Nutrition Assessment. Miranda Kramer, RN, MS Nurse Practitioner/Clinical Nurse Specialist

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1 Nutrition Assessment Miranda Kramer, RN, MS Nurse Practitioner/Clinical Nurse Specialist

2 General Considerations Overall caloric intake is it enough, too little or too much? What s in our calories fats, carbohydrates, proteins, micronutrients/vitamins Water enough, too little or too much? What are our energy requirements?

3 Patient Specific Issues How do we ask our patients to keep track of this it there is a problem? What about caffeine and alcohol consumption? Has their weight been stable lately? If not, up or down over how much time? What other medical problems does the patient have? What medications and supplements does the patient take?

4 What things do you look for in a nutrition assessment? Symptoms? Social factors?

5 What objective measures do we have? Body-Mass-Index (BMI) commonly used Desirable Body Weight (DBW) not used very often but good for describing weight changes

6 Body Mass Index Simple, objective measure Not perfect measurement but very frequently used. Often used in research studies

7 Body Mass Index Calculation o Weight (pounds) x 703 height (inches) = BMI Match result with a table of reference values On line calculator at: mi/ Limitations: o Not for kids o May change depending on ethnicity o Does not consider frame size o What it really estimates is body fat, not muscularity. Underweigh t Normal Overweight Obese Obesity Class I II BMI < Extreme obesity III 40

8 Desirable Body Weight (DBW) Women: 100 pounds for first 5 feet height; plus 5 pounds for each inch thereafter. Men: 106 pounds for first 5 feet height; plus 6 pounds for each inch thereafter Add 10% for a large frame; subtract 10% for a small frame.

9 Calculating Significant Weight Loss Percent Desirable Weight % Usual weight % Weight change

10 Calculating Significant Weight Loss 1 2% in 1 week 5% in 1 month 7.5% in 3 months 10% in 6 months

11 Example A 70 year old woman with colon cancer states her weight 6 months ago was 165 pounds. Her weight today is 143 pounds. She has had a colon resection and is currently receiving outpatient chemotherapy. She is 5 4 tall. Calculate BMI before and after weight loss, desirable body weight, and check if % change is significant weight loss.

12 Example BMI for original weight of 165 lb. was 28.3 ( overweight ). BMI for new weight of 143 lb. is 24.5 ( normal ) Desirable body weight: 106 lb (first 5 feet) + (4 x 5 lb for additional 4 inches) = = 126 pounds % usual weight = 143/165 = % of usual weight. % weight change ( )/165 = 22/165 = 13.3% change in weight in 6 months.

13 Adjustments to Desirable Body Weight Amputation o An entire upper extremity 6.5% o An entire lower extremity 18.65% o Lower leg and foot 7.1% Para/Quadraplegia o Paraplegia subtract 5 10% o Quadraplegia subtract 10-15%

14 Patient-Generated Subjective Global Assessment (PG-SGA ) Utilizes subjective and objective data Invented by Faith Ottery1 Only validated tool used in the oncology setting An easy to use nutrition assessment tool that allows quick identification and prioritisation of malnutrition in hospitalised patients with cancer2 FD Ottery, Patient-generated subjective global assessment of nutritional status. Nutritional Oncology, 1996; 2 (8-9). Bauer, J, Capra, S & Ferguson, M. European Journal of Clinical Nutrition (2002) 56, doi: /sj.ejcn

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16 PG-SGA The PG-SGA has been used in specific cancer patient populations as well as other types of patients (transplant, dialysis, geriatrics, radiation oncology, etc.) Available on line tool

17 Subjective Data Gender Age My current weight is: Weight Change My current height is: A year ago I weighed: Six months ago I weighed: During the past two weeks my weight has decreased not changed increased Food Intake As compared to my normal intake, I would rate my food intake during the past month as unchanged more than usual less than usual much less than usual I am now taking o little solid foods only liquids only nutritional supplements very little of anything Symptoms During the past two weeks I have had the following problems that kept me from eating enough (check all that apply) o no appetite, I did not feel like eating nausea constipation mouth sores pain preventing me from eating things taste funny or have no taste smells bother me vomiting diarrhea dry mouth Functional Capacity Over the past month, I would rate my activity as generally: o normal, with no limitations not my normal self, but able to participate in fairly normal activities not feeling up to most things, but in bed less than half the day able to do little activity and spend most of the day in bed or a chair pretty much bedridden, rarely out of bed

18 Objective Data Stressors of metabolism (see your doctor, nurse, or nutritionist if necessary for help in completing this section I have had a fever within 10 days that was o higher than 99 F but less than 101 F higher than 101 F but less than 102 F higher than 102 F If you had a fever, how long did it last? o less than 72 hours more than 72 hours I am taking steroids for my condition, and the dose is o a low dose a moderate dose a high dose I have been diagnosed with the following (check all that apply) o cancer AIDS cardiac cachexia trauma

19 PG-SGA Score Patient age 41 years Patient weight is 132 lbs. (60 kg) Patient height is 68 in. (173 cm) Patient weight six months ago 140 lbs. (64 kg) Patient weight one year ago 145 lbs. (66 kg) ***** Calculated Clinical Values ***** Body mass index (BMI): 20 Basal energy expenditure (Harris-Benedict): 1473 kcal Resting energy expenditure (Mifflin-St. Jeor): 1479 kcal Basal energy expenditure (Harris-Benedict) with cancer diagnosis: 2356 kcal Resting energy expenditure (Mifflin-St. Jeor): with cancer diagnosis 2366 kcal ***** Weight Change Summary ***** There was a 9% weight loss compared to weight last year There was a 6% weight loss compared to weight six months ago There has been a weight decrease in the past two weeks Food intake has decreased over the past month Patient is eating very little of anything Global assessment of nutritional status score is 6 This score indicates a requirement for the intervention of the physician or interaction with the clinical nurse specialist as indicated for pharmacologic symptom management.

20 PG-SGA Score The score will help with triage and direction of care.

21 Patient age 70 years Patient weight is 143 lbs. (65 kg) Patient height is 64 in. (163 cm) Patient weight six months ago 165 lbs. (75 kg) Patient weight one year ago 165 lbs. (75 kg) ***** Calculated Clinical Values ***** Body mass index (BMI): 25 Basal energy expenditure (Harris-Benedict): 1293 kcal Resting energy expenditure (Mifflin-St. Jeor): 1320 kcal Basal energy expenditure (Harris-Benedict) with cancer diagnosis: 2069 kcal Resting energy expenditure (Mifflin-St. Jeor): with cancer diagnosis 2113 kcal ***** Weight Change Summary ***** There was a 13% weight loss compared to weight last year There was a 13% weight loss compared to weight six months ago There has been a weight decrease in the past two weeks Food intake has decreased over the past month Global assessment of nutritional status score is 5 This score indicates a requirement for the intervention of the physician or interaction with the clinical nurse specialist as indicated for pharmacologic symptom management.

22 Other Objective Measures of Albumin 2008 年 度 兵 庫 県 立 大 学 大 学 院 がんプロ:Advanced Prealbumin Nutrition Basic labs to check: o electrolytes including magnesium, phosphorus, BUN, creatinine, Ionized calcium (why ionized calcium and not total calcium?), o Hemoglobin and hematocrit o Ferritin, folate, B12 o Vitamin D

23 Fluid Balance The human body is comprised of 55 78% water Daily body water turnover in a healthy individual is approximately 4% of body weight On average the adult human needs 2 3 L of water per day. 2 c Water = 1 lb weight = 480 ml = 0.5 kg weight Check the patient s weight in assessment of fluid balance, not just overall nutrition. Assess for edema. If the patient has a lot of edema, are they well hydrated?

24 Are there any specific types of cancer patients that should have automatic nutrition consultations?

25 Absolutely! Head and neck Esophageal Pancreas Stomach Consider in colorectal Consider feeding tube placement in these populations it may increase their quality of life, not just their level of nutrition Consider vitamin and mineral replacement in select populations

26 Diet, nutrition and cancer survivorship Cancer survivors are at increased risk for chronic illness A healthy, balanced diet can prevent or reduce the severity of chronic illness as well as benefit the cancer survivor. A well-balanced diet (low fat, high in plant-based foods) significantly associated with overall survival but not cancer free survival. Certain cancer recurrence may be reduced through proper diet (colon cancer) Toles M & Demark-Wahnfried W (2008) Nutrition and the Cancer Survivor: Evidence to Guide Oncology Nursing Practice, Seminars in Oncology Nursing, 24(3)

27 General Weight Loss Recommendations For healthy weight loss in the cancer patients o Consult with the oncologist first before starting any planned weight loss o Assist the patient with weight loss strategies Provide education Encourage no more than 2 pounds per week weight loss (healthier than quick loss plans and increases the chance that fat will be reduced and lean muscle will be increased) o Encourage exercise o Keep in mind what other medical problems are being treated at the same time (diabetes, hypertension, coronary disease, etc).

28 American Cancer Society Guidelines on Nutrition and Physical Activity for Cancer Prevention Maintain a healthy weight throughout life. o Balance caloric intake with physical activity. o Avoid excessive weight gain throughout the lifecycle. o Achieve and maintain a healthy weight if currently overweight or obese. Adopt a physically active lifestyle. o Adults: engage in at least 30 minutes of moderateto-vigorous physical activity, above usual activities, on 5 or more days of the week; 45 to 60 minutes of intentional physical activity are preferable. o Children and adolescents: engage in at least 60 minutes per day of moderate-to-vigorous physical activity at least 5 days per week. Consume a healthy diet, with an emphasis on plant sources. o Choose foods and beverages in amounts that help achieve and maintain a healthy weight. o Eat 5 or more servings of a variety of vegetables and fruits each day. o Choose whole grains in preference to processed (refined) grains. o Limit consumption of processed and red meats. If you drink alcoholic beverages, limit consumption. o Drink no more than 1 drink per day for women or 2 per day for men. CA Cancer J Clin 56: , 2006

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