Handbook for Nutritional Assessment Through Life Cycle 9781634827683, 9781634846288

Table of contents :
HANDBOOK FOR NUTRITIONAL ASSESSMENT THROUGH LIFE CYCLE
HANDBOOK FOR NUTRITIONAL ASSESSMENT THROUGH LIFE CYCLE
Library of Congress Cataloging-in-Publication Data
CONTENTS
PREFACE
ACKNOWLEDGMENTS
SYNOPSIS
NEED FOR THE BOOK
LIST OF ABBREVIATIONS
Chapter 1 NUTRITIONAL ASSESSMENT DURING PREGNANCY
INTRODUCTION
GOALS AND OBJECTIVES
NUTRITIONAL ASSESSMENT FOR PREGNANCY
1. Relevant History
Obstetric History
Psychological History
Medical History
2. Anthropometric Measurements [12]
3. References of Laboratory Values during Pregnancy
4. Dietary Intake/Needs [1]
PROPER WAYS OF CARRYING OUT THE HISTORY OF DIETARY INTAKE
CASE STUDY
REFERENCES
Chapter 2 NUTRITIONAL ASSESSMENT DURING LACTATION
ANTHROPOMETRIC ASSESSMENT
BIOCHEMICAL ASSESSMENT
ENERGY RECOMMENDATION
CALCIUM
OTHER MICRONUTRIENTS
WEIGHT LOSS
VEGETARIANISM
REFERENCES
Chapter 3 NUTRITIONAL ASSESSMENT OF INFANCY AND CHILDHOOD
LENGTH, STATURE, AND HEAD CIRCUMFERENCE
NUTRITION ASSESSMENT DURING CHILDHOOD
CDC GROWTH CHARTS
How Touse the Chart Properly
Charts for Age 2 to 20 Years
REFERENCES
Chapter 4 NUTRITIONAL ASSESSMENT IN ADOLESCENCE
Triceps
Biceps
APPENDIX 1.
APPENDIX 2.
APPENDIX 3.
APPENDIX 4.
APPENDIX 5.
APPENDIX 6.
REFERENCES
Chapter 5 NUTRITIONAL ASSESSMENT IN ADULTS
DIETARY ASSESSMENT
NUTRIENT INTAKE ANALYSIS (NIA)
FOOD DIARY
RETROSPECTIVE DATA
FOOD FREQUENCY QUESTIONNAIRE (FFQ)
ANTHROPOMETRY
ESTIMATED WEIGHT FOR AMPUTATED BODY PARTS
Knee Height
IDEAL WEIGHT ESTIMATION
MEASURING FRAME SIZE
WRIST CIRCUMFERENCE
BODY FAT DISTRIBUTION
WAIST CIRCUMFERENCE MEASUREMENT
ARM MUSCLE CIRCUMFERENCE
ARM MUSCLE AREA (AMA)
CALF CIRCUMFERENCE (CC)
APPENDIX 1 (36).
APPENDIX 2.
REFERENCES
Chapter 6 NUTRITIONAL ASSESSMENT OF ELDERLY
MINI NUTRITIONAL ASSESSMENT (MNA)
ANTHROPOMETRIC MEASUREMENTS
Calf Circumference (CC)
MID – UPPER – ARM CIRCUMFERENCE
HEIGHT ESTIMATION
1. Knee Height
2. Demi Span
3. Half - Arm – Span
4. Ulna Length (UL)
GERIATRIC NUTRITIONAL RISK INDEX (GNRI)
CLINICAL ASSESSMENT
HYDRATION
ASSESSMENT OF HYDRATION STATUS
a. Urine Specific Gravity (USG)
b. Urine Color
c. Serum Osmolarity
d. BUN: Creatinine Ratio
APPENDIX 1.
APPENDIX 2.
APPENDIX 3.
REFERENCES
GLOSSARY
ABOUT THE AUTHORS
INDEX

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NUTRITION AND DIET RESEARCH PROGRESS

HANDBOOK FOR NUTRITIONAL ASSESSMENT THROUGH LIFE CYCLE

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NUTRITION AND DIET RESEARCH PROGRESS Additional books in this series can be found on Nova‟s website under the Series tab.

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NUTRITION AND DIET RESEARCH PROGRESS

HANDBOOK FOR NUTRITIONAL ASSESSMENT THROUGH LIFE CYCLE

GHAZI DARADKEH M. MOHAMED ESSA AND

NEJIB GUIZANI

New York

2016 by Nova Science Publishers, Inc. All rights reserved. No part of this book may be reproduced, stored in a retrieval system or transmitted in any form or by any means: electronic, electrostatic, magnetic, tape, mechanical photocopying, recording or otherwise without the written permission of the Publisher. We have partnered with Copyright Clearance Center to make it easy for you to obtain permissions to reuse content from this publication. Simply navigate to this publication‟s page on Nova‟s website and locate the “Get Permission” button below the title description. This button is linked directly to the title‟s permission page on copyright.com. Alternatively, you can visit copyright.com and search by title, ISBN, or ISSN. For further questions about using the service on copyright.com, please contact: Copyright Clearance Center Phone: +1-(978) 750-8400 Fax: +1-(978) 750-4470 E-mail: [email protected].

NOTICE TO THE READER The Publisher has taken reasonable care in the preparation of this book, but makes no expressed or implied warranty of any kind and assumes no responsibility for any errors or omissions. No liability is assumed for incidental or consequential damages in connection with or arising out of information contained in this book. The Publisher shall not be liable for any special, consequential, or exemplary damages resulting, in whole or in part, from the readers‟ use of, or reliance upon, this material. Any parts of this book based on government reports are so indicated and copyright is claimed for those parts to the extent applicable to compilations of such works. Independent verification should be sought for any data, advice or recommendations contained in this book. In addition, no responsibility is assumed by the publisher for any injury and/or damage to persons or property arising from any methods, products, instructions, ideas or otherwise contained in this publication. This publication is designed to provide accurate and authoritative information with regard to the subject matter covered herein. It is sold with the clear understanding that the Publisher is not engaged in rendering legal or any other professional services. If legal or any other expert assistance is required, the services of a competent person should be sought. FROM A DECLARATION OF PARTICIPANTS JOINTLY ADOPTED BY A COMMITTEE OF THE AMERICAN BAR ASSOCIATION AND A COMMITTEE OF PUBLISHERS. Additional color graphics may be available in the e-book version of this book.

Library of Congress Cataloging-in-Publication Data ISBN:  (eBook)

Library of Congress Control Number: 2015961019

Published by Nova Science Publishers, Inc. † New York

CONTENTS Preface

vii

Acknowledgments

ix

Synopsis

xi

List of Abbreviations

xiii

Chapter 1

Nutritional Assessment during Pregnancy

1

Chapter 2

Nutritional Assessment during Lactation

15

Chapter 3

Nutritional Assessment of Infancy and Childhood

27

Chapter 4

Nutritional Assessment in Adolescence

49

Chapter 5

Nutritional Assessment in Adults

65

Chapter 6

Nutritional Assessment of Elderly

91

Glossary

121

About the Authors

143

Index

145

PREFACE Nutritional care and management is an essential and vital component of patient care. Nutritional care process provides the basis of nutrition diagnosis and it starts with nutritional assessment. Basic and advanced practice skills to perform complete and accurate nutrition assessment are needed. This pocket guide to nutrition assessment aims to provide clinical dietitians, with up-to-date information, tools, and techniques which may be used for nutritional assessment. In this book, clinical dietitians will use the equations for energy, protein and other nutrient estimations. This pocket guide will cover the nutrition assessment of people throughout their lifetimes, from pregnancy to old age. Charts, tables and graphs, which can be used by practitioners as quick reference tools for nutritional assessment, hydration status, nutrient deficiencies and/or excess and body composition, are included in this pocket guide. Nutritional assessment includes dietary history, physical assessment, biochemical assessment, anthropometric assessment and nutrients estimations. In addition to nutritional assessment guidance, clinical dietitians will be guided also with data evaluation and how to make dietary intervention. This pocket guide book contains chapters about nutritional assessment during pregnancy, infantcy, childhood and adolescence, adulthood and old age.

ACKNOWLEDGMENTS We are greatfully indebted to members of our families for their constant support and understanding to complete this book in right time. Special thanks to Dr. Sylvia Quintana, Oman for language and technical editting. We thank the Nova Science Publishers, INC USA and its staff for their patience and assistance of this book publication stages.

Ghazi Daradkeh M. Mohamed Essa Nejib Guizani

SYNOPSIS Nutritional assessment has been considered as a cornerstone of nutritional diagnosis, management, intervention and dietary planning. Specific criteria, methods and procedures should be used for different age groups through a person‟s life cycle based on the requirements of each age group. Use of precise and accurate nutritional assessment tools and procedure to detect those who are malnourished or at risk of malnutrition will help dietitians to create an accurate dietary plan and intervention, which may help in quality of life improvement. This hand book includes the details of each assessment method for different age groups, from pregnancy to old age. It will be used as a quick, practical guide and reference for clinical dietitains. It includes dietary, anthropometric, biochemical and clinical assessments.

NEED FOR THE BOOK As a member of a medical team, a dietitian should put his/her input (i.e., a dietary plan) as a part of a comprehensive treatment plan, which is basically based on nutritional assessment. As each age group has specific methods, procedures, calculations and requirements, this book discusses in detail all the components of nutritional assessment for each group, to be easy, quick, direct and available for clinical dietitians in the field. This book includes the equations, tables, figures, and procedures for comparison with the normal references to be documented in patient records. Dietitians‟ communication with each other and healthcare providers will be through these documentations; in addition, this book will benefit nutrition and dietetics

xii

Ghazi Daradkeh, M. Mohamed Essa and Nejib Guizani

students, clinical dietitians, and health care providers (doctors, nurses, pharmacists and other disciplines). It may be used as a text book in universities as well.

LIST OF ABBREVIATIONS AC ADH AFI AGA AMA ASPEN BMI BUN CAMA CC CHO cm DBW dl ELBW ESPEN FFQ GIT Gm GNRI Ht HDL Hr Hgb Htc IDA

Arm Circumference Attention Deficit Hyperactivity Arm Fat Index Approprate for Getational Age Arm Muscle Area American Society for Parenteral and Enteral Nutrition Body Mass Index Blood Urea Nitrogen Corrected Arm Muscle Area Calf Circumference Carbohydrate Centimeter Desirable Body Weight Deciliter Extremely Low Body Weight European Society of Parenteral and Enteral Nutrition Food Frequency Questionnaire Gastrointestinal Tract Gram Geriatric Nutrition Risk Index Height High Density Lipoprotein Hour Hemoglobin Hematocrit Iron Deficiency Anemia

xiv

Ghazi Daradkeh, M. Mohamed Essa and Nejib Guizani IDD IQ IOM IBW In IV IU Kg KH L lb LBW LDL LGA M MAC mcg mEq MGRS. ml mmHg mm mmol MNA mOsm MUAA MUAFA MUAC MUAMA NCHS Ng NIA NPO NL NP NPNL PEM Pg QI

Iodine Deficiency Disorder Intelligence Qutenet Institute of Medicine Ideal Body Weight Inch Intra Venous International Unit Kilogram Knee Height Liter Pound Low Birth Weight Low Density Lipoprotein Large for Gestational Age Meter Mid Arm Circumference Microgram MilliEquivalent Multicenter Growth Reference Study Milliliter Millimeter Mercury Millimeter Millimol Mini Nutritional Assessment Milli Osmolar Mid Upper Arm Area Mid Upper Arm Fat Area Mid Upper Arm Circumference Mid Upper Arm Muscle Area National Center for Health Statistics Nano Gram Nutrient Intake Analysis Nothing Per Os Non lactating Non pregnant Non pregnant non lactating Protein Energy Malnutrition Pictogram Quetelets Index

List of Abbreviations R RDA RN SD SGA TSF UAC VAD VLBW WC WHO WHR wt µ

Ratio Recommended Dietary Allowance Registered Nurse Standard Deviation Small for Gestational Age Triceps Skin Fold Upper Arm Circumference Vitamin A Deficiency Very Low Birth Weight Waist Circumference World Health Organization Waist Hip Ratio Weight Micro

xv

Chapter 1

NUTRITIONAL ASSESSMENT DURING PREGNANCY INTRODUCTION Maternal nutrition has a critical role in the reduction of both maternal morbidity and mortality. The term Maternal Nutrition refers to nutritional status during any stage of a woman´s reproductive age that eventually could affect her health and that of the fetus and infant. There are heightened nutrient needs during pregnancy; without an increase in caloric and nutritional intake to meet the increased demands during this period, the fetus uses its own reserves making it more susceptible to pregnancy-related complications [1]. Women´s nutritional status is most vulnerable during pregnancy; maternal malnutrition becomes a cycle when malnourished mothers give birth to low birth weight infants who in turn become malnourished mothers themselves [2]. 

Basic nutritional evaluation tools during pregnancy will be detailed in this chapter, these must be used especially in high risk populations that include: Pregnant adolescents especially those out of wedlock [3, 4]. o Women with low prepregnancy weight. o Women with unfavorable prognostic factors e.g., Obesity and anemia. o Women with a history of low birth-weight infants. o Women who don‟t gain sufficient weight during their pregnancy.

2

Ghazi Daradkeh, M. Mohamed Essa and Nejib Guizani o o o

Women with a frequent history of conception. Women of low socioeconomic status. Women with diseases that can influence the nutritional status e.g., Allergy, diabetes, tuberculosis, drug addiction, and mental depression.

When nutritional assessment has been carried out successfully and high risk populations have been identified the next step would be to follow the recommendations detailed below: [5] 

   

Recommendation 1: Preconception folic acid; folic acid is provided as supplements in addition to the adequate intake of high folic acid food sources. Recommendation 2: Proper antenatal care which ensures a proper weight gain during pregnancy. Recommendation 3: Iron and vitamin A supplementation during pregnancy. Recommendation 4: Nutritional counseling and education to ensure a healthy diet during both pregnancy and lactation. Recommendation 5: Breast feeding and nutritional education during emergencies.

The main forms of maternal malnutrition include [6, 7]: 



Macronutrient deficiencies: (Protein Energy Malnutrition - PEM) which is managed by ensuring adequate variety of foods to include the 6 major groups, adequate frequency of food intake, adequate amounts of food, and proper personal and environmental hygiene. Micronutrient deficiencies: such as vitamin A deficiency (VAD), iron deficiency anemia (IDA), and iodine deficiency disorders (IDD); these conditions result in increased risk of low birth weight, maternal mortality, and neonatal and infant mortality. Anemia accounts for approximately 20% of maternal deaths as it increases the risk of both hemorrhage and prolonged labor, which can lead to sepsis. Management of micronutrient deficiency consists of supplementation with fortified foods and mineral/vitamin formulations, and adequate intake of foods rich in micronutrients such as fruits, dark-green and brightly colored vegetables.

3

Nutritional Assessment during Pregnancy

Dietitians play a vital role in the delivery of care to the patients; as an integral part of the health care team; providing patients with optimal care. Dietitians must have guidelines for giving legal aspects of documentation and avoid the pitfalls of improper investigation, assessment process, and documentation [8, 9]. Causes and consequences of maternal Malnutrition [6]: Causes and consequences of maternal Malnutrition [6]: Consequences:

Immediate causes:

Underlying Causes: o Inadequate maternal care. o Household food insecurity. o Unhealthy environment, insufficient health services, and poor hygiene and sanitation.

o Infections and diseases. o Poor access to basic health services (e.g. inadequate iron and folic acid supplementation) o Frequent parasites and infections. o Inadequate food intake due to diet characterized bylow, highly variable over seasons, and oftenlow nutrient density.

Basic Causes o Political structure o Resources and their control o Heavy workloads o Frequent births o Harmful local practices and food taboos. o Intra-household food distribution does not favor women.

Maternal Health o Increased risk of maternal death o Increased risk of infections. o Anemia o Compromised immune functions. o Lethargy and weakness. o Lower productivity.

Infant/child Health o Increased risk of fetal and neonatal death. o Intrauterine growth retardation, low birth weight, preterm birth. o Compromised immune functions. o Birth defects. o Cretinism and reduced IQ.

4

Ghazi Daradkeh, M. Mohamed Essa and Nejib Guizani

GOALS AND OBJECTIVES The main purpose of the maternal nutritional assessment is to support health care providers in the provision of maternal nutrition care and support services, it can also be used by health training institutions and other organizations, as well as other governing bodies implementing maternal nutrition interventions. These guidelines were established to break the intergeneration cycle of maternal malnutrition through outlining special nutritional aspects that enable optimal nutritional status of the mother as well as providing much safer and ideal birth outcomes. Furthermore, to improve the knowledge and skills necessary for the service providers at all levels to adequately respond to both maternal and infant nutritional needs; provide a basis for advocacy efforts which garner support for the maternal nutritional intervention at all levels. To contribute to the reduction of maternal malnutrition the implementation of the following goals must be achieved: [5, 6]:    



To improve the knowledge and skills of service providers at all levels to respond to maternal and child nutritional needs. To improve provision of quality maternal and child nutritional services at community and health facility level. To advocate for support of appropriate interventions that address maternal nutrition at all levels. To facilitate health care providers and other stakeholders in interpersonal nutrition education and counseling, community dialogue, developing the health education for improved maternal nutrition. To strengthen integration of nutrition interventions for adolescent, pregnant, and lactating women within existing health services.

NUTRITIONAL ASSESSMENT FOR PREGNANCY Pregnant females who are in general at risk for nutritional problems at even greater risk, and because of the importance of nutrition in the course and outcome of pregnancy, all pregnant women should have a formal assessment

Nutritional Assessment during Pregnancy

5

of their nutritional status at the beginning of their prenatal care with ongoing surveillance throughout the pregnancy [6]. The purpose of the nutrition assessment is to:   

Evaluate the nutritional status of the pregnant. Identify those pregnant who are at nutritional risk. Formulate an individualized nutrition care plan with follow-up.

The Nutritional assessment takes into account different aspects: including relevant obstetric, medical, psychology and diet history, BMI along with weight gain, and lab tests and values.

1. Relevant History In order to have much more precise information; the following steps will help [10, 11].

Obstetric History  Women with previous pregnancies may be at increased nutritional risk as a result of depleted nutrient reserves, the length and time between pregnancies can play a vital role as well especially if the time between pregnancies is less than one year.  History of pre-term delivery (29



Pregnancy weight gain recommendations:

Pre-pregnancy BMI categories (kg/m2)

Recommended total weight gain

1st trimester

2nd and 3rd trimester

Underweight Normal Overweight Obese Twins (any BMI) Triplet (any BMI)

12.5-18 11.5-16 7-11.5 6-7 16-20 23

2.3 1.6 0.9

0.49 0.44 0.30 ……… ……… ………

……… ……… ………

7

Nutritional Assessment during Pregnancy 

MUAC (Mid-Upper Arm Circumference) [13]:

MUAC is a good indicator of the protein reserves of a body, and a thinner arm reflects wasted lean mass, i.e., malnutrition. The WHO Collaborative Study 1995 showed MUAC cut-off values of < 21 to 23 cm as having significant risk for low birth weight (LBW).

3. References of Laboratory Values during Pregnancy (According to University of Texas Southwestern Medical Center, Department of Obstetrics and Gynecology, Dallas, TX, USA) [14]: Table 1. Hematology Tests

Non-pregnant

1st trimester

2nd trimester

3rd trimester

Erythropoietin (U/L) Ferritin (ng/ml) Hemoglobin (g/dl) Hematocrit (%) TIBC (µg/dl) RBC (x 106/mm3) WBC (x 106/mm3) Platelet (x106/L) Transferrin (mg/dl) MCH (pg/cell) MCV (µm3) Lymphocytes (x 103/mm3) Neutrophils (x 103/mm3)

4–27 10-150 12-15.8 35.4-44.4 251-406 4.0-5.2 3.5-9.1 165-415 200-400 27-32 79-93 0.7-4.6 1.4-4.6

12–25 6-130 11.6-13.9 31.0-41.0 278-403 3.42-4.55 5.7-13.6 174-391 254-344 30-32 81-96 1.1-3.6 3.6-10.1

8–67 2-230 9.7-14.8 30.0-39.0 Not reported 2.81-4.49 5.6-14.8 155-409 220-441 30-33 82-97 0.9-3.9 3.8-12.3

14–222 1-116 9.5-15.0 28.0-40.0 359-609 2.71-4.43 5.9-16.9 146-429 288-530 29-32 81-99 1.0-3.6 3.9-13.1

Table 2. Blood Chemistries Tests

Non-pregnant

1st trimester

2nd trimester

3rd trimester

ALT (U/L) AST (U/L) Alk-Phos (U/L) Pre-albumin (mg/dl) Albumin (g/dl) Bilirubin (mg/dl) Calcium (mg/dl) Chloride (mEq/L) Creatinine (mg/dl)

7–41 12–38 33–96 17–34 4.1–5.3 0.3–1.3 8.7–10.2 102–109 0.5–0.9

3–30 3–23 17–88 15–27 3.1–5.1 0.1–0.4 8.8–10.6 101–105 0.4–0.7

2–33 3–33 25–126 20–27 2.6–4.5 0.1–0.8 8.2–9.0 97–109 0.4–0.8

2–25 4–32 38–229 14–23 2.3–4.2 0.1–1.1 8.2–9.7 97–109 0.4–0.9

8

Ghazi Daradkeh, M. Mohamed Essa and Nejib Guizani Table 2. (Continued)

Tests

Non-pregnant

1st trimester

2nd trimester

3rd trimester

Lactate dehydrogenase (U/L) Magnesium (mg/dl) Phosphate (mg/dl) Total Protein (g/dl) Sodium (mEq/L) BUN (mg/dl) Uric acid (mg/dl) Copper (µg/dl) Vitamin B12 (pg/ml) Vitamin D (pg/ml) Zinc (µg/dl) Folate (ng/ml) Creatine kinase-MB (U/L) Troponin I (ng/mL)

115–221

78–433

80–447

82–524

1.5–2.3 2.5–4.3 6.7–8.6 136–146 7–20 2.5–5.6 70–140 279–966 25–45 75–120 5.4–18.0 7 days [3] Altered diets (receiving Total Parenteral or Enteral Nutrition)

NOT AT-RISK

AT-RISK

RESCREEN AT: 4. Regular intervals 5.

STABLE

When nutritional/ clinical status changes

NUTRITION ASSESSMENT  Nutrition history  Assess the anthropometric data and Laboratory data  Nutritional focused physical exam

NUTRITIONALLY AT RISK

RE-ASSESSMENT BASED ON  Clinical status changes  Nutritional status changes  Tolerance of nutrition prescription

NUTRITION CARE PLAN BASED ON:  Nutrition care objectives, including short and long term goals  Create nutrition prescription  Enteral and Parenteral Nutrition Support if needed

A.S.P.E.N. Board of Directors. Clinical Pathways and Algorithms for Delivery of Parenteral and Enteral Nutrition Support in Adults. Silver Spring, MD: A.S.P.E.N.: 1998: S. [4]. Figure 1. Adult Nutrition Screening and Assessment Algorithm.

Kcalorie counts (Figure 2), dietary intake, more extensive patient interviewing are additional dietary assessments that can be carried out if required.

68

Ghazi Daradkeh, M. Mohamed Essa and Nejib Guizani

DIETARY ASSESSMENT Dietary assessment includes: patient‟s food preferences, food allergies, food intolerance, eating patterns (meals and snack frequency, timing, location and food preparation). Dietary intake can be assessed retrospectively or prospectively depending on the purpose of the assessment. Day: Date: Meal type

Food Description

Quantity

calorie

Figure 2. KCalorie Counting Chart.

NUTRIENT INTAKE ANALYSIS (NIA) NIA is a tool used to identify nutritional inadequacies before deficiencies are developed by intake monitoring. Direct observation or inventory of food eaten based on what remains on the individual‟s tray or plate is a method of actual intake evaluation. NIA should be recorded for 72 hours to reflect an average intake of an individual correctly.

FOOD DIARY Is a tool to assess food intake by documenting dietary intake as it occurs, usually for non-hospitalized patients. To estimate dietary intake accurately, the record should be on the same day and intake calculated and averaged for 3 to 7

69

Nutritional Assessment in Adults

days and then compared to Recommended Dietary Allowance (RDAs) (Figure 3). Day_______________________________ Meal Food List

Amount Taken

How Prepared

Where (home, work, etc.,)

Breakfast Snack Lunch Snack Dinner Snack

Figure 3. Food Diary. Meal Breakfast

Day1

Day2

Day3

Day4

Day5

Day6

Day7

Snack 1 Lunch

Snack 2 Dinner

Snack 3

Figure 4. 24 hours – Recall.

RETROSPECTIVE DATA 24-Hour Recall is a method of dietary intake estimation in the last 24hours, which then can be analyzed and evaluated. Reliability and validity of dietary recall methods are important [10].

70

Ghazi Daradkeh, M. Mohamed Essa and Nejib Guizani

Retrospective methods of data collection have disadvantages which include: memory lapses, underestimation and/or over estimation of the amount consumed, inaccurate knowledge of portion sizes (Figure 4).

Once per year

Once per 3 months

Once per month

Daily

5 – 6 per week

2 – 4 per week

Once per week

Never

Food Frequency Questionnaire

Milk, yoghurt, regular fat (1 cup) Milk, yoghurt, lowfat (1 cup)

Spinac, kale, other green leafy vegetables (1/2 cup) Carrots (1medium)

Beef (3 oz)

Rice, White (1 cup)

Rice, brown (1 cup)

Cookies (2-2” diameter)

Ice cream, regular fat (1/2 cup)

47

Figure 5. Food Frequency Questionnaire.

FOOD FREQUENCY QUESTIONNAIRE (FFQ) Is a retrospective review of intake frequency that is calculated by food consumed per day, per week, per month? The food frequency chart organizes foods into groups that have common nutrients, because the focus of the food frequency is on the final group rather than the specific nutrientsthe information gathered is general (Figure 5).

Nutritional Assessment in Adults

71

Table 1. Summarize the advantages and disadvantages on dietary intake data [11] Method Nutrient Intake Analysis Daily Food record/diary

Food frequency

24-hour recall

Advantages -Allows actual observation of food intake -Provides daily record of food consumption -Can provide information on quantity of food, how prepared, and timing of meals and snacks -Easily standardized -Can be beneficial when considered in combination with usual intake -Provides overall picture of intake -Quick -Easy

Disadvantages -May yield inconsistent and subjective estimates of food consumption -possible variation in portion size -Variable literacy skills of subjects -Requires ability to measure/judge portion sizes -Actual food intake possibly influenced by the recording process -Questionable reliability of records -Requires literacy skills -Does not provide meal pattern data -Requires knowledge of portion sizes

-Relies on memory -Requires knowledge of portion sizes -May not represent usual intake -Requires interviewing skills

Complied from informationin Hopkins B. Assessment of nutritional status in: gottschlich MM, Matarese LE, Shronts EP, (eds). Nutrition Support Dietetics,2nd ed. Silver Spring, MD: American Society for Parenteral and Enteral Nutrition 1993. pp. 16-17.

ANTHROPOMETRY Anthropometric assessment is one of the components of nutritional assessment, it deals with physical measurement of individuals and relates them to standards for growth and development evaluation. The two most important measurements are weight and height. Unintentional weight loss is an indicator of serious disease [12]. Weight is important for energy expenditure estimation and in Quetelet‟s Index (BMI) [13]. Height is essential for quetelets index (QI), creatinine height index, and body surface area and energy expenditure calculations [14]. Body weight gain may indicate fat and/or lean tissue repletion, fluid retention or fluid overload as in edema, ascites, and pleural effusion; while weight loss may indicate presence of a disease or nutritional impairment.

72

Ghazi Daradkeh, M. Mohamed Essa and Nejib Guizani

Weight loss may result from use of diuretics which increase renal excretion, because of these changes body weight needs to be evaluated carefully. Weight may be evaluated by comparing it with desirable or reference weight, it can be expressed as a percent of desirable body weight as: % desirable body weight = current weight/desirable weight X 100 % DBW of ≤80% is considered as substandard [15]. 80% DBW means the patient is 20% below the desirable body weight. Nutritional status may be indicated by using recent body weight changes than the static weight measurement [16]. Changes in body weight can be assessed by calculation of percentage of usual weight by using the following equation: % Usual weight= current weight/usual weight x 100 Usual weight can be obtained by patient or his relatives or from patient medical record. Percent weight change is another approach to assess recent changes in body weight using the following formula [16, 17]: % Weight change = usual weight - current weight/usual weight * 100 Weight loss can be classified as in Box 2. Box 2. Classification of weight loss < 5% 5% - 10% > 10%

- Small - Potentially significant - Definitely significant

Corish CA, Kennedy NP.2000. Protein – energy undernutrition in hospital in - patients. British Journal of Nutrition 83:575-591. Detsky AS, Smalley PS, Chage J.1994. Is this patient malnourished? Journal of the American medical association, 271:54-58.

73

Nutritional Assessment in Adults

Case Study 1 Mrs. Jee is 46 years old, female, white, married with 3 children, working eight hours daily as a secretary, was admitted to orthopedic surgery unit, she is unable to stand because of hip fracture, mid arm circumference 32 cm and knee height 46 cm, calculate the estimated weight for Mrs. Jee. From table 3 below the suitable equation for Mrs. Jee weight estimation is: Weight = (KH X 1.01) + (MAC X 2.81) - 66.04 Weight = (46 X 1.01) + (32 X 2.81) – 66.04 Weight = 46.46 + 89.92 – 66.04 Weight = 70.34 kg

Table 2. Equations for Estimating Body Weight from Knee Height (KH) and mid arm Circumference (MAC) for Various Groups Age*

Race

6 – 18 6 – 18 19 - 59 19 - 59 60 - 80 60 - 80

Black White Black White Black White

6 – 18 6 – 18 19 - 59 19 - 59 60 - 80 60 - 80

Black White Black White Black White

Equation** Females Weight = (KH x 0.71) + (MACx2.59) - 50.43 Weight = (KH x 0.77) + (MACx2.47) - 50.16 Weight = (KH x 1.24) + (MACx2.97) - 82.48 Weight = (KH x 1.01) + (MACx2.81) - 66.04 Weight = (KH x 1.50) + (MACx2.58) - 84.22 Weight = (KH x 1.09) + (MACx2.68) - 65.51 Males Weight = (KH x 0.59) + (MACx2.73) - 48.32 Weight = (KH x 0.68) + (MACx2.64) - 50.08 Weight = (KH x 1.09) + (MACx3.14) - 83.72 Weight = (KH x 1.19) + (MACx3.21) – 86.82 Weight = (KH x 0.44) + (MACx2.86) - 39.21 Weight = (KH x 1.10) + (MACx3.07) - 75.81

Accuracy ±7.65 kg ±7.20 kg ±11.98 kg ±10.60 kg ±14.52 kg ±11.42 kg ±7.50 kg ±7.82 kg ±11.30 kg ±11.42 kg ±7.04 kg ±11.46 kg

Adapted from Chumlea WC, Guo S, Roche AF, Steinbaugh ML.1988. Prediction of body weight for the no ambulatory elderly from anthropometry. Journal of the American dietetic association 88:564-568. *Age (in years) is rounded to the nearest year. **Weight is in kg: lb÷2.2 = kg, kg x 2.2 = lb, Knee Height is in cm: in. x 2.54 = cm, cm ÷ 2.54 = in.

Body weight change > 0.5 kg/day indicates an accumulation or loss of water and not loss or gain of fat or lean tissue, this means body fluid level changes is the main cause of rapid weight change. Metric measures such as subscapular skin fold, Knee height (KH), mid arm circumference and calf circumference can be used for ambulatory patient‟s weight estimation [18]. Table 2 summarizes the equations that can be used for weight estimation.

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Patient age and the anthropometric measures that are available are the main determinants of which equation to use.

ESTIMATED WEIGHT FOR AMPUTATED BODY PARTS The patient‟s current weight can be adjusted to account for the weight of the amputated body part, if the patient has had an amputation. The following equation can be used to calculate adjusted body weight [15, 32]. Adjusted weight = Current weight/100 - % of amputation x 100 Table 3 shows the percent of total body weight contributed by amputated body parts of individual. Table 3. Percent of total body weight contributed by individual body parts Body part (%) contribution to 6.5 Entire arm Upper arm 3.5 Forearm 2.3 Hand 0.8 Entire leg 18.5 Upper leg 11.6 Lower leg 5.3 Foot 1.8 Adapted from Brunnstrom S. 1983, clinical kinesiology, 4th ed. Philadelphia: Davis.

Case Study 2 Mr. x is a 58 years old type 2 diabetic patient, his current weight is 72 kg, he has amputated at the left knee (left lower leg and foot removed). Calculate the adjusted weight for Mr. X From Table 3 above leg and foot contribute approximately 7.1% of total body. Adjusted wt. = 72/(100-7.1) x 100 = 77.5 kg The adjusted weight of Mr. X is approximately 77.5 kg without amputation.

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Adapted from Chumlea WC, Guo SS, Steinbaugh ML.1994. Prediction of stature from knee height for black and white adults and children with application to mobility – impaired or handicapped persons. Journal of the American Dietetic Association 94:1385-1388. Figure 6. Knee height measurement.

Knee height measurement, Knee height was defined as the distance from the sole of the foot to the most anterior surface of the femoral condyles of the thigh (medial being more anterior), with the ankle and knee each flexed to a 90° angle. Teichtahl et al. BMC Musculoskeletal Disorders 2012 13:19 doi: 10.1186/1471-2474-13-19. Figure 7. Knee Height Measurements by Boardable Sliding Caliper.

Knee Height Knee height can be used for height estimation for patients who cannot stand or with skeletal deformities, severe arthritis paralysis and amputation [14, 18], knee height is the most common approach for height estimation because it has been shown to correlate highly with height [14, 19, 20]. The Quetelet‟s index (BMI) can be calculated and compared with various standards. Knee height measurement, using large, boardable sliding calipers [23] while the subject in the supine position (lying facing up) [14, 18, 21, 22].

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Knee and ankle of left leg are positioned are at 90º degree angle (Figures 6 and 7). Table 4. Equations for Estimating Height from Knee Height for Various Groups Age Equation Error Black Females > 60 H = 58.72 + (1.96 KH) 8.26cm 19 – 60 H = 68.10 + (1.86 KH) - (0.06 A) 7.60cm 6 – 18 H = 46.59 + (2.02 KH) 8.78cm White Females > 60 H = 75.00 + (1.91 KH) – (0.17A) 8.82 cm 19 – 60 H = 70.25 + (1.87 KH) -(0.06 A) 7.20 cm 6 – 18 H = 43.21 + (2.14 KH) 7.80 cm Black Males > 60 H = 95.79 + (1.37 KH) 8.44 cm 19 – 60 H = 73.42 + (1.79 KH) 7.20 cm 6 – 18 H = 39.60 + (2.18 KH) 9.16 cm White Males > 60 H = 59.01 + (2.08 KH) 7.84 cm 19 – 60 H = 71.85 + (1.88 KH) 7.94 cm 6 – 18 H = 40.54 + (2.22 KH) 8.42 cm Adapted from Chumlea WC, Guo SS, Steinbaugh ML.1994. Prediction of stature from knee height for black and white adults and children with application to mobility – impaired or handicapped persons. Journal of the American Dietetic Association 94:1385-1388. * Age in years rounded to the nearest year. H = height KH = Knee height A = age in years. Estimated height will be within this value of 95% of persons within each age, sex, race group.

Researchers developed the equations that can be used for height estimation. Table 4 [14] shows the sex-age and race-specific equations for height estimation of children, adults and older persons. Knee height for persons 60 to 90 years old can be estimated by using the nomogram.

IDEAL WEIGHT ESTIMATION Ideal body weight can be determined by variety of approaches, Hamawi equations is one of the most used equation:

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IBW Male = 48.8 kg for the first 150 cm + 1.1 kg for each cm over 150 cm or (- 1.1) for each cm under 150cm IBW Female = 45.5 kg for the first 150 cm + 0.91 kg for each cm over 150 cm or (- 0.91) for each cm under 150 cm

MEASURING FRAME SIZE Frame size can be measured by several methods including the ratio of height to wrist circumference [34]. The frame size can be calculated by using the following formula, and classified as small, medium and large (Table 5). r = ht/c r: The ratio of body height to wrist circumference ht: Body height in (cm) c: Circumference of the right wrist in (cm).

WRIST CIRCUMFERENCE Wrist circumference is measured just distal to the styloid process at the wrist crease on the right arm using measurement tape (Figure 8). To measure the wrist circumference, the arm should be flexed at the elbow, and the hand muscles relaxed. The tape should be perpendicular to the long axis of the forearm. The tape should be touching the skin but not compressing the soft tissues, measurement is recorded to the nearest 0.1cm [35]. Table 5. Determining frame size for males and females r - Value Frame size Women Men Small > 10.9 >10.4 Medium 10.9 – 9.9 10.4 – 9.6 Large < 9.9 < 9.6 Grant JP, Custer PB, Thurlow J. 1981. Current techniques of nutritional assessment. Surgical Clinics of North America 61:437-463.

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Adapted from Grant JP, Custer PB, Thurlow J. 1981. Current techniques of nutritional assessment. Surgical Clinics of North America 61:437-463. Figure 8. Measurement of Wrist Circumference.

BODY FAT DISTRIBUTION Body fat distribution is an important concern of health implications of obesity [37-39]. Fat distribution within the body is more important than quantity of body fat, it can be classified in to two types: (1) upper body, or male type (android) and (2) lower body, or female type (gynoid) [38]. Table 6. Waist – Hip Ratio and health risk Male ≤ 0.95 0.96 – 1.0 > 1.0

WHR Female ≤ 0.8 0.81 – 0.85 > 0.85

Health Risk Men Low Moderate High

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Nutritional Assessment in Adults Table 7. Height -Weight Table for Persons Ages 25 to 59 Years (Height without shoes, Weight without Clothing*) In.

Height cm

61 62 63 64 65 66 67 68 69 70 71 72 73 74 75

155 157 160 163 165 168 170 173 175 178 180 183 185 188 191

Ib

Small Frame kg

Ib

Medium Frame kg

Ib

Large frame kg

Men 123-129 125-131 127-133 129-135 131-137 133-140 135-143 137-146 139-149 141-152 144-155 147-159 150-163 153-167 157-171

56-59 57-60 58-60 59-61 60-62 60-64 -61-65 6-2-66 63-68 64-69 65-70 67-72 68-74 70-76 71-78

126-136 57-62 133-145 60-66 128-138 58-63 135-148 61-67 130-140 59-64 137-151 62-69 132-143 60-65 139-155 63-70 134-146 61-66 141-159 64-72 137-149 62-68 144-163 65-74 140-152 64-69 147-167 67-76 143-155 65-70 150-171 68-78 146-158 66-72 153-175 70-80 149-161 68-73 156-179 71-81 152-165 69-75 159-183 72-83 155-169 70-77 163-187 74-85 159-173 72-79 167-192 76-87 162-177 74-80 171-197 78-90 166-182 75-83 176-202 80-92 Women 57 145 99-108 45-49 106-118 48-54 115-128 52-58 58 157 100-110 45-50 108-120 49-55 117-131 53-60 59 150 101-112 46-51 110-123 50-56 119-134 54-61 60 152 103-115 47-52 112-126 51-57 122-137 55-62 61 155 105-118 48-54 115-129 52-59 125-140 57-64 62 157 108-121 49-55 118-132 55-61 128-144 58-65 63 160 111-124 50-56 121-135 55-61 131-148 60-67 64 163 114-127 52-58 124-138 56-63 134-152 61-69 65 165 117-130 53-59 127-141 58-64 137-156 62-71 66 168 120-133 55-60 130-144 59-65 140-160 64-73 67 170 123-136 56-62 133-147 60-67 143-164 65-75 68 173 126-139 57-63 136-150 62-68 146-167 66-76 69 175 129-142 59-65 139-153 63-70 149-170 68-77 70 178 132-145 60-66 142-156 65-71 152-173 69-79 71 180 135-148 61-67 145-159 66-72 155-176 70-80 Adapted from 1983 Metropolitan height and weight tables. 1983. Statistical bulletin of the metropolitan life insurance company 64 (jam-Jun):3 [36]. Height without shoes obtained by subtracting 1 in. from heights with shoes for males and females weight without clothes obtained by subtracting 5 lb and 3 lb from weight with clothes for males and females, respectively.

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Case Study 3 Peter is 21 years old white man admitted to accident and emergency department because of car accident, he is unable to stand due to multi fractures, his weight 72 kg, and knee height was 51 cm, wrist circumference 22cm 1. Estimate his height. 2. Calculate his ideal body weight. 3. determine his frame size Numerous studies have shown that person with android obesity are at more risk for insulin resistance, hyper insulinemia, and pre - diabetes, type 2 diabetes mellitus, hypertension, hyperlipidemia and stroke as well as risk for death [38-39, 40 - 42]. Total abdominal fat or adipose tissue present in three regions: Subcutaneous (just under the skin), Visceral (surrounding the organs within the peritoneal cavity), and retroperitoneal (outside of and posterior to the peritoneal cavity). Total abdominal fat can be assessed by two approaches that are relatively easy to practice in clinical setting: Waist – to- hip ratio (WHR) and waist circumference WC is calculated by dividing the waist circumference by the hip (gluteal) circumference (Table 6). Height -Weight with relation to frame size for Persons Ages 25 to 59 Years can be predicted from reference Tables (Table 7).

Figure 9. Waist Measurement.

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Figure 10. Measurement of Arm Circumference.

WAIST CIRCUMFERENCE MEASUREMENT To measure waist circumference, locate the upper hipbone at the top of the right iliac crest, measuring tape is placed horizontal around the abdomen at the level of the iliac crest at fixed position, sung the tape but does not compress the skin, take the measurement at the end of normal expiration [39].

ARM MUSCLE CIRCUMFERENCE Arm Muscle Circumference (AMC) is estimated from Arm Circumference (AC) and Triceps Skin Fold Thickness (TSF) [18, 25, 26], it is accepted as measure of nutritional status as it is an indicator of muscle and subcutaneous adipose tissue. A non-stretchable measuring tape is placed around the arm, while the arm is relaxed, perpendicular to the long axis of the arm at the level of triceps skinfold site (Figure 10). Measurement must without compression of soft tissue and should be recorded to the nearest 0.1cm. Arm circumference can be measured in the supine position, either with the right or left side [18, 27]. AMC (cm) = AC (cm) - [π X TSF (cm)] [28]

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ARM MUSCLE AREA (AMA) Arm muscle area is an important indicator of nutritional status and used as index of lean tissue or muscle in body [18, 28], Arm muscle area (AMA) is an estimation of the area of the bone and muscle portions of the upper arm [29], it is calculated from triceps skinfold measurement and the mid arm circumference. AMA is correlated with creatinine excretion in children [30], and with total body muscle mass in adult [24]. It can be calculated by the standard equation below. Table 8 shows the guidelines for interpretation of age/sex percentile values for arm muscle area [28]. Appendix 1 and Appendix 2 show mid – upper arm muscle area (cm²) by age for males and females respectively: AMA (cm)2 = [MAC (cm) – (π X TSF(cm))] 2/4 π AMA: arm muscle area in mm2, MAC: mid arm circumference in mm, and TSF: triceps skinfold thickness in mm. Table 8. Show the guidelines for interpretation of age/sex percentile values for arm muscle area Percentile Category < 5th Wasted th th >5 but ≤ 15 Below average >15th but < 85th Average >85th but ≤ 95th Above average th >95 High muscle Adapted from Frisancho AR. Anthropometric standards for the assessment of growth and nutritional status. Ann Arbor: University of Michigan Press.

The Corrected Arm Muscle Area (CAMA) is an estimation of the area of the muscle portions of the upper arm, attempting to eliminate the area due to bone [29]. To correct the overestimation of AMA, Heymsfield and coworkers [24] developed the following revised equations by subtracting a constant that represent bone, nervous tissue, and vascular tissue in the upper arm: CAMA (cm)² for males = [MAC (cm) – (π X TSF(cm))]²/4 π] - 10 CAMA (cm)² for females = [MAC (cm) – (π X TSF(cm))]²/4 π] – 6.5

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Where cAMA: corrected arm muscle area in cm², MAC: mid arm circumference in cm and TSF: triceps skinfold thickness in cm. The Mid-Upper Arm Fat Area (MUAFA) is an estimation of the area of the fat portions of the upper arm, and is simply the difference between the MUAA and the MUAMA [31]. MUAFA = MUAA - MUAMA Arm Fat Index (AFI), a percentage of the arm that is fat, using the following formula [31]. AFI = 100 X MUAFA/MUAA

CALF CIRCUMFERENCE (CC) Measure the largest part of the calf. You may need to search for the largest part of the calf by measuring above and below the middle of the calf

Figure 11. Calf measurement, measure the largest part of the calf by measuring above and below the middle of the calf.

APPENDIX 1 (36). Mean (M), standard deviation (SD), and percentiles of mid-upper arm muscle area (cm²) by age for males of 2 to 90 years Age Group (years)

Mean Age (years)

N

M

SD 5th

10th

15th

25th

Percentile 50th 75th

85th

90th

95th

12.5 13.7 14.3 15.1 16.3 17.7 19.1 20.5 22.0 23.9 26.7 30.3 34.7 38.9 42.6 45.3 47.5 48.2 51.4 55.2 56.2 55.8 52.7 48.8 42.9

13.2 14.5 15.2 16.1 17.4 19.0 20.5 22.0 23.7 25.9 29.1 33.0 37.7 42.0 45.8 48.8 51.2 51.8 55.4 59.4 60.5 59.7 56.5 52.2 46.0

14.5 16.1 16.9 18.1 19.8 21.5 23.2 25.1 27.2 30.2 34.1 38.7 43.7 48.3 52.5 56.0 58.6 59.4 63.8 68.1 69.1 67.8 64.4 59.2 52.4

16.9 18.9 19.9 21.6 23.9 26.2 28.2 30.7 33.7 38.0 43.5 49.2 54.9 59.9 64.6 69.0 72.2 73.1 79.1 84.0 84.8 82.3 78.6 71.8 63.9

17.5 19.6 20.7 22.5 25.0 27.4 29.5 32.2 35.5 40.1 46.0 52.1 58.0 63.0 67.9 72.5 75.8 76.7 83.2 88.3 89.0 86.1 82.4 75.2 66.9

18.5 20.7 21.9 23.9 26.7 29.3 31.6 34.5 38.2 43.4 50.1 56.6 62.7 67.8 72.9 78.0 81.5 82.5 89.6 95.0 95.6 92.1 88.3 80.4 71.7

Males 2.0-2.9 3.0-3.9 4.0-4.9 5.0-5.9 6.0-6.9 7.0-7.9 8.0-8.9 9.0-9.9 10.0-10.9 11.0-11.9 12.0-12.9 13.0-13.9 14.0-14.9 15.0-15.9 16.0-16.9 17.0-17.9 18.0-18.9 19.0-19.9 20.0-29.9 30.0-39.9 40.0-49.9 50.0-59.9 60.0-69.9 70.0-79.9 80.0-89.9

2.46 3.45 4.47 5.43 6.45 7.47 8.46 9.50 10.45 11.44 12.47 13.47 14.49 15.45 16.45 17.45 18.45 19.43 24.96 34.72 44.35 54.89 64.83 74.16 84.09

548 481 542 492 258 271 257 282 287 272 201 188 179 177 191 188 167 154 1564 1405 1158 815 1122 820 635

14.7 16.4 17.4 18.2 19.3 20.8 22.8 25.6 28.6 32.1 36.1 40.0 44.1 47.9 51.6 55.0 58.0 60.6 64.5 66.6 69.9 67.4 64.8 59.5 52.7

2.2 2.5 2.8 3.1 3.6 3.9 4.3 5.0 5.9 7.2 8.0 9.4 9.8 9.5 10.4 11.2 11.7 12.2 13.4 13.5 12.8 12.6 12.4 11.1 10.1

11.4 12.4 13.0 13.6 14.6 15.8 17.0 18.2 19.3 20.8 23.1 26.3 30.3 64.3 37.6 40.0 42.0 42.6 45.2 48.7 49.8 49.7 46.8 43.5 38.1

12.0 13.1 13.8 14.5 15.6 16.9 18.2 19.6 20.9 22.6 25.2 28.6 32.9 37.0 40.5 43.1 45.2 45.8 48.8 52.4 53.5 53.3 50.2 46.5 40.9

16.0 17.9 18.8 20.3 22.4 24.4 26.4 28.6 31.3 35.0 40.0 45.3 50.7 55.6 60.1 64.2 67.1 68.0 73.4 78.1 79.0 76.9 73.3 67.2 59.6

APPENDIX 2. Mean (M), standard deviation (SD), and percentiles of mid-upper arm muscle area (cm²) by age for females of 2 to 90 years Age Group (years)

Mean Age (years)

N

2.0-2.9 3.0-3.9 4.0-4.9 5.0-5.9 6.0-6.9 7.0-7.9 8.0-8.9 9.0-9.9 10.0-10.9 11.0-11.9 12.0-12.9 13.0-13.9 14.0-14.9 15.0-15.9 16.0-16.9 17.0-17.9 18.0-18.9 19.0-19.9 20.0-29.9 30.0-39.9 40.0-49.9 50.0-59.9 60.0-69.9 70.0-79.9 80.0-89.9

2.45 3.46 4.43 5.46 6.47 7.44 8.47 9.43 10.43 11.46 12.46 13.45 14.47 15.47 16.46 17.45 18.43 19.48 24.91 34.85 44.28 54.83 64.82 74.46 84.45

534 554 526 540 272 263 245 266 254 281 216 224 218 187 216 202 178 182 1766 1698 1227 928 1092 899 696

M

SD 5th

15.0 14.7 15.3 10.8 18.8 20.9 23.2 25.4 27.6 29.7 31.5 33.1 34.5 35.6 36.6 37.4 38.0 38.5 39.9 42.3 44.8 45.7 45.1 43.7 41.0

2.2 2.4 2.6 3.1 3.6 4.2 4.5 5.6 5.5 6.5 6.9 7.3 7.6 8.0 8.2 8.6 8.7 8.8 9.1 10.5 11.3 11.7 11.7 11.3 10.5

10.9 11.9 12.7 13.2 13.6 14.0 14.6 15.7 17.7 20.2 22.6 24.3 25.1 25.1 24.9 24.7 24.9 25.3 26.4 27.4 29.0 28.8 28.1 27.5 26.2

10th 15th Females 11.5 12.0 12.6 13.1 13.5 14.0 14.1 14.7 14.6 15.4 15.1 15.8 15.7 16.6 17.0 17.9 19.2 20.3 21.9 23.2 24.5 25.9 26.3 27.8 27.2 28.7 27.2 28.7 27.1 28.6 26.8 28.4 27.0 18.6 27.5 29.1 28.7 30.3 30.0 31.9 31.8 33.9 31.7 33.7 30.9 32.9 30.2 32.2 28.8 30.7

25th

Percentile 50th 75th

85th

90th

95th

12.6 13.9 15.0 15.7 16.5 17.1 17.9 19.4 21.9 25.1 28.0 30.1 31.1 31.2 31.0 30.9 31.1 31.6 32.9 34.9 37.1 37.0 36.2 35.3 33.7

14.0 15.5 16.8 17.8 18.8 19.6 20.7 22.5 25.5 29.1 32.5 35.0 36.1 36.2 36.1 36.1 36.3 36.9 38.4 41.3 44.1 44.1 43.1 42.1 40.1

16.4 18.3 20.1 21.5 22.9 24.1 25.7 28.2 32.0 36.6 40.8 43.9 45.3 45.6 45.4 45.8 46.0 46.7 48.6 53.4 57.2 57.4 56.2 54.9 52.2

17.0 19.0 20.9 22.5 24.0 25.3 27.1 29.7 33.7 38.6 43.1 46.3 47.8 48.2 48.0 48.4 48.7 49.4 51.3 56.7 60.9 61.2 59.9 58.5 55.6

18.0 20.1 22.2 24.0 25.8 27.3 29.2 32.2 36.5 41.8 46.6 50.1 51.8 52.2 52.0 52.6 52.9 53.6 55.7 62.0 66.7 67.1 65.7 64.2 61.0

15.5 17.2 18.9 20.1 21.4 22.4 23.8 26.1 29.5 33.8 37.7 40.5 41.9 42.1 41.9 42.1 42.4 43.0 44.7 48.8 52.2 52.4 51.2 50.1 47.6

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[34] [35]

[36]

Ghazi Daradkeh, M. Mohamed Essa and Nejib Guizani Published Data and Recommendations for Future Research Directions. American journal of clinical nutrition 66:683-706. Chumula WC, Roche AF.1988. Assessment of the nutritional status of healthy and handicapped adults. In Lohman TG, Roche AF, Martorell R (eds.), Anthropometric standardization reference manual. Champaign, IL:Human Kinetics Books. Callaway CW, Chumelea WC, Bouchard C, Himes JH, Lohman TG, Martin AD, Mitchell CD, Mueller WH, Roche AF, Seefeldt VD,1988. Circumferences. In Lohman TG, Roche AF, Martorell R (eds.), Anthropometric standardization reference manual. Champaign, IL: Human Kinetics Books. Frisancho AR, 1981. New norms of upper limb fat and muscle areas for assessment of nutritional status. American journal of clinical nutrition 34:2540-2545. Michele Grodner, Sara Long, and Sandra DeYoung (2004). ”Nutrition in Patient Care.” In Sandra DeYoung. Foundations and clinical applications of nutrition: A nursing approach (3rd ed.). Elsevier Health Sciences. pp. 406–407. Hopkins B, 1993. Assessment of nutritional status. In Gottschlich MM, Matarese LE, Shronts EP, eds. Nutrition support dietetics core curriculum, 2nd ed. Silver Spring, MD: American Society for Parenteral and Enteral Nutrition. A. Roberto Frisancho (1990). Anthropometric standards for the assessment of growth and nutritional status. University of Michigan Press. pp. 17–18, 20–23. Brunnstrom S. 1983. Clinical Kinesiology,4th ed. Philadelphia: Davis. 33. Hamwi GJ. Therapy: changing dietary concepts. In: Diabetes Mellitus: Diagnosis and Treatment (vol. 1). Danowski TS (ed). American Diabetes Association. New York. 1964, pp73-8. Grant JP, Custer PB, Thurlow J. 1981. Current techniques of nutritional assessment. Surgical Clinics of North America 61:437-463. Callaway CW, Chumlea WC, bounchard C, Himes, JH, Lohman GT, Martin AD, Mitchell CD, Mueller WH, Roche AF, Seefeldt VD 1998. Circumferences. In Lohman TG, Roche AF, Martorell R, eds. Anthropometric Standardization Reference Manual. Champaign, IL: Human Kinetics Books. Metropolitan height and weight tables. 1983. Statistical Bulletin of the Metropolitan Life Insurance Company 64 (Jan-Jun):2.

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[37] Food and Nutrition Board, National Research Council. 1989. Diet and Health: Implications for reducing chronic disease risk. Washington, dc: National academy press. [38] National Task Force on the Prevention and Treatment of Obesity.2000. Overweight, obesity, and health risk. Achieve of internal medicine 160:898-904. [39] National Institutes of Health. 1998. Clinical Guidelines on the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults. National Heart, Lung and Blood Institute. NIH publication number 98 – 4083. [40] Yang Y, Rim EB, Stampfer MJ, Willet WC, HU FB. 2005. Comparison of abdominal obesity and overall obesity in predicting risk of type 2 diabetes among men. American journal of clinical nutrition 81:555563. [41] Bray GA, Champagne CM, 2004. Obesity and the metabolic syndrome: Implication for dietetics practitioners. Journal of the American Dietetic Association 104:86-89. [42] Kaye SA, Folsom AR, Prineas RJ, Potter JD, Gapstur SM. 1990. The association of body fat distribution with life style and reproductive factors in population study of postmenopausal women. International Journal of Obesity 14: 583 – 591.

Chapter 6

NUTRITIONAL ASSESSMENT OF ELDERLY Nutrition care has a strong focus on disease prevention through healthy life styles in the elderly. Health promotion and disease prevention can be achieved by proper nutrition, independence, improving self-care behaviors and good quality of life education programs and strategies are necessary for elderly to teach them how to eat healthier, do exercise safely and stay motivated. Aging is a normal biologic process, organs change with age, some physiological functions may decline and they do differently between individuals and within organs. These changes can happen as a result of the aging process or as caused by chronic disease such as atherosclerosis. Body composition changes with age, fat mass and visceral fat increase, while lean muscle mass decreases. Loss of muscle mass, strength and function (sarcopenia) are age – related, which lead to alteration of metabolic rate, decrease mobilization and increase risk for falls and quality of life significantly affected [1]. As the number of older adults (65 years of age or older) is increasing worldwide rapidly, poor appetite, low food intake, low food variety among elderly people may expose them to risk of malnutrition [2]. Malnutrition is defined as an imbalance of energy, protein and other nutrient intake that may causes negative effect on body forms, function and clinical outcomes [3]. Malnutrition is more common in the older population. It is usually associated with impaired muscle function, decreased bone mass, impaired status, anemia, decrease cognitive function, immune dysfunction, poor and delayed wound healing, delay of post surgery recovery, increase hospital length of stay, increased hospital readmission rate, increase mortality

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rate and increase cost [4]. Different age related changes in older ages cause reduce in appetite and energy intake has been termed as "anorexia of aging" (Figure 1) [5]. Early nutrition assessment of malnutrition or risk of malnutrition provide the opportunity to start early treatment and reduce the risk of morbidity and mortality, length of hospital stay and cost in this population [6].

MINI NUTRITIONAL ASSESSMENT (MNA) Mini nutritional assessment (MNA) was recommended by European Society of Parenteral and Enteral Nutrition (ESPEN) guidelines for detection of elderly people (>65 years) who are malnourished or at risk of malnutrition [7]. MNA is 18 – items questionnaire published by Guigoz et al. [8], it consist of 6 questions on food intake, weight loss, mobility, psychological stress or acute disease, presence of dementia or depression, and Body Mass Index (BMI). Alternate measurements such as calf circumference may be used when height and/or weight cannot be assessed for BMI calculation scoring. MNA categorizes the nutritional status of elderly into 3 – categories according to scores as: 12 – 14 are normal nutritional status, 8 – 11 indicate at risk of malnutrition, 0 – 7 indicate malnutrition. No laboratory data are needed for MNA (Figure 2).

ANTHROPOMETRIC MEASUREMENTS Calf Circumference (CC) Measure the largest part of the calf. You may need to search for the largest part of the calf by measuring above and below the middle of the calf, see Figure 11, Chapter 3.

Energy Expenditure

Physiological changes with Aging 1. 2. 3. 4.

Hormonal Cytokines Taste & smell Changes in GI tract

Anorexia of Aging

Exercise

Pathological changes with Aging    

Figure 1. A depletion of the “anorexia of aging.”

Medical Drugs Psychological Social

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Last name: First name: Sex: Age: Date:

Weight,

kg:

Height,

cm:

Complete the screen by filling in the boxes with the appropriate numbers. Total the numbers for the final screening score. Screening A Has food intake declined over the past 3 months due to loss of appetite, digestive problems, chewing or swallowing difficulties? 0 = severe decrease in food intake 1 = moderate decrease in food intake 2 = no decrease in food intake B Weight loss during the last 3 months 0 = weight loss greater than 3 kg (6.6 lbs) 1 = does not know 2 = weight loss between 1 and 3 kg (2.2 and 6.6 lbs) 3 = no weight loss C Mobility 0 = bed or chair bound 1 = able to get out of bed/chair but does not go out 2 = goes out D Has suffered psychological stress or acute disease in the past 3 months 0 = yes 2 = no E Neuropsychological problems 0 = severe dementia or depression 1 = mild dementia 2 = no psychological problems F1 Body Mass Index (BMI) (weight in kg)/(height in m2) 0 = BMI less than 19 1 = BMI 19 to less than 21 2 = BMI 21 to less than 23 3 = BMI 23 or greater IF BMI IS NOT AVAILABLE, REPLACE QUESTION F1 WITH QUESTION F2. DO NOT ANSWER QUESTION F2 IF QUESTION F1 IS ALREADY COMPLETED. F2 Calf circumference (CC) in cm 0 = CC less than 31 3 = CC 31 or greater Screening score (max. 14 points) 12-14 points: Normal nutritional status 8-11 points: At risk of malnutrition 0-7: Malnourished

Figure 2. Mini Nutritional Assessment (MNA) (8).

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MID – UPPER – ARM CIRCUMFERENCE Arm muscle circumference (AMC) is estimated from arm circumference (AC) and Triceps Skin Fold Thickness (TSF) [9, 10, and 11]; it is accepted as measure of nutritional status as it is an indicator of muscle and subcutaneous adipose tissue. A non-stretchable measuring tape is placed around the arm, while the arm is relaxed, perpendicular to the long axis of the arm at the level of triceps skinfold site (see Figure 10, chapter 3). Measurement must without compression of soft tissue and should be recorded to the nearest 0.1cm. Arm circumference can be measured in the supine position, either with the right or left side [9, 12]. AMC (cm) = AC (cm) - [π X TSF (cm)] [13]

HEIGHT ESTIMATION 1. Knee Height Knee height can be used for height estimation for patients who cannot stand or with skeletal deformities, severe arthritis paralysis and amputation [9, 14], knee height is the most common approach for height estimation because it has been shown to correlate highly with height [14, 15, 16] (see Figures 6 and 7 in chapter 3). Table 1 shows height estimation by using knee height. The Quetelet‟s index (BMI) can be calculated and compared with various standards (Table 2).

2. Demi Span Demi span is the distance from the midline at the sternal notch to the web between the middle and ring fingers along outstretched arm (Figure 3). Height is then calculated from a standard formula. 1. Locate and mark the midpoint of the sterna notch with the pen. 2. Ask the patient to place the left arm in a horizontal position. 3. Check that the patient‟s arm is horizontal and in line with shoulders.

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Ghazi Daradkeh, M. Mohamed Essaand Nejib Guizani Table 1. Height Estimation from Knee Height

Knee height (cm) 43.0 43.5 44.0 44.5 45.0 45.5 46.0 46.5 47.0 47.5 48.0 48.5 49.0 49.5 50.0 50.5 51.0 51.5 52.0 52.5 53.0 53.5 54.0 54.5 55.0 55.5 56.0 56.5 57.0 57.5 58.0 58.5 59.0 59.5 60.0 60.5 61.0 61.5 62.0 62.5 63.0 63.5 64.0 64.5 65.0

18-59 1.53 1.54 1.55 1.55 1.56 1.57 1.58 1.59 1.60 1.61 1.62 1.63 1.64 1.65 1.66 1.67 1.68 1.69 1.70 1.70 1.71 1.72 1.73 1.74 1.75 1.76 1.77 1.78 1.79 1.80 1.81 1.82 1.83 1.84 1.85 1.86 1.86 1.87 1.88 1.89 1.90 1.91 1.92 1.93 1.94

Men height (m) 60-90 1.48 1.49 1.51 1.52 1.53 1.54 1.55 1.56 1.57 1.58 1.59 1.60 1.61 1.62 1.63 1.64 1.65 1.66 1.67 1.68 1.69 1.70 1.71 1.72 1.73 1.74 1.76 1.77 1.78 1.79 1.80 1.81 1.82 1.83 1.84 1.85 1.86 1.87 1.88 1.89 1.90 1.91 1.92 1.93 1.94

18-59 1.47 1.49 1.50 1.51 1.52 1.53 1.54 1.55 1.56 1.57 1.58 1.59 1.58 1.60 1.61 1.62 1.63 1.64 1.65 1.66 1.67 1.68 1.69 1.70 1.71 1.72 1.73 1.73 1.74 1.75 1.76 1.77 1.78 1.79 1.80 1.81 1.82 1.83 1.84 1.85 1.86 1.87 1.87 1.88 1.89

Women height (m) 60-90 1.44 1.45 1.46 1.47 1.48 1.49 1.50 1.51 1.52 1.53 1.54 1.55 1.56 1.57 1.58 1.59 1.60 1.61 1.62 1.62 1.63 1.64 1.65 1.66 1.67 1.68 1.69 1.70 1.71 1.72 1.73 1.74 1.75 1.76 1.77 1.78 1.79 1.80 1.81 1.82 1.83 1.83 1.84 1.85 1.86

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4. Using the tape measure, measure distance from mark on the midline at the sterna notch to the web between the middle and ring fingers. 5. Check that arm is flat and wrist is straight. Take reading in cm [17] Females: height (cm) = [(1.35 x demi-span in cm)] + 60.1 Males: height (cm) = [(1.40 x demi – span (cm)] + 57.8

Adapted from BAPEN (British Association for Parenteral and Enteral Nutrition) from the „MUST‟ Explanatory Booklet. For further information see www.bapen.org.uk (http://www.bapen.org.uk/pdfs/must/must_explan.pdf). Figure 3. Measurement of Demi – Span.

3. Half - Arm – Span Half arm-span is the distance from the midline at the sternal notch to the tip of the middle finger (Figure 4). Height is calculated by doubling the half arm-span. 1. Locate and mark the edge of the right collar bone (in the sternal notch) with the pen. 2. Ask the patient to place the non-dominant arm in a horizontal position. 3. Check that the patient‟s arm is horizontal and in line with shoulders. 4. Using the tape measure, measure distance from mark on the midline at the sternal notch to the tip of the middle finger. 5. Check that arm is flat and wrist is straight. Take reading in cm [18]. Height = half arm span x 2

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Adapted from http://www.rxkinetics.com/height_estimate.html. Accessed January 15, 2011. Figure 4. Measurement of half arm span.

4. Ulna Length (UL) Ulna length is the distance between the point of the elbow and the midpoint of the prominent bone of the wrist (Figure 5). This value is then compared with a standardized height conversion chart (Table 3). Arm should be bended (left side if possible), palm across chest, fingers pointing to opposite shoulder, measure the length in centimeters (cm) to the nearest 0.5 cm between the point of the elbow (olecranon) and the mid-point of the prominent bone of the wrist (styloid process) [19].

Adapted from, British Association of Parenteral and Enteral Nutrition. October 2008. Malnutrition Universal Screening Tool. The Malnutrition Universal Screening Tool (MUST) is reproduced here with the kind permission of BAPEN. Figure 5. Measurement of Ulna Length.

Triceps skinfold site is on the posterior aspect of the right arm, over the triceps muscle, mid-way between the lateral projection of the acromion process of the scapular and the inferior margin of the olecranon process of the

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ulna. The skinfold site should be marked along the posterior mid line of the upper arm. Measurer should be stand behind the subject; skin grasped with the thumb & index finger of the left hand about 1 cm to the skin fold site. Caliper is about 1 cm from the left thumb & forefingers, caliper is perpendicular to the long axis of the skin fold, and the dial can be easily read see Figure 17 A in chapter 2. Appendix 1 and 2 show the reference values of triceps for males and females 20 years of age and older respectively. Ritz et al. (2004) [20] showed that knee height is accurately sufficient for height estimation in French elderly patients. Estimated height by using knee height and age was calculated by chulmea et al. [21] by the following equation. For men: height (cm) = [2.02 x KH (cm)] - [0.04 x Age (y)] + 64.19

(1)

For women: height (cm) = [1.83 x KH (cm)] - [0.24 x Age (y)] + 84.88 (2) Ideal weight for elderly people can be calculated by using Lorentz equations (WLO) (22) as follows: For men: H – 100 - [(H – 150)/4]

(3)

For women: H – 100 - [(H – 150)/2.5]

(4)

Body Mass Index can be calculated as: BMI = weight (kg)/height (m²) Sub scapular site is 1 cm below the interior border of the scapula, by gentle feeling for the inferior angle of the scapula or by placing the subject right arm behind the back while subject standing with relaxed arms to sides Appendix 3 shows the reference values of sub scapular for females 20 years and. Table 2. Classification of Body Mass Index for Elderly Body Mass Index

> 65 years

Under weight Normal Overweight & obesity

< 23 23 - 29 >29

Height (m)

Table 3. Height estimation from ulna length Men (>65 years) Men (65 years) 1.84 1.83 Women (65 years) Men (65years) Women (98

Nutrition Risk Major risk Moderate risk Low risk No risk

Table 4. Clinical Signs and Nutritional Deficiencies (52) System Skin

Hair Nail

Eyes

Mouth

Neck Abdomen Extremities

Nuerological

Signs or symptoms Dry scaly skin Folicular hyperkeratosis Petechiae Photosensitive Dermatitis Poor wound healing Scrotal dermatitis Thin/depigmentd Easy pluckability Transverse Depigmentation Spooned Night blindness Conjunctival Inflammation Keratomalacia Bleeding gums Glositis Atrophic papillae Hypogeusia Thyroid enlargement Parotid enlargement Diarrhea Hepatomegaly Bone tenderness Joint pain Muscle tenderness Muscle wasting Edema Ataxia Tetany Parasthesia Ataxia Dementia Hyporeflexia

Nutrient deficiency Zinc/essential fatty acids Vitamin A, C Vitamin C, k Niacin Zinc, Vitamin C Riboflavin Protein Protein, Zinc Albumin Iron Vitamin A, zinc Riboflacin Vitamin A Vitamin C, riboflaxin Niacin, piridoxin, riboflavin Iron Zinc, vitamin A Iodine Protein Niacin, folate, vitamin B 12 Protein Vitamin D Vitamin C Thiamine Protein, selenium vitamin D Protein Vitamin B12 Calcium, magnesium Thiamine, vitamin B12 Vitamin B12 Vitamin B, niacin Thiamine12

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GERIATRIC NUTRITIONAL RISK INDEX (GNRI) Geriatric nutritional risk index is a new index for predicting the risk of nutrition – related complications. It can be assessed through the equation of Bouillanne et al. [22]. GNRI = [(1.489 X albumin (g/l)] + [41.7 x (weight/Wlo)] GNRI is defined four grades of nutrition – related risk (Table 3). Weight loss of 5% or 10% and albumin concentration of 38, 35, and 30 g/l were used for determination of GNRI.

CLINICAL ASSESSMENT Clinical signs can develop as a result of nutritional deficiencies; each clinical sign is related to a specific nutrient deficiency. Table 4 summarizes the clinical signs and nutritional deficiencies. The assessment of biological and social determinants of nutritional problems for elderly has been developed by using the DETERMINE checklist which focuses on Disease, Eating problems, Tooth loss and swallowing difficulties, Economic hardship, Reduced social contact, Multiple medications, Involuntary weight loss or gain, Need for assistance in self – care, and Elders at a very advanced age (Table 5) [23].

HYDRATION Hydration is the most common cause of fluid imbalance in older people. Poor hydration is clinically important because inadequate hydration is associated with many adverse consequences including poor oral health, poor skin integrity, constipation, urinary tract infection and confusion. Poor hydration itself can also contribute to reduced food intake and malnutrition. Dehydration, is a well known nutritional problem, can be defined as depletion in total body water content due to pathologic fluid losses, diminished fluid intake, or combination of both, institutionalized elderly patients are most particularly at risk of dehydration related danger [24]. Due to age related

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changes in total body water, renal concentrating ability, decrease thirst, and medication relate hypodypsia [25, 26], confusion, disorientation, weak spells, infection, coronary artery disease, impaired or delayed wound healing, and death are dangerous side effect of dehydration [27-32]. There are different forms of dehydration (Table 6). Table 5. Determine Your Nutritional Health (23) The warning signs of poor nutritional health are often overlooked. Use this checklist to find out if you or someone you know is at risk. Read the statements below. Circle the number in the yes column for those that apply to you or someone you know. For each yes answer, score the number in the box. Total your nutritional score. YES I have an illness or condition that made me change the kind and/or amount 2 of food I eat. I eat fewer than two meals per day. 3 I eat few fruits, vegetables or milk products. 2 I have three or more drinks of beer, liquor or wine almost every day 2 I have tooth or mouth problems that make it hard for me to eat. 2 I don‟t always have enough money to buy the food I need. 4 I eat alone most of the time. 1 I take three or more different prescribed or over the counter drugs a day. 1 Without wanting to, I have lost or gained 10 pound in the last six months. 2 I am not always physically able to shop, cook and/or feed myself. 2 Total: Total Your Nutritional Score 0-2 Good! Recheck your nutritional score in six months. 3-5 You are at moderate nutritional risk. See what can be done to improve your eating habits and lifestyle. Your local health center, senior nutrition program, senior citizens counter or health department can help. Recheck your nutritional score in three months. ≥6 You are at high nutritional risk. Bring your nutritional this checklist the next time you see your doctor, dietitian or other qualified health or social service professional. Talk with him/her about any problem you may have. Ask for help to improve your nutritional health. Remember that warning signs suggest risk, but do not represent diagnosis of any condition. Adapted from: The Nutrition Screening Initiative- A project of: The American of Family Physicians: The American Dietetic Association: and the National Council on the Aging.

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Ghazi Daradkeh, M. Mohamed Essa and Nejib Guizani Table 6. Dehydration forms

Dehydration form Hypertonic dehydration

hypotonic dehydration

Isotonic dehydration

Definition is depletion in total body water (TBW) owing to pathologic fluid losses, diminished water intake, or a combination of both [29–33] a fluid depletion in which more sodium than water is lost and extracellular fluid becomes depleted [29, 31–34] a balanced depletion of both water and sodium, also leads to a loss of extracellular fluid.

Table 7. Assessment of hydration status Hydration status Dehydration Intravascular volume depletion hypovolemia

Criteria Serum osmolarity > 295miliosmolls a BUN(Blood Urea Nitrogen)-creatinine ratio above 20 or a level of serum sodium above 145 mg per deciliter a serum osmolarity above 295 milliosmols and a BUNcreatinine ratio above 20 [30].

ASSESSMENT OF HYDRATION STATUS Hydration status should be assessed at time of admission, as part of comprehensive. Physical assessment, and as deemed appropriate when acute situations occur [35]. Assessment of hydration status includes: a. Urine specific gravity b. Urine color c. serum osmolarity d. BUN: creatinine ratio

a. Urine Specific Gravity (USG) Testing USG has been shown to be a reliable and an important indicator of the body absolute hydration status [36] that can be used as a single measure, which is non-invasive, easy and quick to conduct in the field work [37].

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Australian Pathology Association criteria defined a dehydrated state as a USG > 1.030. USG < 1.020 was the recommended cut-off point for euhydration by Armstrong et al. [38] and Shirreffs and Maughan [39]. Based on USG, hydration status were categories as Table 8 [40]. Table 8. Hydration status according to urine specific gravity Urine Specific Gravity (USG) ≤ 1.015 1.016–1.020 1.021–1.025 1.026–1.030 > 1.030

Hydration Status Optimal (euhydrated). marginally adequate hydration hypohydrated. severely hypohydrated clinically dehydrated state

b. Urine Color Urine color has also been used with reasonable accuracy when laboratory analysis is not available or when a quick estimate of hydration is necessary. Some data indicate that urine color is as good indicator of hydration as plasma or urine osmolality or urine specific gravity [41]. Good hydration can be detected when urine is plentiful, odorless and pale in color. Dark, strong-smelling urine could be a sign of dehydration. Certain foods, medications and vitamin supplements may cause the color of urine to change even though you are hydrated. Note: Use of a urine color chart is suggested for people with adequate renal function and not by people who wear incontinence pads.

c. Serum Osmolarity A common simplified formula for serum osmolarityis: Calculated osmolarity = 2 x serum sodium + serum glucose + serum urea (all in mmol/L) [43].

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Figure 6. Simple urine color chart to assess the hydration status [42]. Adapted from Armstrong, L.E., Soto, J.A., Hacker, F.T., Casa, D.J., Kavouiras, S.A., Maresh, C.M. (1998). „Urinary indices during dehydration, exercise, and rehydration.‟ Int. J. Sport Nutr. 8: 345-355.

Table 9. Conditions that affect the osmolality [44] Conditions that increase osmolality Conditions that decrease osmolality Serum: Serum:  Dehydration/sepsis/fever/sweating/burns  Excess hydration  Diabetes mellitus (hyperglycemia)  Hyponatremia  Diabetes insipidus  Syndrome of Inappropriate ADH secretion (SIADH)  Uremia Urine: Urine:  Diabetes insipidus  Dehydration  Excess fluid intake  Syndrome Inappropriate ADH secretion (SIADH)  Acute renal insufficiency  Adrenal insufficiency  Glomerulonephritis  Glycosuria  Hypernatremia  High protein diet Adapted from Family Practice Notebook.com. Serum http://www.fpnotebook. com/Renal/Lab/SrmOsmlty.htm.Urine http://www.fpnotebook.com/Urology/Lab/Urn Osmlty. htm Accessed 5/27/10.

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Osmolality can also be measure by an osmometer. The difference between the calculated value and measured value is known as the osmoticgap. Serum osmolality: 282 - 295 mOsm/kg water; a serum osmolality of 285 mOsm usually correlates with a urine specific gravity of 1.0 Osmolality may be affected by different conditions (Table 9). For serum osmolality values of less than 240 mOsm or greater than 321 mOsm are considered to be risky. A serum osmolality of 384 mOsm produces stupor. If the serum osmolality rises over 400 mOsm, the patient may have grand mal seizures. Values greater than 420 mOsm are fatal. When the serum osmolality is normal or increased, the kidneys are conserving water. As the serum osmolality rises, the urine osmolality should also rise.

d. BUN: Creatinine Ratio Elevated blood urea nitrogen (BUN) level with a normal or low serum creatinine level, may indicate under – hydration. A BUN: creatinine ratio greater than 20:1 is a sign of dehydration [45]. Dehydration is the loss of body water with or without salt, at a rate greater than the body can replace it [46]. Dehydration is common in the elderly and can lead to constipation, increased risk of infections, and medication toxicity. Risk factors for dehydration [47] as well as for over hydration [48] are summarized in Table 10. Each person considered at risk for over hydration or under hydration should have an individualized goal for daily fluid intake determined by a documented standard for daily fluid intake [47, 49]. The daily fluid intake can be calculated as follows: A. 100 mL/kg for first 10 kg weight B. 50 mL/kg for next 10 kg weight C. 15 mL/kg of remaining kg weight For people receiving a diet consisting of food and fluids: The number calculated for the standard fluid intake represents fluids from all sources (Food plus liquids).

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Ghazi Daradkeh, M. Mohamed Essa and Nejib Guizani Table 10. Risk factors of dehydration and over hydration

Risk factors of dehydration [33]  Acute situation: a. Vomiting b. Diarrhea c. Febrile episodes d. Repeated NPO episode  People with the following diseases: a. Alzheimer‟s and other dementia b. Depression c. Stroke d. Diabetes e. Malnutrition f. Dysphagia g. Reflux h. Four or more chronic conditions  Chronic cognitive impairment  Functional status: semi-dependent  Inadequate nutrition including the use of hyperosmolar or high protein enteral feeding

Risk factors of over hydration [34]  People with diagnosis of: a. Congestive heart failure b. Renal disease c. Major psychiatric disorders schizophrenia  People taking lithium  People receiving excessive intravenous fluid therapy for correction of dehydration

Example: An individual weighs 95 pounds or 43 kilograms (2.2 pounds per kilogram) 100 mL/first 10 kg weight 50 mL/kg for next 10 kg weight 15 mL/kg for remaining 23 kg weight

100 X 10 = 1,000 mL 50 X 10 = 500 mL 15 X 23 = 345 mL

Total fluid intake need from all sources Multiplied by 0.75

1,845 mL x 0.75

Intake needs from liquids alone

1383.75 or 1,385 mL

Figure 7. Required liquid fluid intake for those on a diet consisting of food and fluids.

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Table 11. Recommended daily fluid intake by weight Body weight (kg)

Body weight (pounds)

Recommended total Recommended fluid fluid intake per day intake from liquids (ml) per day (ml) 10 22.0 1000 750 12 26.4 1100 825 14 30.8 1200 900 16 35.2 1300 975 18 39.6 1400 1050 20 44.0 1500 1125 22 48.4 1530 1148 24 52.8 1560 1170 26 57.2 1590 1193 28 61.6 1620 1215 30 66.0 1650 1238 32 70.4 1680 1260 34 74.8 1710 1283 36 79.2 1740 1305 38 83.6 1770 1328 40 88.0 1800 1350 42 92.4 1830 1373 44 96.8 1860 1395 46 101.2 1890 1418 48 105.6 1920 1440 50 110.0 1950 1463 52 114.4 1980 1485 54 118.8 2010 1508 56 123.2 2040 1530 58 127.6 2070 1553 60 132.0 2100 1575 62 136.4 2130 1598 64 140.8 2160 1620 66 145.2 2190 1643 68 149.6 2220 1665 70 154.0 2250 1688 72 158.4 2280 1710 74 162.8 2310 1733 76 167.2 2340 1755 For each additional 2 kg body weight (approximately 4.5 pounds) add 30 ml total fluid intake of which 22 ml should be from liquids.

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Table 12. Relative Strength of Different Signs of Hydration Status in Elderly [47, 48] Parameter

Physical Sign

Vital signs

Rapid pulse Orthostatic hypotension Acute increase Acute increase Dry, pale, decrease saliva Longitudinal furrows Dry Decrease Sunken Decreased Difficulties Acute onset Muscle weakness Pitting edema Distended in supine position

Weight Oral mucous membranes Tongue Skin turgor eyes Axillary sweat Speech Confusion Upper body control Lower extremities Neck veins

Dehydration 47,48 ++ +/-

Over hydration 48

+++ +++ +++ +++ +++ + +++ ++ +++ +++ +++

(Note): (+) = some relationship, (+++) = strong relationship, (-) = no relationship.

a.

Up to seventy-five percent (75%) of total body fluids are consumed from liquids [33]. b. Therefore, total daily fluid intake needs to be multiplied by 0.75 to determine amount needed from liquids alone. c. Figure 7 provides an example of how to calculate required fluid intake needs from fluids alone when a person is on a diet of foods and fluids. For people receiving entire diet from tube feedings alone: As a general rule: A. 1 calorie/mL formulas are approximately 80%-85% water (e.g., 800 - 850 mL water per 1000 mL formula). B. 1.5 calorie/mL formulas are approximately 75%-80% water (e.g, 750 - 800 mL water per 1000 mL formula). C. 2.0 calorie/mL formulas are approximately 70%-75% water (e.g., 700-750 mL water per 1000 mL formula).

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D. Additional water can come from orally consumed food and liquids, water used to irrigate feeding tubes, and IV solutions. Hydration status is correlated with different clinical signs (Table 12). Depending on the basis of the percentage of body weight loss dehydration is classified as mild, marked, severe and fatal (Table 13) [51]. Table 13. Degree of dehydration [51] Degree of dehydration Mild Marked

% of weight loss 2% 5%

Severe

8%

Fatal

22-30% of total body water loss can prove fatal

Symptoms Thirst Marked thirst Dry mucous membrane Dryness and wrinkling of skin Low grade temperature elevation Tachycardia Respiration 28 or greater Decrease (10-15mmHg) in systolic blood pressure standing position Urinary output < 25ml/hr (oliguria) Increased specific gravity (> 1.030) Elevated Hct Elevated Hgb Elevated BUN Body weight loss Symptoms of marked dehydration plus: Flushed skin Systolic blood pressure drop(60mmHg or below) Behavioral changes (restlessness, irritability, disorientation, delirium) Anuria Coma leading to death

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Case Study 1 Mrs. X is 81 years old, she has had Parkinson‟s disease for 5 years, weighing 95 pounds (43 kg) is being fed a 1 calorie/mL formula at 75 mL/hour by Nasogastric Tube(NGT) Over 24 hours (1800 mL, or 1.8L per day). 1. Estimated daily water needs: a. 100 mL/first 10 kg weight 100 X 10 = 1,000 mL b. 50 mL/kg for next 10 kg weight 50 X 10 = 500 mL c. 15 mL/kg for remaining 23 kg weight 15 X 23 = 345 mL Total fluid intake need from all sources 1,845 mL 2. Water provided by tube feeding formula (1 cal/mL formula) a. 800 mL water per 1000 mL formula b. The person received 1.8 liters per day c. 800 mL/L x 1.8 liters = 1440mL Water provided by tube feeding formula 1,440 mL 3. Additional water required: Total fluid needed from all sources 1,845 mL (minus) Water provided by tube feeding formula 1,440 mL Additional water required 445 mL/day Figure 8. Required liquid fluid intake for those on a diet from tube feedings alone [50].

Case Study 2 Mary is 73 years old, female, known case of type 2 diabetes on oral medications 12 years ago, hypertension on medication 3 years ago, admitted to orthopedic ward since last month because of a femur fracture, she is still unable to stand, her current weight is 75 kg, and knee height 51cm, her lab results are: FBS 8.9 mmol/l urine specific gravity 1.1 albumin 28g/l sodium 145mmol/l BUN 9.1 mmol/l creatinine 128mmol/l 1. 2. 3. 4.

Calculate her fluid requirement Calculate BMI& IBwt Assess her hydration status Assess her nutritional risk

APPENDIX 1. Triceps skinfold thickness in millimeters for males 20 years of age and older by race and ethnicity and age, by mean, standard error of the mean, and selected percentiles; United States 2003-2006 Race and ethnicity and age

Number examined

Mean

Standard error

All race and ethnicity groups 20 years and over 4152 15.0 0.19 20-29 years 755 14.3 0.35 30-39 years 690 14.7 0.28 40-49 years 705 15.3 0.35 50-59 years 542 15.1 0.41 60-69 years 618 16.1 0.43 70 -79 years 520 15.6 0.33 80 years and over 322 13.9 0.26 Non-Hispanic white 20 years and over 2177 15.2 0.21 20-39 years 639 14.5 0.33 40-59 years 651 15.5 0.38 60 years and over 887 15.9 0.31 Non-Hispanic black 20 years and over 838 14.3 0.22 20-39 years 318 14.4 0.39 40-59 years 274 13.7 0.36 60 years and over 246 15.5 0.42 Mexican American 20 years and over 848 14.2 0.40 20-39 years 348 14.8 0.59 40-59 years 238 13.3 0.33 60 years and over 262 13.7 0.45 * Figure does not meet standards of reliability and precision. * Persons of other races and unknown race and ethnicity are included.

5th

10th

15th

25th

Percentile 50th 75th Millimeters

85th

90th

6.1 5.0 5.8 6.6 6.2 7.3 7.1 6.8

7.3 6.2 7.1 7.6 7.4 8.3 8.7 7.6

8.3 7.1 8.2 8.7 8.9 9.4 9.5 8.3

10.1 8.8 10.0 10.4 10.8 11.2 11.0 9.7

13.8 12.7 13.6 13.9 14.1 14.9 14.0 12.7

18.8 18.9 18.3 19.2 18.5 19.7 19.2 16.2

21.9 21.7 21.4 22.3 21.5 22.5 22.5 19.8

24.2 25.4 23.4 24.1 23.2 25.2 25.0 21.6

28.1 29.4 27.0 27.9 26.7 30.3 29.1 24.4

6.1 5.4 6.4 7.3

7.4 6.4 7.6 8.6

8.6 7.5 9.1 9.4

10.3 9.2 10.9 11.1

13.9 13.1 14.1 14.4

19.1 18.7 19.3 19.1

22.1 21.4 22.5 22.4

24.4 24.0 24.3 24.9

28.5 28.5 28.0 29.7

4.9 4.7 5.4 4.8

6.1 5.3 6.5 6.9

7.0 6.3 7.1 7.9

8.7 8.4 8.7 10.0

12.8 12.8 12.2 14.0

18.4 18.9 17.4 20.4

21.8 22.4 20.3 24.0

24.1 24.8 22.0 26.2

28.1 30.8 24.7 29.9

6.2 6.0 * *

7.4 7.2 7.7 8.1

8.5 8.5 8.2 8.6

9.8 10.0 9.1 9.7

13.0 13.4 12.0 12.5

17.1 18.0 15.9 6.0

20.1 21.8 18.0 19.6

22.9 24.4 19.7 21.1

26.3 27.3 * *

95th

APPENDIX 2. Triceps skinfold thickness in millimeters for females 20 years of age and older by race and ethnicity and age, by mean, standard error of the mean, and selected percentiles; United States 2003-2006 Race and ethnicity and age

All race and ethnicity groups 20 years and over 20-29 years 30-39 years 40-49 years 50-59 years 60-69 years 70 -79 years 80 years and over Non-Hispanic white 20 years and over 20-39 years 40-59 years 60 years and over Non-Hispanic black 20 years and over 20-39 years 40-59 years 60 years and over Mexican American 20 years and over 20-39 years 40-59 years 60 years and over *

Number examined

Mean

Standard error

5th

10th

15th

25th

3552 599 538 617 477 570 408 343

24.1 21.8 24.3 25.1 25.6 25.3 23.2 20.2

0.22 0.44 0.54 0.44 0.36 0.42 0.41 0.41

11.6 10.4 12.1 12.1 13.3 13.4 11.2 10.1

13.9 11.9 14.7 14.1 16.1 16.6 14.2 11.3

15.5 13.2 15.8 15.9 17.5 18.1 15.7 12.7

18.3 15.5 18.2 19.5 20.5 20.3 17.9 14.7

24.0 21.1 23.9 25.6 25.9 25.4 22.9 19.0

1909 540 565 804

23.9 22.8 25.1 23.5

0.26 0.50 0.40 0.34

11.6 11.1 12.3 11.2

13.7 13.1 14.7 13.9

15.3 14.1 16.3 15.6

18.0 16.8 19.8 18.0

686 242 231 213

25.4 24.1 27.1 24.9

0.37 0.61 0.45 0.44

10.6 10.1 10.6 11.2

14.1 12.4 16.1 14.4

16.0 14.4 18.2 16.3

676 244 196 236

24.9 24.6 26.0 23.0

0.53 0.62 0.64 0.35

13.3 13.0 * *

15.9 14.8 17.0 14.4

17.2 16.8 18.6 15.6

Figure does not meet standards of reliability and precision. Persons of other races and unknown race and ethnicity are included. Note: Pregnant females were excluded. *

Percentile 50th 75th Millimeters

85th

90th

95th

29.9 27.3 30.2 30.9 31.0 30.2 28.7 25.0

32.4 30.3 32.9 33.6 33.2 32.8 31.1 28.5

34.2 32.4 35.3 35.2 34.9 24.2 32.7 30.1

36.4 34.7 37.4 36.9 36.5 36.0 36.0 32.7

23.8 22.1 25.5 23.5

29.8 28.5 31.0 28.8

32.3 31.6 33.1 31.8

34.0 33.2 24.4 32.9

36.1 36.4 36.7 35.2

19.5 18.1 22.0 18.9

25.9 24.2 28.0 25.1

31.6 30.3 33.8 30.8

34.5 33.1 35.7 33.1

35.9 35.0 36.8 34.7

37.3 37.2 38.2 36.2

19.9 19.2 21.2 18.9

24.3 23.5 26.1 22.2

30.1 30.2 30.1 27.3

32.6 32.5 33.5 30.4

34.6 34.7 34.9 32.3

36.3 36.3 * *

APPENDIX 3. Subscapular skinfold thickness in millimeters for females 20 years of age and older by race and ethnicity and age, by mean, standard error of the mean, and selected percentiles; United States 2003-2006 Race and ethnicity and age Number examined

Mean

Standard error

All race and ethnicity groups 20 years and over 3186 20.8 0.24 20-29 years 526 18.3 0.49 30-39 years 492 21.1 0.50 40-49 years 521 22.2 0.46 50-59 years 406 22.6 0.41 60-69 years 534 22.3 0.41 70 -79 years 375 19.3 0.54 80 years and over 333 16.1 0.36 Non-Hispanic white 20 years and over 1904 20.1 0.26 20-39 years 516 18.8 0.45 40-59 years 513 21.7 0.39 60 years and over 775 19.4 0.37 Non-Hispanic black 20 years and over 571 24.0 0.54 20-39 years 210 22.4 0.81 40-59 years 182 26.1 0.66 60 years and over 179 24.0 0.71 Mexican American 20 years and over 569 23.2 0.59 20-39 years 200 23.0 0.99 40-59 years 145 24.1 0.50 60 years and over 224 21.6 0.50 * Figure does not meet standards of reliability and precision. * Persons of other races and unknown race and ethnicity are included. Note: Pregnant females were excluded.

Percentile 50th 75th Millimeters

5th

10th

15th

25th

85th

90th

95th

8.4 7.6 9.2 9.1 8.8 9.1 7.4 6.9

10.0 8.9 10.6 10.7 11.6 10.9 9.3 8.1

11.3 10.0 11.8 12.3 13.0 13.5 10.5 8.8

13.9 11.7 14.3 15.2 16.5 16.7 13.8 10.4

20.3 16.3 20.2 22.7 22.6 21.8 19.3 14.4

26.8 24.1 27.4 28.5 28.9 28.0 23.9 21.3

30.4 27.3 30.9 31.8 31.7 32.0 27.0 24.4

32.6 30.5 32.2 33.9 34.1 33.0 29.5 25.4

35.1 33.9 35.3 35.6 36.2 34.9 32.4 28.2

8.1 7.8 8.7 7.6

9.6 9.2 10.4 9.2

10.8 10.3 12.1 10.2

13.2 12.1 14.8 12.9

19.4 16.8 21.9 19.3

25.8 24.4 28.3 24.8

29.9 28.5 30.9 27.8

31.7 31.0 33.3 30.2

24.8 33.8 35.6 33.0

9.5 * * *

12.0 10.7 15.1 12.6

13.4 12.0 17.0 13.9

17.5 15.0 20.6 17.6

24.3 22.4 26.5 23.6

30.8 29.4 32.6 30.2

33.8 32.5 24.2 32.5

34.6 34.0 35.3 35.1

36.8 * * *

10.9 * * *

13.6 11.9 15.1 13.2

14.6 13.9 16.2 14.1

17.2 16.3 18.8 17.1

23.2 23.2 24.0 20.6

28.2 28.7 28.3 25.7

31.2 31.9 31.14 29.4

33.5 34.0 33.2 31.2

35.7 * * *

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[13] Frisancho AR, 1981. New norms of upper limb fat and muscle areas for assessment of nutritional status. American journal of clinical nutrition 34:2540-2545. [14] Chumlea WC, Guo SS, Steinbaugh ML.1994. Prediction of stature from knee height for black and white adults and children with application to mobility – impaired or handicapped persons. Journal of the American Dietetic Association 94:1385-1388. [15] Cockram DB, Baumgartner RN.1990. Evaluation of accuracy and reliability of calipers for measuring recumbent knee height in elderly people. American Journal of Clinical Nutrition 52:397- 400. [16] Muncie HL, Sobal J, Hoopes JM. Tenney JH, Warren JW. 1987. A practical method of estimating stature of bedridden female nursing home patients. Journal of the American Geriatric Society 35:285-289. [17] Reproduced here with the kind permission of BAPEN (British Association for Parenteral and Enteral Nutrition) from the „MUST‟ Explanatory Booklet. For further information see www.bapen.org.uk (http://www.bapen.org.uk/pdfs/must/must_ explan.pdf). [18] http://www.rxkinetics.com/height_estimate.html. Accessed January 15, 2011. [19] Malnutrition Advisory Group, British Association of Parenteral and Enteral Nutrition. October 2008. Malnutrition Universal Screening Tool. The Malnutrition Universal Screening Tool (MUST) is reproduced here with the kind permission of BAPEN. [20] Ritz P.Validity of measuring knee – height as an estimate of height in diseased French elderly persons. J Nutr Health Aging 2004,8:386 – 8. [21] Chumlea WC, Rochea AF, Stein banjh ML. Estimating stature from knee height for persons 60 to 90 years of age. J Am Geriatric Soc 1985, 33:116 – 20. [22] Bouillanne O, Morinean G, Dupont C, et al.(2005). Geriatric Nutritional Risk Index: a new idea for evaluating at risk elderly medical patients. Am J Clin Nutr 82,777 – 783. [23] Dwyer JT: Screening Older Americans Nutritional Health: Current practices and future possibilities. Nutrition Screening Initiative, Washington,1991,p. 28. [24] Gross CR, Lindquist RD, Woolley AC, Granieri R, Allard K, Webster B. Clinical indicators of dehydration severity in elderly patients. J Emerg Med 1992;10(3):267–74. [25] Bennett JA. Dehydration: hazards and benefits. Geriatr Nurs 2000;21(2):84–8.

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[26] Sheehy CM, Perry PA, Cromwell SL. Dehydration: biological considerations, agerelated changes, and risk factors in older adults. Biol Res Nurs 1999;1(1):30–7. [27] Bruera E, Sala R, Rico MA, Moyano J, Centeno C, Willey J, et al. Effects of parenteral hydration in terminally ill cancer patients: a preliminary study. J Clin Oncol 2005;23(10):2366–71. [28] (Bennett JA, Thomas V, Riegel B. Unrecognized chronic dehydration in older adults: examining prevalence rate and risk factors. J Gerontol Nurs 2004;30(11):22–8. [29] Xiao H, Barber J, Campbell ES. Economic burden of dehydration among hospitalized elderly patients. Am J Health Syst Pharm 2004;61(23):2534–40. [30] Mentes J. Oral hydration in older adults: greater awareness is needed in preventing, recognizing, and treating dehydration. Am J Nurs 2006;106(6):40–9. [31] Rodriguez GJ, Cordina SM, Vazquez G, Suri MF, Kirmani JF, Ezzeddine MA, et al. The hydration influence on the risk of stroke (THIRST) study. Neurocrit Care 2009;10(2):187–94. [32] Rasouli M, Kiasari AM, Arab S. Indicators of dehydration and haemocon-centration are associated with the prevalence and severity of coronary artery disease. Clin Exp Pharmacol Physiol 2008;35(8):889– 94. [33] Public Health Agency of Canada Report on Seniors‟ falls in Canada, 2005. [34] Mentes JC, Culp K. Reducing hydration-linked events in nursing home residents. Clin Nurs Res 2003;12(3):210–25. [35] Assessment of hydration status including Mentes, J.C. & Iowa Veterans Affairs Nursing Research Consortium (2004, February). Hydration Management Evidenced-Based Guideline. The University of Iowa Gerontological Nursing Interventions Research Center, Research Translation and Dissemination Core. Iowa City, IA: University of Iowa. [36] Joubert D, Bates GP. Occupational heat exposure, part 2: The measurement of heat exposure (stress and strain) in the occupational environment. Occup Health South Afr. 2008[cited 2012 May 15]; 14:2– 6, Avail-able from: http://espace.library.curtin.edu.au/webclient/Stream Gate?folder_id=0&dvs=1386078056815~310&usePid1=true& usePid2=true.

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[37] Brake DJ, Bates GP. Fluid losses and hydration status of industrial workers under thermal stress working extended shifts. Occup Environ Med. 2003;60(2):90–6, http://dx.doi. org/10.1136/oem.60.2.90. [38] Armstrong LE, Maresh CM, Castellani JW, Bergern MF, Kenefick RW, LaGasse KE, et al. Urinary indices of hydra-tion status. Int J Sport Nutr. 1994;4:265–79. [39] Shirreffs SM, Maughan RJ. Urine osmolality and conduc-tivity as indices of hydration status in athletes in the heat. Med Sci Sports Exerc. 1998; 30:1598–602, http://dx.doi. org/10.1097/00005768-19981100000007. [40] Miller VS, Bates GP. The Thermal Work Limit is a simple re-liable heat index for the protection of workers in thermally stressful environments. Ann Occup Hyg. 2007;51(6):553–61, http://dx.doi.org/10.1093/annhyg/ mem035. [41] kavouras SA. Assessing hydration status. Currrent Opin Clin Nutr Metab Care, 2002 Sep, 5 (5): 519 -24. [42] Armstrong, L.E., Soto, J.A., Hacker, F.T., Casa, D.J., Kavouiras, S.A., Maresh, C.M. (1998). „Urinary indices during dehydration, exercise, and rehydration.’ Int. J. Sport Nutr. 8: 345-355. [43] SydPath. The Pathology Service of St Vincent's Hospital Sydney, Australia Osmolality http://www.sydpath.stvincents.com.au/tests/ Osmolality.htm. [44] Family Practice Notebook.com. Serum http://www.fpnotebook.com/ Renal/Lab/SrmOsmlty.htmUrinehttp://www.fpnotebook.com/Urology/L ab/UrnOsmlty.htm Accessed 5/27/10. [45] Weinberg AD, Maniker KL. Dehydration: Evaluation and management in older adults. JAMA. 1995, 274(19):1552 – 1556. [46] David R. Thomas et al. understanding clinical dehydration and its treatment. Journal of the American medical directors association vol.9, issue 5, 2008. 292- 301. [47] Mentes, J.C. & Iowa Veterans Affairs Nursing Research Consortium (2004, February). Hydration Management Evidenced-Based Guideline. The University of Iowa Gerontological Nursing Interventions Research Center, Research Translation and Dissemination Core. Iowa City, IA: University of Iowa. [48] Mentes, J.C. & Iowa Veterans Affairs Nursing Research Consortium (1998, September). Hydration Management Research - Based Guideline. The University of Iowa Gerontological Nursing Interventions

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[49] [50] [51] [52]

Ghazi Daradkeh, M. Mohamed Essa and Nejib Guizani Research Center, Research Translation and Dissemination Core. Iowa City, IA: University of Iowa. Chidester, J. & Spangler, A. (1997). Fluid intake in the institutionalized elderly. Journal of the American Dietetic Association, 97, 23-28. Campbell, S.M. (1998). Inquire here. Support Line, 20(1), 17. Kee, J. L, & Paulanka, B. J. (2000). Fluids and electrolytes with clinical application: A programmed Approach. (6th Ed.). Albany, NY: Delmar. Christakis G (ed). Nutritional assessmen in health programs. Washington, DC: American Public Health Association, 1973,pp.26-27.

GLOSSARY 24 – Hour recall: A method of dietary recall in which a trained interviewer asks the subject to remember in detail all foods and beverages consumed during the past 24 hours. This information is recorded by the interviewer for later coding and analysis. 24 – Hour urinary creatinine: A test measures the amount of creatinine in urine collected in 24 hour. 24 – Hour urine urea nitrogen: A test is performed by collecting a 24-hour urine sample. Accuracy: The degree to which a measured value represents the real or true, value. Acromion process: The spine of the scapula (shoulder blade) extending toward the outside of the body. The acromion process, or tip, is used as an anatomic landmark in arm anthropometric measurements (e.g., mid arm circumference and triceps skinfold measurement). Actual Body Weight: Ideal Body Weight x 0.25 + Ideal Body Weight. Adequate intake: The recommended daily dietary intake level assumed to be adequate and based on experimentally determined approximations of nutrient intake by a group of healthy people. It is an observational standard used when there are insufficient data available to determine a Recommended Dietary Allowances. One of four nutrient reference intakes included in the Dietary References. Adjusted body weight: Is a weight which used to calculate calories requirements when BMI ≥ 30 kg/m² by using the following equation: Adolescence: Is a transitional stage of physical and psychological development that generally occurs during the period from puberty to adulthood.

122

Glossary

Aging: The process of becoming older, a process that is genetically determined and environmentally modulated. Albumin: A serum protein, produced by the liver, used as an indicator of nutritional status. Allergy: Hypersensitivity to physical or chemical agents. Alveoli: Rounded cavities present in the breast (singular = alveolus). Amenorrhea: Absence of menstrual cycle. Amputated body parts: Removal of body part partially or totally that is enclosed by skin. Amylophagia: Compulsive consumption of laundry starch or cornstarch. Anaphylaxis: Sudden onset of a reaction with mild to severe symptoms. Android obesity: Excess body fat that is predominantly within the abdomen and upper body, as opposed to hips and thighs. This is the typical pattern of male obesity. Anemia: A hemoglobin level below the normal reference range for individuals of the same sex and age. Anencephaly: Condition initiated early in gestation of the central nervous system in which the brain is not formed correctly, resulting in neonatal death. Anorexia nervosa: A condition of disturbed or disordered eating behavior characterized by a refusal to maintain a minimally normal body weight, an intense fear of gaining weight, and distorted perception of body shape or size in which a person feels overweight (either globally or in certain body areas), despite being markedly underweight. Anorexia of aging: A loss of appetite and/or reduced food intake affects a significant number of elderly people and is far more prevalent among frail individuals. Anovulatory cycles: Menstrual cycles in which ovulation does not occur. Anthropometry: The science of measuring the human body and its parts. It is the measurement of body (weight, height, circumferences, and skinfold thickness). Appropriate gestational age (AGA): Weight, length, and head circumference are between the 10th and 90th percentiles for gestational age. Arm circumference: Is an estimation of the area of the arm. Arm fat index: Is the quotient of triceps skinfold thickness (in mm) and the olecranon-acromial distance (in cm) squared. Arm muscle area: An indicator of total body muscle calculated from the triceps skinfold thickness and mid arm circumference.

Glossary

123

Arm muscle circumference: Is an estimation of the muscle area of the upper arm, calculated from triceps skinfold thickness and arm circumference. Arteriosclerosis: Age – related thickening and hardening of the artery walls. Ascites: An accumulation of fluid in the peritoneal cavity. Asthma: Condition in which the lungs are unable to exchange air due to lack of expansion of air sacs. Atherosclerosis: A type of hardening of arteries in which cholesterol id deposited in the arteries. Athetosis: Uncontrolled movement of the large muscle groups as a result of damage to the central nervous system. Atrial fibrillation: Degeneration of the heart muscle, causing irregular contractions. Attention Deficit Hyperactivity Disorder (ADHD): Condition characterized by low impulse control and short attention span, with and without a high level of overall activity. Autism: Condition of deficit in communication and social interaction with onset generally before age 3 years. Autoimmune disease: A disease related to the destruction of body‟s own cells by substances produced by the immune system that mistakenly recognize certain cell components as harmful. Basal energy expenditure: Is the rate of energy expenditure by humans at rest Basal metabolic rate (BMR): An individual‟s energy expenditure measured in the post absorptive state (no food consumed during the previous 12 hours) after resting quietly for 30 minutes in a thermally neutral environment. Behavior modification: A behavioral change theory that attempts to alter previously learned behavior or to encourage the learning of new behavior through a variety of action-oriented methods, as opposed to changing feelings or thoughts. Biceps: A muscle that has two heads. Binge-eating disorder (BED): An eating disorder characterized by periodic binge eating, which normally is not followed by vomiting or the use of laxatives. Bioactive food components: Constituents in food or dietary supplements, other than those needed to meet basic human nutritional needs, that are responsible for changes in health status. Blood urea nitrogen (BUN): Test measures the amount of nitrogen in your blood that comes from the waste product urea. Body Mass Index (BMI): Body Mass Index. See Quetelteʼs index.

124

Glossary

Body surface area: Is the measurement surface area of a human body. Bone age: Bone maturation, correlates well with stage of pubertal development. Bronchopulmonary dysplasia (BPD): Condition in which the underdeveloped lungs in preterm infant are damaged so that breathing requires extra efforts. Bulimia nervosa: An eating disorder characterized by episodes of binge eating (bouts of uncontrolled, rapid ingestion of large quantities of food) followed by some behavior to prevent weight gain, such as purging, fasting, or exercising excessively (self-induced vomiting, laxatives or diuretic use, fasting or vigorous exercise) in order to prevent weight gain. Cachexia: Profound physical wasting and malnutrition usually associated with chronic disease, advanced acquired immune deficiency syndrome, alcoholism, or drug abuse. Calf circumference: Is the measurement of the underlying musculature and adipose tissue at the widest point of the calf. Calorie count: Calculation of the energy and nutrient value of foods eaten by a subject, such as hospitalized patient. Cancer: A group of diseases characterizes by abnormal growth of cells that, when uncontrolled, invade other tissues or organs, interfering with their normal function and nutrition. Carotenemia: A condition, caused by ingestion of high amounts of carotenoids (or carotene) from plant foods, in which the skin turns yellowish color. Carotid artery disease: Condition in which the arteries that supply blood to the brain and neck become damaged. Catabolism: The breakdown of more complex compounds into simple biological substances, generally resulting in energy release. Catch-up growth: Period of time shortly after a slow period when the rate of weight and height gains is likely to be faster than expected for age and gender. Celiac-disease: An autoimmune disease characterized by inflammation of the small intestine lining resulting from a genetically based intolerance to a component of gluten. The inflammation produces diarrhea, fatty stool, weight loss, and vitamins and minerals deficiencies. Also called tropical sprue and gluten-sensitive enteropathy. Cerebral palsy: A group of disorders characterized by impaired muscle activity and coordination present at birth or developed during early childhood.

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125

Cerebral spine atrophy: Condition in which muscle control declines over time as a result of nerve loss, causing death in childhood. Cerebrovascular disease: A group of disorders, characterized by decreased blood supply to the brain, resulting from hemorrhage of or atherosclerosis within the cerebral arteries. Cholesterol: A fatlike sterol found in animal products and normally produced by the body. It serves as a precursor for bile acids and steroid hormones and is an essential component of the plasma membrane and the myelin sheaths of nerves. Serum cholesterol levels are causally related to risk for coronary artery disease. Chronic diseases: Slow – developing, long lasting diseases that are not contagious. They can be treated but not always cured. A disease progressing over a long period of time, such as coronary heart disease, certain cancers, stroke, diabetes mellitus, and atherosclerosis. Chronic inflammation: Low – grade inflammation that lasts weeks, months, or years. Inflammation is the first response of the body‟s immune system to infection or irritation. Clift lip and palate: Condition in which the upper lip and roof of the mouth are not formed completely and are surgically corrected, resulting in feeding, speaking, and hearing difficulties in childhood. Cognitive function: The process of thinking. Colic: A condition marked by a sudden onset of irritability, fussiness, or crying in a young infant between 2 weeks and 3 months of age who is otherwise growing and healthy. Congenital abnormality: A structural, functional, or metabolic abnormality present at birth. Also called congenital anomalies. Congenital anomaly: Condition evident in a newborn that is diagnosed at or near birth, usually as a genetic or chronic condition, such as spina bifida or cleft lip and palate. Coronary Heart Disease (CHD): A disease of the heart resulting from inadequate circulation of blood to local areas of the heart muscle. The disease is almost always a consequence of focal narrowing of the coronary arteries by atherosclerosis and is known as ischemic heart disease or coronary artery disease. Creatine: A nitrogen-containing compound, 98% of which is found in muscle in the form of creatine phosphate. Creatine spontaneously dehydrates to form creatinine, which is then excreted unaltered in the urine. Creatinine-height index (CHI): An index or a ratio sometimes used to assess body protein status. CHI = 24-hour urinary creatinine excretion ÷

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expected creatinine excretion of a reference adult of the same sex and stature x 100. Creatinine: The end product of creatine metabolism. Twenty-four hour urinary creatinine excretion is used as an index of body muscle mass. Current weight: Someone‟s body weight at the mean time or at the moment. Cystic fibrosis: Condition in which a genetically changed chromosome 7 interferes with all the exocrine functions in the body, but particularly pulmonary complications, causing chronic illness. Daily Reference Value (DRV): A dietary reference value serving as a basis for the Daily Values. DRVs are for nutrients (e.g., total fat, cholesterol, total carbohydrate, and dietary fiber) for which no set of standards existed before passage of the Nutrition Labeling and Education Act of 1990. Daily Value (DV): A dietary reference value appearing on the nutrition labels of foods regulated by the FDA and the USDA as part of the Nutrition Labeling and Education Act of 1990. It is derived from the Daily Reference Values (DRVs) and the Reference Daily Intakes (RDIs). The daily value on food labels shows the percent of the DRVs or RDIs that a serving of food provides. Deciliter (dl): A unit of volume in the metric system. One deciliter equals 10-1 liter, 1/10 of a liter, or 100 milliliters. Deficiency diseases: Disease caused by a lack of adequate dietary nutrients, vitamins, or minerals (e.g., rickets, pellagra, beriberi, xerophthalmia, and goiter). Dehydration: Excessive loss of body water, with an accompanying disruption of metabolic processes. Dementia: General term for a decline in mental ability severe enough to interfere with daily life. Demi span: Distance from the midline at the sternal notch to the web between the middle and ring fingers along outstretched arm. Density: See body density. Depression: A state of low mood and aversion to activity that can affect a person's thoughts, behavior, feelings and sense of well-being. Desirable body weight: The best body weight according to someone‟s height. Diabetes mellitus: A metabolic disorder characterized by inadequate insulin secretion by the pancreas or the inability of certain cells to use insulin and resulting in abnormality high serum glucose levels. Diabetes mellitus can be classified as type 1 diabetes, type 2 diabetes, or gestational diabetes (GDM).

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Diaphragmatic hernia: Displacement of the intestines up into the lung area due to incomplete formation of the diagram in utero. Diet history: An approach to assessing an individual‟s usual dietary intake over an extended period of time (e.g., past month or year). This typically involves Burke‟s four assessment steps: collecting general information about the subject‟s health habits, questioning the subject about his or her usual eating pattern, performing a “cross check” on the data given in step 2, and having the subject complete a 3-day food record. Dietary fiber: Non digestible carbohydrate and lignin that are naturally present in plant foods and that are consumed in their natural, intact state as part of an unrefined food. Dietary intake: Amount of food or drink that is taken into your body during a day. Dietary Reference Intake (DRI): Reference values that are quantitative estimates of nutrient intakes to be used for planning and assessing diets for apparently healthy people in various life-stage and gender groups in the United States and Canada. The dietary Reference Intakes include the Estimated Average Requirement, the Recommended Dietary Allowance, the Adequate Intake, and the Tolerable Upper Intake Level. DiGeorge syndrome: Condition, in which chromosome 22 has a small deletion, resulting in a wide range of heart, speech, and learning difficulties. Diplegia: Condition, in which the part of the brain controlling movement of the legs is damaged, interfering with muscle control and ambulation. Diverticulitis: Infected: pockets” within the large intestine. Down syndrome: condition in which three copies of chromosome 21 occur, resulting in lower muscle strength, lower intelligence, and greater risk for overweight. Dumping syndrome: A condition characterized by weakness, dizziness, flushing, and warmth, nausea, and palpitation immediately or shortly after eating and produced by abnormal rapid emptying of the stomach, especially in individuals who have had part of the stomach removed. Dysmenorrhea: Painful menstruation due to abnormal cramps, back pain, headache, and/or other symptoms. Dysphagia: Difficulty in swallowing. Eating disorder: Abnormal attitude towards food that causes someone to change their eating habits and behavior.

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Edema: Swelling caused by fluid accumulation in body tissues (extracellular fluid). It usually occurs in the feet, ankles and legs, but it can involve your entire body. Elderly: Being past middle age and approaching old age; rather old. Electrolyte: An electrically charged particle (anion or cation), present in solution within the body, that is capable of conducting an electrical charge. Sodium, chloride, potassium, and bicarbonate are electrolytes commonly found in the body. Embryo: The developing organism from conception through 8 weeks. Endocrine: A system of ductless glands, such as thyroid, adrenal gland, ovaries, and testes, that produce secretions that affect body functions. Endothelium: The layer of cells lining the inside of blood vessels. Enteral nutrition: The delivery of food or nutrients into the esophagus, stomach, or small intestine through tubes to improve nutritional status. Epididymis: Tissue on top of the testes that store sperm. Epithelial cells: Cells that line the surface of the body. Erythrocyte: Red blood cell, or RBC. Essential lipid: The small amount of lipid (constituting about 1.5% to 3% of lean body weight), serving as a structural component of cell membranes and the nervous system, that is necessary for life. Estimated Energy Requirement: The average dietary energy intake that is predicted to maintain energy balance in a healthy adult of a defined age, gender, weight, height, and level of physical activity, consistent with good health. In children and pregnant and lactating women, it includes the needs associated with the deposition of tissues or the secretion of milk consistent with good health. Estimated food record: A method of recording individual food intake in which the amounts and types of all food and beverages are recorded for a specific period of time, usually ranging from 1 to 7 days. Portion sizes are estimated using household measures (e.g., cups, tablespoons, and teaspoons), a ruler, or containers (e.g., coffee cups, bowls, and glasses). Certain items (e.g., eggs, apples, 12-ounce cans of soda) are counted as units. Estimated of Average Requirement: The daily dietary intake level estimated to meet the nutrient requirement of 50% of healthy individuals in a particular life stage and gender group. One of four nutrient reference intakes included in the Dietary Reference Intakes. Etiology: The cause of a disease or an abnormal condition.

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Extremely low birth weight: Is an infant who weighs less than 1000 g (2¼Ib). Faddism is an eating regime that focuses on a particular food or food group. Failure to thrive (FTT): Condition of inadequate weight or height gain thought to result from a calorie deficit. Fat mass: Portion of the human body that is composed strictly of fat. Febrile seizure: An epileptic seizure associated with a high body temperature but without any serious underlying health issue. Fecundity: Biological ability to bear children. Ferritin: The combination of the protein Apo ferritin and iron that functions as the primary storage form for body iron. It is primarily found in liver, spleen, and bone marrow. Fetus: The term used to refer to a prenatal mammal between its embryonic state and its birth. Fever: Defined as a body temperature above the normal range due to an increase in the temperature. Food allergy: An immune system reaction that occurs soon after eating a certain food. Food and Drug Administration (FDA) Food balance sheet: See balance sheet approach. Food diary: A powerful tool to help you become more aware of your eating habits and activity levels. Food exchange system: A meal planning method, originally developed for diabetic diet, that simplifies control of energy consumption, helps ensure adequate nutrient intake, and allows considerable variety in food selection. Food frequency questionnaire: A questionnaire listing food on which individuals indicate how often they consume each listed item during certain time intervals (daily, weekly, or monthly). Standard portion sizes are used and an estimate of nutrient intake is provided on the questionnaire. Sometimes referred to as the semi-quantitative food frequency or listed-based diet history approach. Food intolerance: A detrimental reaction, often delayed, to a food, beverage, food additive, or compound found in foods that produce symptoms in one or more body organs and systems, but it is not a true food allergy. Food inventory record: An approach to household food consumption measurement in which total household food use in calculated by subtracting food on hand at the end of the survey period (ending inventory) from the sum of food on hand at the start of the survey period

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(beginning inventory) and food brought into the household during the survey. Food preferences: Process in which other like or dislike food items. Fortified food: Process of adding micronutrients (essential trace elements and vitamins) to food. Frame size: Frame size is determined by a person's wrist circumference in relation to his height. Frankfort horizontal plane: An imaginary plane intersecting the lowest point on the margin of the orbit (the bony socket of the eye) and the tragion (the notch above the tragus, the cartilaginous projection just anterior to the external opening of the ear). This plane should be horizontal with the head and in line with the spine. Galactosemia: A rare genetic condition of carbohydrate metabolism in which a blocked or inactive enzyme does not allow breakdown of galactose. Gastroesophageal reflux Disease (GERD): Movement of the stomach contents backward into the esophagus, due to stomach muscle contractions. Geophagia: Compulsive consumption of clay or dirt. Geriatric nutritional risk index: Index for evaluating at-risk elderly medical patients. Gestational diabetes: Carbohydrate intolerance with onset or first recognition in pregnancy. A condition in which women without previously diagnosed diabetes exhibit high blood glucose. Glomerulonephritis: Inflammation of the tiny filters in your kidneys (glomeruli). Glossitis: A problem in which the tongue is swollen and changes color, often making the surface of the ton. Glycolated hemoglobin: Hemoglobin that has glucose bound to it. Also referred to as hemoglobin A1C or simply as A1C test, it reflects average blood glucose levels during the past 8 to 12 weeks. Glycosuria or glucosuria: The excretion of glucose into the urine. Gram: A unit of mass in the metric system. One gram equals 10-3 kilogram, 1 pound equals 453.5924 grams, and 1 ounce equals 28.350 grams. Gravida: Number of pregnancies a woman has experienced. Gynecological age: Defined as chronological age minus age at menarche. For example, a female with the chronological age of 14 years minus age at first menstrual cycle of 12 equals a gynecological age of 2.

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Gynoid obesity: Excess body fat that is predominantly within the hips and thighs, as opposed to within the abdomen and upper body. This is the usual pattern of female obesity. Haemorrhaging is blood escaping from the circulatory system. Half arm span: Distance from sternal notch to the tip of the middle finger of the hand. Head circumference: A measurement of a child's head around its largest area. Healthy eating index: An instrument developed by the U.S. department of agriculture to provide a single summary measure of overall dietary quality. Height – weight indices: Various ratios or indices expressing body weight in terms of height. Among these are Quetelet‟s index and Benn‟s index. Hemoglobin A1C: See glycated hemoglobin. Hemoglobin: The iron containing protein pigment of red blood cells that carries oxygen to body cells. Blood hemoglobin levels can reflect iron status (e.g, abnormally low hemoglobin may mean anemia). High density lipoprotein (HDL): A serum lipoprotein synthesized by the liver and intestine that transports cholesterol within the bloodstream. As the serum level of HDL increases, risk of coronary artery disease decreases. Hydration: A term used to indicate that a substance contains water; Hydration fluid, a liquid substance that supplies the body with water. Hyper lipidemia: Excessively high levels of lipids in the blood. Hyper metabolism: An increased rate of energy and protein metabolism trauma, infection, burns, or surgery. Hyper vitaminosis A: An excessive consumption of vitamin A. Hyperbilirubinemia: Elevated blood levels of bilirubin, a yellow pigment that is a by – product of the breakdown of fetal hemoglobin. Hyperinsulinemia: Means tThe amount of insulin in your blood is higher than what's considered normal. Hypertension: High blood pressure (typically exceed 140/90mmHg). Hypertonia: Condition characterized by high muscle tone, stiffness, or spasticity. Hypertonic: Refers to a greater concentration. Hypocalcemia: Condition in which body pools of calcium are unbalanced, and low levels in blood. Hypogonadism: Atrophy or reduced development of testes or ovaries. Results in immature development of secondary sexual characteristics.

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Hypothyroidism: Condition characterized by growth impairment and mental retardation and deafness when caused by inadequate maternal intake of iodine during pregnancy. Used to be called cretinism. Hypotonia: Condition characterized by low muscle tone, floppiness, or muscle weakness. Hypotonic: Solution that has a lower osmotic pressure than another solution. Ideal body weight: Comparing a person‟s current (actual) weight against a recommended weight based on height. Illiac crest: The crest. Or top, of the ileum (the largest of three bones making up the outer half of the pelvis). The crest is the bony spine located just below the waist. Used as an anatomic landmark in skin fold measurement sites. Incidence: The number of new cases of a disease divided by the total number of persons at risk of the disease within a specific time period, usually one year. It indicates a person‟s risk or changes of developing the disease per year. Index of nutritional quality (INQ): A concept related to nutrient density that allows the quantity of a nutrient per 1000 kcal in a food, meal, or diet to be compared with a nutrient standard. Infant: Referred for who born between 37th and 42nd weeks of gestation. Infant mortality: Infant mortality is the death of a child less than one year of age. Infectious disease: Any disease caused by the invasion and multiplication of microorganisms, such as bacteria, fungi, or viruses. Insulin resistance (IR): A physiological condition in which cells fail to respond to the normal actions of insulin. Iodine deficiency disorder: Occurs when the soil is poor in iodine, causing a low concentration in food products and insufficient iodine intake in the population. Iron deficiency anemia: A low hemoglobin value found in association with iron deficiency. Theoretically, anemia corresponding to the third stage of iron deficiency. Iron deficiency: The depletion of body iron stores, corresponding to the second and third stages in the development of iron deficiency. IU: international unit. Kat/L: The SI unit of enzyme activity. One katal per liter is the amount of enzyme necessary to catalyze a reaction at the rate of 1 mole of substrate per second per liter (mol, s – 1, L – 1).

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Kcal: Kilocalorie. The amount of energy required to raise the temperature of 1 liter of water 1C. A unit of heat equal to 1000 calories. Also known as a large calorie. One kcal equals 0.239 kilojoules. Kilogram (kg): Kilogram. A unit of mass in the metric system. One kilogram equals 1000 grams, or 2.2046 pounds. Klinefelter’s syndrome: A congenital abnormality in which testes are small and firm, legs abnormally long, and intelligence generally subnormal. Knee height: Is correlated with stature and, until recently, was the preferred method for estimating height in bedridden patients. Kwashiorkor: A protein deficiency, generally seen in children, characterized by edema, growth failure, and muscle wasting. It is a severe form of protein energy malnutrition characterized by swelling, fatty liver, susceptibility to infection, profound apathy, and poor appetite. The cause of kwashiorkor is unclear. Lactation: Describes the secretion of milk from the mammary glands and the period of time that a mother lactates to feed her young. Lapse: A single or temporary recurrence of an unwanted habit or behavior that one has become or has turned from for a period of time. Large for gestational age: Infant whose birth weight is above the 90th percentile. LDL receptors: Molecules on the surface of plasma membranes of hepatic and peripheral cells that recognize and remove low-density lipoprotein from the blood. Lean muscle mass: Fat-free mass represents the weight of your muscles, bones, connective tissue and internal organs. Length: The distance from one end of something to the other end. Low birth weight: Is an infant who weighs less than 2500 gm (5½ Ib). Low-density lipoprotein (LDL): A serum lipoprotein whose primary role is transporting cholesterol to the various cells of the body. LDL contains approximately 70% of the serum's total cholesterol, is considered the most atherogenic (atherosclerosis-producing) lipoprotein, and is the prime target of attempts to lower serum cholesterol. Low serum levels of LDL cholesterol are desirable. M: meter. Macrocephaly: Large head size for age and gender as measured by centimeters (or inches) of head circumference. Macrophages: A white blood cell that acts mainly through phagocytosis. Malnutrition: This can mean any nutrition disorder but usually refers to failing health caused by long-term nutritional inadequacies.

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Maple syrup urine disease: Rare genetic condition of protein metabolism in which breakdown by-products build up in blood and urine, causing coma and death if untreated. Marasmic Kwashiorkor: A combination of chronic energy deficiency and chronic or acute protein deficiency. Marasmus: Predominantly an energy (kilocalorie) deficiency presenting with significant loss of body weight, skeletal muscle, and adipose tissue mass, but with serum protein concentrations relatively intact. Maternal mortality: Death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of the duration and the site of the pregnancy, from any cause related to or aggravated by the pregnancy or its management, but not from accidental or incidental causes. Maternal nutrition: Nutritional status during any stage of her reproductive age that eventually can affect fetus health and infant. MCV model: A model for assessing the prevalence of iron deficiency that requires abnormal values for at least two of the following measurements: mean corpuscular volume, transferrin saturation, or erythrocyte protoporphyrin level. Mean: A value calculated by summing all the observations in a sample and dividing the sum by the number of observations. Also referred to as the arithmetic mean or, simply, average. One of three measures of central tendency, along with median and mode. Mean corpuscular (red blood cell) volume (MCV) Median: The observation that divides the distribution into equal halves, with 50% of the observations above and 50% of the observations below this point. Also known as the 50th percentile. One of the three measures of central tendency, along with mean and mode. Memory lapses: Is a momentary inability to remember a piece of information. Menarche: The occurrence of the first menstrual cycle. Menopause: Cessation of the menstrual cycle and reproductive capacity in females. Menses: The process of menstruation. MI: Myocardial infraction. Microcephaly: Small head size for age and gender as measured by centimeters (or inches) of head circumference. Mid arm circumference: The measurement of the circumference of the nondominant (left) arm, at the midpoint between the tip of the shoulder and the tip of the elbow.

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Mid axillary time: An imaginary line running vertically through the middle of the axilla, used as an anatomic landmark in skin fold measurement. Mid upper arm fat area: An estimation of the fat area of the upper arm. Mid upper arm muscle area: An estimation of the muscle area of the upper arm. Milligram (mg): A unit of mass in the metric system 10-3 gram, or onethousandth of a gram. Millimeter (mm): A unit of distance in the metric system. 10-3 meter, or 1/1000 of a meter. Millimole (mmol): 10-3 mole. Or 1/1000 of a gram. Mini nutritional assessment: A screening tool used to identify older adults (> 65 years) who are malnourished or at risk of malnutrition. Miscarriage: Loss of conceptus in the first 20 weeks of pregnancy. Morbidity: Illness or sickness. Mortality: Death. National health and nutrition examination survey (NHANES): A continuous, annual cross-sectional survey, conducted by the U.S. department of health and human services that assesses food intake, height, weight, blood pressure, vitamin and mineral levels, and a number of other health parameters in a statistically selected group of Americans. Negative nitrogen balance: A condition in which nitrogen loss from the body exceeds nitrogen intake. Negative nitrogen balance is often seen in the case of illness, trauma, burns, or recovery from major surgery. Neonatal mortality: Number of neonates dying before reaching 28 days of age. Nitrogen balance: A condition in which nitrogen losses from the body are equal to nitrogen intake. Nitrogen balance is the expected state of the healthy adult. Nomogram: A graphic device with several vertical scales allowing calculation of certain values when a straightedge is connected between two scales and the desired value is read from a third scale. Non-quantitative food frequency questionnaire: A food frequency questionnaire assessing frequency of food consumption but not the size of food servings. Nutrient density: The nutritional composition of foods expressed in terms of nutrient quantity per 1000 kcal. If the quantity of nutrients per 1000 kcal is great enough, then the nutrient needs of a person will be met when his or her energy needs are met.

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Nutrient intake analysis: Calculation of a resident's food and beverage intake for calories and protein for 72 hours. Nutritional assessment: The measurement of indicators of dietary status and nutrition-related health status of individuals or populations to identify the possible occurrence, nature, and extent of impaired nutritional status (ranging from deficiency to toxicity). Nutritional epidemiology: The application of epidemiologic principles to the study of how diet and nutrition influence the occurrence of disease. Nutritional monitoring: The assessment of dietary or nutritional status at intermittent times with the aim of detecting changes in the dietary or nutritional status of a population. Nutritional quality of the diet: How much the consumed food items are good or bad to human body depends on its contents. Nutritional screening: The process of identifying characteristics known to be associated with nutrition problems in order to pinpoint individuals who are malnourished or at risk for malnutrition. Obesity: An excessive accumulation of body fat. Osmolarity: Concentration of osmotically active particles in solution, which may be quantitatively expressed in osmoles of solute per liter of solution. Osteoblasts: Bone cells involved with bone formation, bone – building cells. Osteoclasts: Bone cells that absorb and remove unwanted tissue. Osteopenia: A condition in which bone mineral density is decreased but not to the point that a diagnosis of osteoporosis can be made. According to WHO criteria, osteopenia occurs when the T-score is between -1.0 and 2.5. Osteoporosis: A condition in which there is a marked decrease in bone mineral density and deterioration of bone micro architecture, compromised bone strength, and an increased susceptibility to fracture and painful morbidity. According to WHO criteria, osteoporosis occurs when the T-score is less than -2.5. Over estimation: To estimate at too high a value, rate comparing to what it should be. Over nutrition: The condition resulting from the excessive intake of foods in general or particular food components. Overweight: Body weight in excess of a particular standard and sometimes used as an index of obesity. Oxytocin: A hormone produced during letdown that causes milk to be ejected into the ducts. Pagophagia: Compulsive consumption of ice or freezer frost.

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Parenteral nutrition: The process of administering nutrients directly into veins to improve nutritional status. Parity: The number of times a female has given birth. Percentiles: Divisions of a distribution into equal, ordered subgroups of hundredths. The 50th percentile is the median. The 90th percentile, for example, is an observation whose value exceeds by only 10%. Periconceptional period: Around the time of conception, generally defined as the month before and the month after conception. Pica: An eating disorder characterized by the compulsion to eat substances that are not food. Pitting edema: Observable swelling of body tissues due to fluid accumulation that may be demonstrated by applying pressure to the swollen area. Plasma: The liquid component of blood that has not clotted. An anticoagulant added to the glass tube used to draw blood from a subject's vein prevents clotting of the blood. This tube is then centrifuged, leaving the blood cells at the bottom of the tube and the plasma at the top. Unlike serum, plasma contains the clotting factors. Pleural effusion: Excess fluid that accumulates in the pleural cavity, the fluidfilled space that surrounds the lungs. Polycystic ovary syndrome (PCOS): (Abnormal sacs with membranous lining). A condition in females characterized by insulin resistance, high blood insulin and testosterone levels, obesity, menstrual dysfunction, amenorrhea, infertility, hirsutism (excess body hair), and acne. Positive nitrogen balance: Nitrogen intake exceeds nitrogen loss from the body. This is commonly seen during growth, pregnancy, and recovery from trauma, surgery, or illness. Post natal age: Period beginning immediately after the birth of a child. Postictal state: Time after a seizure of altered consciousness, appears like a deep sleep. Post-partum: The period beginning immediately after the birth of a child and extending for about six weeks e. Postprandial: After a meal. Post-term: Infant who born after 42 weeks of gestation. Prader-willi syndrome: Condition in which partial deletion of chromosome 15 interfere with control of appetite, muscle development, and cognition. Pre-diabetes: A term used to represent impaired fasting glucose (IFG) or impaired glucose tolerance (IGT) based on the observation that most people have either IFG or IGT before they are diagnosed with type 2 diabetes.

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Preeclampsia: A pregnancy – specific condition that usually occurs after 20 weeks of pregnancy (but may occur earlier). It is characterized by increase blood pressure and protein in the urine and is associated with decreased blood flow to maternal organs and through the placenta. Pregnant adolescence: Intended pregnancy during adolescence. Premature: Infant who born before 37 weeks of gestation. Prenatal care: Health care you get while you are pregnant. It includes your checkups and prenatal testing. Pre-pregnancy BMI: Body Mass Index value for women before being pregnant. Pre-term delivery: Birth of a baby of less than 37 weeks gestational age. Prevalence: The number of existing cases of a disease or condition divided by the total number of people in a given population at a designated time. It indicates the burden of a disease or how common it is. Prolactin: A hormone that stimulates milk production. Protein-energy malnutrition (PEM): An inadequate consumption of protein and energy, resulting in a gradual body wasting and increased susceptibility to infection. Quantitative food frequency questionnaire: See semi-quantitative food frequency questionnaire. Quetelet's index: Weight in kilograms divided by height in meters sequare (kg/m2). The most widely used weight-height or power-type index. Recommended dietary allowance (RDA): The average daily dietary intake level sufficient to meet the nutrient requirement of nearly all (97% to 98%) healthy individuals in a particular life stage or gender group. One of four nutrient reference intakes included in the dietary reference intakes. Reference daily intakes (RDIs): A set of dietary references that serves as the basis for the daily values and are based on the recommended dietary allowances (RDAs) for essential vitamins and minerals and, in selected groups, protein. The RDIs replace the U.S. Relative weight: A subject‟s actual body weight divided by the midpoint value of weight range for a given height and then multiplied by 100. See also metropolitan relative weight. Reliability: See reproducibility. Resting energy expe (REE): Amount of energy needed by individual in awake, resting, and post absorptive. Retinol: A form of vitamin A.

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Retrospective methods: A method of looking backwards and examines exposures to suspected risk or protection factors in relation to an outcome that is established at the start of the study. Rett syndrome: Condition in which a genetic change on the X chromosome results in severe neurological delays, causing children to be short, thin appearing, and unable to talk. Sarcopenia: Degenerative loss of skeletal muscle mass. Schizophrenia: A severe brain disorder in which people interpret reality abnormally. Semi-quantitative food frequency questionnaire: A food frequency questionnaire that assesses both frequency and portion size of food consumption. See also food frequency questionnaire. Sensitivity: A test‟s ability to indicate an abnormality where there is one. Sepsis: Is a potentially life-threatening complication of an infection. Serum osmolarity: A measure of the different solutes in plasma. Serum proteins: Proteins present in serum (the liquid portion of clotted blood) that are often regarded as indicators of the body‟s visceral protein status (e.g., albumin). Serum: The liquid component of blood that has clotted. A plain glass tube is used to draw blood from a subject‟s vein, and after several minutes the blood clots. This tube is then centrifuged, leaving the blood cells at the bottom of the tube and the serum at the top. Unlike plasma, serum doesn‟t contain the clotting factors. Shoulder dystocia: Blockage or difficulty of delivery due to obstruction of the birth canal by the infant‟s shoulders. Skin fold thickness: A double fold of skin that is measured with skin folds calipers at various body sites. Small for gestational age: Infant who weighs less than 10th percentile of the standard weight for that gestational age. Somatic protein: Protein contained in the body‟s skeletal muscles. Specificity: A test‟s ability to indicate normalcy where there is no abnormality. Stadio meter: A device capable of measuring stature in children over 2 years of age and in adults. This measure is taken in a standing position. Standard deviation (SD): A measure of how much a frequency distribution varies from the mean. Stature: Standing height. Stroke: A blockage or rupture of a blood vessel supplying the brain, with resulting loss of consciousness, paralysis, or other symptoms.

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Stunting: A decreased height-for-age. It is generally seen in long-term, mild to moderate protein-energy malnutrition. Subjective global assessment: A clinical approach to assessing the nutritional status of a patient using information gained from the patient‟s history and physical examination. Subscapular: Is a large triangular muscle which fills the subscapular fossa and inserts into the lesser tubercle of the humerus and the front of the capsule of the shoulder-joint. Suckle: A reflexive movement of the tongue moving forward and backward. Sunken: Situated beneath the surface; submerged. Supine: The position in which one is lying on his or her back. Suprailliac: Measurement of the area on the side of the waist, just above the point of the hipbone and a inch or so forward. Symptoms: Disease manifestations that the patient is usually aware of and often complains of. Testes: Male reproductive glands located in the scrotum. Also called testicles. Thermic effect of food (TEF): Also known as diet-induced thermogenesis or the specific dynamic action of food. TEF is the increased energy expenditure following food consumption or administration of parenteral or enteral nutrition caused by absorption and metabolism of food and nutrients. Total fiber: The sum of dietary fiber and functional fiber. See dietary fiber and functional fiber. Total water: The total number of water a person consumes which includes drinking water, water in other beverages, and water or moisture in food. Transferrin: The form in which iron is transported within the blood. Triceps: Is the large muscle on the back of the upper limb of many vertebrates. Triglyceride: A lipid composed of a glycerol molecule to which are attached three fatty acid molecules and the chemical form of most fat in food and in the body. Triglyceride is also found in the blood, primarily in very lowdensity lipoprotein particles and chylomicrons. U.S. recommended daily allowance (USRDA): A set of nutrition standards developed by the FDA for use in regulating the nutrition labeling of food. They were replaced by the reference daily intakes. Ulna: The larger, inner bone of the forearm. Used as an anatomic landmark in arm anthropometry. Under estimation: To estimate at too low a value, rate comparing to normal level.

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Under nutrition: A condition resulting from the inadequate intake of food in general or particular food components. Unintentional weight: Losing weight without dieting or increasing physical activity. Upper arm circumference: The estimation of the amount of upper arm muscle. Urine specific gravity: A measure of the concentration of solutes in the urine. Usual weight: Person's most frequent body weight. Validity: The ability of an instrument to measure what it is intended to measure. Validating a method of measuring dietary intake, for example, involves comparing measurements of intake obtained by that method with intake measurements obtained by some other accepted approach. Venous thromboembolism: A blood clot in a vein. Very low birth weight: Is an infant who weighs less than 1500 gm. (31/3 Ib). Very- low density lipoprotein (VLDL): A lipoprotein, present in blood, that is synthesized by the liver and primarily carries triglyceride to cells for storage and metabolism. Viscera: Organs of the body (such as liver, kidneys, heart). Visceral fat: Fat tissues located inside the abdominal cavity, packed between the organs. Visceral protein: Protein found in the body‟s organs or viscera, as well as that in the serum and in blood cells. Waist circumference: The distance around the horizontal plane through the abdomen at the level of the iliac crest of a standing subject. This measurement is used as an index of abdominal fat content. Waist-to-hip ratio: A ratio of the circumference of the waist to that of the hips. Wasting: A decreased weight for age. It is generally seen in severe proteinenergy malnutrition. Weight food record: A method of recording individual food intake in which the amounts and types of all food and beverages are recorded for a specific period of time, usually ranging from 1 to 7 days. Portion sizes are determined by accurate weighing. Weight-height indices: See height-weight indices. Wrist circumference: Is a simple check to tell how much body fat and where it is placed around someone‟s body Calculate r value: ht(cm)/wrist circ. (cm). Xerostomia: Dry mouth.

ABOUT THE AUTHORS Ghazi Daradkeh Research Scholar

Dr. M. Mohamed Essa Associate Professor

Professor Nejib Guizani Professor and Head Department of Food Science and Nutrition, CAMS, Sultan Qaboos University, Muscat, Oman Ghazi Daradkeh is Research scholar (PhD candidate) of Nutrition and food science at Sultan Qaboos University, Oman. He is an expert in the field of clinical nutrition and dietetics, has 25 years of experience in clinical nutrition and dietetics field, published 12 papers, 1 book chapter. He is holding memberships in various international bodies including Linnean Society FLS UK, International Society for Neurochemistry (ISN) , etc.., He has so many TV interviews about nutritional counseling and diet therapy , he wrote a chapter in “Food and Brain health” book which was awarded as best book in the world by GOURMAND Cook Book Awards. He has received so many awards from local and international bodies Email: [email protected] Dr. M. Mohamed Essa, PhD, is an Associate Professor of Nutrition at Sultan Qaboos University, Oman and holding visiting A/Prof position in Neuropharmacology group, ASAM, Macquarie University, Sydney, Australia. He is an editor-in-chief for International Journal of Nutrition, Pharmacology,

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About the Authors

Neurological Diseases published by Wolters & Kluwer, USA and an involved in editor/reviewer board of various well known journals such as Frontiers in Neuroscience, Biochemie, PLOS one, etc. He is an expert in the field of Nutritional Neuroscience and published 84 papers, 31 book chapters and 7 books (4 published and 3 in press). He has strong international collaborations with institutes in USA, Australia and India. Recently he founded a new foundation named “Food and Brain Research Foundation” to support research in nutritional neuroscience. He is holding memberships in various international bodies including American Society for Neurochemistry (ASN), International Society for Neurochemistry (ISN), etc. He has received so many awards from local and international bodies and this year one of his book titled “Food and Brain health” was awarded as best book in the World by GOURMAND Cook Book Awards. He has received many research grants from local and international agencies. Email: [email protected]; [email protected]

Dr. N. Guizani obtained his PhD in Food Science from the University of Florida, USA. He presently works as professor in the Department of Food Science and Nutrition at Sultan Qaboos University, Oman. During his academic career, Dr. Guizani has developed a research program based on a multidisciplinary approach combining food chemistry, processing, and microbiology using local commodities such as dates, fish and fermented products. This program has generated a valuable scientific data base and permitted the development of methods to safely manufacture traditional foods and incorporate new products and ingredients in local processed food. His most current research deals with the study of the functional properties of plant foods and their impact on health. Specific interests of this research include the antioxidant and anti-inflammatory effects of phenolics and flavonoids and related compounds. He has published more than 68 research papers in peer reviewed journals, 24 conference proceedings and 11 book chapters. In addition, he has presented more than 50 papers in international and national conferences and serves in the editorial board of 3 international journals. Email: [email protected]

INDEX A adolescence, vii, 49, 52, 54, 128, 139 adulthood, vii, 128 age group, xi, 60, 61, 62, 63, 84, 85 anthropometric, vii, xi, 6, 15, 16, 28, 31, 33, 64, 65, 74, 92, 128 anthropometric assessment, vii, 15, 66, 71 Approprate for Getational Age (AGA), xiii, 31, 32, 133 Arm Circumference (AC), xiii, xiv, xv, 7, 36, 90, 91, 97, 105, 130 Arm Fat Index (AFI), xiii, 92 Arm Muscle Area (AMA), xiii, xv, 91, 92 Attention Deficit Hyperactivity (ADH), xiii, 117, 134

B biochemical, 16, 66 biochemical assessment, vii, xi, 16 Blood Urea Nitrogen (BUN), xiii, 9, 115, 118, 122, 124, 141

Body Mass Index (BMI), xiii, 5, 6, 7, 10, 13, 25, 36, 47, 48, 49, 50, 51, 58, 59, 73, 80, 84, 102, 104, 105, 109, 110, 124, 140, 141, 151 body composition, vii, 15, 28, 31, 91

C Calf Circumference (CC), xiii, 38, 39, 40, 52, 92, 102, 104 carbohydrate (CHO), 10, 136, 142, 143 childhood, vii, 27, 31, 122, 123 clinical assessment(s), xi, 30, 102 comprehensive treatment plan, xi, 145 Corrected Arm Muscle Area (CAMA), xiii, 92

D Desirable Body Weight (DBW), xiii, 80 dietary, 11 dietary, vii, xi, 9, 10, 11, 12, 13, 43, 64, 65, 66, 67, 69, 84, 86, 120, 126, 128, 129, 130, 131, 135, 137, 139

dietary history, vii, 13

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Index

dietary intake, 9, 43, 65, 66, 67, 69, 84, 126, 129, 137, 139 dietary intervention, vii dietary plan/dietary planning, xi dietitian(s), vii, xi, 12, 73, 98, 114 doctors, xii

Institute of Medicine (IOM), xiv, 6, 10, 25, 28 Intelligence Qutenet (IQ), xiv intervention(s), vii, xi, 4, 15, 28 Intra Venous (IV), xiv, 122 Iodine Deficiency Disorder (IDD), xiv, 2 Iron Deficiency Anemia (IDA), xiv, 2

E

K

European Society of Parenteral and Enteral Nutrition (ESPEN), xiii, 102, 128 Extremely Low Body Weight (ELBW), xiii, 31

Knee Height (KH), xiv, 81, 82, 84, 85, 105, 106, 109

F Food Frequency Questionnaire (FFQ), xiii, 78

G Gastrointestinal Tract (GIT), xiii Geriatric Nutrition Risk Index (GNRI), xiv, 112, 113

H health care providers, xi, xii, 4 Hematocrit (Htc), vii, xiv, 7, 115, 116, 117, 124, 130, 131 Hemoglobin (Hgb), xiv, 7, 9, 18, 73, 122, 145, 146 High Density Lipoprotein (HDL), xiv, 10, 146 hydration status, vii, 104, 105, 106, 110, 111, 112

I Ideal Body Weight (IBW), xiv, 85, 140 infancy, 27

L Large for Gestational Age (LGA), xiv, 31, 32 life cycle, xi Low Birth Weight (LBW), xiv, xv, 7, 31 Low Density Lipoprotein (LDL), xiv, 10, 147, 148

M malnourished, xi, 1, 15, 45, 70, 85, 90, 114, 135, 136 malnutrition, xi, 1, 2, 4, 6, 64, 89, 90, 92, 100, 114, 120, 123, 125, 135, 136, 137, 140 medical team, xi Mid Arm Circumference (MAC), xiv, 81, 91, 92 Mid Upper Arm Area (MUAA), xiv, 92 Mid Upper Arm Circumference (MUAC), xv, 7 Mid Upper Arm Fat Area (MUAFA), xiv, 92 Mid Upper Arm Muscle Area (MUAMA), xv, 92 Mini Nutritional Assessment (MNA), xiv, 102, 104, 105, 128 Multicenter Growth Reference Study (MGRS), xiv, 49

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Index

N National Center for Health Statistics (NCHS), xv, 46, 47, 48, 52, 56, 57, 71 National Center for Health Statistics (NCHS), xv, 36, 56 Non lactating (NL), xv, 23 Non pregnant (NP), xv, 23, 80, 98 Non pregnant non lactating (NPNL), xv, 20 Nothing Per Os (NPO), xv, 119 nurses, xii nutrient, vii, 1, 5, 11, 15, 35, 47, 89, 100, 126, 127, 129, 130, 132, 135, 137 nutrient deficiencies, vii Nutrient Intake Analysis (NIA), xv, 76, 79 nutrients, vii, 10, 11, 15, 19, 47, 68, 128, 129, 135, 136, 138 nutrients estimations, vii nutrition, vii, xi, 1, 3, 4, 14, 15, 16, 28, 63, 64, 83, 84, 85, 86, 87, 89, 90, 100, 101, 106, 114, 115, 127, 128, 129, 133, 134, 135, 136, 138, 139 nutritional assessment, vii, xi, 2, 3, 5, 15, 23, 31, 35, 44, 45, 51, 62, 64, 69, 75, 76, 85, 86, 90, 114, 135 nutritional assessment guidance, vii nutritional assessment tools, xi nutritional care, vii nutritional deficiencies, 6, 100 nutritional diagnosis, xi nutritional status, 1, 2, 4, 11, 12, 23, 28, 31, 43, 63, 64, 69, 79, 80, 84, 85, 86, 90, 92, 93, 114, 115, 126, 129, 135, 136, 138 nutritional care, 74

O obesity, 12, 44, 46, 50, 51, 52, 76, 78, 86, 87, 97, 124, 126, 131, 136 old age, vii, xi, 129

P patient care, vii

patient records, xi pharmacists, xii physical activity, 6, 130, 139 physical assessment, vii, 46 pregnancy, vii, xi, 1, 2, 4, 5, 6, 9, 11, 12, 15, 16, 19, 22, 24, 122, 123, 124, 125, 134, 136, 137 premature infant, 28, 29, 31, 45 prematurity, 28, 30 Protein Energy Malnutrition (PEM), xv, 2, 151

Q quality of life, xi, 89 Quetelets Index (QI), xv, 80

R Recommended Dietary Allowance (RDA), xv, 21, 23, 55, 71, 77, 140, 143, 151 Registered Nurse (RN), xv, 98, 129 requirements, xi, 15, 18, 25, 110, 126, 129, 137 risk of malnutrition, xi, 89, 90, 92, 135

S Small for Gestational Age (SGA), xv, 31, 32 Standard Deviation (SD), xv, 13, 66, 67, 68, 69, 94, 95, 152

T Triceps Skin Fold (TSF), xv, 90, 91, 92, 105

U Upper Arm Circumference (UAC), xv, 7, 36

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Index

V Very Low Birth Weight (VLBW), xv, 31 Vitamin A Deficiency (VAD), xv, 2

W Waist Circumference (WC), xv, 14, 26, 38, 39, 40, 51, 52, 82, 83, 85, 89, 90, 98, 99, 100, 128, 129 Waist Hip Ratio (WHR), xv, 87, 89 World Health Organization (WHO), xv, 7, 27, 52, 53, 150