nutritional disorders
Overview of Undernutrition
Evaluation of Undernutrition
Diagnosis of undernutrition is based on results of medical and diet histories, physical examination, Body composition analysis , and selected laboratory tests. Explicit consensus criteria have been proposed but are not yet universally adopted ( History should include questions about , a nutrition screening and assessment tool that can identify patients age ≥ 65 who are undernourished or at risk of undernutrition ( Evaluation references ) , a quick way to assess the risk of undernutrition in people with chronic disorders ( Evaluation references ) Recent changes in weight Risk factors for undernutrition, including drug and alcohol use Unintentional loss of≥10% of usual body weight during a 3-month period indicates a high probability of undernutrition. Social history should include questions about food security and the patient's ability to shop and cook. ). For example, impaired night vision may indicate Vitamin A Deficiency . Physical examination should include Measurement of height and weight Inspection of body fat distribution Anthropometric measurements of lean body mass Body Mass Index (BMI) None estimates lean body mass. This area is derived from the triceps skinfold thickness (TSF) and mid upper arm circumference. Both are measured at the same site, with the patient’s right arm in a relaxed position. The average mid upper arm circumference is about 34.1 cm for men and 31.9 cm for women ( Evaluation references ). The formula for calculating the mid upper arm muscle area in cm This formula corrects the upper arm area for fat and bone. Average values for the mid upper arm muscle area are 54±11 cm2for men and 30±7 cm2for women. A value < 75% of this standard (depending on age) indicates depletion of lean body mass (see table). This measurement may be affected by physical activity, genetic factors, and age-related muscle loss. Physical examination should focus on signs of specific nutritional deficiencies. Signs of Protein-Energy Undernutrition (PEU) (eg, edema, muscle wasting, skin changes) should be sought. Examination should also focus on signs of conditions that could predispose to nutritional deficiencies, such as dental problems. The following assessment tools may be useful: The widely used Subjective Global Assessment (SGA) uses information from the patient history (eg, weight loss, change in intake, gastrointestinal symptoms), physical examination findings (eg, loss of muscle and subcutaneous fat, edema, ascites), and the clinician’s judgment of the patient’s nutritional status. has been validated and is widely used, especially in older patients. The MNA consists of 18 scored questions that are divided into four sections: anthropometric measurements, comprehensive assessment, dietary history, and metabolic stress. The possible total score is 30; scores of ≥ 24 indicate normal nutritional status, scores between 17 and 23.5 indicate risk of undernutrition, and scores of < 17 points indicate undernutrition ( Evaluation references , The Simplified nutrition assessment questionnaire (SNAQ) , a simple, validated method of predicting future weight loss, may be used. The extent of laboratory testing needed is unclear and may depend on the patient’s circumstances. If the cause is obvious and correctable (eg, a wilderness survival situation), testing is probably of little benefit. Other patients may require more detailed evaluation. and other proteins (eg, prealbumin [transthyretin], transferrin, retinol-binding protein) may indicate protein deficiency or Protein-Energy Undernutrition (PEU) (PEU). As undernutrition progresses, Total lymphocyte count,which often decreases as undernutrition progresses, may be determined. Undernutrition causes a marked decline in CD4+ T lymphocytes, so this count may not be useful in patients who have AIDS. is related to muscle mass. Urinary creatinine excretion over a 24-hour period can be used to compute the creatinine height index (CHI [%]), which reflects lean muscle mass. The CHI is calculated as (24-hour urine creatinine x 100)/ideal creatinine excretion for height (obtained from standard tables). The CHI indicates extent of muscle depletion as follows: > 30% is severe, 15 to 30% is moderate, and 5 to 15% is mild ( Evaluation references ). Initial testing None Other laboratory tests, such as measuring vitamin and mineral levels, are used selectively to diagnose specific deficiencies. 1.Cederholm T, Jensen GL, Correia MITD, et al: GLIM (Global Leadership Initiative on Malnutrition) criteria for the diagnosis of malnutrition: a consensus report from the global clinical nutrition community.Clin Nutr38 (1):1–9, 2019. doi: 10.1016/j.clnu.2018.08.002 2.Guigoz Y, Vellas B: Nutritional assessment in older adults: MNA® 25 years of a screening tool and a reference standard for care and research; What next?J Nutr Health Aging25 (4):528–583, 2021. doi: 10.1007/s12603-021-1601-y 3.Bromage S, Batis C, Bhupathiraju SN, et al: Development and validation of a novel food-based Global Diet Quality Score (GDQS).J Nutr151 (12 Suppl 2):75S–92S, 2021. doi: 10.1093/jn/nxab244 4.Fryar CD, Gu Q, Ogden CL, Flegal KM: Anthropometric reference data for children and adults: United States, 2011–2014. National Center for Health Statistics.Vital Health Stat3 (39), 2016. 5.Laporte M, Keller HH, Payette H. et al: Validity and reliability of the new Canadian Nutrition Screening Tool in the ‘real-world’ hospital setting.Eur J Clin Nutr69 (5):558–564, 2015. doi: 10.1038/ejcn.2014.270 Epub 2014 Dec 17. 6.Kaiser MJ, Bauer JM, Rämsch C, et al: Frequency of malnutrition in older adults: A multinational perspective using the mini nutritional assessment.J Am Geriatr Soc58 (9):1734–1738, 2010. doi: 10.1111/j.1532-5415.2010.03016.x 7.Guigoz Y: The Mini Nutritional Assessment (MNA) review of the literature—What does it tell us?J Nutr Health Aging10 (6):466–485; discussion 485–487, 2006. 8.Soysal P, Veronese N, Arik F, et al: Mini Nutritional Assessment Scale-Short Form can be useful for frailty screening in older adults.Clin Interv Aging14:693–699, 2019. doi: 10.2147/CIA.S196770 eCollection 2019. 9.Hamada Y: Objective data assessment (ODA) methods as nutritional assessment tools.J Med Invest62 (3–4):119–122, 2015. doi: 10.2152/jmi.62.119 