CHAPTER 4

Biochemical
Assessment
of Nutritional
Status
 Laboratory Methods
 Biochemical tests, also known as biomarkers, often can
detect nutrient deficits long before anthropometric
measures are altered and clinical signs and symptoms
appear
 Some of these tests are useful indicators of recent
nutrient intake and can be used in conjunction with
dietary methods to assess food and nutrient
consumption
 Biochemical

assessment
Involves measurement of nutrient levels or their
metabolites in body tissues or fluids
 Estimation of tissue desaturation, enzyme activity
or blood composition
 Tests are confined to 2 easily obtainable fluids
namely blood and urine and results are generally
compared to standards
 Results are generally compared to standards, i.e.
normal levels for age and sex

•
 Biochemical
assessment
 An objective method of nutritional assessment
 Provides specific information on the body's status
regarding specific nutrients and may also identify
borderline nutritional deficiencies or excesses
 Can be used to assess the nutritional status of large
population groups

•
 Purposes of Biochemical Tests
1. To recognize acute malnutrition for which the clinical
signs are non-specific, e.g. potassium deficiency.
2. To confirm the clinical diagnosis of a deficiency disease,
e.g. xerophthalmia, scurvy, beri-beri , rickets, kwashiorkor
3. For monitoring nutritional management in intensive care
4. In community nutrition surveys, to detect Subclinical
micro nutrient deficiency, e.g. iodine deficiency, iron
deficiency.
5. To demonstrate objectively the response to a nutrition
education program E.g. Reduction of plasma cholesterol
or Practice EBF
6. To diagnose nutritional supplement overdosing E.g.
Vitamin A ( BF, fortification, VAS, VA rich food…)
 Advantag
es
 Objectivity
 Independent of the emotional and subjective factors
that usually affect the investigator
 Free from bias compared to other methods of
nutritional status
 Can detect early subclinical states of nutritional
deficiency
 Can identify nutritional deficiency before appearance of
clinical signs

•  Reveals nutrient deficiency at an early stage

 Advantag
es
 Can confirm existence of abnormality, since
clinical signs are non-specific
 Precision and accuracy

•
 Disadvanta
ges
 Costly, usually requiring expensive equipments
 Time consuming
 Difficult to collect samples
 Lack of practical standards of sample collection

•
 Factors affecting
accuracy of results
 Method of sample collection
 Method of transport and storage of samples
 Technique employed

•
 Ideal Biochemical
Tests
 Specific
 Simple
 Inexpensive
 Reveal tissue depletion at an early stages.
 Require less sophisticated equipment and
skill

•
 What is the biological
sample to be used

1. Blood

2. Urine

•
 Bloo
d
• Random sample

• Taken at any time of the day

• Depending on what is being measured,
may be influenced by recent food
intake, physical activity, fluid intake

•
 What is the biological sample
to be used?
1. Blood
2. Urine

•
 Urine
• First voided morning urine sample
• Assumed that subjects have been asleep for
the past 6-8 hours
• No food and fluid intake immediately
before sample taken
• Physical activity standardized

• between different subjects

 Urine
2. 24-hour sample
• More difficult to make a complete
collection, especially in free-living
subjects

•
 ''Mid-stream
sample''
• Breastmilk, saliva, sweat, adipose tissues,
feces, hair and nails, buccal mucosal cells

•
 Preservation of
biological samples
• Any separation/initial processing required

• Containers for storage and transport

• Considerations (cold storage, transport)

 It is of utmost importance to preserve the integrity

of the collected samples prior to actual analysis in
the laboratory
•
 Analysis of biological
samples
• Equipment required for analysis
• Are they available?
• Is the procedure being done locally?
• Is there a laboratory person technically
trained to perform the procedure?

•
 Analysis of biological
samples
• Coordination of sample collection, storage
and transport
• Techniques for collection of
samples
• Informed consent from subjects
• Methods vary in cost, reliability, degree of

• technical expertise required

 Interpretation of
results
1. Low nutrient levels 2. Compare individual
 Dietary deficiency results with
 Poor absorption normal reference
values appropriate
 Impaired transport
for:
 Abnormal
a. Age
utilization
b. Sex
 Combination of
factors c. Physiological
• state
 Laboratory Methods
 grouped into two general and somewhat arbitrary
categories: static tests (direct) and
functional(indirect) tests
 Static tests are also referred to as qualitative and
quantitative biochemical indicators.
 Functional tests are also referred to as biological,
functional, and histologic indicators.
 Static Vs

Functional tests
Static tests are based on measurement of a nutrient or its
metabolite in the blood, urine, or body tissue
 These may indicate nutrient levels in the particular tissue or fluid
sampled, yet they often fail to reflect the overall nutrient status of
an individual or whether the body as a whole is in a state of
nutrient excess or depletion.
 Functional tests based on the ultimate outcome of a nutrient
deficiency which is the failure of the physiologic processes that
rely on that nutrient for optimal performance
Problems with Biochemical Tests
 Non-nutritional factors can have an effect on test results.
 A variety of pathologic conditions, use of certain medications,
and technical problems in a sample collection or assay can
affect test results in ways that make them unusable.
 No single test, index, or group of tests by itself is sufficient
for monitoring nutritional status.
 Biochemical tests must be used in conjunction with measures
of dietary intake, anthropometric measures, and clinical
methods.
 Protein Status
Protein

Somatic Visceral
Protein Protein
 Found within skeletal  Found within the organs
muscle (liver, kidneys, pancreas,
heart), red and white blood
 75% of the body cell
cells as well as the serum
mass
proteins
 Protein Energy Malnutrition
 The causes of PEM can be either primary (inadequate food intake) or secondary
(other diseases leading to insufficient food intake, inadequate nutrient absorption or
utilization, increased nutritional requirement, and increased nutrient losses
 Serum proteins (albumin, prealbumin, transferrin, and retinol-binding protein) are
used to measure malnutrition.
 C-reactive protein (CRP), total lymphocyte count (TLC), and serum total cholesterol
are not serum proteins but sometimes are used as indicators of malnutrition.
 Protein Status Measurement
 Assessment of protein status is central to the prevention, diagnosis, and
treatment of PEM.
 Lean body mass can be measured by,
 Creatinine Excretion and Creatinine-Height Index
 Serum Proteins
 Albumin
 Transferrin
 Prealbumin
 Retinol-Binding Protein
 Creatinine Excretion
 24-hour urinary creatinine excretion can be used for estimating body muscle mass
 Creatinine, a product of skeletal muscle, is excreted in a relatively constant
proportion to the mass of muscle in the body.
 Creatinine Excretion
 Urine creatinine (24-hour urine collection) depend on
age and amount of lean body mass.
 14 to 26 mg per kg of body mass per day for men (123.8 to
229.8 µmol/kg/day)
 11 to 20 mg per kg of body mass per day for women (97.2
to 176.8 µmol/kg/day)
 Serum Proteins
 Use of serum protein measurements is based on the
assumption that decreases in serum concentrations are due to
decreased liver production (the primary site of synthesis).
 A total serum protein test measures the total amount
of proteins in the blood.
 It also measures the amounts of two major groups of proteins
in the blood: albumin and globulin.
Serum Proteins Used in
Nutritional Assessment
Serum Proteins Used in
Nutritional Assessment
Normal Results
 Limitations of Serum albumin
level for PEM
 Serum albumin and PAB decreases in the presence of
inflammation, caused by trauma, surgery, burns, or a chronic
illness such as cancer, heart disease, or hepatic failure.
 In addition, albumin levels are sometimes inaccurate in cases of
underhydration, overhydration, ascites, and nephrotic syndrome.
 PAB may be more valuable than albumin as an indicator; because
it has a shorter half-life, PAB can respond more quickly to
increases in nutrient intake or improvements in inflammation.
 Limitations of RBP level for
PEM
 RBP seems relatively unaffected by inflammation; RBP decreases
during protein-calorie malnutrition..
  However, RBP is decreased in renal failure, hepatic failure,
stress, and zinc or vitamin A deficiency and is not a reliable
indicator of protein status in persons with advanced liver
disorders because it is synthesized in the liver
 Summary on PEM
 Protein-energy malnutrition can be either primary (insufficient
intake of protein and calories) or secondary (resulting from other
diseases).
 When severe, it results in kwashiorkor (principally a protein
deficiency), marasmus (predominantly an energy deficiency), or
marasmic kwashiorkor (a combination of chronic energy deficit
and chronic or acute protein deficiency).
 Summary on PEM
 Creatinine is a muscle metabolite excreted in urine used to
quantitate muscle mass.
 Creatinine is excreted in a relatively constant proportion to the
body’s muscle mass.
 Muscle mass can be estimated by comparing 24-hour urine
creatinine excretion with certain standards.
 Summary on PEM
 Included among the serum proteins used to assess protein
nutriture are albumin, transferrin, prealbumin, and retinol-
binding protein.
 Considerations in their use include their body pool amount,
half-life, and responsiveness to protein and energy depletion
and repletion.
 Other considerations include how serum proteins are affected
by nutritional and non-nutritional factors and how they
correlate with morbidity and mortality.
 Iron Status
 Iron deficiency results when ingestion or absorption of dietary
iron is inadequate to meet iron losses or iron requirements
imposed by growth or pregnancy.
 Considerable iron can be lost from heavy menstruation, frequent
blood donations, early feeding of cow’s milk to infants, or
disorders characterized by gastrointestinal bleeding.
 Risk of iron deficiency increases during periods of rapid growth
—notably, in infancy adolescence, and pregnancy.
 Iron Forms
 Reading Assignament: Consequences of Fe deficiency during
pregnancy, infanthood
 Found in three components:
1. Essential iron
2. Transport iron
3. Storage iron
 Iron Forms
1. Essential iron
a. in RBC (70%)
b. in myoglobin (4%)

c. in enzymes (<1%)
2. Transport iron (bound to transferrin)
3. Storage iron
a. Ferritin (seen primariIy in Iiver, smaller
amounts in bone marrow and spleen; some in
circulation)
b. Hemosiderin
 Iron Status
 Three stages of the development of iron-
deficiency anemia
1. Iron depletion
2. Iron-deficient erythropoesis
3. Iron deficiency anemia
Stage 1 – Storage Depletion Ferritin
which is the storage form of iron is
lowered, and low ferritin levels are the
first sign that the body’s iron stores are
compromised.
Stage 2 – Mild Deficiency-Transport
iron (known as transferrin) decreases.
This is often accompanied by a reduction
in size of red blood cells even though
hemoglobin levels remain normal.

Stage 3 – Iron Deficiency Anemia –

Hemoglobin begin to drop in the final
stage which, may formally be defined as
IDA. At this stage red blood cells are
fewer in number, smaller and contain
less hemoglobin.
Stages of Iron Deficiency
 Serum Ferritin
 Determines iron stores as they are the first to decline
 Serum concentrations correlates with total amount of storage iron;
provides an estimate of the amount of iron stores (approximately
30% of all iron in the body is in the storage form, most of this as
Ferritin)
 Although low serum ferritin concentration is a sensitive indicator of
early iron deficiency, it does not necessarily reflect the severity of the
depletion as it progresses
 Serum ferritin levels are influenced by infections and chronic disease
 Limitations of transferrin level
for PEM
 Inflammation leads to a decrease in transferrin; iron deficiency
causes it to increase.
  It cannot be used with people with iron deficiency.
 Many underlying factors affect serum transferrin levels, putting
its sensitivity as an indicator of nutrition depletion and response
to depletion in question
 Soluble Transferrin Receptor

 Transferrin is the main iron transport protein found in the blood and
plays a role in maintaining cellular iron homeostasis through
regulation of cellular iron intake
 When cellular iron content is low, more transferrin receptors appear
on cell surfaces as a mechanism for cells to sequester the iron they
need
 Soluble Transferrin Receptor
 The sTfR concentration begins to increase in early iron deficiency
with the onset of iron-deficient erythropoiesis (red blood cell
production) before anemia develops and continues to increase as iron-
deficient erythropoiesis worsens.
 Measurement of serum sTfR concentration is now regarded as a
valuable tool in diagnosing iron deficiency and monitoring
erythropoiesis.
 Serum sTfR concentration is not affected by concurrent inflammation
or infection.
 Iron deficiency
Anemia
 Final stage of iron deficiency
 Caused by exhaustion of iron stores and declining levels of
circulating iron; microcytic, hypochromic anemia
 Reduced concentration of Hb in RBC, hematocrit and red cell
indices
 Anemia
 is a hemoglobin level below the normal reference range for
individuals of the same sex and age.
 Common cause of anemia is iron deficiency. Other common
causes include inflammation, infection, tissue injury, and cancer.
 Anemia can also result from folate and vitamin B 12 deficiencies.
 Thus iron-deficiency anemia should be differentiated from
anemia caused by inflammatory disease, infection, chronic
diseases.
 Hemoglobin
 is iron-containing molecule found in red blood cells that is
capable of carrying oxygen and carbon dioxide.
 The amount of hemoglobin in blood depends primarily on the
number of red blood cells and to a lesser extent on the amount of
hemoglobin in each red blood cell.
 Hemoglobin
 Despite its use as a screening test for iron deficiency anemia,
isolated measurements of hemoglobin concentration or hematocrit
level are not suitable as the sole indicator of iron status.
 They tend not to become abnormal until the late stages of iron
deficiency and are not good indicators of early iron deficiency.
 Hemoglobin also fails to distinguish between iron deficiency
anemia and anemia of inflammation
 Hematocrit
 Hematocrit (also known as packed cell volume ) is defined as the
percentage of red blood cells making up the entire volume of
whole blood.
 It can be measured manually by comparing the height of whole
blood in a capillary tube with the height of the RBC column after
the tube is centrifuged.
Cutoff points
 Assessing Iron Status
 No single biochemical test is diagnostic of impaired iron status.
 using two or more different indicators of iron status together provide a
much better measure of iron status
 two most commonly used are the ferritin model and the more recently
introduced body iron model
Models for Assessing Iron Status
 Iron Overload
 refers to accumulation of excess iron in body tissues
 results of genetic diseases characterized by excessive
intestinal iron absorption and deposition of excessive amounts
of iron
 Can also result from multiple blood transfusions and the
excessive intake of iron from fortified foods and supplements
 Affects the liver, heart, and pancreas, leading to the failure of
these organs and possibly death.
 Summary on Iron
 Iron deficiency is the most common cause of anemia.
 Serum ferritin is the most useful index of the body’s iron stores.
 Hemoglobin is the most widely used screening test for iron deficiency anemia but is
not an early indicator of iron depletion. Hematocrit is defined as the percentage of
red blood cells making up the entire volume of whole blood.
 Summary on Iron
 Models that combine several indicators of iron status are
better at predicting the presence of iron deficiency.
 Among these are the body iron model, the ferritin model, and
the MCV model.
 These models allow better discrimination between iron
deficiency anemias and those caused by infection,
inflammation, and chronic disease than do single
measurements
 Assessment of vitamin A status
 Vitamin A status can be grouped into five categories: deficient, marginal, adequate,
excessive, and toxic.
 In the deficient and toxic states, clinical signs are evident, while biochemical or
static tests of vitamin A status must be relied on in the marginal, adequate, and
excessive states
Metabolism of Vitamin A
Biochemical tests for vitamin A status
 Vitamin A Deficiency (VAD)
 VAD can be defined clinically or sub-clinically. 
 Xerophthalmia is the clinical spectrum of ocular manifestations of VAD; ranging
from the milder stages of night blindness and Bitot spots to the potentially blinding
stages of corneal xerosis, ulceration and necrosis (keratomalacia).
 The various stages of xerophthalmia are regarded both as disorders and clinical
indicators of VAD
 Reading assignment: Clinical signs if VAD
 Biochemical tests for vitamin A status

 Plasma concentrations of retinol

 Retinol binding protein (RBP)
 Dose-response tests
 Retinol isotope dilution
 Vitamin A levels in breast milk can also be used as an index of vitamin A status in
lactating women and in detecting response to maternal supplementation
 Plasma Levels
 Retinol is the main circulating form of vitamin A in blood and plasma.
 Serum retinol levels reflect liver vitamin A stores when they are severely depleted or
extremely high;
 However, between these extremes, plasma or serum retinol is homeostatically
controlled and hence may not correlate well with vitamin A intake. 
 Plasma Levels
 Serum retinol levels reflect liver vitamin A stores only when they are severely
depleted (< 0.07 µmol/g liver) or extremely high (> 1.05 µmol/g liver)
 Most common biochemical measure of vitamin A in a population group (not in an
individual)
Vitamin A Deficiency (VAD)
 Drawbacks of serum retinol
 In healthy individuals, serum retinol concentrations are homeostatically controlled
and do not begin to decline until liver reserves of vitamin A are dangerously low.
 Serum retinol and RBP concentrations will fall during times of infection.
 Iron deficiency, may also negatively affect serum retinol concentrations, causing
decreased mobilization of vitamin A from liver storage 
 Serum retinol Binding Protein
 Serum RBP occurs in a 1:1:1 m complex with retinol
 Thus the 1:1 complex, serum RBP concentration reflects serum retinol concentration
and therefore might be substituted for it as an indicator of vitamin A status.
 Assessment of RBP is easier than assessment of serum retinol (test procedure is
simple, RBP is more stable under light and temperature than retinol, very small
amount of serum is needed for the test, 10–20 μL, which can be obtained from a
finger prick)
 Drawbacks of SRBP
 Not all RBP found in serum is complexed with retinol (holo-RBP), and the
proportion that is not (apo-RBP) varies under a range of concentrations.
 Second, the binding of RBP to retinol is influenced by a number of factors such as
protein energy malnutrition, liver disease, chronic renal failure and acutely stressful
situations (for example, just before delivering a baby).
 Relative Dose Response Method (RDR)
 Fasting blood sample is taken, followed by oral administration of vitamin A as
retinyl palmitate.
 Another blood sample is drawn 5 hours later. Comparison of the fasting and
postdosing holo-RBP measurements represents the extent of apo-RBP accumulation,
which is directly related to the shortage of vitamin A
 The RDR is calculated using the following formula;

 vit A5 is serum vitamin A level 5 hours after receiving the dose of vitamin A
 vit A0 is fasting serum vitamin A level
 Principle of Method (RDR)
 When stores of retinol are high, plasma retinol concentration is little affected by oral
administration of vitamin A.
 As hepatic vitamin A stores become depleted, RBP accumulates in the liver in an
unbound state as apo-RBP
 When vitamin A is given to a subject with depleted stores, the vitamin A is absorbed
from the intestinal tract; is taken up by the liver, binds to the apo-RBP and thus the
plasma retinol concentration reaches its peak after 5 hours.
 Relative Dose Response Method (RDR)

RDR Interpretation
> 50% acute deficiency
20%-50% Marginal deficiency
< 20% Adequate intake
 Limitations of the RDR include the 5-hour waiting period rand the need to draw two blood samples
 Direct Measurement of Liver Stores
 “Gold standard” method of determining hepatic vitamin A stores in liver tissue
because it is direct measurement but its invasive nature limits its usefulness
 Direct measurement of vitamin A concentration in the liver is not practical because a
liver biopsy is a highly invasive surgical procedure.

Concentration Interpretation
(retinol/g of liver tissue )
> 20 mg adequate for both children and
adults of all ages
<5mg Presence of VAD
 Retinol Isotope Dilution
 Indirect approach to measuring total body stores of vitamin A
 A known amount of vitamin A that is labeled with a nonradioactive isotope is
administrated to the subject, with an adequate amount of fat to ensure suitable
absorption.
 After a period of approximately two to three weeks, the isotopically labeled vitamin
A mixes with the body’s existing total pool of unlabeled vitamin A.
 A sample of blood is then removed from the subject and the plasma concentrations
of the labeled and unlabeled vitamin A are measured. Using a mathematical formula,
the ratio of the labeled vitamin A to the unlabeled vitamin A is calculated.
 Limitations Retinol Isotope Dilution

 High cost of the isotopically labeled vitamin A and the sophisticated laboratory
techniques needed to measure the plasma concentrations of the labeled and
unlabeled vitamin A.
 Summary
 Assessing vitamin A status involves measurement
 plasma concentrations of retinol or the vitamin A carrier protein
 retinol-binding protein (RBP)
 retinol isotope dilution
 dose-response tests
 Zinc
 Zinc is an essential micronutrient for human health and has numerous structural and
biochemical roles.
 The search for a reliable, sensitive, and specific index of zinc status has been the
subject of considerable research, which has resulted in the identification of a number
of potentially useful biomarkers.
 There is currently no specific sensitive biochemical or functional indicator of zinc
status
 Plasma Zinc Concentrations
 Plasma zinc usage is complicated by the body’s homeostatic control of zinc levels
and by factors influencing serum zinc levels that are unrelated to nutritional status
 Human body does not have stores for Zinc and body’s zinc levels are maintained by
both conservation and redistribution of tissue zinc.
 In mild zinc deficiency, conservation is manifested by reduction or cessation of
growth in growing organisms and by decreased excretion in nongrowing organisms.
 If the deficiency is severe, however, additional clinical signs soon appear
 Plasma Zinc Concentrations
 Several factors unrelated to nutritional status can influence plasma zinc levels.
Decreased levels can result from stress, infection or inflammation, and use of
estrogens, oral contraceptives, and corticosteroids.
 Plasma zinc can fall by 15% to 20% following a meal.
 Increased plasma zinc concentrations can result from fasting and red blood cell
hemolysis.
 Hair Zinc Concentrations
 Several researchers have investigated the use of zinc in hair as an indicator of body
zinc status
 Because hair grows slowly, levels of zinc and other trace elements in hair reflect
nutritional status over many months, unlike Serum Zinc which reflect short term
Zinc status
 Advantage of using hair is that obtaining a sample is noninvasive, and analyzing
hair for zinc and other trace elements is relatively easy.
 Limitations of Hair Zinc Concentrations
 Hair is susceptible to contamination from exogenous sources (contamination from
trace elements in dust, water, cosmetics, and so on)
 Some exogenous contaminants can be removed by carefully washing the hair sample
before analysis, and several standardized washing procedures
 Trace element content of hair can be affected by certain diseases, rate of hair
growth, hair color, sex, pregnancy, and age
 These factors limit the usefulness of hair as an index of zinc and other trace element
status
 Urine Zinc Concentrations
 Factors other than nutritional status can influence urinary zinc levels, such as liver
cirrhosis, viral hepatitis, sickle-cell anemia, surgery, and total parenteral nutrition.
 Problems associated with obtaining 24-hour urine collections can also complicate
use of this indicator.
 Consequently, urine measurements of zinc are not the preferred approach to
assessing zinc status.
 Iodine status
 Iodine is a trace element essential for the synthesis of thyroid hormones that regulate
metabolic processes related to normal growth and development in humans and
animals
 Inadequate intake of iodine leads to insufficient production of thyroid hormones,
resulting in a variety of adverse effects collectively referred to as iodine deficiency
disorders
IDD
Clinical Sign of Iodine deficiency
 Assessing Iodine Status
 More than 90% of dietary iodine is eventually excreted in the urine, so urinary iodine
(UI) is the most widely used indicator of recent iodine intake and nutrition status
 For individuals, a 24-hour urine collection is necessary to estimate iodine intake using
UI concentration.
 But because of impracticality, spot urine collections from a representative sample of
the target population can be used to calculate median UI in nanograms of iodine per
milliliter of urine (ng/mL)
 Assessing Iodine Status
 On a population basis, the median urinary iodine concentration (mUIC) of spot urine from
sufficiently large randomly selected 8–10-year-old children or adults has been shown to
provide useful information on the average iodine intake or status of a community.
 On an individual basis, urinary iodine varies from day to day and even within a given day so
urinary iodine wont serve a good marker.
Criteria for assessing IDD in a population based on
mUIC
Criteria for assessing IDD in a population based on
mUIC
 mUIC
 Advantages
 directly reflects iodine supply of the individual, it is objective and non-invasive
and urine samples can be kept for later analysis
 Disadvantages
 requires laboratory space, special facilities and skilled technician to provide
accurate determinations.
 mUIC reflects only current but not past intake of iodine 
Thyroid hormones
 The Cycle Of Thyroid Hormone Formation

 The rate at which T3 and T4  are released and is controlled by the
pituitary gland and hypothalamus (acts as a thermostat).
 The hypothalamus signals the pituitary gland it makes Thyroid-
stimulating hormone (TSH).
 The pituitary gland is a source of TSH.
 The amount of TSH depends on the amount of T3 and T4 in blood.
 There is a feedback mechanism. If there is a decreased level of T3
and T4  TSH level will increase.
 The Cycle Of Thyroid Hormone Formation

 If T3 and T4 are increased then the TSH level will fall below

normal.
 The thyroid gland regulates its production of T3 and T4 based
on the amount of TSH it receives.
 Hypothyroidism when the thyroid does not produce enough T3
and T4.
 Hyperthyroidism when thyroid glands produce an excess of T3
and T4.
  Clinical Signs of hypothyroidism

• Fatigue
• Reflex delay, relaxation phase
• Constipation
• Weight gain from fluid
• Memory and mental
retention
impairment
• Dry skin and cold intolerance • Decreased concentration
• Yellow skin • Depression
• Coarseness or loss of hair • Irregular or heavy menses and
infertility
• Goitre
  Clinical Signs of hyperthyroidism

• Nervousness and irritability • Menstrual disturbance (decrease

• Heat intolerance or increased flow)
sweating • Impaired fertility
• Weight loss or gain • Mental disturbances
• Alterations in appetite • Sleep disturbances (insomnia)
• Frequent bowel movements or
• Changes in vision, photophobia,
diarrhoea
eye irritation, diplopia
• Dependent lower-extremity
• Fatigue and muscle weakness
oedema
• Sudden paralysis
• Goitre (depending on cause)
 CHAPTER 5

Assessment of the
Hospitalized Patient
 Why assessing nutritional status of the hospitalized patients?

• Malnutrition in hospitalized patients is generally related to decreased muscle

function, respiratory function, immune function and quality of life and impaired
wound healing
• Poor nutritional status is associated with prolonged hospital stay, decreased quality
of life, and increased morbidity and mortality.
 Why assessing nutritional status of the hospitalized patients?

• Nutritional screening and assessment are important parts of patient care

• Nutritional screening and assessment identify patients at nutritional risk and those
requiring nutritional support
• Nutritional screening is a rapid and simple tool and should be done in every patient
• Nutritional assessment is important for detailed diagnosis of acute and chronic
malnutrition
• Food intake should be evaluated in all patients at risk of malnutrition
Assessment of hospitalized patient
involves
•
four steps
First, all patients must receive a nutritional screening to determine whether they are at risk
of impaired nutritional status.
• Second, patients who are nutritionally at risk should receive a more in-depth nutritional
assessment to determine the severity and causes of their nutritional impairment
• Third, if the patient is nutritionally impaired, the dietitian should develop a nutritional
support plan for improving the patient’s nutritional status.
• Finally, the patient should be monitored to ensure an appropriate response to nutritional
support
Nutritional Screening
 The process of identifying characteristics
known to be associated with nutrition problems.
 Its purpose is to pinpoint individuals who are
malnourished or at nutritional risk
 Screening should be a simple and rapid process,
which can be carried out by admitting nursing
and medical staff.
 Screening should be sensitive enough to detect
all or nearly all patients at nutritional risk.
 Methods of nutritional screening should be
validated in clinical trials
 Nutritional Screening
 Screening should be performed within the first 24-48 h after the first contact and
thereafter at regular intervals.
 The standards for nutrition care established by the Joint Commission on the
Accreditation of Health Care Organizations (JCAHO) do not require that nutritional
screening be done within a specific time following admission but, rather, indicate
that it be carried out “in a timely, effective, and efficient manner
 Patients identified as at risk need to undergo nutritional assessment.
 Outcomes of Nutritional
Screening
 Improvement or at least prevention of deterioration in mental and physical function after
nutritional intervention
 Reduced number or severity of complications of disease or its treatment after nutritional
intervention
 Accelerated recovery from disease and shortened convalescence after nutritional
intervention
 Reduced consumption of resources, e.g. length of hospital stay and other prescriptions
after nutritional intervention
 Nutritional Assessment
 Nutritional assessment should be more detailed and done in those patients found on
screening to be at risk or when metabolic or functional problems prevent a standard plan
being carried out 
 Nutritional assessment also provides the basis for the formal diagnosis of malnutrition.
 Screening can be greatly facilitated by using a checklist or form on which pertinent patient
information can be entered.
 This form can be placed in the patient’s medical record for other members of the health
care team to refer to
 Nutritional Assessment
 Nutritional assessment should be more detailed and done in those patients found on
screening to be at risk or when metabolic or functional problems prevent a standard
plan being carried out 
 Nutritional assessment helps to
 to determine the severity and causes of the patient’s nutritional impairment,
 to evaluate whether the nutritional impairment is a factor contributing to the worsening of the
patient’s medical condition,
 to monitor the patient’s response to nutritional support
 Screening Protocol
 Hospital and healthcare organizations should have a policy and a specific set of
protocols
 for identifying patients at nutritional risk, leading to appropriate nutritional care plans:
 For estimation of energy and protein requirements including possible allowance for weight
gain, followed by prescription of food, oral supplements, tube feeding or parenteral nutrition,
or a combination of these
Screening Protocol
 Screening
 Outcomes
The patient is not at risk, but may need to be re-screened at specified intervals, e.g.
weekly during hospital stay.
 The patient is at risk and a nutrition plan is worked out by the staff.
 The patient is at risk, but metabolic or functional problems prevent a standard plan
being carried out.
 There is doubt as whether the patient is at risk
 In case of outcome 3 and 4 referral should be made to an expert for more detailed
assessment
 Assessment
 detailed examination of metabolic, nutritional or functional variables by an expert
clinician, dietitian or nutrition nurse.
 It is a longer process than screening which leads to an appropriate care plan
considering indications, possible side-effects, and, in some cases, special feeding
techniques
 Assessment
History
Dietary Information
Physical Examination
Knee Height
MUAC
Calf Circumference
Recumbent Skinfold Measurements
 History
 Data on the patient’s history can be obtained from the medical record and from
interviews with the patient or others knowledgeable about the patient’s habits.
 Parts of the medical record that are particularly helpful include the medical history;
entries made by physicians, nurses, social workers, and other members of the health
care team; and medical records
 Dietary Information
 the patient’s food preferences, allergies and intolerances, and usual eating pattern
(timing and location of meals and snacks).
 Data should also be collected about the amount of money available for purchasing
food, ability to obtain and prepare food, eligibility for and access to food assistance
programs, and use of vitamin, mineral, and other supplements (if not obtained in the
history).
 A 24-hour recall or simple food frequency questionnaire can provide important data
on usual eating patterns and can help generate additional questions on dietary intake
 Physical Examination
 Two of the most important measurements to obtain are body weight and stature (or
length, in the case of infants and young children unable to stand without assistance)
 Screening tools are designed to detect protein and energy undernutrition, and/or to
predict whether undernutrition is likely to develop/worsen under the present and
future conditions of the patient/client
 Monitoring and outcome
 A process of monitoring and defining outcome should be in place.
 The effectiveness of the care plan should be monitored by defined measurements
and observations, such as recording of dietary intake, body weight and function, and
a schedule for detecting possible side effects.
 This may lead to alterations in treatment during the natural history of the patient’s
condition
 Communication
 Results of screening, assessment and nutrition care plans should be communicated
to other healthcare professionals when the patient is transferred, either back into the
community or to another institution.
 When patients are transferred from the community to hospital or vice versa, it is
important that the nutritional data and future care plans be communicated.
 Audit
 If this process is carried out in a systematic way, it will allow audit of outcomes
which may inform future policy decisions
 Other assessments
 Determining Energy Requirements
 Measuring Energy Expenditure
 Direct Calorimetry
 Indirect Calorimetry
 Doubly Labeled Water
 Bicarbonate-Urea Method
 Estimating Energy Needs
 Commonly Used Equations
 Estimated Energy Requirement Equations
 Energy Expenditure in Disease and Injury
 Energy Needs: Estimated or Measured?
 Determining Protein Requirements
 Protein Losses in Disease and Injury
 Estimating Protein Needs