Which of the following measurement is the best indicator of the patients nutritional status?

Introduction

“Nutritional assessment can be defined as the interpretation from dietary, laboratory, anthropometric, and clinical studies. It is used to determine the nutritional status of individual or population groups as influenced by the intake and utilization of nutrients” (Gibson, 2005). Nutritional status represents meeting of human body needs for nutritive and protective substances and the reflection of these in physical, physiological, and biochemical characteristics, functional capability, and health status. Information about nutritional status, i.e., nutritional assessments, is essential for identification of potential critical nutrients (at population groups at risk of deficiency); formulation of recommendations for nutrient intake; development of effective public health nutrition (PHN) program for nutrition-related diseases prevention; and monitoring the efficiency of such interventions (Elmadfa and Meyer, 2014). In current nutrition epidemiology (NE) and PHN research, data collection and comparison against each other, and recommendations, and further development and application of a harmonized and standardized nutritional assessment methodology is a necessity (Gurinović, 2016). Beside these major instruments, to correctly interpret the results of nutritional assessment methods, other factors (socioeconomic status, cultural practices, and health and vital statistics–ecological factors) should also be considered.

This article elaborates dietary, biochemical, and anthropometric measurements as nutritional assessment methods that can be applied in four forms of nutritional assessment system: surveys, surveillance, screening, or interventions.

Nutrition Surveys are usually national cross-sectional studies that are performed to assess the nutritional status of a selected population, identify the group at risk of chronic malnutrition, evaluate existing nutritional problems, and inform evidence-based nutrition policies. Another application of nutrition surveys is to evaluate the efficacy of an intervention using data from baseline and final assessments (Gibson, 2005).

Nutritional surveillance—Public health surveillance is the continuous, systematic collection, analysis and interpretation of health-related data needed for the planning, implementation, and evaluation of public health practice (WHO, 2017). Data in nutritional surveillance studies are collected, analyzed, and evaluated in a standardized manner during a longer period of time. They can be used for the identification of possible nutritive risk factors of malnutrition of a whole population or specific vulnerable group. Formulation, evaluation, and monitoring of the nutrition intervention programs and policies are main objectives of nutrition surveillance (Gibson, 2005).

Nutrition screening is used to identify malnourished individuals. It can be carried out on the whole population, on specific subpopulations at risk or on selected individuals (Gibson, 2005). During nutritional screening, simple, cheap, and rapid measurement methods are used.

Nutrition interventions are carried out on population subgroups at risk, which are identified during nutrition surveys or screening. Supplementation and fortification are some examples of nutrition interventions. Providers require efficient monitoring and evaluation to prove the efficiency and soundness of these interventions. There are three types of evaluation designs. In the simplest one, the whole targeted group is exposed to the intervention, and the outcome is measured against previously defined goals—“adequacy evaluation.” The second—“plausibility evaluation” requires quasiexperimental conditions, where one group receives an intervention while the othercontrol group does not, or receives a “placebo.” In this design, the subjects are not randomized, and multivariate analysis is used to remove external factors and biases. This approach is more expensive than the previous one. The third type of evaluating design is a randomized, controlled, double-blind experimental trial, where subjects are randomly assigned to an intervention or control group. Evaluation of an intervention with this design, especially when it is well-planned and conducted, gives the highest level of confidence that the outcome is the result of the intervention—“probability evaluation” (Gibson, 2005).

Abstract

Nutritional assessments of genetically modified crops are a critical component of the regulatory safety process. Animal models can be useful for the determination of the nutritional value of genetically modified crops, provided that a proper model and an applicable experimental design are used for correct interpretation of the results. The use of animal models should be justified by existing data from other analyses, including compositional analysis, and is a poor choice as a general screen for unanticipated adverse effects. An overview of the history of nutritional assessments, background information, and other nutritional considerations is provided. Further details of two critical regulatory studies, the 42-day broiler chicken study and the 90-day rodent study, are presented here.

1 General Aspects of Nutritional Assessment

Nutritional assessment, in any application, has three general purposes:

Detection of deficiency states

Evaluation of nutritional qualities of diets, food habits, and/or food supplies

Prediction of health effects.

The need to understand and describe the health status of individuals, a basic tenet of medicine, spawned the development of methods to assess nutrition status as appreciation grew for the important relationship between nutrition and health. The first applications of nutritional assessment were in investigations of feed-related health and production problems of livestock, and, later, in examinations of human populations in developing countries. Activities of the latter type, consisting mainly of organized nutrition surveys, resulted in the first efforts to standardize both the methods employed to collect such data and the ways in which the results are interpreted.1 More recently, nutritional assessment has also become an essential part of the nutritional care of hospitalized patients, and has become increasingly important as a means of evaluating the impact of public nutrition intervention programs.

Conclusions

Nutritional assessment at the population level is of increasing relevance in the world. Availability of reliable and precise information in this area shapes development in many ways: it enhances understanding of national nutritional scenarios, provides necessary tools for crafting and monitoring development interventions, and guides decision-makers towards improved planning and policy-making in matters of public health. Selecting the right assessment method depends on the specific objectives, context, and population of each study. However, all research projects must follow minimal quality-control criteria and harmonize their data-collection, analysis and presentation methods with internationally recognized standards in order to ensure comparability with the studies and surveys of other countries. This will undoubtedly redound to an improvement in the implementation of specific and sensitive nutrition programs, as well as to opportune decision-making.

I Nutrition Assessment in SBS

Nutrition assessment in the SBS patient involves accurate measurement of current weight and weight history, height, and body composition by measuring skin folds or other available methods. For pediatric patients, anthropometrics should be compared to standardized growth charts. Surgical history and radiologic examination aid in determining the anatomical location and length of residual bowel, which will influence individual nutrition concerns. Hydration status evaluation includes stoma or stool output, serum electrolytes, and urine sodium content [95,133]. Serum proteins such as albumin, transferrin, prealbumin, and hematological assessment can also help establish nutrition status. Vitamin- and mineral-specific laboratory tests are also available.

Determining the level of intestinal function in the residual tissue is a challenge in the clinical setting. Steatorrhea and fecal levels of macronutrients are the current gold standard [134]. A relatively new proposed measure of intestinal functional mass is plasma concentration of the amino acid citrulline, a metabolite not inserted into proteins and produced almost exclusively by the enterocytes. Studies indicate a strong correlation between plasma citrulline concentration and residual intestine length [135–138]; however, the evidence is conflicting with regard to the use of citrulline to predict function [136–138].

Nutrition Assessment in Patients with Chronic Kidney Disease

Nutrition assessment is a major component of kidney disease management. There is no single measure to assess malnutrition in a patient with kidney disease. The following criteria have been proposed to identify kidney disease-related protein energy wasting:

Serum chemistry

Serum albumin < 3.8 g dl− 1

Serum prealbumin < 30 mg dl− 1 (transthyretin) (applicable only for patients on maintenance hemodialysis since the serum levels may vary depending on GFR in patients with CKD stage 2–4)

Serum cholesterol < 100 mg dl− 1

Body mass index (BMI)

BMI < 23 kg m− 2

Unintentional weight loss over time: 5% over 3 months and 10% over 6 months

Total body fat percentage < 10%

Muscle mass

Muscle wasting: reduction in muscle mass by 5% over 3 months or by 10 % over 6 months

Reduced midarm muscle circumference area (> 10% reduction in comparison to 50 percentile of reference population)

Creatinine appearance

Dietary intake

Unintentional low dietary protein intake <0.80 g kg− 1 day− 1 for at least two months for dialysis patients or <0.6 g kg− 1 day− 1 for patients on CKD stages 2 to 5

Unintentional low dietary energy intake <25 kcal kg− 1 day− 1 for at least 2 months

At least three out of the four listed categories (and at least one test in each of the selected categories) must be satisfied for the diagnosis of kidney disease-related PEW. Optimally, each criterion should be documented on at least three occasions, preferably two to three weeks apart. In short, PEW may be suspected if the serum albumin is < 3.8 g dl− 1, serum prealbumin < 30 mg dl− 1, and serum cholesterol < 100 mg dl− 1.

Nutritional Assessment

“Nutritional assessment can be defined as the interpretation from dietary, laboratory, anthropometric and clinical studies. It is used to determine the nutritional status of individual or population groups as influenced by the intake and utilization of nutrients” (Gibson, 2005).

There are four forms of nutritional assessment: surveys, surveillance, screening, and interventions.

Selection of the forms depends from the objectives. For example, nutrition surveys are used to assess the nutritional status of selected population to identify the group at risk for chronic malnutrition or for evaluation of the existing nutritional problems in order to formulate nutrition policies. In nutritional surveillance studies data are collected, analyzed, and evaluated on standardized method during longer period for identification of the possible nutritive risk factors for malnutrition for policy formulation of the whole population or specific vulnerable group or for evaluation and monitoring of the nutrition intervention. Nutrition screening is used for the identification of malnourished individuals and nutrition interventions are used for the population subgroups at risk (Gibson, 2005).

Nutritional assessment methods are based on dietary, laboratory-biochemical, anthropometric and clinical observations. Correct interpretation of the results of nutritional assessment usually requires consideration of other factors, such as socioeconomic status, cultural practices, health and vital statistics (ecological; factors).

Nutritional status represents satisfaction of the human body with nutritive and protective substances and the reflection of this to the physical characteristics, biochemical composition, physiological characteristics, functional capability, and the health status. Aim of the examinations and nutritional status assessments is an early discovery of nutritive disorders in individual and/or population and undertaking appropriate preventive measures.

B Effective Use of Stages of Change Technique in Nutrition Counseling

Nutrition assessments are typically done at the initial counseling session. It is important for dietitians to use the stages of change model in each session to assess attitudes toward nutrition and health, readiness to learn, and willingness to change. Assessment of these attitudes requires proficient use of open-ended questions and listening skills.

Open-ended questions begin with “what,” “how,” “why,” and “could.” The first clue about a client’s stage of change is in the response to opening questions such as “How can I help you?” “What are your goals for our meeting today?” Attentive listening is an important tool to assess the client’s responses to these questions. Attentive listening involves not only allowing sufficient silence to hear the client’s verbal response but also paying attention to facial expression, voice tone, and body language as the person is speaking. The nutrition counselor can use the listening technique of paraphrasing to determine if he or she has accurately understood the content of the client’s statements or the listening technique of reflection to find out if he or she understands the emotional feeling that the client is trying to convey [61]. It is the combination of open-ended questioning and proficient listening skills that builds rapport.

As the counselor collects assessment information in the first part of the counseling session, there are repeated opportunities to evaluate a client’s stage of change through the use of open-ended questions and effective listening skills.

Nutritional Status and Health Indices

The assessment of nutritional status includes, in addition to dietary intake, indicators of nutrition-related health status, such as anthropometric measurements, hematological and biochemical tests, clinical signs of deficiencies, and risk factors for diseases associated with diet (e.g., overweight). Furthermore, determinants of food and health-related behavior, such as nutritional knowledge and attitudes, may be studied as well. These indicators can be included in the surveys or studied in separate samples. Several national studies listed in Table 2 studied both dietary intake and nutrition-related health-status indicators. In most surveys, anthropometric data were collected (sometimes self-reported data on body weight and body height); in some countries, also, medical examination and⧸or biochemical and hematological tests (e.g., Germany, Hungary, UK) were carried out, and information on physical activity was included (e.g., Norway, Sweden).

A major advantage of collecting comprehensive (broad oriented) information at the individual level is that interrelationships can be studied. In studying correlations between diet and nutritional status indicators, one of the characteristics of a cross-sectional study is that mostly low correlations are found. This is attributable to, among other things, intraindividual variation and inaccurate assessment of intake and status indicators. In a cross-sectional design, the observation that a particular dietary factor is positively or inversely associated with relevant variable is meaningful, even when there is a low P-value, since this provides suggestive evidence for diet–health relationships which should be studied in more detail. To establish a causal link between diet and health, both intervention and (semi)-longitudinal studies are necessary. Endpoints, such as morbidity and mortality data, provide valuable additional information on the role of nutritional factors in diseases.

Mini-Nutritional Assessment

The MNA is the most widely used questionnaire (developed by Guigoz et al.) for evaluating nutritional status in the elderly (Guigoz and Vellas, 1998). It shows the highest sensitivity (>83%) and specificity (>90%). It consists of a screening part (6 questions) or a patient assessment (12 questions) or both. The survey includes questions on meals, usual body mass, neurological disorders, stress history over the preceding 3 months, BMI measurement, and calf circumference. Rating a patient also means determining frequency of consumption of various food groups and medications, housing quality, and a person’s subjective perception of his or her own health and nutritional status. The maximum number of points a patient can get is 30. Scores in the range of 24–30 indicate a normal nutritional status. A range of 17–23 indicates a risk of malnutrition, and below 17 points suggests malnourishment (Ożga and Małgorzewicz, 2013).