fcm nutrition

PROMOTING HEALTHY NUTRITION PART 2

By Marialisa S. Dauigoy, MD, DPAFP

Contents

Nutritional assessment Diet history Anthropometric measurements

Food Energy Definition / terminology Components of energy expenditure Estimating energy requirements

Diet prescription Food Exchange list

NUTRITIONAL ASSESSMENT

Determining an individual's nutritional status Are adequate amounts of required

nutrients are available to and absorbed by the body?

Does the person's nutrient intake balance his/her requirement?

NUTRITIONAL ASSESSMENT

brief screen, if patient healthy more in depth, if patient with nutritional

inadequacy/ malnutrition risks grossly overweight or underweight chronic or severe acute illness growing infants & children elderly patients in poverty, nontraditional dieters (fad

dieters)

Dietary History

patient's usual & recent diet patient's usual pattern of food intake any factors that may influence food

choices and availability cultural or religious food practices, personal

preferences

number of daily meals and examples of what is consumed

Dietary History

nutrient intake analysisMeasure food intake, nutritional composition

of foods, determine nutrient intakes, compare w/ RDAs food diary/journal: for a specific period of

time includes times, food and beverages consumed, and activity

dietary recall: patients report foods and beverages consumed over the past 24 to 48 hours.

Physical Examination

important in evaluating nutritional status

general inspection immediately reveal obvious overweight or underweight

physical measurements of an individual that are compared with reference standards Anthropometry

Anthropometry

Height & Weight

Both height and weight are needed to calculate the body mass index (BMI).

Body Mass Index

BMI

Normal BMI 18.6-22.9

Overweight 23-24.9

Obesity class I 25-29.9

Obesity class II 30

Asia-Pacific Obesity GuidelinesBMI Risk of co-morbidities

Normal BMI 18.5-24.9 average

Overweight 25.0-29.9 increased

Obesity class I 30.0-34.9 moderate

Obesity class II 35.0-39.9 severe

Obesity class III 40 very severe

WHO standard classification

Weight implications

Significant weight loss 5% loss in 1 month or 7.5% loss in 3 months, or 10% loss in 6 months.

Severe weight loss any loss higher than these percentages in the same time interval.

Weight implications

Weight within 85% to 90% of usual body weightmild malnutrition

Weight within 75% to 84% of usual body weightmoderate malnutrition

Weight less than 74% of usual body weightsevere malnutrition

Hammond 2004

Anthropometry

skin fold thickness Assesses subcutaneous fat triceps, biceps, subscapular

tissue, above the iliac crest Measurements with

calipers , compared with standardized tables to determine the percentage of body fat

Anthropometry

Waist circumference correlates with abdominal fat content increased waist circumference has been

associated with cardiovascular disease risk factors ( Dalton et al, 2003 )

Waist measurements >40 inches (>90cm) in men >35 inches (>80 cm) in women are independent risk factors for disease ( NHLBI, 2005 )

Waist to hip ratio

Abdominal ratio Measures fat distribution

& adiposity

Anthropometry

Waist to Hip Ratio

Formula:Waist Circumference (cm)Hip circumference (cm)

1 in men =android obesity> 0.8 in women = android

obesity

Anthropometry

Mid-Upper Arm Circumference evaluate fat stores measures the arm, muscle mass,

subcutaneous fat and bone estimates wasting of an

individual

Anthropometry

Mid Upper Arm Circumference (Children 1- 5)

MUAC Level of nutrition

> 14 Normal

12.5 - 14 Mild / moderate malnutrition

< 12.5 Severe malnutrition

Mid Upper Arm Circumference (Adults)

MUAC Level of nutrition

Male: > 23 Normal

< 23 Malnourish

Female: > 22 Normal

< 22 Malnourish

FOOD ENERGY & DIETARY CALCULATIONS

ENERGY

The capacity to do work mechanical, chemical, heat, electrical, light &

nuclear energies Ultimate source of energy is the SUN LAW OF THERMODYNAMICS:

each type of energy can be converted from one form to another. as our bodies function, chemical energy

from food is converted to mechanical energy and heat.

ENERGY from FOOD

KILOCALORIES/CALORIES (K calories or kcal)

unit of energy measurement energy value of food may be derived

from CHO, CHON, FAT

CALORIE

energy needed to increase the temperature of 1 kg of water by 1 C

about 4.184 Kj Empty calorie - calories present in high-

energy foods with poor nutritional profiles, typically from processed carbohydrates or fats

CALORIE

An "empty calorie" has the same energy content of any other calorie but lacks accompanying micronutrients such as vitamins, minerals, or amino acids as well as fiber such as is found in whole grains but less so in white flour

PHYSIOLOGICAL FUEL VALUES OF FOOD

4 kcal/g for CHO (17 j) 4 kcal/g for CHON (17 j) 9 kcal/g for FAT (38 j)

Using these values, the caloric values of foods may be determined.

FUEL VALUES OF FOOD

Example: A slice of cake which contains 3g of CHON, 1 g of FAT, 15 g of CHO will provide the ff Kcal: 3g CHON X 4 Kcal/g = 12kcal

1g FAT X 9 Kcal/g = 9 kcal

15g CHO X 4 kcal/g = 60 kcal

TOTAL 81 or 80 kcal

FACTORS AFFECTING THE CALORIC VALUE OF FOOD

THE COMPOSITION OF FOOD food high in FAT & CHO are foods with high caloric value

VARIATIONS IN RECIPES & PROCESSING METHODS - a cup of plain rice versus a cup of fried rice

AMOUNT & KIND OF INGREDIENTS ADDED DURING PREPARATIONS such as milk, eggs, flour, sugar, or butter

COMPONENTS OF ENERGY EXPENDITURE

1. Basal metabolic rate (BMR)2. Energy expended in physical activity3. Thermic effect of food (TEF)

BODYS ENERGY NEEDS

* TEE-total energy expenditure

TEE

BODYS ENERGY NEEDS BASAL METABOLIC RATE

amount of energy required to maintain life sustaining activities (breathing, heartbeat, secretion of hormones) for a specific period

measured in the morning upon waking up before any physical activity & again 12 to 18 hours after the last meal

also referred as RESTING ENERGY EXPENDITURE (REE)

accounts for approximately 60% - 75% of our total energy needs

FACTORS THAT INFLUENCE BMR

BODY SIZE SEX = 6% TO 10% lower in women Body temperature Growth, pregnancy, lactation Age: decreases by 5% to 10% as we

grow older Body composition Thyroid function

BODYS ENERGY NEEDS PHYSICAL ACTIVITY

second largest component of energy expenditure (20%-30% of total energy needs)

most variable component of TEE ranges from 10% in a person who is bedridden

to as much as 50% of TEE in an athlete Includes energy expended in voluntary exercise

and during involuntary activities (shivering, maintaining postural control)

BODYS ENERGY NEEDS THERMIC EFFECT OF FOOD (TEF)

increase in energy expenditure associated with the consumption of food

Approximately 10% of the TEE Required to digest, absorb, metabolize nutrient,

including the synthesis and storage of protein, fat and carbohydrate

ENERGY BALANCE

Desirable body weight Reasonable weight loss is to 2 lbs/week For every 3500 kcal excess or expended

a lb of fat is stored or lost

AMOUNT OF ENERGY INTAKE DURING THE DAY

AMOUNT OF ENERGY EXPENDED DURING THE DAY

OVERWEIGHT caloric intake in excess

of energy expenditurepositive energy

balance excess calories from

CHO, CHON, or FAT is converted to fat

ENERGY BALANCE

UNDERWEIGHT food intake or energy

value is less than energy expenditurenegative energy

balance

STEPS IN CALCULATING DIET PRESCRIPTION

I. Calculate Desirable Body Weight (DBW)

II. Calculate Total Energy Allowance (TEA)

III.Calculate Carbohydrate, Protein, Fat allowance/day

IV.Indicate Sodium + Cholesterol level per day if needed

CALCULATE

DESIRABLE BODY WEIGHT (DBW)

Step 1

Desirable Body Weight

Ideal body weight Healthy weight Indicates a persons body composition

has a good balance of lean body mass and fat tissue

Based on birth weight and age First 6 months:

DBW = Birth weight (gm) + (age in mo. X 600)

7 months 1 year:DBW = Birth weight (gm) + (age in mo. X 500)

DBW ESTIMATION FOR CHILDREN

Based on age: DBW (k) = (age in mo./2) + 3

DBW (k) = (age in years x 2) + 8

DBW ESTIMATION FOR CHILDREN

Infants weightDoubled at 5-6 months

Tripled at 12 months or 1 year

Quadrupled at 2 years

QUICK ESTIMATION

At birth : 50 cm

At 1 yr : + 24 cm

At 2 yrs : + 12 cm

At 3 yrs : + 8 cm

At 4-8 yrs: + 6 cm

Example:

50 + 24 = 74 cm

74 + 12 = 86 cm

86 + 8 = 94 cm

94 + 6 = 100 cm

Height /Length

DBW ESTIMATION FOR ADULTS

A. Use of Standard Tables:FNRI Tables of Weight for Height for Filipinos 25-65 years

Ex: 5 ft female (152 cm) DBW 43.0 52.6 kg (95-116 lbs)

B. NDAP MethodDBW (men) = 5 ft is 112 lbs ;

add (subtract) 4 lbs for every inch above (below) 5 ft

DBW (women) = 5 ft is 106 lbs ;

add (subtract) 4 lbs for every inch above (below) 5 ft

Example: Compute the DBW of a 56 male student

5 ft 112 lbs

6 x 4 _+ 24__

DBW = 136 lbs


C. Tannhausers Method: 1. Measure ht in cm2. Deduct 100 from the measurement. 3. Difference is the DBW (kg)4. Deduct 10% (for Filipino)

Example: An adult sedentary female 5 1

Ht = 5 1 = 61 in 61in X 2.54 cm= 154.94 cm

DBW = 154.94 100 = 54.94 kg54.94 5.94 (10% of 54.94)49.95 kg or 50kg


Exercises:

5 ft 112 lbs6 x 4 _+ 24_DBW = 136 lbs

2. Compute the DBW of a 52 female 5 ft 106 lbs2 x 4 + 8_DBW = 114 lbs

5 ft 106 lbs2 x 4 - 8_DBW = 98 lbs

1. Compute the DBW of a 56 male

3. Compute the DBW of a 410 female

C. Use of BMI derived formula

DBW (kg) = Ht in meters2 x 22.0 (Men)DBW (kg) = Ht in meters2 x 20.8 (women)

Example: Compute the DBW of a 56 male student

56 male = 1.6764 m

DBW : (1.6764)2 = 2.8103 x 22 = 61.8 kg (136 lbs)


BUILD WOMEN MENSmall -10% -10%

Medium no addition nor subtraction

Large +10% +10%


Overweight : 10% above IBW

Obese : 20% above IBW

%Overweight = DBW AW

DBWX 100

Desirable Body Weight (Amputees)

Formula: Compute DBW Adjust DBW accdg to type of amputation

Adjusted DBW = DBW - (DBW x % total wt. amputed)

Estimated weight of the amputated part is subtracted from the DBW to arrive at the adjusted body weight.

Desirable Body Weight (Amputees)

Body part % of total body weight

Hand 0.3Forearm and hand 2.6

Entire arm 6.2Foot 1.7

Below knee amputation 7.0

Above knee amputation 11.0

Entire leg 18.6

Example:

Compute the DBW of a 54 male who has below the knee amputation.

5 ft -------------------112 lbs

4x4------------------- +16

DBW = 128 lbs

Below Knee Amputation:

= 128 lbs x .07

= 8.96 or 9 lbs

= 128 9 lbs

Adjusted Body Weight :

119 lbs or 54 kg

CALCULATE TOTAL ENERGY ALLOWANCE (TEA) /TOTAL ENERGY REQUIREMENT (TER)

PER DAY

Step 2

Total Energy Requirement

For muscular and metabolic activities of the body which requires energy

Energy comes from oxidation of food Measured in kilocalories / kilojoules Consider: age, sex, physical activity and

health condition TER is rounded off to the nearest 50 kcal

Total Energy Requirement (Infants)

1 6 monthsTER (kcal /day) = 120 kcals

K DBW

7 months 1 yearTER (kcal /day) = 110 kcals

K DBW

Narins and WeilTER = 1000 + (100 x age in years)

Calorie Needs for age & DBWTER = DBW (k) x calorie allowance accdg to age

Age Suggested kcal / k DBW /day

1 3 105

4 6 90

7 9 75

10 - 12 65 (boys); 55 (girls)

Total Energy Requirement (Infants)

Total Energy Requirement (Adolescents)

TER = DBW (k) x calorie allowance based on age

Age Suggested kcal / k DBW /day

13 15 55 (boys); 45 (girls)

16 19 45 (boys); 40 (girls)

Average 45

Total Energy Requirement (Adults)

Energy Allowance Based on Activity LevelTEA = DBW (k) x Physical Activity

ACTIVITY CALORIE EQUIVALENTS

Male Female

Sedentary 35 30

Light 40 35

Moderate 45 40

Heavy 50 ---

SEDENTARY those people whose work is mostly sitting like cashier, secretary, using computers, clerk typist , computer programmer

LIGHT students, teachers, technicians, engineers, wife with maid, nurse, doctor, stewardess

MODERATE wife without maid, vendor running on streets, jeepney drivers, carpenters

HEAVY cargador, coal miners, heavy equipment operators

EXAMPLE OF ACTIVITIES

Example:

Calculate TER/TEA of an adult sedentary female 5 1

1. Compute DBW (Tannhauser method):

DBW = 154.94 100 = 54.94 kg54.94 5.94 (10% of 54.94)49.95 kg or 50kg

2. Compute TER/TEA:50 kg x 30 =1500 kcal/day

CALCULATE CARBOHYDRATE, PROTEIN AND FAT ALLOWANCE/DAY

Step 3

BARBA and CABRERA,Recommended energy and nutrient intakes for Filipinos, 2002

Asia Pac J Clin Nutr. 2008;17(S2):399-404.

CARBOHYDRATES

contribute 55%-70% of total dietary energy 70% should come from complex

carbohydrates not more than 10% should come from

simple sugars

RDA 55-70% of the TEAUse : 60-65% of the TEA

FATS

RDA: 20-30% of TEA Use: 10-25% of TEA

Obese & individual with elevated lipid levels Use: 10-15% of TEA

Reduce saturated fat intake or fat from animal source Saturated fats are needed for prostaglandin

synthesis

MUFA & PUFA are recommended MUFA does not affect cholesterol in the body

PROTEIN

Use : 10-15% of TEA Pregnant : + 9 grams to normal allowance Lactating : + 16 grams to normal allowance Children (1-3 yrs) : 2 grams/KDBW Children up to 12yrs: 1.5 grams /KDBW Adolescents 13-19 yrs: 1.25 grams/KDBW If with nephropathy: 6-8% of TEA or 0-8g/kg/DBW

Estimation of CHO, PROTEIN & FAT needs

TEA (kcal) x % CHO = kcal / 4 = gm CHOTEA (kcal) x % CHON = kcal /4 = gm CHONTEA (kcal) x % fat = kcal / 9 = gm fat

A good ratio of carbohydrates to fat to

protein is 60-25-15 of TEA.

4kcal/g CHO4kcal/g CHON9kcal/g Fat

Example:Calculate dietary allowance for carbohydrate, protein

and fate of an adult sedentary female 5 1

1. Compute DBW (Tannhauser method):

DBW = 154.94 100 = 54.94 kg54.94 5.94 (10% of 54.94)49.95 kg or 50kg

2. Compute TER/TEA:50 kg x 30 =1500 kcal/day

Example (continuation):Calculate dietary allowance for carbohydrate, protein

and fats of an adult sedentary female 5 1

60% CHO 25% fat15 % CHON

TEA = 1,500 kcal/day 4kcal/g CHO9kcal/g Fat4kcal/g CHON

CHO requirement: 1,500 kcal/day x 0.60 = 900 kcal/day 4 kcal/g = 225 g

Fat requirement:1,500 kcal/day x 0.25 =375 kcal/day 9 kcal/g = 41.67 or

42 g

Protein requirement:1,500 kcal/day x 0.15 = 225 kcal/day 4kcal/g = 56.25 or

56 g

Compute the carbohydrate, protein and fat allowance of a 52 male student

DBW 5 ft -------- 112 lbs2 x 4 ------ 8

120 lbs 55 kgs

TEA =

CHO =

CHON =

Fats =

55 x 40 = 2200 kcal

2200 x .60 = 1320 kcal 4 kcal = 330 gm

2200 x .15 = 330 kcal 4 kcal = 85 gm

2200 x .25 = 550 kcal 9 kcal =61 or 60 gm

THE FOOD EXCHANGE LIST

Uses:

1. Facilitates the planning of meals with a prescribed amount of carbohydrates, protein, fat and energy

2. Estimate the carbohydrate, protein, fat and energy values of a meal

List all the foods furnishing carbohydrates with exception of rice

Determine how many rice exchanges (23 gCHOfurnished by 1 rice exchange)

Determine how many meat and fish exchanges are allowed (8 g CHON per meat and fish exchange)

Follow the same procedure for fat (1 fat exchange contains 5 g of fat)

Distribute the food allowance into breakfast, lunch, supper and snacks

HOW TO USE THE FOOD EXCHANGE LISTS IN MEAL PLANNING

COMPOSITION OF FOOD EXCHANGES

Food Measure CHO(g)

CHON(g)

FAT(g)

Energy (kcal)

Veg A 1 cup raw cup cooked

- - - -

Veg. A 2 cups raw1 cup cooked

3 1 - 16

Veg. B cup raw cup cooked

3 1 - 16

Fruit varies 10 - - 40

Milkwholelow fatskimmed

Varies4 tbpsvaries

121212

888

105

trace

17012580

Rice varies 23 2 - 100

Food Measure CHO(g)

PRO(g)

FAT(g)

Energy(kcal)

Meatlow fatmed fathi fat

VariesVariesvaries

---

888

1610

4186

122Fat 1 tsp - - 5 45

Sugar 1 tsp 5 - - 20

COMPOSITION OF FOOD EXCHANGES

Vegetable: 3g CHO1g CHON16 kcal

Fruit: 10g CHO40g kcal

Rice: 23gCHO2g CHON100g kcal

Milk: 12g CHO8g CHON

w:10g fat/170kcallowf: 5g fat/125kcalskim:tr/80g kcal

Fat: 5g fat45kcal

Meat:low: 8g CHON/1g fat/

41kcalmed:8g CHON/6g fat/

86 kcalhigh:8g CHON/10g fat/

122 kcal

Sugar: 1 tsp : 5g CHO20 kcal

Diet Prescription:TEA: 2200 Kcal CHO 330g CHON 85g FAT60g

FOOD ITEM

NO. OF XCHANGE

S

BREAKFAST

LUNCH SUPPER SNACKS

Veg A 1 1 1 -

Veg B 2 - 1 1 -

Fruit 4 1 1 1 1

Milk 1 1 - - -

Rice 12 3 4 3 2

Meat 6 2 2 2 -

Fat 7 2 - 4 1

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