals, subjective measurements)

Medical history and physical exam are used to detect signs and symptoms of malnutrition. a. loss of subcutaneous fat b. yellow skin c. loss of teeth d. dry/brittle hair

Thirst _______ a good indicator of fluid needs

NOT

4 Steps of the Nutrition Care Process (NCP)

Nutrition assessment Nutrition diagnosis Nutrition intervention Nutrition monitoring and evaluation

Old and new purpose of DRI's

Old: prevent deficiencies New: prevent deficiencies and prevent chronic disease

Cross-Sectional studies

Provide a snapshot of the health of a population at a specific point in time. Dietary measurements are performed on small group of people that are representative of the larger, general population. Example: NHANES survey (National Health and Nutrition Examination Survey). The 24-hr recall is the most common method used.

What is Dietary Reference Intakes (DRI)?

Reference values that are quantitative estimates of nutrient intakes to be used for planning an assessing diets for apparently healthy people. Developed to address the weaknesses of the RDA's and to expand on the RDAs by adding new reference values and recommendations for energy intake. They are to be used by US and Canadian populations. They replaced the RDA's in the mid 1990's. Refers to average daily intake of healthy persons over time; nutrients do not have to be consumed daily.

POSSIBLE TEST QUESTION Assessing the diet of a child whose lab values indicate low Hg. Which method would be most useful for estimating usual iron intake? a) diet hx b) food records c) FFQ d) 24-hr. recall

Rule out 24-hr. recall and food record because it limits the time frame.

Estimated Energy Requirements (EER)

The average dietary energy intake that is required to maintain energy balance in a healthy person of a defined age, gender, weight, height, and physical activity level consistent with good health.

Reference Daily Intakes are __________

a set of dietary references based on the Recommended Dietary Allowances for essential vitamins and minerals and, in selected groups, protein. - They are not intended to serve as recommended intakes - Percent daily values are based on a 2000 kcal diet

Daily Reference Values are ___________

a set of dietary references that applies to fat, saturated fat, cholesterol, carbohydrate, protein, fiber, sodium, and potassium. - They are not intended to serve as recommended intakes - Percent daily values are based on a 2000 kcal diet

The Nutrition Care Process (NCP)

a systematic process describing how food and nutrition professionals provide care to patients/clients. It is designed to improve the consistency and quality of individualized care for patients/clients or groups and the predictability of the patient/client outcomes. It is not intended to standardize nutrition care for each patient/client, but to establish a standardized process for providing care. (IDNT)

ACTUAL TEST QUESTION You have a classroom of 200 students and they're all 20 yr. old females (so RDA is same for all of them). The RDA is established so it exceeds the requirements for all of them except how many? a) 2.5 b) 66.6 c) about half the class

a) 2.5 Basically you'd know the definition of RDA

POSSIBLE TEST QUESTION Most nutrient levels for infants are expressed as _____ because many studies can't be ethically performed on infants. a) AI b) RDA c) UL d) EAR

a) AI

Biochemistry

a. blood glucose b. hemoglobin c. albumin Samples may be taken from blood, feces, urine, body tissues. Results are compared to standards/normal values.

Anthropometrics

a. height b. weight c. head circumference d. skinfold thickness e. body density Results are compared with standard values (population norms)

Example of population group that would be monitored and the UI used

athletes who use supplements elderly who are high users of supplements

Intervention studies

begin with disease-free subjects who are exposed to something of interest and are followed forward in time and observed to determine whether the exposure of interest (or lack of expsore) affects risk of disease. Subjects are randomly assigned to either an exposure group or a control group (non-exposure, subjects receive placebos).

ACTUAL TEST QUESTION The Adequate Intake (AI) for Ca for 19-30 year old males and females is 1000 mg. This means the amount of Ca... a) covers the needs of most healthy people b) is the average Ca requirement c) appears to be adequate for this population

c) appears to be adequate for this population Notice this is AI...a mean intake value

Correlational studies

compare the level of some factor such as saturated fat, with the level of another factor, such as coronary heart disease. They do not determine a cause and effect relationship between the two variables. Food data used is not based on actual dietary intake measurements.

POSSIBLE TEST QUESTION Which of the following nutrients is most likely to be interpreted / assessed using the UL component of the DRI? a) Pro b) Fat c) Cho d) Vit. C

d) Vit. C

ACTUAL TEST QUESTION What must be established before an RDA can be set? a) adequate intake b) dietary reference intake c) UL d) estimated average requirement

d) estimated average requirement It's the daily intake value that is estimated to meet the requirement in half of the apparently healthy individuals in a life stage or gender group. If an EAR cannot be established, then an RDA cannot be set.

Longitudinal or cohort studies

exposures of interest are assessed at baseline in a group (cohort) of participants to determine how exposure to the factors relates to diseases that may develop over time. Require methods that measure current diet or dietary habits in the immediate past: 24-hr recall, food records, food frequency questionnaires.

Tolerable Upper Limit (UL)

highest level of continuing daily nutrient intake that is likely to pose no risk of adverse health effects in almost all individuals in the specified life stage group. Developed in response to concerns about potential for excessive nutrient intakes resulting from increased consumption of nutrient fortified foods and dietary supplements. it is NOT intended to be a recommended level of intake

Healthy Eating Index (HEI)

instrument developed to provide an overall picture of the type and quantity of foods consumed by an individual and the individual's compliance with the dietary guidelines - measure of overall diet quality as defined by adequacy, moderation and variety

Diet Quality Index

instrument used to assess the overall diet quality of groups and to evaluate risk for chronic disease related to dietary patterns. - the higher the score, the better the diet -one use is to assess the diets of groups using data from national nutrition surveys - based on 10 US diet and health recommendations - developed based on the food guide pyramid which is no longer used

Water generally sufficient for sports activities lasting _______

less than one hour. electrolytes lost in sweat are covered by most diets. Over 1 hr, sports beverages recommended.

Athletes should consume ______ ________ than non-athletes

more carbohydrates

Adequate Intake (AI) is an _____________

observational standard. Based on observed or experimentally derived approximations of average nutrient intake that appear to maintain a defined nutritional state of adequacy.

Dietary Guidelines 2010

provide authoritative advice for people two years and older about how good dietary habits can promote health and reduce risk for major chronic diseases. - Intended to address more common related health problems such as heart disease, cancer, stroke, hypertension and diabetes. - They are revised every 5 years.

Multiple Pass Procedure

review the previous day's eating several times to obtain detailed and accurate information What foods were eaten? what did you eat or drink starting yesterday at this time? Where were you? What did you have next? interviewer acts as a prompter help client remember and include little things (missing foodstext annotation indicator) (phantom foodstext annotation indicator) do not include supplements Food Description type of food how packagaed, prepared, or cooked brand names if possible Amount of food use a diet or postal scale to show approximate weights plastic food models can clarify amounts (Nasco) paper models of foods (Dairy Council) household measurement cups are useful to clarify amounts showing standard size cups and glasses can clarify amounts Re-check list interviewer reads back list pf foods eaten in last 24 hours ask "was this a normal day"

The Estimated Average Requirement (EAR) is the basis for...

setting the Recommended Dietary Allowance (RDA). If an EAR cannot be established, an RDA cannot be established.

Nutrient Adequacy Ratio (NAR)

shows what percent of the RDA you are getting for each nutrient. It is not adjusted proportional to energy intake.

Formula for total % kcal from _____, you do not just add up the % kcal from the answers. Instead, you.....

take total g of _____ answer x ___ kcal and divide by total kcal. Example: total % kcal from fat with 11 gms fat and 1200 kcal 11 x 9 kcal / 1200 = 0.08

There is no Recommended Dietary Allowance (RDA) for energy because ________

the RDA is an AVERAGE, and intake above the EER would be expected to result in weight gain.

For infants, children and adolescents, the EER includes ___________

the energy needed for physical activity as well as optimal growth and maturation for the age/gender appropriate rate.

Estimated Average Requirement (EAR)

the median usual intake value that is estimated to meet the requirement of half of the healthy individuals in a life stage and gender group. At this level of intake, the other half of hte individuals in the specified group would not have their needs met. It is an estimated median requirement.

% of kcal from CHO for athletes

typically 60-70% 6 - 10g carbohydrates/kg body weight