Nutrition Screening and Assessment Nutrition 526: 2010

1. Nutrition Screening and AssessmentNutrition 526: 2010

2. Steps to Evaluating Pediatric Nutrition Problems • Screening • Assessment • Data collection • Evaluation and interpretation • Intervention • Monitor • reassessment

3. Nutrition Screening: Purpose To identify individuals who appear to have or be at risk for nutrition problems To identify individuals who require further assessment or evaluation

4. Screening: Definition Process of identifying characteristics known to be associated with nutrition problems ASPEN, Nutri in Clin Practice 1996 (5):217-228 Simplest level of nutritional care (level 1) Baer et al, J Am Diet Assoc 1997 (10) S2:107-115

5. Anthropometrics: weight, length/height, BMI Growth measures < than 5th %ile Growth measures > than 90th %ile Alterations in growth patterns Change in Z-scores Change 1-2 SD Change percentiles Medical and developmental Conditions Medications Improper or inappropriate food/formula choices or preparation Psychosocial Laboratory Values Examples of Screening risk factors

6. Jayden: PG Weight gain Nutritional Practices Barbara: Breastfeeding Weight changes Dietary practices Infant feeding practices Mark Newborn Weight loss Breastfeeding Jake 10 month old Hct: 29 Examples of Screening risk factors

7. Assessment Systematic process Uses information gathered in screening Adds more in depth, comprehensive data Links information Interprets data Develops care plan monitor Reassess

8. Identify Problem or risk Identify Etiology Determine intervention Monitor and Reevaluate Process

9. Goals of Nutrition Assessment • To collect information necessary to document adequacy of nutritional status or identify deficits • To develop a nutritional care plan that is realistic and within family context • To establish an appropriate plan for monitoring and/or reassessment

10. NCP: Nutrition Care Process • Provides a framework for critical thinking • 4 Steps • Assessment • Diagnosis • Intervention • Monitoring/Evaluation

11. NCP • Assessment • Obtain, verify, interpret information • Data used might vary according to setting, individual case etc… • Questions to ask • Is there a problem? • Define the problem? • Is more information needed?

12. NCP • Diagnosis • Identification or labling of problem that is within RD practice to treat • Examples: • Inadequate intake • Inadequate growth

13. Altered GI Function Altered nutrition related laboratory values Decreased nutrient needs Evident malnutrition Inadequate protein-energy intake Excessive oral intake Increased energy expenditure Increased nutrient needs Involuntary weight loss Overweight/obesity Limited adherence to nutrition related recommendations (vs food and nutrition related knowledge) Underweight Food and medication interactions Examples of Nutrition Diagnosis Options

14. NCP: • Diagnosis written as a PES statement Problem/Etiology/Signs and symptoms “Must be clear and concise. 1 problem one etiology”

15. Jayden: PG Weight gain Nutritional Practices Barbara: Breastfeeding Weight changes Dietary practices Infant feeding practices Mark Newborn Weight loss Breastfeeding Emma 12 months Weight @ 95th percentile Diet information Jake 10 month old Hct: 29 Examples of Screening risk factors

16. NCP Process Jayden, Barbara, Mark, Emma, Jake

17. NCP • Intervention • Etiology drives the intervention • Monitoring and Evaluation

18. Challenges and Pitfalls

19. Challenges Nutrient needs influenced by: genetics, activity, body composition, medical conditions and medications Individuals anthropometric date influenced by: genetics, body composition, development, history

20. Challenges Identification of etiology Weighing risk vs benefit Supportive of: Family Individual Development/temperament

21. Challenges • Information • Availability • Accurate • Representative • complete • Goals and expectations • Available • Evidence bases • applicable

22. Comprehensive Nutrition Assessment • Collection of Nutritional data • Interpretation of data • Linking information • Goals and expectations • Individual data • evidence • Asking questions • individualized intervention • monitoring outcomes of intervention

23. Potential Pitfalls Excuses Assumptions Faulty reasoning Incorrect or inaccurate information Not evidence based Biased

24. Information Collected: Current and Historical Growth Dietary Medical history Diagnosis Feeding and developmental information Psychosocial and environmental information Clinical information and appearance (hair, skin, nails, eyes) Other (laboratory)

25. Assessment Tools

26. Tools of Assessment Growth Measurements Growth charts Absolute size (percentile) Pattern Body composition Water, bone, muscle, fat Intake Additional information Intake Food record, food recall, analysis Additional information Medical, Development Social Laboratory Other anthropometrics etc Nutrition Assessment

27. Who is the regulator of growth? Who regulates Intake? What do measurements mean? Weight Weight gain Lab values Intake information

28. Growth

29. Growth Growth is a dynamic process defined as an increase in the physical size of the body as a whole or any of its parts associated with increase in cell number and/or cell size Reflects changes in absolute size, mass, body composition

30. Growth A normal, healthy child grows at a genetically predetermined rate that can be compromised by imbalanced nutrient intake

31. Growth Assessment Progress in physical growth is one of the criteria used to assess the nutritional status of individuals

32. Absolute size • Absolute size • Body composition • Growth/changes over time

33. Absolute size

34. Other Anthropometrics • Upper arm circumference, triceps skinfolds • Arm muscle area, arm fat area • Sitting height, crown-rump length • Arm span • Segmental lengths (arm, leg) All have limitations for CSHCN, but can be additional information for individual child

35. Body Mass Index for Age • Body mass index or BMI: wt/ht2 • Provides a guideline based on weight, height & age to assess overweight or underweight • Provides a reference for adolescents that was not previously available • Tracks childhood overweight into adulthood

36. Guidelines to Interpretation of BMI • Underweight • BMI-for-age <5th percentile • At risk of overweight • BMI-for-age  85th percentile • Overweight • BMI-for age  95th percentile

37. Interpretation of BMI • BMI is useful for • screening • monitoring • BMI is not useful for • diagnosis

38. Who might be misclassified? • BMI does not distinguish fat from muscle • Highly muscular children may have a ‘high’ BMI & be classified as overweight • Children with a high percentage of body fat & low muscle mass may have a ‘healthy’ BMI • Some CSHCN may have reduced muscle mass or atypical body composition

39. Nutrient Analysis • Fluid • Energy • Protein • Calcium/Phosphorus • Iron • Vitamin D • Other

40. Recommendations established for over 43 essential and conditionally essential nutrients Nutrient Needs

41. Basis of recommendations • Basis • Physiology • GI • Renal • Growth and Development • Preventing deficiencies • Meeting nutrient needs • Water • Energy • Vitamin D • Iron

42. Dietary Information Collect data Nutrient Analysis Comparison with recommendations, guidelines, evidence Link with additional information Interpret

43. Dietary Information • Family Food Usage • 24 hour recall • Diet history • 3-7 day food record or diary • Food frequency • Other Information • Food preparation, history, feeding observation, feeding problems, likes/dislikes, feeding environment

44. Approaches to Estimating Nutrient Requirements • Direct experimental evidence (ie protein and amino acids) • extrapolation from experimental evidence relating to human subjects of other age groups or animal models • ie thiamin--related to energy intake .3-.5 mg/1000 kcal • Breast milk as gold standard (average [] X usual intake) • Metabolic balance studies (ie protein, minerals) • Clinical Observation (eg: manufacturing errors B6, Cl) • Factorial approach • Population studies

45. Dietary Reference Intakes (DRI)(including RDA, UL, and AI) are the periodically revised recommendations (or guidelines) of the National Academy of Sciences

46. DRI: Dietary Reference Intakes expands and replaces RDA’s reference values that are quantitative estimates of nutrient intakes for planning and assessing diets for healthy people AI: Adequate Intake UL: Tolerable Upper Intake Level EER: Estimated Energy Requirement Comparison of individual intake data to a reference or estimate of nutrient needs

47. DRI • Estimated Average Requirement (EAR): expected to satisfy the needs of 50% of the people in that age group based on review of scientific literature. • Recommended Dietary Allowance (RDA): Daily dietary intake level considered sufficient by the FNB to meet the requirement of nearly all (97-98%) healthy individuals. Calculated from EAR and is usually 20% higher • Adequate intake (AI): where no RDA has been established. • Tolerable upper limit (UL): Caution agains’t excess

48. DRI • Nutrition Recommendations from the Institute of Medicine (IOM) of the U.S> National Academy of Sciences for general public and health professionals. • Hx: WWII, to investigate issues that might “affect national defense” • Population/institutional guidelines • Application to individuals.

49. DRI’s for infants • Macronutrients based on average intake of breast milk • Protein less than earlier RDA • AAP Recommendations • Vitamin D: 200 IU supplement for breastfed infants and infants taking <500 cc infant formula • Iron: Iron fortified formula (4-12 mg/L), Breastfed Infants supplemented 1mg/kg/d by 4-6 months

50. Other Guidelines • AAP • Bright Futures • Educational or Professional teaching • Public Policy Guidelines • Consider source • Consider Purpose • ? How apply to individual