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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.
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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
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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
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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.
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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)
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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
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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
DBW ESTIMATION FOR ADULTS
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
DBW ESTIMATION FOR ADULTS
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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)
DBW ESTIMATION FOR ADULTS
BUILD WOMEN MENSmall -10% -10%
Medium no addition nor subtraction
Large +10% +10%
DBW ESTIMATION FOR ADULTS
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
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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
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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
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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
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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
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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