MACRONUTRIENTS: MUSCLE AND FAT MASS

ASSESSMENT

Andrea K. JeVenn, RD, LD, CNSC

Baltimore, June 12, 2015

OBJECTIVES

Understand the reason for performing a nutrition focused physical exam (NFPE)

Demonstrate a technique to accurately identify and grade malnutrition-related muscle and subcutaneous fat loss

Practice the demonstrated NFPE technique

STEPS FOR DIAGNOSING MALNUTRITION

Step 1 – Determine Etiology:

Social / Environmental Circumstances

Chronic Illness Acute Illness or InjuryStep 2 – Eval

Characteristics: Energy Intake * Weight Loss

Muscle Mass Loss * Body Fat LossFluid AccumulationHand Grip Strength

> 2 characteristics?

YES!

1 characteristic? NO

Step 3 – Is Pt Malnourished?

MODERATE

SEVERE

WHAT IS NFPE?Exam which uses physical assessment and physical function findings to help determine nutritional status and diagnose malnutrition

Components Macronutrient-

Fat (orbital, triceps, ribcage) Muscle (temples, shoulders, clavicles, scapula, thigh, calves) Fluid-extremitiesMicronutrient-

Skin, Nails, Hair, Head/neck, Oral cavity, Eyes, Nose/Face

WHY SHOULD DIETITIANS USE NFPE? Reveals & confirms problem areas that indicate

malnutrition & micronutrient deficiencies Academy has made the NFPE a standard of

practice for RDs starting in 2012 Subjective Global Assessment (SGA)

Looks similar to newest adult malnutrition criteria - energy intakes, weight changes, muscle & fat loss, fluid status, functional capacity

SGA has been validated in multiple patient populations as a tool to assess malnutrition

ASPEN-Academy criteria was created to be a more objective framework for assessing malnutrition

Baker JP, et al. Nutritional assessment: a comparison of clinical judgment and objective measurements. NEJM, 1982.Detsky AS, McLaughlin JR, et al. What is subjective global assessment? JPEN, 1987.

SGA VS NEW CRITERIA

SGA ASPEN-Academy Criteria

Weight Changes 1 week 12 months

Nutrition Intake Changes

5 days 1 month

Eval of GI Symptoms

Eval Functional Status

grip strength

Disease Process acute, chronic inflammation vs. no inflammation

Fat Stores eyes, upper arms, mid-axillary line

Muscle Wasting temporalis, pectoralis/deltoids/trapezius, interosseous, quads/gastrocnemius

Edema/Ascites extremities, sacral/scrotum/vulva

Inspection Most frequently used Broad observation followed

by closer look Critical evaluation

Palpation Examining body structures,

pulsations by touch

HOW TO DO ITTECHNIQUES OF THE PHYSICAL EXAM

KEEP CALM. PREPARE YOURSELF.

Review the medical record, social history, labs, medications

Gather necessary equipment Wash hands Wear gloves/PPE when

appropriate

Obtain patient’s nutrition history

PREPARE THE PATIENT.

Introduce self & explain the process

Respect patient privacy & ask permission Draw curtains, close doors Expose areas of body only as

needed

Use professional language

Exam Area: Temples - Temporalis MuscleView patient when standing directly in front of them,

ask patient to turn head side to sideSevere Mild -Moderate Normal

Hollowing, scooping,

depressionSlight depression

Can see/feel well-defined muscle

Exam Area: Oribital Area - Fat Pad Around Eye

View patient when standing directly in front of them, touch above cheekbone

Severe Mild -Moderate Normal

Hollow look, depressions, dark circles, loose skin

Slightly dark circles, somewhat

hollow look

Slightly bulged fat pads. Fluid

retention may mask loss

Exam Area: Clavicle & Acromion Bone - Deltoid Muscle

Patient arms at side; observe shapeSevere Mild -Moderate Normal

Shoulder to arm joint looks square. Bones prominent.

Acromion protrusion very prominent

Acromion process may slightly

protrude

Rounded, curves at arm/shoulder/neck

Exam Area: Scapular Bone Region Trapezius, Supraspinatus, Infraspinatus

Muscles Ask patient to extend hands straight out, push against

solid object. Severe Mild -Moderate Normal

Prominent, visible bones,

depressions between

ribs/scapula or shoulder/spine

Mild depression or bone may show

slightly

Bones not prominent, no

significant depressions

UPPER ARM ASSESSMENT TECHNIQUE

Severe

Mild -Moderate

Normal

BeforeAfter

Exam Area: Upper Arm Region - Triceps/Biceps

Arm bent, roll skin between fingers, do not include muscle in pinch

Severe Mild -Moderate NormalVery little space between folds, fingers touch

Some depth pinch, but not ample

Ample fat tissue obvious between

folds of skin

Keys A. JAMA. 1948;138:500-511

Exam Area: Dorsal Hand - Interosseous Muscle

Look at thumb side of hand; look at pads of thumb when tip of forefinger touching tip of thumb

Severe Mild -Moderate Normal

Depressed area between thumb-

forefingerSlightly depressed

Muscle bulges, could be flat in

some well nourished people

Exam Area: Thoracic & Lumbar Region – Ribs, Lower Back, Midaxillary Line

Have patient press hands hard against a solid objectSevere Mild -Moderate Normal

Depression between the ribs very apparent; iliac crest very

prominent

Ribs apparent, but depressions less pronounced;

iliac crest somewhat prominent

Chest is full, ribs do not show. Slight to no

protrusion of the iliac crest.

Exam Area: Anterior Thighs – Quadriceps

& Patellar RegionAsk patient to sit, leg propped up, knee bent

Grasp quads to differentiate muscle vs. fat tissueSevere Mild -Moderate Normal

Depression/line on thigh, obviously thin

Bones prominent, little sign of muscle around

knee

Mild depression on inner thigh

Knee cap less prominent, more

rounded

Well rounded, well developed

Muscles protrude, bones not prominent

Exam Area: Posterior Calf Region - Gastrocnemius Muscle

Grasp the calf muscle to determine amount of tissueSevere Mild -Moderate Normal

Thin, minimal to no muscle definition

Not well developed

Well-developed bulb of muscle

THINGS TO CONSIDER: ETIOLOGY OF MUSCLE WASTING

CAUSES OF MUSCLE ATROPHY

Amyotrophic lateral sclerosis (ALS or Lou Gehrig's disease)

Polio Guillain-Barre syndrome Motor neuropathy (such

as diabetic neuropathy) Injury Burns Long-term corticosteroid

therapy

Muscular dystrophy Not moving

(immobilization) Osteoarthritis Dermatomyositis and

polymyositis Rheumatoid arthritis   Spinal cord injury Stroke Malnutrition

http://www.nlm.nih.gov/medlineplus/ency/article/003188.htm

SUMMARY: FAT LOSS

3 areas Orbital Region Upper Arm Area

Triceps Biceps

Thoracic & Lumbar Regions Rib cage Lower back Mid-axillary line

SUMMARY: MUSCLE LOSS

Upper Body Temporalis Clavical Bone Region

Pectoralis Major, Deltoid, Trapezius

Acromion Bone Region Deltoids

Scapula Bone Area Trapezius,

Supraspinatus, Infraspinatus

Hands (Interosseous Muscles)

Lower Body Patellar Area Anterior Thigh

(Quadriceps) Posterior Calf

(Gastrocnemius)