Built and nutrition
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This document discusses various methods for nutritional assessment, including anthropometric, clinical, biochemical, and dietary assessments. It focuses on anthropometric methods such as measuring height, weight, body mass index, skin fold thickness, waist circumference, and waist-to-hip ratio. Clinical assessment involves taking a medical history and physical examination including checking for loss of subcutaneous fat and muscle wasting. The document also discusses using a subjective global assessment to classify a patient's nutritional status as severely, moderately, or well-nourished based on combining various assessment elements.
Built and nutrition
- 1. C H A I R P E R S O N - D R . B A S A V A R A J B A L I G A R M D D M C A R D I O L O G Y S T U D E N T - D R . C H E T H A N . Y BUILT AND NUTRITIONAL ASSESSMENT
- 2. INTRODUCTION Nutritional assessment is defined by the American Society for Parenteral and Enteral Nutrition as “a comprehensive approach to diagnosing nutrition problems that uses a combination of the following: medical, nutrition, and medication histories; physical examination; anthropometric measurement; and laboratory data
- 3. Nutritional Assessment Methods Four different methods are used to collect data used in assessing a person’s nutritional status: Anthropometric Clinical Biochemical Dietary
- 4. Importance of Nutritional Assessment Nutrition can have a profound influence on health, affecting growth and development of infants, children, and adolescents; immunity against disease; morbidity and mortality from illness or surgery; and risk of such diseases as cancer, coronary heart disease, and diabetes.
- 5. Nutritional assessment is important in identifying persons at nutritional risk, in determining what type of nutrition intervention, if any, may be appropriate to alter nutritional status, and in monitoring the effects of nutrition intervention.
- 6. ANTHORPOMETRY Anthropometry is the measurement of body size, weight, and proportions Anthropometric measures can be used to evaluate nutritional status, whether it be obesity caused by overnutrition or emaciation resulting from protein-energy malnutrition
- 7. HEIGHT : Stature, or standing height, can be measured for subjects 2 to 3 years of age and older who are cooperative and able to stand without assistance In nonambulatory persons (those unable to walk) or those who have such severe spinal curvature that measurement of height would be inaccurate, stature can be estimated from knee height.
- 10. SHORT STATURE Height below 3rd centile or more than 2SD below the median height for age and sex. Normal variant Familial short stature Constitutional growth delay Pathological Proportionate Prenatal 1. Intrauterine growth retardation 2. Antenatal infection in mother (TORCH*, syphilis, AIDS) 3. Antenatal consumption of alcohol, tobacco, heroin 4. Chromosomal disorders (Down’s syndrome, Turner’s syndrome).
- 11. Postnatal 1. Malnutrition (Protein-energy malnutrition, anorexia nervosa) 2. Endocrine disorders (growth hormone deficiency, hypothyroidism, congenital adrenal hyperplasia, precocious puberty) 3. Cardiovascular disorders (cyanotic and acyanotic congenital heart disease, early onset rheumatic heart disease) 4. Respiratory disorders (Kartagener’s syndrome, cystic lung disease, childhood asthma) 5. Renal disorders (renal tubular acidosis, renal rickets, nephrotic syndrome, chronic pyelonephritis)
- 12. Disproportionate Rickets Skeletal dysplasia (kyphosis, lordosis, scoliosis) Defective bone formation (osteopetrosis, osteogenesis imperfecta) Defective cartilage growth (achondroplasia, multiple cartilagenous exostosis
- 14. WEIGHT Body weight, though not an accurate measure of fat, is a widely used index. Diurnal variations (cyclical changes occurring throughout the day) in weight of about 1 kg in children and 2 kg in adults are known to occur. For this reason, it is a good practice to also record the time weight was measured. Ideally, children and adults should be weighed after voiding and dressed in an examination gown of known weight or in light underclothing with the scales placed where adequate privacy is provided
- 15. For the age interval 2 to 20 years, the charts give percentile curves for stature-for-age, weight-for-age, body mass indexfor- age, and weight-for-stature.
- 17. Percentile Cut-Off Value( FOR 2-20 YEARS) < 5th percentile 5th and < 85th percentile 85th and < 95th percentile 95th percentile or 30 kg/m 2 (whichever is smaller)
- 18. Classification of Overweight and Obesity by Body Mass Index (BMI) in Adults Underweight <18.5 <18.5 Normal weight 18.5-24.9 18.5-22.9 Overweight 25-29.9 23-24.90 Obesity Class 1 30-34.9 25-29.90 • (PRE OBESE) Obesity Class 2 35-39.9 >30 (OBESE) Extreme Obesity Class 3 >40
- 19. INDICATORS Body mass index (Quetelet's index) = Weight (kg)/ Height(m)(2) Ponderal index = Height (cm) /Cube root of body weight (kg) Brocca index = Height (cm) -100 (For example, if a person's height is 160 cm, his idealweight is (160-100) = 60 kg)
- 20. SKINFOLD THICKNESS A large proportion of total body fat is located just under the skin. Since it is most accessible, the method most used is the measurement of skinfold thickness. It is a rapid and "noninvasive“ method for assessing body fat. Several varieties of callipers (e.g., Harpenden skin callipers) are available for the purpose.
- 23. The measurement may be taken at all the four sites - mid- triceps, biceps, subscapular and suprailiac regions. The sum of the measurements should be less than 40 mm in boys and 50 mm in girls Further, in extreme obesity, measurements may be impossible. The main drawback of skinfold measurements is their poor repeatability.
- 24. WAIST CIRCUMFERENCE AND WAIST : HIP RATIO (WHR) Waist circumference is measured at the mid point between the lower border of the rib cage and the iliac crest. It is a convenient and simple measurement that is unrelated to height. Correlates closely with BMI WHR and is an approximate index of intra - abdominal fat mass and total body fat.
- 25. Changes in waist circumference reflect changes in risk factors for cardiovascular disease and other forms of chronic diseases. There is an increased risk of metabolic complications for men with a waist circumference > 102 cm,and women with a waist circumference > 88 cm High WHR (> 0.95 in men and > 0.80 in women) indicates abdominal fat accumulation.
- 26. SL.N O ETHNICITY WAIST CIRCUMFERENCE 1 Europeans Men >94 cm (>37 in) Women >80 cm (>31.5 in) 2 South Asians and Chinese Men >90 cm (>35 in) Women >80 cm (>31.5 in) 3 Japanese Men >85 cm (>33.5 in) Women >90 cm (>35 in
- 27. TYPES OF OBESITY Generalised obesity:Over eating is the most common cause. It is characterised by the presence of a ‘double chin’. Android obesity: It is a type of obesity, which is characterised by excess deposition of fat over the region of the waist. (GREATER RISK) Gynoid obesity: It is a type of obesity, which is characterised by excess deposition of fat over the region of the hips and thighs. Superior or central type of obesity:
- 31. HISTORY Ask about usual weight, peak weight, and deliberate weight loss. A 4.5 kg (10-lb) weight loss over 6 months is noteworthy and a weight loss of >10% of usual body weight is prognostic of clinical outcomes
- 32. Medical and surgical conditions; chronic disease Look for medical or surgical conditions or chronic disease that can place one at nutritional risk secondary to increased requirements, or compromised intake or assimilation Constitutional signs/ symptoms :Fever or hypothermia can indicate active inflammatory response. Anorexia is another manifestation of inflammatory response and is also often a side effect of treatments and medications.
- 33. Eating difficulties/ gastrointestinal complaints : Poor dentition or problems swallowing can compromise oral intake. Vomiting, nausea, abdominal pain, abdominal distension, diarrhea, constipation, and gastrointestinal bleeding can be signs of gastrointestinal pathology that may place one at nutritional risk. Medication use : Many medications can adversely affect nutrient intake or assimilation. Review potential drug–drug and drug–nutrient interactions.
- 34. Dietary practices and supplement use : Look for dietary practices including therapeutic, weight reduction, vegetarian, macrobiotic, and fad diets. Also record use of dietary supplements, including vitamins, minerals, and herbals Influences on nutritional status : Ask about factors such as living environment, functional status (activities of daily living and instrumental activities of daily living), dependency, caregiver status, resources, dentition, alcohol or substance abuse, mental health (depression or dementia), and lifestyle.
- 38. PHYSICAL EXAMINATION The first of the three elements of the physical examination is LOSS OF SUBCUTANEOUS FAT. The four anatomic areas (shoulders, triceps, chest, and hands) should be checked for loss of fullness or loose-fitting skin. Loss of subcutaneous fat should be noted as normal (0), mild loss (1+ ), moderate loss (2 + ), or severe loss (3 + )
- 39. The PRESENCE OF MUSCLE WASTING (the second element of the physical examination) is best assessed by examining the deltoid muscles (located at the sides of the shoulders) and the quadriceps femoris muscles (the muscles of the anterior thigh).
- 40. Loss of subcutaneous fat in the shoulders and deltoid muscle wasting gives the shoulders a squared-off appearance.
- 41. The presence of edema at the ankle or sacrum can also be assessed as absent, mild, moderate, or severe. The presence of “pitting” edema can be checked by momentarily pressing the area with a finger and then looking for a persistent depression (more than 5 seconds) where the finger was. When considerable edema or ascites are present, weight loss is a less important variable.
- 42. SUBJECTIVE GLOBAL ASSESSMENT SGA depends on the clinician’s subjectively combining the various elements to arrive at an overall, or global, assessment. Patients with weight loss > 10% that is continuing, poor dietary intake, and severe loss of subcutaneous fat and muscle wasting fall within the severely malnourished category (class C rank).
- 43. Patients with at least a 5% weight loss, reduced dietary intake, and mild to moderate loss of subcutaneous fat and muscle wasting fall within the moderately malnourished category (class B rank). A class A rank would be given to patients having a recent increase in weight (that is not fluid retention), even if their net loss for the past 6 months was between 5% and 10%.
- 44. It is regarded by many as the most reliable and efficient method to assess nutritional status at the bedside and is considered the gold standard for bedside assessment tools.
- 47. PROTEIN ENERGY MALNUTRITION PEM is the disease caused by prolonged inadequate energy and protein consumption— starvation—with consequent depletion of the BCM and body fat. The body normally adapts to starvation by reducing energy expenditure and curtailing protein catabolism, partly by hormone- and nervous system-regulated alterations in cellular metabolism, and partly by reducing its muscle mass.
- 48. These adaptations enable prolonged survival during sub-lethal starvation, but survival comes at a cost that includes lethargy, a tendency to hypothermia, muscle atrophy (including of the cardiac and respiratory muscles), skin thinning, and functional disability. The cardinal diagnostic features of PEM—generalized muscle atrophy and subcutaneous adipose tissue depletion—are easy to detect by simple physical examination
- 49. Starvation-Related Malnutrition (Uncomplicated Protein- Energy Malnutrition) Chronic Disease-Related Malnutrition and Cachexia Acute Disease-Related Malnutrition
- 50. PROTEIN ENERGY MALNUTRITION
- 54. EATING DISORDERS ANOREXIA NERVOSA Anorexia nervosa is characterized by a refusal to maintain a minimally normal body weight, an intense fear of gaining weight that is not alleviated by losing weight, and a distorted perception of body shape or size in which a person feels overweight (either globally or in certain body areas) despite being markedly underweight.
- 55. A prominent clinical feature of persons with anorexia nervosa is marked weight loss, which in some instances can become extreme and life threatening. In postmenarcheal females, amenorrhea—i.e., the absence of at least three consecutive menstrual cycles (a woman is considered to have amenorrhea if her periods occur only following hormone administration—e.g., estrogen)
- 57. BULIMIA NERVOSA BINGE Eating, in a discrete period (e.g., within any 2-hour period), an amount of food that is definitely larger than most people would eat during a similar period of time and under similar circumstances A sense of lack of control over eating during the episode (e.g., a feeling that one cannot stop eating or control what or how much one is eating)
- 58. Recurrent inappropriate compensatory behavior in order to prevent weight gain, such as self-induced vomiting; misuse of laxatives, diuretics, enemas, or other medications; fasting; or excessive exercise The binge eating and inappropriate compensatory behaviors both occur, on average, at least twice a week for 3 months.
- 60. HEAD TO TOE EXAMINATION FOR NUTRITIONAL STATUS
- 61. HAIR EXAMINATION Hair loss in protein, folate and vit B12 deficiency
- 62. D/D for ALPOPECIA Cicatricial Alopecia Trauma Burns Infections: folliculitis, herpes zoster, gumma, lupus vulgaris Morphea, lichen planus, sarcoidosis, DLE Cutaneous neoplasms: basal cell Ca Drugs—mepacrin
- 63. Non-cicatricial Alopecia: Alopecia areata (most common) Physiologic: Androgenic alopecia Systemic diseases: SLE, hyperthyroidism, hypothyroidism, ACRODERMATITIS ENTEROPATHICA, PERNICIOUS ANAEMIA and Down’s syndrome. Infection: Moth eaten type in syphilis and fungal infections. Drugs: Antimetabolites, cytotoxics, heparin, carbimazole, iodine, bismuth, vitamin A, allopurinol and amphetamines. Telogen effluvium: Systemic illness (typhoid, measles, pneumonia) post-partum and post-surgical, MALNUTRITION Radiation.
- 64. VITAMIN B9 Recommende d Daily Enteral Intake Signs and Symptoms Populations At Risk for Deficiency Signs and Symptoms of Toxicity Status Evaluation 400 mcg Bone marrow suppression, macrocytic megaloblastic anemia, glossitis, diarrhea Can be precipitated by Sulfasalazine and Phenytoin Alcoholics, celiac or tropical sprue, chronic sulfasalazine use PO: May lower seizure threshold in those taking anticonvulsants Folic acid(serum), RBC folic acid(plasma)
- 66. VITAMIN B12 Recommende d Daily Enteral Intake Signs and Symptoms Populations At Risk for Deficiency Signs and Symptoms of Toxicity Status Evaluation 2.4 mcg Bone marrow suppression, macrocytic megaloblastic anemia, glossitis, diarrhea posterolateral column demyelination, AMS, depression, psychosis Vegetarians, atrophic gastritis, pernicious anemia, celiac sprue, Crohn's disease, patients postgastrectomy or ileal resection None Cobalamin (B12)(serum), methylmalonic acids (plasma)
- 69. BRITTLE HAIR – BIOTIN DEFICIENCY
- 70. VITAMIN B7 Recommended Daily Enteral Intake Signs and Symptoms Populations At Risk for Deficiency Signs and Symptoms of Toxicity Status Evaluation 30 mcg Mental status changes, myalgias, hyperesthesias, anorexia,(excessive egg white consumption results in avidin-mediated biotin inactivation) Alcoholics None Biotin(plasma), methyl- citrate(urine)
- 72. CHANGE OF COLOUR – ZINC DEFICIENCY
- 73. Colour of Hair White - hair albinism (due to absence of pigment). Grey hair is a sign of ageing. Poliosis patchy loss of pigmentation of hair in the region of an adjoining vitiligo. Flag sign brownish discolouration of hair, with interspersed normal colour of hair, is seen in protein energy malnutrition. ZINC DEFICINECY
- 74. ZINC Nutrient Recommended Daily Enteral Intake Signs and Symptoms Populations At Risk for Deficiency1,4 Signs and Symptoms of Toxicity4 Status Evaluation4,5 Zinc 11 mg Poor wound healing, diarrhea (high fistula risk), dysgeusia, hypogonadism, infertility, acro-oroficial skin lesions (glossitis, alopecia), behavioral changes Intrinsic: Acrodermatitis enteropathica Chronic diarrhea, cereal-based diets, alcoholics, any intestinal malabsorptive states, fistulas/ nephrotic syndrome, diabetes, post– gastric bypass/ anorexia, pregnancy Intrinsic: Acrodermatitis enteropathica PO: Nausea, vomiting, gastritis, diarrhea, low HDL, gastric erosions, Competition with GI absorption can precipitate Cu21 deficiency Inhaled: Hyperpnea, weakness, diaphoresis Zinc,S,P, alkaline phosphatases (good for those on TPN, but in general Zincs,p, hair, RBC, WBC levels can be misleading) Zinc radioisotope studies (most accurate tests at present;
- 76. FLAG SIGN- PROTEIN MALNUTRITION
- 77. Dry hair – vit A and vit E deficiency Easily pluckable hair in zinc, biotin and protein deficiency
- 78. Coiled and corkscrew hair – vit A and vit C deficiency
- 79. EYE EXAMINATION Bitots spot – vit A deficiency
- 82. Recommended Daily Enteral Intake Signs and Symptoms Populations At Risk for Deficiency Signs and Symptoms of Toxicity Status Evaluation 900 mcg VITAMIN A Conjunctival xerosis, keratomalacia, follicular hyperkeratosis, night blindness, Bitot spots, corneal , retinal dysfunction Any malabsorptive state involving proximal small bowel, vegetarians, chronic liver disease Acute: Teratogenic, skin exfoliation, intracranial hypertension, hepatocellular necrosis Chronic: Alopecia, ataxia, cheilitis, dermatitis, conjunctivitis, pseudotumor cerebri, hyperlipidemia, hyperostosis Retinol(serum), retinol esters(plasma), electroretinogram, liver biopsy (diagnostic for toxicity), retinol binding protein (useful in ESRD, accurately assesses blood levels)
- 84. WHO Classification of Vitamin A Deficiency 1. Primary X-1A Conjunctival xerosis X-1B Conjunctival xerosis + Bitot’s spots X-2 Corneal xerosis X-3A Corneal ulcer—< 1/3 of cornea involved X-3B Corneal ulcer—> 1/3 of cornea involved— keratomalacia 2. Secondary X-N Night blindness X-F Xerophthalmic fundus X-S Corneal scars
- 85. ANGULAR PALPEBERITIS – RIBOFLAVIN DEFICIENCY
- 86. Recommende d Daily Enteral Intake Signs and Symptoms Signs and Symptoms Populations At Risk for Deficiency Signs and Symptoms of Toxicity Status Evaluation 1.3 mg RIBOFLAVIN Cheilosis, angular stomatitis, glossitis, seborrheic dermatitis, normocytic normochromic anemia Alcoholics, severely malnourished None RBC glutathione reductase activity(plasma)
- 88. PERIORAL EXAMINATION Angular somatitis and chelitis : deficiency of Iron, vitamin B complex and protein
- 90. Glossitis – niacin, folate and vit B 12 deficiency, riboflavin, pyridoxine
- 91. Pale tongue
- 92. ATROPHIC LINGUAL PAPPILAE Deficinecy Of IRON Riboflavin, niacin, folate, vitamin B12, protein
- 93. Red beefy tongue in vit B12 deficiency
- 96. Magenta tongue – riboflavin deficiency
- 97. Bleeding gums – vit C deficiency
- 98. D/D OF BLEEDING GUMS: Ill fitting Dentures and other dental appliances Bleeding disorders Improper flossing Gingivitis Leukemia Vitamin c def Use of anticoagulants Vit k deficiency
- 99. Manifestations Infancy and Childhood Painful swelling over the long bones due to subperiosteal haemorrhage Gingivitis, swollen, spongy gums if teeth have erupted Lassitude, anorexia and pain in limbs Inward sinking of sternum with sharp elevation of costochondral junctions (scorbutic rosary) Purpura and echymoses may appear in the skin Painful joint swelling due to haemorrhage into the joint cavities. Retrobulbar, subarachnoid and intracerebral hemorrhages
- 101. ADULTS: Swollen, spongy gums Perifollicular hyperkeratosis with haemorrhage Haemorrhage into the muscles of the arms and legs Petechial haemorrhages in the viscera and echymoses Delayed wound healing Other clinical manifestations are icterus, oedema, fever, convulsions and hypotension Vitamin C deficiency causes normochromic normocytic anaemia
- 102. Recommended Daily Enteral Intake Signs and Symptoms Populations At Risk for Deficiency Signs and Symptoms of Toxicity Status Evaluation 90 mg VIT C Scurvy, ossification abnormalities Tobacco lowers plasma and WBC vitamin C Sudden cessation of high dose vitamin C can precipitate scurvy Fruit-deficient diet, smokers, ESRD Nausea, diarrhea, increased oxalate synthesis (theoretical nephrolithiasis risk) Ascorbic acid(plasma), leukocyte ascorbic acid
- 105. SKIN EXAMINATION Skin desquamation – riboflavin deficiency
- 106. Cellophane appearance and Cracking (flaky paint or crazy pavement dermatosis) – protein deficiency
- 107. Yellow pigmentation of skin (sparing sclera) –carotene excess
- 108. Petechiae – vit A and vit C deficiency
- 109. D/D for petichiae (<3mm) Physical trauma : repeated bout of coughing, vomitting Asphyxiation Sun burn Hickey NON INFECTIOUS VIT C VIT K DEF Thrombocytopenia Leukemia Von villebrands disease Aplastic anemia
- 110. Infectious Dengue ,Chickungunya , Influenza, Ebola, Cmv, Infectious Mononucleosis Malaria Syphylis Endocarditis Meningococciemia Scarlet Fever Typhus
- 111. Ecchymosis – vit K and vit C deficiency
- 112. Recommended Daily Enteral Intake Signs and Symptoms Signs and Symptoms Populations At Risk for Deficiency Signs and Symptoms of Toxicity Status Evaluation 120 mcg VITAMIN K Hemorrhagic disease of newborn, coagulopathy Any malabsorptive state involving proximal small bowel, chronic liver disease In utero: Hemolytic anemia, hyperbilirubinemi a, kernicterus IV: flushing, dyspnea hypotension (possibly related to dispersal agent) Prothrombin time (plasma)
- 115. Perifollicular hemorrhage – vit C deficiency
- 116. Ecchymosis and perifollicular hemorrhage in vit C deficiency
- 117. Aceniform lesions in vit A deficiency
- 118. Follicular keratosis in vit A deficiency
- 119. Xerosis – essential fatty acid deficiency , VIT A def
- 120. Pigmentation, cracking and crusting – niacin deficiency (CASTELS NECKLACE)
- 121. Recommende d Daily Enteral Intake Signs and Symptoms Signs and Symptoms Populations At Risk for Deficiency Signs and Symptoms of Toxicity Status Evaluation 16 mg/40 mg VITAMIN B3 Pellagra dysesthesias, glossitis, stomatitis, vaginitis, vertigo, diarrhea, dementia Intrinsic: Hartnup disease Alcoholics, malignant carcinoid syndrome, severely malnourished Flushing, hyperglycemia, hyperuricemia, hepatocellular injury N-methyl- nicotinamide(ur ine)
- 123. HARTNUPS DISEASE
- 124. GENERALISED HYPERPIGMENTATION: VIT B12 FOLATE DEF
- 125. D/D for generalised hyperpigmentation Endocrinopathies Addison’s disease Nelson syndrome Ectopic ACTH syndrome Hyperthyroidism Metabolic Porphyria cutanea tarda Hemochromatosis VITAMIN B12, FOLATE DEFICIENCY PELLAGRA Malabsorption, including Whipple’s disease Melanosis secondary to metastatic melanoma
- 126. Autoimmune Biliary cirrhosis Systemic sclerosis (scleroderma) POEMS syndrome Eosinophilia-myalgia syndromed Drugs (e.g. cyclophosphamide) and metals (e.g. silver
- 127. Acro-orificial dermatitis – zinc deficiency
- 128. NAIL EXAMINATION KOILONYCHIA – IRON DEFICIENCY ANEMIA
- 129. D/D OF KOILONYCHIA Iron deficiency Anemia Hemochromatosis Raynauds syndrome Porphyria Inherited
- 130. IRON Recommended Daily Enteral Intake/ Parenteral Intake Signs and Symptoms Signs and Symptoms Populations At Risk for Deficiency Signs and Symptoms of Toxicity Status Evaluation 8 mg Fatigue, hypochromic microcytic anemia glossitis, koilonychia Reproductive age females, pregnant females, chronic anemias, hemoglobinopath ies post–gastric bypass/ duodenectomy, alcoholics PO or IV: hemosiderosis, followed by deposition in liver, pancreas heart and glands Intrinsic: Hereditary hemochromatosis Ferritins, TIBCs % Transferrin saturation, serum iron
- 132. WHITE NAILS AND TRANSVERSE RIDGING OF NAILS – HYPOALBUMINEMIA
- 133. D/D OF WHITE NAILS Anemia Hypoalbumunaemia Diabetes CCF RA Malignancy
- 134. Bones, Joints Beading of ribs, epiphyseal swelling, bowlegs –VIT D deficiency.
- 136. VITAMIN D Recommended Daily Enteral Intake Signs and Symptoms Signs and Symptoms Populations At Risk for Deficiency Signs and Symptoms of Toxicity Status Evaluation 5–15 mcg Rickets/osteomal acia Any malabsorptive state involving proximal small bowel, chronic liver disease Of note: Those with higher skin melanin content (i.e., darker skin) have low baseline 25-OH vitamin D levels; it is unclear whether this merits their inclusion as an “at risk” population Hypercalcemia, hyperphosphatemi a, which can lead to CaPO4 precipitation, systemic calcification +/- AMS +/-AKI 25-OH vitamin D serum levels is Of note: lively debate between IOM and Endocrine Society regarding definitions of deficiency, goal serum 25-OH levels, and at risk populations
- 137. 15
- 140. Tenderness (subperiosteal hemorrhage in child) – Vit C deficiency
- 141. NEUROLOGICAL EXAMINATION Dementia - Niacin, vitamin B12 Confabulation, disorientation Thiamin (Korsakoff’s psychosis). WERNICKES encephalopathy – Thiamine Peripheral neuropathy - Thiamin, pyridoxine, vitamin B12 Tetany - Calcium, magnesium
- 142. VITAMIN B1 Recommende d Daily Enteral Intake Signs and Symptoms Signs and Symptoms Populations At Risk for Deficiency Signs and Symptoms of Toxicity Status Evaluation 1.2 mg Irritability, fatigue, headache Wernicke's encephalopathy, Korsakoff psychosis, “Wet ” beri-beri , “Dry ” beri-beri Alcoholics, severely malnourished IV: Lethargy and ataxia RBC transketolase activity(blood), thiamine(blood and urine)
- 144. VITAMIN B6 Recommended Daily Enteral Intake Signs and Symptoms Signs and Symptoms Populations At Risk for Deficiency Signs and Symptoms of Toxicity Status Evaluation 1.3–1.7 mg Cheilosis, stomatitis, glossitis, irritability, depression, confusion, normochromic normocytic anemia Alcoholics, diabetics celiac sprue, chronic isoniazid or penicillamine use Peripheral neuropathy, photosensitivity Pyridoxal phosphate(plas ma)
- 146. OTHERS Parotid enlargement – Protein def (also consider bulimia) Heart failure - Thiamin (wet beriberi), phosphorus def Sudden heart failure, death - Vitamin C def Edema - Protein, thiamin def Poor wound healing, pressure ulcers - Protein, vitamin C, zinc
- 147. CHROMIUM Recommende d Daily Enteral Intake Signs and Symptoms Signs and Symptoms Populations At Risk for Deficiency Signs and Symptoms of Toxicity Status Evaluation 30–3 5 mcg Glucose intolerance peripheral neuropathy None PO: gastritis IV: skin irritation Cr61: (steel, welding) lung carcinogen if inhaled Chromium (serum)
- 149. COPPER Recommended Daily Enteral Intake Signs and Symptoms Signs and Symptoms Populations At Risk for Deficiency Signs and Symptoms of Toxicity Status Evaluation 900 mcg Hypochromic normocytic or macrocytic anemia (rarely microcytic) neutropenia, thrombocytopenia, diarrhea, osteoporosis pathologic fractures Intrinsic: Menkes‘disease Chronic diarrhea high zinc/low protein diets PO: gastritis, nausea, vomiting, coma, movement/ neurologic abnormalities, Wilsons disease. Copper ,Ceruloplasmin
- 151. IODINE Recommended Daily Enteral Intake Signs and Symptoms Signs and Symptoms Populations At Risk for Deficiency Signs and Symptoms of Toxicity Status Evaluation 150 mcg Thyroid hyperplasia (goiter) functional hypothyroidism Intrinsic in utero: cretinism, poor CNS development, hypothyroidism Those without access to fortified salt grain, milk, or cooking oil Hypothyroidism blocks thyroxine synthesis OR hyperthyroidism Excess supplementation in severe deficiency TSH(serum), iodine(urine) (24 hr intake or iodine: Cr ratio are more representative than a single sample) Thyroglobulins
- 152. GOITER
- 154. MANGNESE Nutrient Recommende d Daily Enteral Intake/ Parenteral Intake Signs and Symptoms Signs and Symptoms Population s At Risk for Deficiency Signs and Symptoms of Toxicity Status Evaluation Manganese 2.3 mg Hypercholes terolemia, dermatitis, dementia, weight loss Chronic liver disease, iron deficient populations PO: None Inhalation: Hallucinatio n, Parkinsonian -type symptoms No reliable markers Manganeses does not reflect bodily stores, especially in the CNS
- 156. SELENIUM Nutrient Recommend ed Daily Enteral Intake Signs and Symptoms Signs and Symptoms Populations At Risk for Deficiency Signs and Symptoms of Toxicity Status Evaluation Selenium 55 mcg Myalgias cardiomyopath y Intrinsic: Keshan's disease (Chinese children), Endemic areas of low soil content include certain parts of China and New Zealand PO: Nausea, diarrhea, AMS, irritability, fatigue, peripheral neuropathy, hair loss, white splotchy nails, halitosis (garlic-like odor) Selenium(seru m), glutathione peroxidase activity(blood)
- 158. KESHANS DISEASE
- 159. MOLYBDENUM Nutrient Recommende d Daily Enteral Intake/ Parenteral Intake Signs and Symptoms Signs and Symptoms Populations At Risk for Deficiency Signs and Symptoms of Toxicity Status Evaluation Molybdenum 45 mcg/45 mcg CNS toxicity, hyperoxypurine mia, hypouricemia, low urinary sulfate excretion (also reported with parenteral sulfite infusion) Intrinsic: Molybdenum cofactor deficiency, isolated sulfite oxidase deficiency None PO or any exposure: Hyperuricemia gout Inhaled: Pneumoconiosi s (industrial exposure) Molybdenum
- 161. VITAMIN B5 Recommende d Daily Enteral Intake Signs and Symptoms Signs and Symptoms Populations At Risk for Deficiency Signs and Symptoms of Toxicity Status Evaluation 5 mg Fatigue, abdominal pain, vomiting, insomnia, paresthesias Alcoholics PO: Diarrhea Pantothenic acid(urine)
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