Volume 5, Number 4, Section 2
1st
APCNS Training Course in Clinical Nutrition
SESSION
I. Diagnostic skills in clinical
nutrition
80. Approaches to nutritional diagnosis
Tanphaichitr V
Despite tremendous knowledge of nutrition, humans
are still facing 3 major nutritional problems, ie, nutrient deficiency
diseases, diet-related chronic diseases, and food hazards. Thus nutritional
diagnosis is crucial to detect nutritional disorders in high risk
individuals who require appropriate nutritional management. The 3
diagnostic tools consisting of the patient's history, physical examination,
and laboratory tests should be employed to assess the patient's nutritional
status. Careful review of the patient's history including medical,
psychosocial, and dietary history provides valuable information on
the patient's nutritional status. Inspection for physical signs of
nutritional disorders and practical anthropometric measurements should
be incorporated into routine physical examination. Laboratory tests
employed must not be overly invasive and should be sensitive enough
to identify impaired nutritional status before the appearance of clinical
manifestations. Whenever nutritional disorders are found their causes
should be identified in order to provide appropriate management.
81. Nutritional support in paediatric
AIDS: a case study
Prasong Tienboon
A 1.5 years-old-Thai boy was admitted to hospital
with a 3 week history of diarrhoea. Two weeks prior to admission,
it was noticed that the child had a fluctuating fever. An upper respiratory
tract infection was diagnosed by a general practitioner. As the father
had a chronic cough the child's mother thought that the child had
a similar problem. The child had diarrhoea with frequent mucoid loose
yellowish-green stools, 5-6 times a day. The parents gave him some
boiled rice to help treat the diarrhoea. However, the child's condition
deteriorated and he was taken to hospital. He was a first child, born
at 39 weeks gestation. His birthweight was 2500g, length 48cm, occipito-frontal
circumference (OFC) 33cm. The Apgar score at birth was 8. The child
was breastfed from birth and also fed with commercial infant formula,
boiled rice, mashed banana twice a day. Routine BCG and Hepatitis
B vaccination had been given at birth. Both parents were 23 years
old and were diagnosed HIV positive when the mother was 3 months pregnant.
They were both currently asymptomatic. The father was a labourer.
On admission, the child was febrile with a temperature
of 38C, pulse rate 120/min, respiratory rate 40/min and blood pressure
90/60mmHg. The weight was 6.5kg, (% weight for age 56%, % weight for
height 59% and % height for age 96%). The percent OFC for age was
99%. He appeared moderately dehydrated with sunken anterior fontanelle
and was drowsy. He was mildly icteric and with a slight pallor. Bitot's
spots were found on both eyes. Both angles of eyes were inflamed.
There was generalised non-tender lymphadenopathy. Four umbilicated
infected ulcers were present on his face. He had oral thrush and inflamed
both angles of mouth. Fine crepitation was found on the right upper
chest wall. The heart was regular and no murmur. Hepatomegaly (2cm
below costal margin) was present. The spleen was not palpable. Further
examination revealed dry and scaly dermatitis on chest wall and lower
legs. There were also some rashes around the perineum and anal orifice.
Laboratory investigations:
- Full blood count: haemoglobin 8.0g/dL, haematocrit
32%, white blood cell count 5000/mm3 with neutrophil
46%, lymphocyte 54%. The platelet count was 237,000 mm3
and normal appearance of red blood cell on the smear.
- Urine examination: yellow, clear, pH 6, specific
gravity 1.003, no casts, no white blood cell nor red blood cell.
Protein and sugar were negative.
- Stool examination: mucus, yellowish and green loose
stools with numerous fat droplets. Occult blood was negative and
no parasite ova were detected.
- Chest X-ray: infiltration at right upper lung field.
- Enzyme-linked immunosorbent assay (ELISA) test
for HIV was positive.
- Direct smear from face ulcer was positive for mycelium
and on culture Penicillium marneffei was identified.
- Electrolytes: sodium 133meq/L, potassium 2.5meq/L,
chloride 100meq/L, bicarbonate 17meq/L.
- Liver function tests: GOT 180mg/dL, GPT 150mg/dL,
direct bilirubin 1.2mg/dL, total bilirubin 2.9mg/dL, albumin 3.0g/dL,
globulin 5.0g/dL.
- Blood urea nitrogen 8mg/dL.
- Fasting blood glucose: 83mg/dL.
- Lipid profile: cholesterol 80mg/dL, triglyceride92
mg/dL, high density lipoprotein cholesterol 40mg/dL.
- Calcium (7-11mg/dL) 8.5, Magnesium (1.5-2.2meq/L)
2.1, Phosphorous (3.5-5.3mmol/L) 4.9.
- Zinc (92-112ug/dL) 60, Copper (78-131ug/dL) 72.
- Lumbar puncture: no cells, protein 50mg/dL, sugar
50mg/dL.
Answer:
Problem list:
- Marasmus with AIDS
- Diarrhoea due to fat malabsorption and possibly
infection
- Pneumonia
- Penicillium marneffei skin infection
- Oral thrush
- Anaemia
- Vitamins A, B2 deficiency
- Trace elements deficiency: zinc & copper
- Essential fatty acid deficiency
82. A case of renal failure
Surat Komindr MD
A 57 year-old female was transferred from a suburban
hospital because of dyspnoea and deterioration of consciousness. Following
skin-grafting at the left breast, the patient went into sepsis and
her urine flow dropped. She became dyspnoeic and stuporous. BUN and
creatinine rose from 30 and 1.3mg/dL to 85 and 3.2mg/dL, respectively.
On admission, the patient was afebrile with normal
vital signs. She was moderately obese, drowsy, slight pale with no
jaundice. A big pressure-sore was present at the sacrum. Rhonchi and
fine crepitation were audible over both lungs. The heart sounds were
normal. Bowel sound was hypoactive. The liver was 4cm below the costal
margin. Moderate pretibial edema was recognised. The chest X-rays
was compatible with pulmonary edema. The urine was turbid with a specific
gravity of 1.020, the urinalysis revealed protein +3 and negative
for blood, glucose and ketones. The blood chemistries revealed Na
130, K 2.4, Cl 91, HCO3- 13 mEq/L; SGOT 17, SGPT 15 unit/ml,
total bilirubin 0.7 mg/dL, albumin 1.52 g/dL; BUN 115, creatinine
5.1 and glucose 105 mg/dL.
The patient was clinically stable after fluid-electrolyte
resuscitation. Infections were under controlled. The patient had received
nothing per oral. In spite of large doses of diuretic her urine output
was less than 700 ml/d. Nutrition service was consulted on the sixth
hospital-day. The nutritional management will be discussed.
83. Methods in designing investigations
in critically ill patients
Iapichino G, Raddrizzani D, Note A, Pasetti G,
Marzorati S
The aim of this study is to design a method able to
investigate the variations of metabolism during substrate infusion
in the acute injury phase. Such a phase is characterised by an high
degree of variability that can impair the demonstration of the metabolic
variation due to the substrate infusion. Many are the problems, such
as the time necessary to detect the effect of the treatment and the
meaning of an eventual metabolic effect (treatment or physiological
vanishing of the acute phase?). The first step is to check if the
treatment is done during acute phase and/or is overlapping with the
weaning phase of the trauma reaction. Obviously, short term study
periods should be mandatory. Nevertheless, to safely reduce the study
length we had to consider: the lag time in the appearance of the effect;
the lag time in full blown effect; the effect resetting phenomenon
during treatment. On the contrary, at the end of the study, we had
to consider: the lag in the weaning of the effect and always to check:
the stability of trauma reaction. We will present our experience an
assessing appearance and disappearance of the treatment effect an
N output and balance, 3MH output, leg AA efflux, plasma AA variations
and gas exchange in severely injured or septic stressed patients in
acute injury phase. For the full appearance of the metabolic effect,
24/48 h for N output, 24 h for 3MH, 24 h for plasma AA level variations,
24/48 h for leg AA efflux and 8/24 h for gas exchange are mandatory.
The disappearance of the effect is completed in 12 h for N output,
5h, at least, for plasma AA level variations, 6/24 h for leg AA effl.
and 8 h for gas ex. As a result, the minimal study length in a injured
critically ill patient in the early phase of trauma reaction should
be 24 h.
84. Dietary assessment in clinical
practice
Mark L Wahlqvist
Clinical practice can be facilitated in a number of
situations by a knowledge of what is eaten. These situations include
the evaluation of growth and development in the child; disease prevention;
management of energy imbalance, whenever there is a deficit or excess;
food component deficiency, not just nutrient and food component excess.
There are several methods which may be used to obtain
relevant food intake information: a targeted enquiry with key questions
about protective or detrimental foods; an evaluation of food variety;
an assessment of energy expenditure and inappropriate nutrient loss.
More systematically, a usual 24 hour food intake history may be taken,
or a week-long food record obtained.
Aside from the foods themselves, the food culture,
food knowledge and skills, food patterns across the day and seasons,
genetic background, physical activity, past and present illness and
non-nutritionally related health priorities must be established.
A knowledge of community food supply and its nutritionally-related
epidemiology make the clinical process more informed. In the course
of the evaluation, opportunities for change can be established. Dietary
assessment leads on to nutritional therapy and to monitoring the outcome.
85. Roles of dietitians in patient-care
service and metabolic studies
Taechangam S, Tanphaichitr V
The roles and responsibilities of dietitians in teaching
hospitals include patient-care service, teaching and training, and
research. Such activities at Faculty of Medicine, Ramathibodi Hospital
are illustrated here. The patient-care service consists of nutritional
care for hospitalised patients and outpatients attending the Nutrition
Clinic. Dietitians are involved in meal planning, supervising food
preparation and service including enteral formula, assessing patient
food acceptance and recommending an appropriate diet, dietary counselling
and educating patients on modified diets. The activities for teaching
and training in dietetics cover education for dietetic students, candidates
for master degree in nutrition, dietetic personnel, and other health
care professionals. A postgraduate dietetic diploma program is offered
by Ramathibodi Hospital for dietitians who are working in hospitals.
Graduates of the program are assigned to perform the expected functions
of the dietetic practitioner. In addition, dietitians also participate
in nutrition and metabolic studies to improve the quality of nutrition
care. The activities include: (a) formulation and provision of menus
according to the study design; (b) reviewing the dietary history of
the subjects and giving the orientation of the assigned diets to them;
(c) calculation of their dietary intake; (d) collecting, analysing,
and reporting the data; and (e) motivating and educating subjects
to consume proper diets at home. In the future, as the advances in
nutrition and medical science and the demand for high quality nutrition
care services, dietitians in the health care setting should consider
to expand their traditional roles with a greater participation in
direct patient-care functions and as a member of the hospital nutrition
support team to improve the health status of the patient. Specialisation
in clinical dietetic practice in various areas, eg, renal disease,
diabetes mellitus, and cardiovascular disease may also be considered.
These concepts offer the clinical dietitian a mode of increasing the
effectiveness of dietetic services. However, to achieve these concepts
the dietitians must acquire and keep up with the advance knowledge
in nutrition and dietetics and implement it into their clinical practice.
86. Measuring body composition
Boyd JG Strauss
The measurement of human body composition has mostly
been possible only over the past half century. Although cadaver chemical
assay has been attempted in a limited way, in vivo methods allow for
research and clinical decision-making. A number of models of body
composition exist, of which the five level model, from atomic through
molecular, cellular, tissue/organ to whole body levels makes biological
sense. However, the decision to use a particular technique also requires
consideration of precision, cost, side-effects, portability, availability
and applicability. At the atomic level, potassium and nitrogen are
most often measured, but in vivo neutron activation analysis allows
other elements to be measured. Water, protein, and lipid are the most
common molecules measured, using direct and indirect techniques. At
the cellular level, cell mass, extra and intracellular water can be
measured. Both these levels allow for integration of data with biochemical
and physiological control mechanisms. CT and MRI can assess adipose
tissue and skeletal muscle volume; at the whole body level. The traditional
anthropometric techniques allow assessment in individuals and populations.
Knowledge of changes in body composition with age, between males and
females is necessary to choose the appropriate technique for measuring
body composition components in disease.
87. Health risks of body composition
disorders
Leelahagul P, Tanphaichitr V
An important assumption of nutritional assessment
is that body composition is an indirect measure of cellular function.
Body composition estimates are usually highly correlated with specific
functional tests. Body composition changes throughout the adult life
span, and this must be considered when evaluating the body composition
assessment. Height declines and, assuming body weight remains unchanged,
there is more fat and less fat-free mass in an elderly subject than
in a younger individual of the same sex. Body composition is in a
dynamic state throughout the day. Both total body protein mass and
energy content decline between meals as a result of obligatory amino
acid oxidation and metabolism of other fuels. The result is negative
protein and energy balance. With food intake, balance becomes positive,
and total body protein and energy content increase. Over a typical
day, net protein and energy balances are zero and body weight remains
constant. Many diseases and disorders are accompanied by changes or
abnormalities in body composition. The most common problem may be
obesity, in which the excessive amount of body fat probably causes
the cardiovascular diseases, several chronic diseases, and different
forms of cancer. Abdominal obesity is associated with metabolic aberrations,
morbidity, and mortality in both genders. Gluteal-femoral obesity
could be considered a cosmetic problem rather than a morbid condition,
whereas abdominal obesity markedly increases the risk for cardiovascular
disease and breast cancer. Depletion of body nutrient stores and loss
of specific cellular functions are common to many acute and chronic
diseases. Progressive loss of fat-free body mass is associated with
the evolution of various complications, including loss of cell-mediated
immunity, infections, bedsores, and ultimately, death. Protein-energy
malnutrition causes a decrease in the amount of fat and protein stores
in the body and many diseases are related to abnormalities in total
body water or to its distribution among intra- and extracellular space.
88. Assessment of immune function
Lukito W
Immunocompetence is known to be a functional index
of nutritional status. Immunoincompetence in protein-energy malnutrition
(PEM) and micronutrient deficiencies can be reversed with nutritional
repletion. With other nutritional indices, such as serum albumin and
serum transferrin, immunocompetence (assessed by delayed type hypersensitivity)
can be used to determine Prognostic Nutritional Index (PNI). PNI is
useful for predicting morbidity and mortality of nonemergency surgical
patients.
Several methods have been used to assess immune function.
Measurement of total lymphocytes in the peripheral circulation is
usually performed routinely on almost all hospital patients. Peripheral
whole blood immunophenotyping using a flow cytometry has been widely
used to enumerate lymphocyte subpopulations. Delayed type hypersensitivity
(DTH) is considered to be a useful in vivo assessment of immunocompetence.
The ability of mononuclear phagocytes and polymorphonuclear cells
to kill pathogens can be assessed using reactive oxygen species (ROS)
generation test. Lymphoproliferative assays are used to measure lymphocyte
function. The level of specific antibodies and complements can also
be measured.
Immunological tests should be interpreted with caution,
considering many other factors affect the immunocompetence. Technical
variation and difficulties in the assays can influence the results.
Correct interpretation of the results would require the overall clinical
and nutritional indices.
Pakpeankitvatana R
Lipids are transported in the plasma as lipoproteins
which can be categorised into 4 main classes: chylomicron, very low
density lipoprotein (VLDL), low density lipoprotein (LDL), and high
density lipoprotein (HDL). These lipoproteins are water soluble complex
composed of cholesterol, triglycerides, phospholipids, and apoproteins.
There are three general ways of isolating lipoproteins in practicable
quantities: ultracentrifugation, precipitation and chromatography.
After separation, the different lipid component including total cholesterol,
free cholesterol, triglycerides, and phospholipids are determined
in each lipoprotein fraction by using enzymatic techniques. Ultracentrifugation
technique separates the lipoproteins according to differences in their
hydrated density and the most widely used procedure is the sequential
centrifugation at different solvent densities. Although this technique
is comparatively time-consuming and is therefore not well adapted
to the routine characterisation of lipoprotein preparations, it offers
the best combination of capacity and resolution that is available.
Precipitation method is based on the interaction of lipoproteins with
macromolecular polyanions and allows the plasma lipoproteins to be
divided into two fractions that approximate to the high density and
the low density classes. However, the fractions obtained by precipitation
differ somewhat from those isolated by ultracentrifugation. Chromatography
has been used for the fractionation of lipoproteins that have been
isolated by other methods and does not permit the complete separation
of the lipoproteins from plasma. Moreover, chromatography usually
produces a diluted product rather than a concentrated one. The other
two techniques developed for quantitative measurement of serum lipoproteins
such as electrophoresis or nephelometer can be used for the separation
of particles that have the same density but differ markedly in electrical
charge or differ in a light scattered by particles in suspension.
Sequential ultracentrifugation technique and lipid composition in
each lipoprotein fraction in hyperlipoproteinaemic patients is described
in detail in this session.
SESSION II. Nutritional therapy and support
90. Criteria of an adequate diet
Mark L Wahlqvist
Historically, an adequate diet has been evaluated
in terms of recommended dietary intakes (RDIs), along with consideration
of certain macronutrient components like water, essential amino acids
and fatty acids which protein and fat provide, and dietary fibre.
To address problems of national food shortage, preferred food intakes
to avoid nutrient deficiency were formulated in terms of food group
usage. More recently, the World Health Organization has developed
a Food Based Dietary Guidelines (FBDGs) approach to ensure both adequacy
and nutritionally-related disease prevention. This takes account of
the sum total of all food components and their effects on human biology,
along with the properties of food other than those prescribed by chemistry,
such as its physical properties and its organoleptic properties, to
ensure interest in it and consumption.
Nutritional adequacy must be considered in relation
to energy expenditure and, therefore, an individual's energy balance
is pivotal. With greater or lesser energy throughput, food intake
needs to be less or more nutrient dense, respectively. Some prediction
of energy requirements can be made on the basis of basal energy expenditure
(BEE), knowledge of particular physical activities and their duration,
and state of health. But because of poorly defined contributors to
energy expenditure, like variations in efficiency of energy utilisation,
and spontaneous movement, it is often necessary to document current
food intake, level of physical activity, and degree of steady state
in body weight or, better, body composition as a basis for any effort
to change energy balance.
There has been much debate over the years about the
level of protein intake required in healthy individuals to maintain
health and be in nitrogen balance and most evidence now points to
a level of about 0.8 kg body weight/day to achieve these, perhaps
rising in the elderly and in certain elite sports. In the nutritionally
compromised, body nitrogen may be spared by increasing protein intakes
to the region of 1.0-1.5g protein kg body weight/day. To provide non-protein
energy, carbohydrate and fat can be added. The adequacy of intake
of dietary fibre, resistant starch and oligosaccharides resistant
to digestion is poorly defined, but for dietary fibre itself this
is probably between 20-30g/day for adults. However, even for dietary
fibre, the particular function in question may determine whether or
not these preferred intakes should be expressed in terms of anthropometric
measures or some other dietary reference point like energy intake
or absorbable carbohydrate. That dietary fibre should be obtained
from a variety of plant food is quite certain.
The preferred level of intakes of phytochemicals,
like flavonoids, monoterpenes, isothiocyanates, salicylates, and non-provitamin
A carotenoids, remain to be determined, but will be forefront areas
of nutrition research in the next decade. These compounds are often
multifunctional.
Some food components are "conditionally essential",
including some amino acids and peptides.
The nutrient requirements in transitional nutritional
states, as in refeeding may also be quite complicated and conditional,
as with increased phosphate requirements during refeeding.
A detailed knowledge of food chemistry, and a dynamic
view of human biology in health and disease is required to ensure
nutritional adequacy.
91. The use of routine assessment
for nutritional diagnosis
Tanphaichitr V, Leelahagul P
Early nutritional diagnosis is the important mode
to reduce the morbidity and mortality rates of malnutrition. Physicians
must be aware of nutritional problems encountered by the population
in their community as well as capable to make early nutritional diagnosis
and provide appropriate management to the affected persons. This can
be achieved by their willingness to incorporate nutritional assessment
into their clinical practice through the triad of diagnostic approaches
in clinical medicine, ie, the subject's history, physical examination,
and laboratory tests. Appropriate and accurate dietary assessment
provides the information on the adequacy of dietary intake of the
subjects quantitatively and qualitatively. Physical examination should
include the measurements of body mass index, waist-over-hip circumference
ratio, and inspection of common suggestive signs of malnutrition.
Several routine laboratory tests are useful to make provisional diagnosis
of nutritional disorders, ie, haemoglobin, mean corpuscular volume,
total lymphocyte count, serum albumin, urea nitrogen, creatinine,
total cholesterol, triglyceride, low density lipoprotein-cholesterol,
high density lipoprotein-cholesterol, uric acid, and blood glucose.
However, under certain circumstances, special laboratory tests are
needed for the definite diagnosis of nutritional disorders and for
detecting subclinical malnutrition.
SESSION III. Nutritional epidemiology and publication
92. Biostatistics and epidemiology
in nutrition intervention
Hsu-Hage BH-H
Biostatistics and epidemiology are two important branches
of medical science. They are often taught concurrently in medical
and research courses. Epidemiologists employ biostatistical methods
to work out design issues (including sample size requirements and
statistical power calculations), data analyses (including various
statistical tests and controlling of confounding effects) and data
presentation (including understanding of types of variables and descriptive
statistics). On the other hand, medical and health researchers engage
epidemiological methods to consider occurrence of human disease patterns,
to measure disease frequency, distribution and determinants, and to
assess a cause-effect relationship between exposure and disease. Biostatistics
and epidemiology provide the basis for medical and health research.
It's potential cannot be fully utilised without a sound research plan
(including how to conduct a study, a time-table and budgetary items).
This paper will consider biostatistical and epidemiological methods
in the conduct of a nutrition intervention at a clinical and community
setting.
93. Preparation for nutritional publication
Wahlqvist Mark L, Tanphaichitr Vichai, Okada Akira
Several sequential requisites are needed for a successful
publication. The order in which the steps in developing a paper is
taken can be invaluable. Firstly, one must be well motivated about
one's ideas and research work. Capture the main idea or finding of
your work in an illustration or table somewhere in the paper so that
it can be progressed into other literature. Anticipate this finding
in the introduction and develop it in a persuasive and critical way
in the discussion. Reflect it in the "key words". Choose
a journal which best fits the focus of the paper and where you believe
the editors will understand and be sympathetic to your purpose. Prepare
yourself for the exercise of writing the paper by systematically gathering
references in full detail and compiling them in a database; and by
being systematic about documenting methodological detail and findings.
Spend time tabulating and illustrating your findings in various ways
and then organise the data in logical sequence, with the hypotheses
in mind, whether fulfilled or not. Display the data in such a way
that newly generated hypotheses or constructs become evident. Then
produce a written description of the results as best you can on the
basis of the tables and illustrations. Before going any further, write
an abstract so that the paper is focussed. It will be easy now to
write an introduction which states the background to the present work,
what you plan to do and what you expected to find. Set out the discussion
in point form so that you do not miss key issues which will come up
in the minds of referees and the ultimate readership. Argue your way
through the hypotheses. Return to the methods. Include an appropriate
statement of ethics. Include the study design or experimental protocol,
investigatory, analytic and statistical methods. Draft a letter to
the editor of the journal you have chosen in which you state the principal
purpose of the paper, its main idea and what benefit there will be
to the readership. Welcome the referees comments when you have the
journal's decision and use them for revision for the present journal
or for submission to another journal. Be perseverant.
Copyright © 1996 [Asia Pacific Journal
of Clinical Nutrition]. All rights reserved.
Revised:
January 19, 1999
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