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