Case Western Reserve University Department of Nutrition
Coordinated Dietetic Internship/Master's Degree Program
Syllabus, Nutrition 516: Seminar in Dietetics

NUTRITIONAL ASSESSMENT

Objectives:

Upon completion of this unit the student will be able to:

understand the importance of knowing the origin and limitations of reference data.

select appropriate assessment indices when given a variety of clinical situations.

perform accurate and appropriate calculations.

perform skinfold and circumference measures.

Learning Activities:

1. Watch video tape: NHANES III Anthropometric Procedures.

2 Working in groups of three (A,B,C), each student should take the measurements listed below on a fellow classmate (A measured by B & C; B measured by A & C; C measured by A & B). Continue to take each measurement until you have two figures which are within the guidelines for duplicate measures (see below).  This procedure illustrates intra-measurer and inter-measurer variability.  Intra-measurer-variability refers to variations in reproducing your own measurements of others.
Intermeasurer-variability refers to the variation that can occur when more than one person measures the same subject.

GUIDELINES FOR ANTHROPOMETRIC MEASUREMENTS

3.  After each measurer is satisfied with the accuracy of their measurement, record them below and compute the mean.  These will be the measurements used in question no. 4.

4.  Record the mean of your anthropometric measurements from question no. 3 in the spaces below and evaluate them against reference data by indicating the placement of your data on the percentile continuum below.

*Midarm muscle circumference (MAMC)            
MAMC (cm) = MAC (cm)-[3.14XTSF(cm)]   (Show calculations)

Reference data:  Frisancho AR.  Anthropometric Standards for the Assessment of Growth and Nutritional Status.  Ann Arbor: The University of Michigan Press; 1990.  (On reserve at Health Center Library)

Bishop CW,  Bowen PE, Ritchey SJ.  Norms for nutritional assessment of American adults by upper arm anthropometry.  Am J Clin Nutr. 1981;34:2430-2439.

5.  Compute your BMI using the nomograph and BMI chart.  Evaluate your body weight using each standard. ('59 Metropolitan Standard, '83 Metropolitan Standard, and '98 BMI Nomograph).  Then, comment on interpretation of all three measurements.

*http://www.nhlbisupport.com/bmi/
*http://www.nhlbi.nih.gov/guidelines/obesity/bmi_tbl.htm

6.  Define basal metabolic rate and resting energy expenditure.

7.  Refer to Table 3-1 in RDA and predict your resting energy expenditure from your body weight.  Show calculations.

8.  Refer to Table 3-5 in the RDA and compute your average energy allowance per kilogram of body weight and per day. Show calculations.

9.  Estimate your caloric expenditure using Long's equation.

ECE (men) = (66.47+13.75W+5.0H-6.76A) X (activity factor) X (injury factor)

ECE (women) = (655.10+9.56W+1.85H-4.68A) X (activity factor) X (injury factor)

 

NUTRITIONAL ASSESSMENT

10. You have been consulted to evaluate energy and protein needs for the following patients. Read the cases and answer all the questions. Make sure you show all calculations with any relevant justification for your answers.

A. Patient A is a 45 year male admitted to the orthopedic service with a broken femur from a skiing accident.

Ht. 5'10"
Wt. 160 lbs.
Usual Wt. 169 lbs.

Determine the following:

a. Ideal Body Weight: ____________________
b. % IBW: ____________________________
c. % Usual Body Weight: ________________________
d. % Weight Change: _____________________
e. Basal Energy Expenditure:________________

BEE equation used (show calculation)________________________

f. You have discussed this patient's case with your preceptor. Together you have decided that you will use an activity factor of _____ and an injury factor of______ for estimating total energy needs. In addition, you have discussed protein needs and decided to supply protein at___________gm/kg. Explain the rationale for these figures.

g. Estimated Energy Needs: ___________________

h. Estimated Protein Needs: ___________________

References:

11. B. Patient B. is a 65 year old female with a chief complaint of shortness of breath, chronic cough, and loss of appetite. A lung biopsy report in the chart notes cancerous cells. An oncology consult is pending.

Ht. 5'5"

Wt. 180 lbs. with edema

Usual Wt. 170 lbs.

 

Determine the following:

a. Ideal Body Weight:_________________

b. % IBW: ____________________

c. % Usual Wt.: __________________________

d. % Weight Change: __________________

e. Basal Energy Expenditure: _________________

Equation Used:_____________________

f. Injury factor_____and Activity Factor______

Justification:

 

g. Total Estimated Energy Needs:_____________________

Show equation and if you used a formula to adjust for obesity, justify why.

 

h. Estimated Protein Needs: ___________________

Justification:

 

References:

 

Evaluation:

1. Answers to questions may be submitted handwritten or typed. It is not necessary to use complete sentences.

2. Grading will be based on completion of questions  and accuracy of calculations.

 

 

Nutrition Assessment

Background for Standards

PHYSICAL EXAMINATION

Jelliffe DB: The assessment of the Nutritional Status of the Community. WHO Monograph Series 53, Geneva, 1966.

Christakis G. (ed.): Nutritional Assessment in Health Programs. Am J Public Health 63: Part Two (November) 1973.

Detsky AS, McLaughlin JR, Baker JP, Johnston N, Whittaker S, Mendelson RA, Jeejeebhoy KN. What is Subjective Global Assessment of Nutritional Status. JPEN 11:8, 1987.

ANTHROPOMETRIC MEASUREMENTS

Height:

Measure without shoes
Adjust, if necessary, for heel height
Indicate if stated height or estimated from knee height

Estimated Height:

Chumlea WC, Roche AF, Steinbaugh ML. Estimating stature from knee height for persons 60 to 90 years of age. Journal of the American Geriatric Society 33: 116, 1985.

Use sliding broad blade caliper; limited to persons over 59 years of age.

Weight:

Indicate if stated or estimated from anthropometry.

Estimated Weight:

Chumlea WC, Guo S, Roche AF, Steinbaugh ML. Prediction of body weight for the nonambulatory elderly from anthropometry. Journal of the American Dietetic Association. 88: 564, 1988.

Equations Developed with 2, 3 or 4 Predictor Variables:

Arm circumference
Calf circumference
Subscapular skinfold
Knee height

Valid for patients over 65 years of age. However, author has personally communicated the belief that the method may be applied to persons over 39 years of age and still be considered valid.

Frame Size:

• Visual assessment by clinician
• Frisancho, AR: New standards of weight and body composition by frame size and height for assessment of nutritional status of adults and the elderly. Am J Clin Nutr 40: 808, 1984.
  Frame size by elbow breadth of U.S. male and female adults derived from the combined NHANESI and II data sets.
• Estimated based on elbow breadth - Build Study, 1979. Society of Actuaries and Association of Life Insurance Medical Directors of America. Philadelphia, Recording and Statistical Corporation, 1980.
• Estimated based on wrist circumference - Grant JP. Handbook of Total Parenteral Nutrition. Philadelphia, W.B. Saunders, Co., 1980, page 15.
  
  

Ideal/Desirable Body Weight:

Hamwi, GT. Therapy: Changing Dietary Concepts in Diabetes Mellitus: Diagnosis and Treatment. Vol.1, edited by T.S. Danowski. American Diabetes Association, Inc., 500 5th Avenue, New York, NY 10020,
1964, pages 73-78.

Women:

Allow 100 lb. for first 5' of height, plus 5 lb. for each additional inch.

Men:

Allow 106 lb. for first 5' of height, plus 6 lb. for each additional inch.

Women or Men:

Small frame - subtract 10%
Large frame - add 10%

Metropolitan Life Insurance Co., 1983 Height and Weight Tables:

Metropolitan Life Foundation: Statistical Bulletin Vol. 64, No. 1, Jan. - June 1983. 1983 Metropolitan Height and Weight Tables.

Build Study 1979, Society of Actuaries and Association of Life Insurance Medical directors of America, 1980.

Patient 25-59 years of age
Male: 61" - 75" assumes 5 lbs for clothing; 1" heels
Female: 58" - 72" assumes 4 lbs for clothing; 2" heels

Metropolitan Life Insurance Co.; 1959 Desirable Weights for Men and Women:

Male: assumes 7 lbs for clothing; 1" heels
Female: assumes 4 lbs for clothing; 2" heels

Spinal Cord Injury Patients:

Peiffer SC, Blust P, Leyson JF: Nutritional Assessment of the spinal cord injured person. Journal of the American Dietetic Association, 78: 501, 1981.

Patients 25-59 years of age

Paraplegia Injury:

10-15 lbs below Metropolitan Life Insurance ideal body weight for a given height and frame size (1979 table).

Quadriplegia Injury:

15-20 lbs below that of the 1979 Metropolitan Life Insurance table.

Geriatric Patients:

Beck AM, Ovesen L.  At which body mass index and degree of weight loss should hospitalized elderly patients be considered at nutritional risk?  Clin Nutr. 1998;17:195-198.

Kuczmarski MF, Kuczmarski RJ, Najjar M.  Descriptive anthrompometric reference data for older Americans.  J Am Diet Assoc.  2000; 100:59-66.

Master AM, Lasser RP, Beckman G. Tables of average weight and height of Americans aged 65 to 94 years. Journal of the American Medical Association, 172: 658, 1960.

Patients 66 years of age
Male: 61" - 73"
Female: 58" - 69"

Pediatric Patients:

NCHS/CDC Normalized Anthropometric Reference Data, United States, DHEW Vital and Health Statistics Series 11, #165, DHEW Pub. No. (PHS), pages 78-1650, 1977.

Patients with Amputations:

Clauser CE, McConville JT, Young JW: Weight, volume and center of mass segments of the human body. Wright-Patterson Air Force Base, Ohio 1969 (AMRL-TR-69-70).

Body Mass Index: (Body Weight in Kg/Height in m2)

Burton BT, Foster WR, Hirsch J, Van Itallie TB. Health implications of obesity Am NIH concensus development conference. International Journal of Obesity 9: 155, 1985.

Recommended in Diagnoses, Treatment and Monitoring of Obesity:

Weight goals for men at given heights
Weight goals for women at given heights
Nomograph for BMI and weight goals (1959 tables)
Nomograph for BMI and weight goals (1983 tables)

National Heart, Lung and Blood Institute.  Clinical Guidelines on the Identification, Evaluation, and
Treatment of Overweight and Obesity in Adults. 
http://www.nhlbi.nih.gov/guidelines/obesity/ob_home.htm; 1998

Dietary Intake

Burke BS. 1947 The dietary history as a tool in research. J Am Diet Assoc. 23: 1041-1046.

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