Assessment of Nutritional Status Biochemical assessment 1
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2 Involves measurement of nutrient levels or their metabolites
in body tissues or fluids Estimation of tissue desaturation, enzyme
activity or blood composition
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Biochemical assessment 3 Tests are confined to 2 easily
obtainable fluids namely blood and urine and results are generally
compared to standards Results are generally compared to standards,
i.e. normal levels for age and sex
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Biochemical assessment 4 An objective method of nutritional
assessment Provides specific information on the bodys status
regarding specific nutrients and may also identify borderline
nutritional deficiencies or excesses Can be used to assess the
nutritional status of large population groups
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Advantages 5 Objectivity Independent of the emotional and
subjective factors that usually affect the investigator Free from
bias compared to other methods of nutritional status
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Advantages 6 Can detect early subclinical states of nutritional
deficiency Can identify nutritional deficiency before appearance of
clinical signs Reveals nutrient deficiency at an early stage
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Advantages 7 Can confirm existence of abnormality, since
clinical signs are non-specific Precision and accuracy
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Disadvantages 8 Costly, usually requiring expensive equipments
Time consuming Difficult to collect samples Lack of practical
standards of sample collection
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Objectives 9 1. To detect marginal nutritional deficiency in
individuals, particularly when dietary histories are questionable
or unavailable; their use is especially important before overt
clinical signs of diseases appear, thus permitting the initiations
of appropriate remedial steps 2. To supplement or enhance other
studies such as dietary or community assessment among specific
population groups in order to pinpoint nutritional problems that
these modalities may have suggested or failed to reveal
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Factors affecting accuracy of results 10 1. Method of sample
collection 2. Method of transport and storage of samples 3.
Technique employed
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Ideal Biochemical Tests 11 1. Specific 2. Simple 3. Inexpensive
4. Reveal tissue depletion at an early stage 5. Require less
sophisticated equipment and skill
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Common biochemical parameters/tests 12
FluidParameterNutritional deficiency BloodSerum albuminProtein
deficiency Amino acid imbalanceProtein deficiency Serum vitamin
AVitamin A deficiency Serum caroteneVitamin A deficiency Serum
alkaline phosphataseVitamin D deficiency Serum ascorbic acidVitamin
C deficiency HemoglobinIron and Vitamin B12 deficiency
HematocritIron deficiency UrineHydroxyproline excretionProtein
deficiency Urinary ureaProtein deficiency Urinary creatinineProtein
deficiency Urinary thiamineThiamine deficiency Urinary
ribiflavinRiboflavin deficiency
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Choosing the biochemical assessment method 13 1. Direct
measurement of the nutrient a. Serum proteins (albumin, globulin,
fibrinogen, carrier proteins) b. Blood glucose c. Blood lipids :
free fatty acids, total cholesterol, LDL-cholesterol, triglycerides
d. Serum retinol, ascorbic acid, calcium, sodium, B-vitamins
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Choosing the biochemical assessment method 14 2. Measurement of
substances that indirectly reflect level of the nutrient in the
body a. Hematocrit, hemoglobin b. Hormones (e.g. Thyroid hormones)
c. Binding proteins (e.g. Retinol binding proteins) d. Urinary
excretion of metabolites (iodine, B6 deficiency: increased
excretion of xanthurenic acid, other tryptophan metabolites)
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Choosing the biochemical assessment method 15 3. Know the
physiology and metabolism of the nutrient to be measured a. Is it a
water or fat soluble nutrient? b. Can it be stored by the body in
significant amounts? c. How are levels of the nutrient in the body
regulated? d. What are the normal roles of the nutrient in the
body? e. What will likely happen if the nutrient becomes
deficient?
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What is the biological sample to be used? 16 1. Blood 2.
Urine
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Blood 17 Arterial, venous, plasma, serum, blood cells
erythrocytes Measurements of nutrients/ metabolites are often
controlled by homeostasis tend to reflect recent intake
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Blood 18 Random sample Taken at any time of the day Depending
on what is being measured, may be influenced by recent food intake,
physical activity, fluid intake
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What is the biological sample to be used? 19 1. Blood 2.
Urine
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Urine 20 1. First voided morning urine sample Assumed that
subjects have been asleep for the past 6-8 hours No food and fluid
intake immediately before sample taken Physical activity
standardized between different subjects
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Urine 21 2. 24-hour sample More difficult to make a complete
collection, especially in free-living subjects
Preservation of biological samples 23 Any separation/initial
processing required Containers for storage and transport
Considerations (cold storage, transport) It is of utmost importance
to preserve the integrity of the collected samples prior to actual
analysis in the laboratory
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Assay 24 Analysis done to determine the presence of a substance
and the amount of that substance May be done for example to
determine the level of thyroid hormone in the blood of a person
suspected of being hypothyroid (or hyperthyroid)
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Analysis of biological samples 25 Methods to be used in
analysis 1. Spectrophotometry 2. Immunological methods 3.
Chromatography
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Spectrophotometry 26 Based on the principle that different
substances have different characteristics with regard to light
spectrum
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Analysis of biological samples 27 Methods to be used in
analysis 1. Spectrophotometry 2. Immunological methods 3.
Chromatography
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Immunological methods 28 Radioimmunoassay, enzyme immunoassay
methods, based on the principle that substances have specific
ability to bind to certain antigens/antibodies
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Analysis of biological samples 29 Methods to be used in
analysis 1. Spectrophotometry 2. Immunological methods 3.
Chromatography
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Chromatography 30 Gas chromatography, HPLC-based on the
principle that substances have differences in chemical
characteristics (mol wt) that allow then to be isolated from each
other
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Analysis of biological samples 31 Equipment required for
analysis Are they available? Is the procedure being done locally?
Is there a laboratory person technically trained to perform the
procedure?
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Analysis of biological samples 32 Coordination of sample
collection, storage and transport Techniques for collection of
samples Informed consent from subjects Methods vary in cost,
reliability, degree of technical expertise required
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Interpretation of results 33 1. Low nutrient levels a. Dietary
deficiency b. Poor absorption c. Impaired transport d. Abnormal
utilization e. Combination of factors
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Interpretation of results 34 2. Compare individual results with
normal reference values appropriate for: a. Age b. Sex c.
Physiological state
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Biochemical measurements of selected nutrients 35 1. Protein 2.
Iron 3. Vitamin A 4. Vitamin D 5. Vitamin E 6. Vitamin C 7.
Thiamine 8. Riboflavin 9. Niacin 10. Vitamin B6 11. Folate 12.
Vitamin B12 13. Calcium 14. Phosphorus 15. Magnesium 16. Iodine 17.
Lipid and glucose 18. Zinc
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Protein status 36 Laboratory indices of protein status measure
somatic protein status, visceral protein status, metabolic changes,
muscle function and immune function
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Protein status 37 Proteins-body stores are determined from
by-products of protein catabolism and products of protein
synthesis
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Protein status 38 1. Urinary creatinine excretion 2.
3-methylhistidine excretion 3. Serum proteins 4. Serum albumin 5.
Serum transferrin 6. Serum retinol-binding protein 7. Serum
thyroxine-binding pre-albumin 8. Serum somatomedin-C 9. Serum
amino-acid ratio 10. Urinary 3-hydroxyproline excretion 11.
Nitrogen balance 12. Urinary urea nitrogen: Creatinine ratios 13.
Functional tests of protein status
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Urinary creatinine excretion 39 Used to assess the degree of
depletion of muscle mass in marasmic patients, and degree of
repletion after long terms intervention, provided that 72-hour
urine collections are made Frequently expressed as creatinine
height index
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Guidelines for the interpretation of creatine height index 40
Less than acceptableAcceptable (low risk) Deficient (high risk) Low
(medium risk) Creatinine height index (3 months to 17 years of age)
< 0.50.5 0.9> 0.9 Source : Gibson, 1991
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Factors affecting daily creatinine excretion 41 1. Strenuous
exercise 2. Emotional stress 3. Dietary intakes of creatine and
creatinine 4. Menstruation 5. Age 6. Infection, fever and trauma 7.
Chronic renal failure
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Protein status 42 1. Urinary creatinine excretion 2.
3-methylhistidine excretion 3. Serum proteins 4. Serum albumin 5.
Serum transferrin 6. Serum retinol-binding protein 7. Serum
thyroxine-binding pre-albumin 8. Serum somatomedin-C 9. Serum
amino-acid ratio 10. Urinary 3-hydroxyproline excretion 11.
Nitrogen balance 12. Urinary urea nitrogen: Creatinine ratios 13.
Functional tests of protein status
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3-Methylhistidine excretion 43 3-methylhistidine is an amino
acid present almost exclusively in the actin of all skeletal muscle
fibers and the myosin of white fiber A marker of muscle protein
that is not widely used
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Protein status 44 1. Urinary creatinine excretion 2.
3-methylhistidine excretion 3. Serum proteins 4. Serum albumin 5.
Serum transferrin 6. Serum retinol-binding protein 7. Serum
thyroxine-binding pre-albumin 8. Serum somatomedin-C 9. Serum
amino-acid ratio 10. Urinary 3-hydroxyproline excretion 11.
Nitrogen balance 12. Urinary urea nitrogen: Creatinine ratios 13.
Functional tests of protein status
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Serum proteins 45 Index of visceral protein status Easily
measured but a rather insensitive index of protein status
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Factors affecting serum protein concentrations 46 1. Inadequate
protein intake 2. Altered metabolism 3. Specific deficiency of
plasma protein 4. Reduced protein synthesis 5. Pregnancy 6.
Capillary permeability 7. Drugs 8. Strenuous exercise
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Guidelines for the interpretation of total serum protein
concentrations, g/dL 47 Subjects Less than acceptable Acceptable
(low risk) Deficient (high risk) Low (medium risk) Infants 0-11
months-< 5.0> 5.0 Children 1 to 5 years-< 5.5> 5.5
Children 6 to 17 years-< 6.0> 6.0 Adults< 6.06.0 to
6.4> 6.5 Pregnant, 2 nd and 3 rd trimester < 5.55.5 to
5.9> 6.0 Source : Sauberlich et al, 1974
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Protein status 48 1. Urinary creatinine excretion 2.
3-methylhistidine excretion 3. Serum proteins 4. Serum albumin 5.
Serum transferrin 6. Serum retinol-binding protein 7. Serum
thyroxine-binding pre-albumin 8. Serum somatomedin-C 9. Serum
amino-acid ratio 10. Urinary 3-hydroxyproline excretion 11.
Nitrogen balance 12. Urinary urea nitrogen: Creatinine ratios 13.
Functional tests of protein status
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Serum albumin 49 Reflects changes occurring within the
intravascular space and not the total visceral protein pool Not
very sensitive to short-term changes in protein status Has a long
half-life of 14 to 20 days
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Interpretative guidelines for serum albumin concentrations,
g/dL 50 Subjects Less than acceptable Acceptable (low risk)
Deficient (high risk) Low (medium risk) Infants 0-11 months-<
2.5> 2.5 Children 1 to 5 years< 2.8< 3.0> 3.0 Children
6 to 17 years< 2.8< 3.5> 3.5 Adults< 2.82.8 to 3.4>
3.5 Pregnant 1 st trimester< 3.03.0 to 3.9> 4.0 Pregnant, 2
nd and 3 rd trimester< 3.03.0 to 3.4> 3.5 Source : Gibson,
1991
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Protein status 51 1. Urinary creatinine excretion 2.
3-methylhistidine excretion 3. Serum proteins 4. Serum albumin 5.
Serum transferrin 6. Serum retinol-binding protein 7. Serum
thyroxine-binding pre-albumin 8. Serum somatomedin-C 9. Serum
amino-acid ratio 10. Urinary 3-hydroxyproline excretion 11.
Nitrogen balance 12. Urinary urea nitrogen: Creatinine ratios 13.
Functional tests of protein status
Slide 52
Serum transferrin 52 Transferrin is a serum beta-globullin
protein synthesized primarily in the liver and is located almost
totally intravascularly Serves as the iron transport protein Is
bacteriostatic (binds with free iron and prevents the growth of
gram- negative bacteria which require iron for growth)
Protein status 54 1. Urinary creatinine excretion 2.
3-methylhistidine excretion 3. Serum proteins 4. Serum albumin 5.
Serum transferrin 6. Serum retinol-binding protein 7. Serum
thyroxine-binding pre-albumin 8. Serum somatomedin-C 9. Serum
amino-acid ratio 10. Urinary 3-hydroxyproline excretion 11.
Nitrogen balance 12. Urinary urea nitrogen: Creatinine ratios 13.
Functional tests of protein status
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Serum retinol-binding protein 55 is a carrier protein for
retinol Serum RBP concentrations tend to fall rapidly in response
to protein and to energy deprivation and respond quickly to dietary
treatment
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Interpretative guidelines for retinol- binding protein 56
ParameterProtein deficit NoneMildModerateSevere Retinol- binding
protein (mg/dL) 2.6 7.6--- Source : Gibson, 1991
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Protein status 57 1. Urinary creatinine excretion 2.
3-methylhistidine excretion 3. Serum proteins 4. Serum albumin 5.
Serum transferrin 6. Serum retinol-binding protein 7. Serum
thyroxine-binding pre-albumin 8. Serum somatomedin-C 9. Serum
amino-acid ratio 10. Urinary 3-hydroxyproline excretion 11.
Nitrogen balance 12. Urinary urea nitrogen: Creatinine ratios 13.
Functional tests of protein status
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Serum thyroxine-binding pre- albumin 58 TBPA serves as
transport protein for thyroxine and as a carrier protein for RBP
More sensitive index of protein status and responds more rapidly to
dietary treatment
Protein status 60 1. Urinary creatinine excretion 2.
3-methylhistidine excretion 3. Serum proteins 4. Serum albumin 5.
Serum transferrin 6. Serum retinol-binding protein 7. Serum
thyroxine-binding pre-albumin 8. Serum somatomedin-C 9. Serum
amino-acid ratio 10. Urinary 3-hydroxyproline excretion 11.
Nitrogen balance 12. Urinary urea nitrogen: Creatinine ratios 13.
Functional tests of protein status
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Serum somatomedin-C 61 Somatomedins are growth-hormone
dependents serum growth factors produced by the liver Circulate
blood to carrier proteins and have a half-life for several hours
More sensitive to acute changes in protein status than the other
serum proteins
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Protein status 62 1. Urinary creatinine excretion 2.
3-methylhistidine excretion 3. Serum proteins 4. Serum albumin 5.
Serum transferrin 6. Serum retinol-binding protein 7. Serum
thyroxine-binding pre-albumin 8. Serum somatomedin-C 9. Serum
amino-acid ratio 10. Urinary 3-hydroxyproline excretion 11.
Nitrogen balance 12. Urinary urea nitrogen: Creatinine ratios 13.
Functional tests of protein status
Slide 63
Serum amino-acid ratio 63 Children with kwashiorkor generally
have serum NEAA:EAA ratios above 3 Normal children and those with
marasmus, ratios are usually less than 2
Interpretative guidelines for serum non- essential: essential
amino acid ratios 65 Source : Gibson, 1991 Parameter Less than
acceptable Acceptable (low risk) Deficient (high risk) Low (medium
risk) Nonessential : essential amino acid ratio > 3.02.0 3.0<
2.0
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Protein status 66 1. Urinary creatinine excretion 2.
3-methylhistidine excretion 3. Serum proteins 4. Serum albumin 5.
Serum transferrin 6. Serum retinol-binding protein 7. Serum
thyroxine-binding pre-albumin 8. Serum somatomedin-C 9. Serum
amino-acid ratio 10. Urinary 3-hydroxyproline excretion 11.
Nitrogen balance 12. Urinary urea nitrogen: Creatinine ratios 13.
Functional tests of protein status
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Urinary 3-hydroxyproline excretion 67 Urinary 3-hydroxyproline
is an excretory product derived from the soluble and insoluble
collagens of both soft and calcified tissues
Hydroxyproline:creatinine ratio (corrects for differences in adult
body size) Hydroxyproline (mg) per 24 hour Creatinine (mg) per 24
hour
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Urinary 3-hydroxyproline excretion 68 Hydroxyproline index
Hydroxyproline = index Mg hydroxyproline per mL urine x kg body
weight_____________ mg creatinine per mL urine
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Interpretative guidelines for urinary hydroxyproline index 69
Source : Gibson, 1991 Parameter Less than acceptable Acceptable
(low risk) Deficient (high risk) Low (medium risk) Hydroxyproline
index (3 months to 10 years of age > 1.01.0 2.0> 2.0
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Protein status 70 1. Urinary creatinine excretion 2.
3-methylhistidine excretion 3. Serum proteins 4. Serum albumin 5.
Serum transferrin 6. Serum retinol-binding protein 7. Serum
thyroxine-binding pre-albumin 8. Serum somatomedin-C 9. Serum
amino-acid ratio 10. Urinary 3-hydroxyproline excretion 11.
Nitrogen balance 12. Urinary urea nitrogen: Creatinine ratios 13.
Functional tests of protein status
Slide 71
Nitrogen balance 71 measure of net changes in total body
protein mass
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Protein status 72 1. Urinary creatinine excretion 2.
3-methylhistidine excretion 3. Serum proteins 4. Serum albumin 5.
Serum transferrin 6. Serum retinol-binding protein 7. Serum
thyroxine-binding pre-albumin 8. Serum somatomedin-C 9. Serum
amino-acid ratio 10. Urinary 3-hydroxyproline excretion 11.
Nitrogen balance 12. Urinary urea nitrogen: Creatinine ratios 13.
Functional tests of protein status
Slide 73
Urinary urea nitrogen: creatinine ratios 73 Urea is the largest
source of urinary nitrogen and is synthesized in the liver Urinary
urea nitrogen:creatinine ratios are used as an index of dietary
protein intake but not an index of long-term protein status
Slide 74
Interpretative guidelines for urinary urea nitrogen:creatinine
ratios 74 Source : Gibson, 1991 Parameter Less than acceptable
Acceptable (low risk) Deficient (high risk) Low (medium risk) Urea
nitrogen : creatinine ratio < 6.06.0 12.0> 12.0
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Protein status 75 1. Urinary creatinine excretion 2.
3-methylhistidine excretion 3. Serum proteins 4. Serum albumin 5.
Serum transferrin 6. Serum retinol-binding protein 7. Serum
thyroxine-binding pre-albumin 8. Serum somatomedin-C 9. Serum
amino-acid ratio 10. Urinary 3-hydroxyproline excretion 11.
Nitrogen balance 12. Urinary urea nitrogen: Creatinine ratios 13.
Functional tests of protein status
Slide 76
Functional tests of protein status 76 Include muscle function
and immunological tests Muscle function measure changes in muscle
contractility, relaxation rate, endurance, and hand grip strength
Immunological tests include lymphocyte count, delayed cutaneous
hypersensitivity, measurement of thymus-dependent lymphocytes, and
lymphocyte nitrogen assays
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Assessment of Nutritional Status Biochemical assessment 77
Slide 78
Biochemical measurements of selected nutrients 78 1. Protein 2.
Iron 3. Vitamin A 4. Vitamin D 5. Vitamin E 6. Vitamin C 7.
Thiamine 8. Riboflavin 9. Niacin 10. Vitamin B6 11. Folate 12.
Vitamin B12 13. Calcium 14. Phosphorus 15. Magnesium 16. Iodine 17.
Lipid and glucose 18. Zinc
Slide 79
Iron 79 Total body composition of iron in adults: 3 5 grams
elemental iron Found in three components: 1. Essential iron 2.
Transport iron 3. Storage iron
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Iron 80 1. Essential iron a. in RBC (70%) b. in myoglobin (4%)
c. in enzymes (
Criteria for assessing goiter Total goiter rate (%)Severity of
IDD < 5.0 Normal 5.0 19.9Mild 20.0 29.9Moderate > 30.0Severe
Sources: Indicators for assessing IDD and their control through
salt iodization. Geneva, World Health Organization, 1994 223
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In summary The iodine status of children, 6-12 years old, 13-19
years old and adults, 20-59 years and 60 years and over are optimal
as indicated by median UIE levels The iodine status of pregnant and
lactating women of public health concern 224
Slide 225
Laboratory tests for iodine status 225 1. Urinary iodine
excretion 2. Serum thyroxine (T4) 3. Blood levels of TSH 4.
Radioactive iodine uptake levels 5. Protein bound iodine in blood
plasma
Slide 226
Serum thyroxine (T4) 226 Measure of thyroid function If low is
an evidence of poor thyroid function, which may be related to
goiter
Slide 227
Laboratory tests for iodine status 227 1. Urinary iodine
excretion 2. Serum thyroxine (T4) 3. Blood levels of TSH 4.
Radioactive iodine uptake levels 5. Protein bound iodine in blood
plasma
Slide 228
Blood levels of TSH 228 Blood is taken from the umbilical cord
or heel of all infants born in hospital and sent on filter paper to
a special laboratory for determination of thyroxine or TSH Test is
done because about one in 4,000 infants born is hypothyroid because
the thyroid gland did not develop properly
Slide 229
Blood levels of TSH 229 If the condition is not diagnosed and
treated soon after birth, there will be serious consequences,
including poor brain development Generally, T4 levels below 4 g
percent are considered low, requiring treatment
Slide 230
Blood levels of TSH 230 As with urinary iodine, few hospitals
in most developing countries are equipped to do T4 and TSH
concentrations
Slide 231
Laboratory tests for iodine status 231 1. Urinary iodine
excretion 2. Serum thyroxine (T4) 3. Blood levels of TSH 4.
Radioactive iodine uptake levels 5. Protein bound iodine in blood
plasma
Slide 232
Radioactive iodine uptake levels 232 Usually using l131 to
assess the avidity or hunger of the subjects thyroid gland for
iodine In persons with hypothyroidism caused by iodine deficiency,
most of the dose of iodine is taken up by the thyroid gland, and
less than 10 percent remains
Slide 233
Laboratory tests for iodine status 233 1. Urinary iodine
excretion 2. Serum thyroxine (T4) 3. Blood levels of TSH 4.
Radioactive iodine uptake levels 5. Protein bound iodine in blood
plasma
Slide 234
Protein Bound Iodine (PBI) in blood plasma 234 Widely used test
in the past
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Biochemical measurements of selected nutrients 235 1. Protein
2. Iron 3. Vitamin A 4. Vitamin D 5. Vitamin E 6. Vitamin C 7.
Thiamine 8. Riboflavin 9. Niacin 10. Vitamin B6 11. Folate 12.
Vitamin B12 13. Calcium 14. Phosphorus 15. Magnesium 16. Iodine 17.
Lipid and glucose 18. Zinc
Biochemical measurements of selected nutrients 237 1. Protein
2. Iron 3. Vitamin A 4. Vitamin D 5. Vitamin E 6. Vitamin C 7.
Thiamine 8. Riboflavin 9. Niacin 10. Vitamin B6 11. Folate 12.
Vitamin B12 13. Calcium 14. Phosphorus 15. Magnesium 16. Iodine 17.
Lipid and glucose 18. Zinc
Slide 238
Zinc status 238 1. Hair zinc 2. Serum zinc
Slide 239
Hair zinc 239 Low hair zinc concentrations were reported in the
first documented cases of human zinc deficiency in young adult male
dwarfs from the middle East (Strain et al., 1966)
Slide 240
Hair zinc 240 Hair zinc concentrations probably reflect a
chronic suboptimal zinc status when the confounding effect of
severe PEM is absent Standardized procedure for sampling, washing
and analyzing hair samples are essential
Slide 241
Hair zinc 241 Collected from close to the occipital portion of
the scalp with stainless steel scissors, and only the proximal 1.0
1.5 cm of the hair strands retained from analysis Any nits and lice
must be removed before washing the hair samples using a
standardized method
Slide 242
Hair zinc 242 A non-ionic detergent ( e.g. Actinox) with or
without acetone is often used
Slide 243
Zinc status 243 1. Hair zinc 2. Serum zinc
Slide 244
Serum zinc 244 12-22% of zinc in the blood is in the serum, the
rest is within the erythrocyte Transported in three serum bound to
proteins 1. Albumin (70%) 2. 2-macroglobulin (18%) 3. Rest other
proteins like transferrin and ceruloplasmin and to amino acids
(histidine and cysteine)
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The State of the Nations NUTRITION Source: FNRI, 2008 247
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Biochemical 250
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Biochemical Assesses the prevalence of: Iron deficiency anemia,
Vitamin A deficiency, and Iodine deficiency disorders Zinc, folate
and Vitamin B6 was done for the first time 252
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Public health significance problem Vitamin A deficiency More
than 15% serum or plasma retinol of
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Assessment criteria
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Thank You janicepaladfeliciano 255
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11 March (Tue) 256 Quiz on Biochemical assessment (both lecture
and laboratory) Planning a community nutrition survey Overview
Steps in the conduct of survey