4900 Exam 1

High BP (Htn stage 1)

systolic 140-159 diastolic 90-99

High BP (htn stage 2)

systolic 160+ diastolic 100+

hypertensive crisis

systolic 180+ diastolic 110+

Nutrition intervention

tailored to person & problem meet them where they are

Anthropometry

"Man + measure" Simple measures = Weight Height (sitting, standing, limb lengths) Circumferences Bone widths Convert to metric

Anthropometry

"Measure the Man" Includes: Height/length, weight, Circumference, skinfold thickness Normative Data = Reference Point, what we use to compare people to

PES statement

"Problem, Etiology, Sign/symptoms" Format used in NCP to write nutrition diagnosis Clarifies the specific nutrition problem & links nutrition diagnosis to intervention & monitoring/evaluation problem = what etiology = why signs/symptoms = how do i know, how severe is problem

Brozek equation

%BF = (4.57/Db - 4.142) X 100

Siri equation

%BF = (4.95/Db - 4.50) X 100 (used most often, general pop)

Calculating EER for Amputees

Hand = .8 percent of total forearm + hand = 3.1 percent of total entire arm = 6.6 percent of total foot = 1.8 percent of total lower leg below knee = 6.5 percent of total leg above knee = 8 percent of total entire leg = 18.5 percent of total

Skinfolds (SKF) & Calipers

- Equations assume: 50% of fat is subcutaneous, rest is visceral fat, standard sites (NHANES) defined: equation, gender, age, ethnicity, specific, require density calculations

Current causes of death

-All nutritional diseases 24.6% heart disease, 23.3% cancer, 24.8% "other"

What is a body fundamentally

-Atoms (C, H, O, N, K) and sub-atomic (neutrons, etc.) -Molecules (H2O, Carbs, fat, protein, salts) -Cells (an expected organization/function) -Tissues-Systems (an integrative function) Whole body (several compartments composed of a variety of components: -Component/compartment models

SGA (Subjective Global Assessment)

-Clinical technique for assessing the nutritional status of a patient based on features of the patient's history and physical examination -Rely less on objective anthropometric & biochem data -Based on 4 elements of patient history: 1. recent loss of body weight 2. changes in usual diet 3. presence of significant GI symptoms 4. patients functional capacity 3 elements of physical exam: 1. loss of subcutaneous fat 2. muscle wasting 3. presence of edema or ascites ***Most oft. used in longterm care

Surrogate measures of height

-Knee height -Arm Demispan -Forearm length

How do we get actual numbers for body comp

-determine density of body (Db = mass/volume) -Use equation that takes density and calculates FM or FFM -Determine other (FM or FFM) by subtracting from 100

Height

-measured using stadiometer -ideal in stocking feet -shoulders, butt, feet, head against flat surface -deep breath -Frankfurt horizontal plane: orbital (lower margin of eye socket + Tragion (notch above tragus of ear) horizontal line -Sitting height: military, gymnasts -Infants: longitudinal height + head circumference

BodPod (ADP - Air Displacement Plethysmography)

-measurement of pressure -gold standard for some but can be w/ in 2% error -very easy to use -Based on Boyle's law where relationship btwn pressure & volume when in a container of given size -Poisson's law takes into account how the body temp will affect the volume/pressure relationship Sources of error - anything to change volume - clothes, hair, temp., moisture (will change accuracy)

Issues measuring body comp

-standardize methods -inspection and calibration of instruments -Validity and reliability

SMART goals

-stated in terms of what the patient will do Specific Measurable Attainable Relevant Timely

Pulse sites

-temporal -carotid -Apical -Brachial -Radial -Femoral -Popliteal -Dorsalis pedis -Posterior tibial

8 most commonly used skinfold sites (pp 190)

1. Chest (pectoral)- long axis running from top of anterior axillary fold to nipple 2. Triceps - most commonly measured site- posterior aspect of right arm, over triceps muscle, midway btwn lateral projection of acromion process of scapula & inferior margin of olecranon process of ulna 3. Subscapular = 1cm below lowest (inferior) angle of scapula; long axis of skinfold on 45* angle directed down to right side 4. midaxillary - right midaxillary line, level w/ xiphisternal junction 5. Suprailiac - measured just above iliac crest at midaxillary line; runs diagonally 6. Abdomen - horizontal skinfold 3cm to right and 1cm below midpoint of umbilicus 7. Thigh - vertical skinfold along midline of anterior aspect of thigh, midway between junction of midline and inguinal crease & proximal border of the patella 8. Medial calf - right leg; point of maximum calf circumference is marked @ medial (inner) aspect of calf; vertical skinfold is grasped ~1cm proximal to marked site & measured at the site

Basic Steps for finding landmarks/folds

1. Respect personal space 2. Palpate w/ thumb & forefinger 3. Use left hand to lift fat & skin (thumbs up/down, open hand, lift) 4. Use right hand to hold caliper 5. DO NOT release caliper - be gentle 6. Learn correct boney markings 7. Calipers ~.5 inches away from where pinch is

2 supporting systems outside NCP

1. Screening/referral system - identifies those benefiting from nutrition care 2. Outcomes management system - monitors, evaluates and improves the NCP

Three domains of nutrition diagnosis

1. intake 2. clinical 3. behavioral/environmental

Hamwi equation IBW females

100lb first 5 feet + 5lbs/inch after

Hamwi equation IBW males

106lb first 5 feet + 6lbs/inch after

Nomogram method for calculating bmi

3 columns, find where values intersect

Typical ratio of fat to lean mass lost

3:1 or 4:1

Body Temperature

98.6F = normal (range: 97.8-99) -oral -rectal (little higher than oral) -axillary (little lower than oral) -ear -skin (forehead)

Nutritional Assessment (ASPEN Definition)

A comprehensive approach to diagnosing nutrition problems that uses a combination of the following: medical, nutrition, and medication histories; physical examination; anthropometric measurement and laboratory data

Nutritional Screening (ASPEN Definition)

A process to identify an individual who is malnourished or who is at risk for malnutrition to determine if a detailed nutrition assessment is indicated (i.e. YP4H at OSU) - a generalized test before true assessment

Nutritional Assessment (AND Definition)

A systematic method for obtaining, verifying, and interpreting data needed to identify nutrition-related problems, their causes and their significance

Adjusted body weights - overweight

ABW equation: ABW = 0.25 (BW-IBW) + IBW

Inner ring of NCP Model

ADIME

Adjusted body weights - underweight

Add 25% diff. between current weight & IBW: Current + ((IBW+BW) X.25) Current + IBW/2

Android Body fat distribution

Adipose distribution is primarily located within the abdominal region More often seen in males than females Adipose tissue within the abdominal region is associated w/ greater risk of hypertension, coronary heart disease, T2DM compared to when adipose tissue is located predominantly w/ in hip and thigh regions

Gynoid body fat distribution

Adipose tissue is predominantly located w/ in hip and thigh regions more often seen in females than males Adipose tissue in hips and thighs is associated w/ lower risk of hypertension, coronary heart disease, T2DM compared to when located predominantly w/ in abdominal region

Nutritional Assessment methods (ABCDE)

Anthropometric, Biochemical, Clinical, Dietary, Everything else

4 steps in NCP

Assessment Diagnosis Intervention Monitoring/Evaluation

Less than ideal methods

BIA: total body, hand, feet Infrared Interactanc: Futrex

Dual X ray Absorptiometry (DXA, iDXA)

Based on emitting 2 levels of x ray energy through your body & seeing what passes thru, how it attenuates, and what does not -low dose of radiation (~1/10 amount from chest x ray) Very little scatter radiation to tech Limitations: Person must fit w/ in scanner (surface area, height of belly etc)

Heart rate

Beats/min = resting 60-100 in adults; higher for children (75-130) -Tachycardia (fast) -Bradychardia (slow) -Quality of pulse (bounding, weak, etc.) -note for head injuries -Low sodium diet? only effective in ~1 in 6

Vitals

Blood Pressure Pulse Rate Respiratory Rate Temperature

Diastolic BP

Bottom number; measures force of blood on arteries between beats(~80)

Weight

Calibration and care of scales --standard = lbs to nearest .10 Minimal clothing no shoes Convert to metric

Lean tissues

Composed of significant water and electrolytes Proteins, minerals inside them (muscle is 72-74% water, significant potassium) Conduct electricity via water so we can quantify it Composed of electrolytes which can be quantified Diffracts X rays different than fat ability to make body sink when placed in water inaccurate if measured after working out, electrolytes sweat out, wont measure as much

Fat mass

Contains little water, cannot conduct electricity very little water inside fat cell (adipocyte ~14% water) limited electrolytes (no potassium) -->does not conduct electricity well Resistance to electric current can be quantified --> diffracts x rays, thus quantifiable-- differently than muscle/bone -ability to be lifted from underlying muscle --> Assumptions that half is under skin (50% is subcutaneous ---may not be legit anymore) -Ability to make body float when body is in water

Body density calculation

Db= mass/volume Db = Ma (((Ma-Mw)/Dw) -(RV + GI volume))

Body composition definition

Description of component tissues & amounts that compose or make up the total body mass -Ratio of fat mass (FM) to fat free mass (FFM; aka lean body mass) -%FM + %FFM = 100% -Either it is fat or not

Knee height

Elderly Tricky to get angle Measured w/ subject lying face up (supine) Measurements made on left leg Knee and ankle positioned at 90* angle Caliper shaft placed: -Parallel to fibula -over lateral malleolus posterior to head of fibula pressure applied to 2 blades to compress soft tissues Measurement recorded to nearest 0.1 cm

Nutrition Assessment

Ensures appropriate and accurate data are collected to identify specific nutrition problems and their severity Data are organized and categorized according to possible nutrition diagnoses Allows tracking and evaluation Screening vs Assessment: screening = basic number, assessment = more in depth, costly

Outer ring of NCP model

Environmental factors that can impact patient/client's ability to receive & benefit from NCP --Practice settings --Healthcare systems --Social systems ---Economics

Nutrition Care Process (NCP)

Established by Academy to standardize consistent, uniform language (standardized terminology) for describing specific nutrition problems, communicating with others, classifying, measuring & documenting outcomes of nutrition care "a systematic problem solving method in which dietetic practitioners use critical thinking skills to make evidence-based decisions addressing the nutrition-related problems of those they serve"

Dietary

Estimating food and nutrient intake--> exchange system estimates kcals, often entered into computer What goes in the body Input into software Software estimation of intake Most common methods: 24 hour recall FFQ- advantage = collects data over time Vioscreen ESHA (~ 200kcals diff between ESHA and Vioscreen) Food record or food diary - number of days to track, (problem) requires patient honesty; looking at typical day allows small changes Assessment contributes to treatment --> determine which to use based on what setting youre in

Underwater (hydrostatic) weighing

Gold Standard Archimedes principle - volume of object is equal to volume of water displaced, body volume is equal to diff. of mass in air and water Important to correct for errors (air in lungs & GI) Population, age, gender specific equations Find Db then can find % body fat - body density is what whole body comp is based on ---> underlying assumption that muscle density/fat density is same on everyone (not true) Calculates density (mass per unit volume) of a subject using - subject's weight in air, subject's weight while submerged in water, density of water in which subject is submerged (temp. of room) Body comp is estimated using subject's density --> fatter a person is, float more density of fat < 1 Density of lean> 1

Growth charts

Growth and development of infants, children and adolescents based on growth data obtained from large numbers of healthy infants, children and adolescents

Historical Causes of death

Influenza, pneumonia, diphtheria, tuberculosis, GI infections

Biochemical

Laboratory assays on various body tissues, fluids or excretions -Anything measured from a sample of the body -Hemoglobin, hemocrit, serum ferratin (iron) -Serum lipids and lipoproteins (i.e. HDL, LDL) -Plasma glucose & hemoglobin A1C (Blood glucose) -Serum vitamin D concentration -Urinary sodium excretion -Skin carotenoids -Poop

5 Korotkoff sounds

Listen for 1st and 5th 1st = snapping sound first heard at systolic pressure; clear tapping sound; onset of sound for 2 consecutive beats = systolic 5th Korotkoff sound is silence as cuff pressure drops below diastolic BP. Disappearance of sound is considered diastolic BP 2 points below last sound heard (2nd and 3rd sounds no clinical significance)

Female Athlete triad

Low energy availability Amennorhea Low bone mass

High risk waist circumference in Adult Males and females

Males >40 inches (>102 cm) Females >35 ( >88cm)

Blood Pressure

Normal = 120/80 BP tools: Old fashioned: stethoscope for auscultation Sphygmomanometer(goes around arm) - familiar aneroid mercury column, random zero if blinding is important (take BP + record numbers, tells you how much falsified by, then gives you # to subtract More modern: auscilatory vs. oscilometric Wrist or finger Brachial Track or not computer or not telemetry apps Cuff size important; might give false reading, too high if bigger arms (pediatric, adult, XL) Listening for brachial artery (medial to biceps tendon)

Clinical

Nutritional physical assessment - looking at and documenting the evidence of nutritional status from head to toe Subjective global assessment Documentation -Acute care settings

Monitoring & evaluation

Often uses same assessment tools & require a threshold For instance, would monitor an iron-deficiency anemia by monitoring same indices that diagnosed the issue

Forearm Length

Pediatrics Good measure to detect growth Ulna (pinky side) to radial notch

Middle ring of NCP Model

Practitioner Strengths/abilities: --dietetics knowledge -- Skills and competencies --Critical thinking --Collaborations --Communication --Evidence Based Practice --Code of Ethics

Symptoms for corroboration

Reinforce high BP rating: -blood spots in eyes -Flushing -Dizziness -Comments on headaches & nosebleeds

Center of NCP Model

Relationship between patient/client/group & dietetics professional

Alternative methods for documenting

SOAP notes: Subjective - something patient tells Objective - you can asses yourself Assessment - what you think about it Plan - management piece

BMI

Several types of weight: height ratios have been developed Most common = Quetelet Index (kg/m^2) Also: (Wt(#) X 704.5/Ht. (inches))/Ht. (inches) Good measure of overweight in large population studies *Body composition not considered -Getting too thin: dangerous for immune system; BMI 16/17 just as dangerous as obesity

Limitations of SKFs

Significant skill and practice required, not all equations apply to all people (inappropriate for obese, big assumption about 50%) +/- 3% error on a person +/-6% error between people

Issues and concerns

Standardize methods Same person measure Inspection and calibration of instruments Validity and reliability BMI considerations: athlete, pregnant, geriatric

Arm Demispan

Sternal notch at manubrium (top part) of sternum out to middle fingertip X 2 = height (w/ in 3cm standing height) off by avg 7cm

Overall fitness characteristics

Strength - hand grip dynamometer; biodex or other isokinetic device Flexibility: sit and reach Aerobic fitness Pushups Sit ups

Prehypertension

Systolic 120-139 Diastolic 80-90

Normal BP

Systolic >120 Diastolic >80

Other measures about body

Tanner scores: puberty changes; breast development, pubic hair, body hair (5 stages) Metacarpal scoring: x ray of carpals/metacarpals; skeletal development Disease specific characteristics: Ferriman-Gallway scoring for body hair in PCOS

Dx: intake domain

Terms describing problems related to inadequate, excessive or inappropriate food or nutrient consumption Labels such as "inadequate", "excessive" or "inappropriate" are often used to describe food or nutrient intake

Nutrition Diagnosis

The identification and descriptive labeling of a nutrition problem that the dietetics practitioner is responsible for independently addressing Different than a "medical diagnosis" Written in terms of a problem for which nutrition-related activities provide the primary intervention

Systolic BP

Top number; measures force of blood on arteries when heart beats (~120)

Other methods for determining body comp

Total Body Water Methods Potassium Counter Neutron activation analysis TOBEC (electromagnetic field) CT MRI

Head circumference

Used to detect abnormalities in cranial growth & development Increases rapidly in 1st year after 2yrs age, cranial growth much slower

Sagittal abdominal diameter

Used to measure intra (firm) vs. extra abdominal fat --> studies of metabolic syndrom

Circumference sites

Waist-hip ratio Thigh measurement: suprapatellar pole --> 3, 6, 9" from it Acute care similarities: MAC - put skinfolds w/ this and MAMC

Waist and hip circumferences

Waist: 6 different "waist" measures defined in scientific literature NHANES location: best due to bone top of iliac crest parallel to ground end of exhalation to nearest 0.1cm w/ linen tape Hips Usually 2 are defined from front or side w/ linen tape to nearest .1com over little clothin g

Women vs. men

Women have more body fat (due to estrogen) **20-30%**-- holding lower than 18% = concern, artificially holding BW down = metabolic damage (obesity marker 32-34%) Men have more lean mass (due to testosterone) **12-18%** artificially holding in single digits = concern (obesity marker = 25%)

Respiration rate

breaths/min = resting 12-20 adults 16-60 children (including infants) *Tachypnia = high resp. rate

Density of tissues

doesnt change much and can be assumed; can use Archimedes principle to learn composition Density of Lean: 1.10 g/cm^3 Density of Fat = 0.900 g/cm^3

Cons of UWW

equipment is expensive & bulky Subject training & cooperation are critical Not practical for testing large #s of subjects Gas in GI tract & air in lungs (residual volume) can affect subject's weight while submerged &, thus, calculated density & estimate of body comp

ISAK

international society for advancement of kinanthropometry: human size, shape, proportion, composition, maturation, and gross function Similar to Heath Carter Somatotyping popular in 80s

Single Site skinfold measurement

most common single site is triceps single site skinfold measurement cannot be used to estimate body fat It is useful for comparing one individual's measurements w/ sex & age specific reference data to determine how that individual compares w/ others of the same sex & age Some use in acute care settings to estimate patient weight

Region percent mass vs tissue percent mass

region percent mass = muscle + bone tissue percent mass = lean mass + fat mass

Dx: behavioral-environmental domain

terms in this domain describe problems related to nutrition knowledge, attitudes and beliefs about food and nutrition, physical environment, access to food, food safety

BMI classifications

underweight <18.5 18.5 - 24.9 normal 25.0 - 29.9 overweight 30.0-34.9 obesity class 1

Dx: clinical domain

uses terms describing nutritional problems related to specific medical or physical diseases or conditions Examples of clinical domain terms include problems chewing, swallowing, digesting, absorbing & maintaining a healthy weight

Advantages of SKFs

very convenient Cheap method -except for training, can do anywhere, also demonstrates distribution of fat