laboratory data in nutrition assessment...

Evaluation of Laboratory Data in

Nutrition Assessment

Laboratory Data and the NCP

•• Used in nutrition assessment (a clinical Used in nutrition assessment (a clinical

sign supporting nutrition diagnosis)sign supporting nutrition diagnosis)

•• Used in Monitoring and Evaluation of Used in Monitoring and Evaluation of

the patient response to nutritional the patient response to nutritional

interventionintervention

Specimen Types

•• Serum: the fluid from blood after blood cells and Serum: the fluid from blood after blood cells and clot removedclot removed

•• Plasma: fluid from blood centrifuged with Plasma: fluid from blood centrifuged with anticoagulantsanticoagulants

•• Erythrocytes: red blood cellsErythrocytes: red blood cells

•• Leukocytes: white blood cellsLeukocytes: white blood cells

•• Other tissues: scrapings and biopsy samplesOther tissues: scrapings and biopsy samples

•• Urine: random samples or timed collectionsUrine: random samples or timed collections

•• Feces: random samples or timed collectionsFeces: random samples or timed collections

•• Less common: saliva, nails, hair, sweatLess common: saliva, nails, hair, sweat

Types of Assays

•• Static assays: measures the actual level of Static assays: measures the actual level of

the nutrient in the specimen (serum iron, the nutrient in the specimen (serum iron,

white blood cell ascorbic acid)white blood cell ascorbic acid)

•• Functional Assays: measure a Functional Assays: measure a

biochemical or physiological activity that biochemical or physiological activity that

depends on the nutrient of interest (serum depends on the nutrient of interest (serum

ferritin, TIBC)ferritin, TIBC)

•• (Functional assays are not always (Functional assays are not always

specific to the nutrient) specific to the nutrient)

Assessment of Nutrient Pool

Basic Metabolic Panel

Charting Shorthand

BMPBMP

NaNa ClCl BUNBUN

glucoseglucose

K+K+ CO2CO2 CreatinineCreatinine

Clinical Chemistry Panels:

Comprehensive Metabolic Panel

Includes Includes

•• BMP except CO2BMP except CO2

•• AlbuminAlbumin

•• Serum enzymes (alkaline phosphatase, AST Serum enzymes (alkaline phosphatase, AST

[SGOT], ALT [SGPT][SGOT], ALT [SGPT]

•• Total bilirubinTotal bilirubin

•• Total calciumTotal calcium

Phosphorus, total cholesterol and triglycerides Phosphorus, total cholesterol and triglycerides

often ordered with the CMPoften ordered with the CMP

Clinical Chemistry Panels:

Complete Blood Count (CBC)

•• Red blood cellsRed blood cells

•• Hemoglobin concentrationHemoglobin concentration

•• HematocritHematocrit

•• Mean cell volume (MCV)Mean cell volume (MCV)

•• Mean cell hemoglobin (MCH)Mean cell hemoglobin (MCH)

•• Mean cell hemoglobin concentration (MCHC)Mean cell hemoglobin concentration (MCHC)

•• White blood cell count (WBC)White blood cell count (WBC)

•• Differential: indicates percentages of different Differential: indicates percentages of different

kinds of WBCkinds of WBC

RBC Indexes

�� MCV = average red blood cell size MCV = average red blood cell size

�� The MCV is measured directly by a machineThe MCV is measured directly by a machine

�� MCV: 80 MCV: 80 -- 100 femtoliter100 femtoliter

�� Increased: liver dis., megaloblastic anemia, Increased: liver dis., megaloblastic anemia,

phenytoin usephenytoin use

�� Decreased: iron def, thalassemiaDecreased: iron def, thalassemia

�� Normal : Simultaneous iron and folate def. Normal : Simultaneous iron and folate def.

�� MCH = Hemoglobin amount per red blood cellMCH = Hemoglobin amount per red blood cell

�� MCH = Hgb/RBC countMCH = Hgb/RBC count

�� 2727--31 picograms (pg)/cell in adult31 picograms (pg)/cell in adult

�� Low levels: hypochromic/ microcytosisLow levels: hypochromic/ microcytosis

�� High levels: macrocytosisHigh levels: macrocytosis

�� MCHC = The amount of hemoglobin relative to the size of MCHC = The amount of hemoglobin relative to the size of

the cell (hemoglobin concentration) per red blood cellthe cell (hemoglobin concentration) per red blood cell

�� MCHC = Hgb/HctMCHC = Hgb/Hct

�� MCHC: 32MCHC: 32--36 g/dL in adult36 g/dL in adult

• A MCHC blood test could be ordered for

someone who has signs of fatigue or

weakness, when there is an infection, is

bleeding or bruising easily or when there is

noticeable inflammation.

• The MCHC test is most commonly used to

evaluate for macrocytic anemia.

MCHC

• If the levels are high then there’s a chance

of macrocytic anemia.

• A deficiency in folic acid and vitamin B12

could lead to this. Also, liver disease, and is

sometimes responsible for this type of

result.

• Burn victims also show elevated mean

corpuscular hemoglobin concentration.

Assessment of AnemiasAssessment of Anemias

�� Iron deficiency anemiaIron deficiency anemia

��HctHct

��% RBC in total blood volume% RBC in total blood volume

��Affected by : Affected by : -- High WBCHigh WBC

-- Hydration statusHydration status

-- High altitudeHigh altitude

High levels: vomiting, burns, polycythemia, High levels: vomiting, burns, polycythemia,

dehydration, exercisedehydration, exercise

Low levels: macrocytosis, hypothyroidism, normocytic Low levels: macrocytosis, hypothyroidism, normocytic

anemia, microcytic anemiaanemia, microcytic anemia

��HgbHgb A more direct measure of iron A more direct measure of iron

deficiency (quantifies total Hgb in RBC deficiency (quantifies total Hgb in RBC

not a % of blood volumenot a % of blood volume))

•• High levels: hemocondensation High levels: hemocondensation

(dehydration, burn, vomiting), (dehydration, burn, vomiting),

polycythemia, exercise, smokingpolycythemia, exercise, smoking

•• Low levels: macrocytic/ normocytic/ Low levels: macrocytic/ normocytic/

microcytic anemiamicrocytic anemia

•• False high levels: high TG, high WBC False high levels: high TG, high WBC

�� Serum IronSerum Iron

�� Amount of circulating iron that is bound to transferrinAmount of circulating iron that is bound to transferrin

�� Poor index of iron status :Poor index of iron status :

�� Large day to day changesLarge day to day changes

�� Diurnal variations (highest between 6Diurnal variations (highest between 6--10 AM)10 AM)

�� High levels: hemosidrosis, hemolytic anemia, aplastic High levels: hemosidrosis, hemolytic anemia, aplastic

anemia, Pb toxicity, thalassemiaanemia, Pb toxicity, thalassemia

�� Low levels: Iron Def., nephrotic syndrome, Low levels: Iron Def., nephrotic syndrome,

hypothyroidism, post surgery, kwashiorkor hypothyroidism, post surgery, kwashiorkor

��Total iron binding capacity (TIBC)Total iron binding capacity (TIBC)

�� Transferrin binds ferric ironTransferrin binds ferric iron

�� TIBC usually increases in iron TIBC usually increases in iron

deficiencydeficiency

�� High levels: Iron Def., late pregnancy, High levels: Iron Def., late pregnancy,

infancy, hepatitis, OCPsinfancy, hepatitis, OCPs

�� Low levels: low pro levels Low levels: low pro levels

(nephrotic syndrome, malnutrition, (nephrotic syndrome, malnutrition,

cancer, chronic liver disease, chronic cancer, chronic liver disease, chronic

inflammatory diseaseinflammatory disease

�� FerritinFerritin

�� Storage protein for ironStorage protein for iron

�� A small amount of it leaks into the circulation A small amount of it leaks into the circulation

(1 ng/ml of ferritin is approximately 8 mg of stored iron)(1 ng/ml of ferritin is approximately 8 mg of stored iron)

�� An indicator of body iron storage poolAn indicator of body iron storage pool

�� It is an It is an acute phase reactant acute phase reactant (elevates in 1 to 2 (elevates in 1 to 2 days after onset of acute illness , peaks at 3 to days after onset of acute illness , peaks at 3 to 5 days)5 days)

�� Infection, metastatic cancer, acute Infection, metastatic cancer, acute inflammation, lymphoma ,inflammation, lymphoma ,……

•• High levels: hemochromatosis, High levels: hemochromatosis,

hemosidrosis, acute and chronic liver hemosidrosis, acute and chronic liver

disease, alcohol abuse, neoplasms disease, alcohol abuse, neoplasms

(leukemia), chronic inflammation, blood (leukemia), chronic inflammation, blood

transfusion, minor thalassemiatransfusion, minor thalassemia

•• Low levels: Iron def.Low levels: Iron def.

RDW (red blood cell distribution width)

��11.5 11.5 –– 14.5%14.5%

RBCRBCنشانگری برای تعيين تنوع سایز نشانگری برای تعيين تنوع سایز ��

ھا است ھا استRBCRBCافزایش آن بيانگر تنوع بيشتر در سایزافزایش آن بيانگر تنوع بيشتر در سایز��

--آنمی فقر آھن آنمی فقر آھن : : MCVMCVکاھش کاھش + + RDWRDWافزایش افزایش ��تا'سمیتا'سمی

آنمی ناشی از کمبود آنمی ناشی از کمبود : : MCVMCVافزایش افزایش + + RDWRDWافزایش افزایش �� B12B12فو'ت و ویتامين فو'ت و ویتامين

�� RDW RDW کاھش کاھش + + نرمال نرمالMCVMCV : : تا'سمیتا'سمی

.. نرمال است نرمال است RDW RDW در تاسمی مينور در تاسمی مينور

Anemia of vitamin B12 / folate deficiencyAnemia of vitamin B12 / folate deficiency

�� FolateFolate

�� RBC Folate is calculated by measuring the difference RBC Folate is calculated by measuring the difference

between whole blood folate and serum folate between whole blood folate and serum folate

�� Vitamin B12Vitamin B12

�� Is measured in the serumIs measured in the serum

�� Schilling test for vitamin B12 Schilling test for vitamin B12

Complementary testsComplementary tests

•• Stool ExamStool Exam

•• Hb electrophoresisHb electrophoresis

Blood Glucose

•• FBSFBS

•• BSBS

•• Glucose Tolerance TestGlucose Tolerance Test

•• HBA1CHBA1C

FBS & BS

Plasma Glucose

Impaired Fasting Glucose (mg/dl)

Impaired Glucose Tolerance (mg/dl)

DM (mg/dl)

Fasting >/= 100 and <126

- >126

2-Hour Post-load

- >/=140 and <200

>200

random - - >/=200 with symptoms

Criteria for the Diagnosis of DM

�� For FBS an 8 hour fasting is mandatory

Diabetes can be provisionally diagnosed with:Diabetes can be provisionally diagnosed with:

any one of the three any one of the three criteria listed below. In the absence of unequivocal criteria listed below. In the absence of unequivocal

hyperglycemia with acute metabolic decompensation the diagnosis hyperglycemia with acute metabolic decompensation the diagnosis should should

be confirmed, on a subsequent day, by be confirmed, on a subsequent day, by anyany one of the same three criteria. one of the same three criteria.

1.1. A fasting plasma glucose of >126 mg/dl (after no caloric intake A fasting plasma glucose of >126 mg/dl (after no caloric intake for at least for at least

8 hours) or, 8 hours) or,

2.2. A casual plasma glucose >200 mg/dl (taken at any time of day witA casual plasma glucose >200 mg/dl (taken at any time of day without hout

regard to time of last meal) with classic diabetes symptoms: incregard to time of last meal) with classic diabetes symptoms: increased reased

urination, increased thirst and unexplained weight loss or, urination, increased thirst and unexplained weight loss or,

3.3. An oral glucose tolerance test (OGTT) (75 gram dose) of >200 mg/An oral glucose tolerance test (OGTT) (75 gram dose) of >200 mg/dl for dl for

the two hour sample. the two hour sample. Oral glucose tolerance testing is not necessary if Oral glucose tolerance testing is not necessary if

patient has a fasting plasma glucose level of >126 mg/dl. patient has a fasting plasma glucose level of >126 mg/dl.

�� The fasting plasma glucose is the preferred test because of its The fasting plasma glucose is the preferred test because of its ease of ease of

administration, convenience, acceptability to patients, and loweadministration, convenience, acceptability to patients, and lower cost in r cost in

comparison to the OGTT. comparison to the OGTT.

Glucose Tolerance Test

Oral Glucose Tolerance Test (OGTT)Oral Glucose Tolerance Test (OGTT)

◦◦ Is the standard for diagnosis of DMIs the standard for diagnosis of DM

◦◦ Defined by WHO:75 gr glucose loadDefined by WHO:75 gr glucose load

�� Gestational DMGestational DM

Plasma Glucose (mg/dl)

50 gr screening test (mg/dl)

75 gr diagnostic test (mg/dl)

100 gr diagnostic test (mg/dl)

Fasting - >/= 95 >/= 95

1 hr >/= 140 >/= 180 >/= 180

2 hr - >/= 155 >/= 155

3 hr - - >/= 140

HbA1C

•• The A1C test measures the average blood glucose The A1C test measures the average blood glucose

for the past 3 months.for the past 3 months.

•• The patient doesnThe patient doesn’’t have to fast or drink anything.t have to fast or drink anything.

•• It shows how well diabetes is being controlled.It shows how well diabetes is being controlled.

•• Diabetes is diagnosed at a HbA1C of greater than Diabetes is diagnosed at a HbA1C of greater than

or equal to 6.5%or equal to 6.5%

•• Normal: Less than 5.7%Normal: Less than 5.7%

•• PrePre--diabetes: 5.7% to 6.4%diabetes: 5.7% to 6.4%

•• Diabetes: 6.5% or higherDiabetes: 6.5% or higher

What is prediabetes?What is prediabetes?

�� Prediabetes is a condition when blood Prediabetes is a condition when blood glucose is higher than normal but not high glucose is higher than normal but not high enough to be diabetes enough to be diabetes

�� This condition puts the patient at risk for This condition puts the patient at risk for developing type 2 diabetesdeveloping type 2 diabetes

�� Results indicating prediabetes are:Results indicating prediabetes are:

◦◦ An A1C of 5.7% An A1C of 5.7% –– 6.4%6.4%

◦◦ Fasting blood glucose of 100 Fasting blood glucose of 100 –– 125 mg/dl125 mg/dl

◦◦ An OGTT 2 hour blood glucose of An OGTT 2 hour blood glucose of 140mg/dl 140mg/dl –– 199 mg/dl199 mg/dl

�� Total cholesterolTotal cholesterol

�� Acceptable <170 mg/dlAcceptable <170 mg/dl

�� Borderline 170Borderline 170--199 mg/dl199 mg/dl

�� High >/= 200 mg/dlHigh >/= 200 mg/dl

�� HDLHDL

�� Desirable > 40 mg/dlDesirable > 40 mg/dl

Lipid indexes of cardiovascular riskLipid indexes of cardiovascular risk8 8 –– 12 fasting is required12 fasting is required (no food or drink, except water)(no food or drink, except water)

�� LDLLDL

�� Friedewald formula : Friedewald formula :

�� LDL = TC LDL = TC -- --HDL HDL ––

TG/5TG/5

•• (TG levels should be (TG levels should be

<400 mg/dl)<400 mg/dl)

�� Acceptable <110 mg/dlAcceptable <110 mg/dl

�� Borderline 110Borderline 110--129 129

mg/dlmg/dl

�� High >/= 130 mg/dlHigh >/= 130 mg/dl

Lipid Indices of Cardiovascular

Risk

•• Total cholesterolTotal cholesterol

•• LDLLDL

•• HDL: HDL2a, HDL2b, HDL2c, HDL3a, HDL: HDL2a, HDL2b, HDL2c, HDL3a,

HDLdbHDLdb

•• IDLIDL

•• VLDLVLDL

•• Lp(a)Lp(a)

•• LDL in more details: LDL in more details:

•• Less than 70 mg/dL for those with Less than 70 mg/dL for those with heartheart or or blood blood

vessel diseasevessel disease and for other patients and for other patients at very high risk at very high risk

of heart disease (those with metabolic syndrome)of heart disease (those with metabolic syndrome)

•• Less than 100 mg/dL Less than 100 mg/dL for high risk for high risk patients (e.g., some patients (e.g., some

patients who have multiple heart disease risk factors)patients who have multiple heart disease risk factors)

•• Less than 130 mg/dL for individuals who Less than 130 mg/dL for individuals who are at low are at low

risk risk for coronary artery diseasefor coronary artery disease

Goal is Less than 150 mg/dl

Causes of high triglycerides in the general population

• Overweight and obesity

• Physical inactivity

• Cigarette smoking

• Excess alcohol intake

• Very high carbohydrate diets (>60% of energy)

• Other disease (diabetes, renal failure, nephrosis)

• Drugs: steroids, protease inhibitors, estrogen, etc

• Genetic factorsNCEP JAMA 2001;285:2486 Final Report Circula�on 2002;106:3143-3421

TriglyceridesTriglycerides

Risk Classification of Serum TriglyceridesRisk Classification of Serum Triglycerides

Normal Normal <150 mg/dL<150 mg/dL

Borderline highBorderline high 150150––199 mg/dL199 mg/dL

HighHigh 200200––499 mg/dL499 mg/dL

Very highVery high ≥≥500 mg/dL500 mg/dL

NCEP JAMA 2001;285:2486 Final Report Circula�on 2002;106:3143-3421

TriglyceridesTriglycerides

•• Smoking cessationSmoking cessation

•• EnergyEnergy--restricted diet Low cholesterolrestricted diet Low cholesterol

•• Low saturated and trans fatty acidsLow saturated and trans fatty acids

•• Low refined carbohydratesLow refined carbohydrates

•• Include viscous fibres, plant sterols, nuts, Include viscous fibres, plant sterols, nuts,

soy proteinssoy proteins

•• Alcohol in moderationAlcohol in moderation

•• Physical activityPhysical activity

Statin Therapy Should be

Concomitant with Lifestyle Therapy

Dietary ModificationsDietary Modifications

��Eat more fiberEat more fiber

��Know your fatsKnow your fats

��Smart proteinSmart protein

��LowLow--carb dietcarb diet

Eat More FiberEat More Fiber

�� Good sources of soluble Good sources of soluble

fiber include wholefiber include whole--grain grain

breads and cereals, breads and cereals,

oatmeal, fruits, dried fruits, oatmeal, fruits, dried fruits,

vegetables, and legumes vegetables, and legumes

such as kidney beans.such as kidney beans.

Know Your FatsKnow Your Fats

�� No more than 35% of your daily calories should No more than 35% of your daily calories should

come from fat. come from fat.

�� But not all fats are equalBut not all fats are equal

��Saturated FatsSaturated Fats

��Trans FatsTrans Fats

��Unsaturated FatsUnsaturated Fats


�� Saturated fats Saturated fats ---- from animal products and tropical from animal products and tropical

oils oils ---- raise LDL cholesterol.raise LDL cholesterol.

�� Trans fats increase bad cholesterol and lowers the Trans fats increase bad cholesterol and lowers the

good cholesterolgood cholesterol

�� These two bad fats are found in many baked These two bad fats are found in many baked

goods, fried foods (doughnuts, french fries, chips), goods, fried foods (doughnuts, french fries, chips),

stick margarine, and cookies. stick margarine, and cookies.


�� Unsaturated fats may Unsaturated fats may

lower LDL when lower LDL when

combined with other combined with other

healthy diet changes. healthy diet changes.

They're found in They're found in

avocados, olive oil, and avocados, olive oil, and

peanut oil. peanut oil.

Smart ProteinSmart Protein

�� Meat and fullMeat and full--fat milk are fat milk are

protein but they are also protein but they are also

major sources of major sources of

cholesterol. cholesterol.

�� Switch to soy protein, such Switch to soy protein, such

as tofu.as tofu.

�� Fish is rich in omegaFish is rich in omega--3 3

fatty acids, which can fatty acids, which can

improve cholesterol levels.improve cholesterol levels.

�� The AHA recommends The AHA recommends

eating fish at least twice a eating fish at least twice a

week.week.





��LowLow--carb dietcarb diet

LowLow--Carb DietCarb Diet

�� There's growing evidence that There's growing evidence that lowlow--carb diets may be better carb diets may be better than lowthan low--fat diets for fat diets for improving cholesterol levels.improving cholesterol levels.

�� In a twoIn a two--year study funded year study funded by the National Institutes of by the National Institutes of Health, people who followed Health, people who followed a lowa low--carb plan had carb plan had significantly better HDL significantly better HDL (good cholesterol) levels than (good cholesterol) levels than those who followed a lowthose who followed a low--fat fat plan.plan.

Lifestyle ModificationsLifestyle Modifications

��Lose weightLose weight

��Quit smokingQuit smoking

��ExerciseExercise

Lose WeightLose Weight

�� If you're overweight, talk If you're overweight, talk to your doctor about to your doctor about beginning a weight loss beginning a weight loss program.program.

�� Losing weight can help Losing weight can help you reduce your levels of you reduce your levels of triglycerides, LDL, and triglycerides, LDL, and total cholesterol. total cholesterol.

�� Good cholesterol level Good cholesterol level tends to go up 1 point for tends to go up 1 point for every 6 pounds you lose.every 6 pounds you lose.

A couple were talking, and the wife

says, “It’s my birthday tomorrow.”

Her husband responds with, “What do

you want for your birthday?”

The wife says, “I want something that

goes very fast.”

The next day, the husband comes

home and says, “I have a gift for you,

which goes from 0 to 300 in 3 seconds.”

The wife asks, “Is it a Ferrari? Or a

Lamborghini?”

The husband says, “No, it’s a weighing

scale!!!”

…The husband’s funeral is tomorrow.

Quit SmokingQuit Smoking

�� Tobacco use is one of the Tobacco use is one of the

most important risk factors most important risk factors

for CHDfor CHD

�� It is the most preventable It is the most preventable

cause of death in the UScause of death in the US

�� 440,000 deaths each year are 440,000 deaths each year are

attributable to tobacco useattributable to tobacco use

�� When you stop smoking, When you stop smoking,

your good cholesterol is your good cholesterol is

likely to improve likely to improve




��ExerciseExercise

ExerciseExercise

�� If you're healthy but not very If you're healthy but not very active, starting an aerobic active, starting an aerobic exercise program could increase exercise program could increase your good cholesterol by 5% in your good cholesterol by 5% in the first two months.the first two months.

�� Regular exercise also lowers bad Regular exercise also lowers bad cholesterol. Choose an activity cholesterol. Choose an activity that boosts your heart rate, such that boosts your heart rate, such as running, swimming, or as running, swimming, or walking brisklywalking briskly

�� Aim for at least 30 minutes on Aim for at least 30 minutes on most days of the week. It doesn't most days of the week. It doesn't have to be 30 continuous have to be 30 continuous minutes; two 15minutes; two 15--minute walks minute walks works just as well.works just as well.

MedicationsMedications

�� StatinsStatins

�� NonNon--StatinsStatins

��Cholesterol Absorption Inhibitor (Ezetimibe)Cholesterol Absorption Inhibitor (Ezetimibe)

��Nicotinic Acid (Niacin)Nicotinic Acid (Niacin)

��Bile Acid SequestrantsBile Acid Sequestrants

��Fibric Acid DerivativesFibric Acid Derivatives

��OmegaOmega--3 Fatty Acids 3 Fatty Acids

StatinsStatins

�� AtorvastatinAtorvastatin

�� FluvastatinFluvastatin

�� LovastatinLovastatin

�� PravastatinPravastatin

�� RosuvastatinRosuvastatin

�� SimvastatinSimvastatin

StatinsStatins

�� Decrease LDL by 18 Decrease LDL by 18 –– 55 %55 %

�� Increase HDL by 5 Increase HDL by 5 –– 15 %15 %

�� Decrease TG by 7 Decrease TG by 7 –– 30 %30 %

NonNon--statinsstatins�� Decrease LDL by 18 Decrease LDL by 18 –– 20%20%

�� Increase HDL by 1 Increase HDL by 1 –– 5%5%

�� Decrease TG by 5 Decrease TG by 5 –– 11%11%

NonNon--Statins: Statins:

OmegaOmega--3 Fatty Acids3 Fatty Acids

�� Decrease TG by 45 %Decrease TG by 45 %

�� Increase HDL by 9 %Increase HDL by 9 %

�� Increase LDL by 44 %Increase LDL by 44 %

NonNon--Statins: Statins:

OmegaOmega--3 Fatty Acids3 Fatty Acids�� Fish OilsFish Oils

�� Its major use is in hypertriglyceridemia greater than Its major use is in hypertriglyceridemia greater than

500mg/dL500mg/dL

�� Contraindicated in patients with known Contraindicated in patients with known

hypersensitivity to fish and in women who are hypersensitivity to fish and in women who are

pregnant or breastfeedingpregnant or breastfeeding

�� Adverse effects include eructation, dyspepsia, and Adverse effects include eructation, dyspepsia, and

taste perversiontaste perversion

StatinsStatins

�� The drug of choice for elevated LDL levelsThe drug of choice for elevated LDL levels

�� Prevents cardiovascular and cerebrovascular Prevents cardiovascular and cerebrovascular

eventsevents

�� Contraindicated in active or chronic liver disease, Contraindicated in active or chronic liver disease,

pregnancy and lactationpregnancy and lactation

�� Adverse effects include myopathy and increase in Adverse effects include myopathy and increase in

liver transaminasesliver transaminases

•• Specific GravitySpecific Gravity

•• PHPH

•• ProteinProtein

•• GlucoseGlucose

•• KetonesKetones

•• BloodBlood

•• BilirubinBilirubin

•• Urobilinogen Urobilinogen

•• NitriteNitrite

•• Leukocyte esteraseLeukocyte esterase

Urinalysis (UA)Urinalysis (UA)

Clinical Chemistry Panels: Urinalysis

Specific gravitySpecific gravity 1.0101.010--1.025 mg/ml1.025 mg/ml

pHpH 66--8 (normal diet)8 (normal diet)

ProteinProtein 22--8 mg/dl8 mg/dl

GlucoseGlucose Not detectedNot detected

KetonesKetones NegativeNegative

BloodBlood NegativeNegative

BilirubinBilirubin Not detectedNot detected

UrobilinogenUrobilinogen 0.10.1--1 units/dl1 units/dl

NitriteNitrite NegativeNegative

Leukocyte esterageLeukocyte esterage Negative Negative

CRP

•• CC--reactive protein is produced by the liver.reactive protein is produced by the liver.

•• CRP level rises when there is inflammation in the body.CRP level rises when there is inflammation in the body.

•• Normal CRP values vary from lab to lab. Generally, there is Normal CRP values vary from lab to lab. Generally, there is

no CRP detectable in the bloodno CRP detectable in the blood

•• A positive test means you have A positive test means you have inflammationinflammation in the body. in the body.

This may be due to a variety of different conditions:This may be due to a variety of different conditions:

•• CancerCancer

•• Connective tissue diseaseConnective tissue disease

•• Heart attackHeart attack

•• InfectionInfection

•• Inflammatory bowel disease (IBD)Inflammatory bowel disease (IBD)

•• LupusLupus

•• PneumococcalPneumococcal pneumoniapneumonia

•• Rheumatoid arthritisRheumatoid arthritis

•• Rheumatic feverRheumatic fever

•• TuberculosisTuberculosis

Remember …•• Positive CRP results also occur during the last half of Positive CRP results also occur during the last half of

pregnancy or with the use of birth control pills (oral pregnancy or with the use of birth control pills (oral

contraceptives).contraceptives).

•• hshs--CRP CRP (Risk CVD)(Risk CVD)

•• < 1.0mg/L = low risk< 1.0mg/L = low risk

•• 11--3 = average risk3 = average risk

•• > 3 = high risk> 3 = high risk

WHICH ONES?

Some foods increase inflammation (Foods That Hurt)Some foods increase inflammation (Foods That Hurt)

�� Saturated FatsSaturated Fats

�� Trans FatsTrans Fats

�� High Glycemic Index FoodsHigh Glycemic Index Foods

Some foods decrease inflammation (Foods That Heal)Some foods decrease inflammation (Foods That Heal)

�� OmegaOmega--33

�� Vitamin DVitamin D

�� AntioxidantsAntioxidants

�� Extra Virgin Olive OilExtra Virgin Olive Oil

AntiAnti--inflammatory foodsinflammatory foods

Alaskan Salmon (wild)Alaskan Salmon (wild)Fresh whole fruits, Fresh whole fruits, vegetablesvegetablesBright multiBright multi--colored colored vegetablesvegetablesGreen teaGreen teaWaterWaterOlive oilOlive oilLean poultryLean poultryNuts, legumes and seedsNuts, legumes and seedsDark green leafy Dark green leafy vegetablesvegetablesOld fashioned oatmealOld fashioned oatmealSpices, especially Spices, especially Turmeric and GingerTurmeric and Ginger

Inflammatory foodsInflammatory foods

Sugar, from any sourceSugar, from any sourceProcessed foodsProcessed foodsFrench FriesFrench FriesFast FoodsFast FoodsWhite breadWhite breadPastaPastaIce CreamIce CreamCheddar CheesesCheddar CheesesSnack FoodsSnack FoodsOils such as vegetable and Oils such as vegetable and corncornSoda, caffeine and alcoholSoda, caffeine and alcohol

FOODS THAT HURT: SATURATED

FATS�� A study, published in Journal of the American A study, published in Journal of the American

College of Cardiology showed that just one high College of Cardiology showed that just one high

saturated fat meal increased inflammation. It appears saturated fat meal increased inflammation. It appears

that saturated fats increase inflammation by that saturated fats increase inflammation by

impairing your bodyimpairing your body’’s natural antis natural anti--inflammatory inflammatory

processes.processes.

�� The amount of eicosonoids that your body produces The amount of eicosonoids that your body produces is proportional to the amount of saturated fats that is proportional to the amount of saturated fats that you eat. Eicosonoids cause inflammation.you eat. Eicosonoids cause inflammation.

�� Saturated fats also increase your levels of total Saturated fats also increase your levels of total cholesterol and LDL cholesterol (cholesterol and LDL cholesterol (““bad bad cholesterolcholesterol””),, thus increasing your risk of ),, thus increasing your risk of atherosclerosis.atherosclerosis.

Source: Nicholls SJ. Consumption of saturated fat impairs the anSource: Nicholls SJ. Consumption of saturated fat impairs the antiti--inflammatory inflammatory properties of highproperties of high--density lipoproteins and endothelial function. J Am Coll density lipoproteins and endothelial function. J Am Coll Cardiol. 2006 Aug 15;48(4):715Cardiol. 2006 Aug 15;48(4):715--20. Epub 2006 Jul 2420. Epub 2006 Jul 24

Saturated fats tend to be found

in animal products.

7 Easy Ways to Lower Saturated Fats

1. Use Egg Whites (Egg Beaters) instead of the whole egg.

2. Trim the skin and visible fat from meat before cooking.

3. Choose lean meats like chicken or fish instead of beef and pork

(which tend to have a ton of saturated fat).

4. At restaurants, choose baked, broiled, or grilled instead of fried.

5. Choose low or no fat dairy (for example, skim milk instead of

whole milk).

6. Sauces and gravy are loaded with saturated fat. Avoid them or

ask for them on the side.

7. When choosing salad, try oil based dressings vs. ranch or blue

cheese.

TRANS FATS

EVEN MORE DANGEROUS THAN EVEN MORE DANGEROUS THAN

SATURATED FATS!!!SATURATED FATS!!!

•• The mechanism for this is essentially the The mechanism for this is essentially the

same as saturated fats: clogging arteries and same as saturated fats: clogging arteries and

increasing inflammation.increasing inflammation.

•• Trans fats go a step further by not only Trans fats go a step further by not only

increasing LDL, but decreasing HDL (good increasing LDL, but decreasing HDL (good

cholesterol).cholesterol).

•• Avoid this cholesterol double whammyAvoid this cholesterol double whammy

% Source of Trans Fats in Diet

•• Cakes, Cookies, Crackers, Pies, Bread 40%Cakes, Cookies, Crackers, Pies, Bread 40%

•• Animal Products 21%Animal Products 21%

•• Candy 1%Candy 1%

•• Breakfeast Cereal 1%Breakfeast Cereal 1%

•• Salad Dressing 3%Salad Dressing 3%

•• Shortening 4%Shortening 4%

•• Potato Chips, Corn Chips, Popcorn 5%Potato Chips, Corn Chips, Popcorn 5%

•• Fried Potatoes 8%Fried Potatoes 8%

•• Margarine 17%Margarine 17%

4 Tips to Avoid Trans Fats1. Read food labels - Since 2003, the FDA has mandated that trans fat be listed on all food labels. A loophole in the labeling is that foods with a half gram (0.5g) of trans fat or less can still say “trans fat free”2. Portion Control: While it’s best to avoid these high trans fat foods altogether, if you can limit how much you eat at a sitting, you will be doing your back a big favor.3. Limit the amount of baked goods - These tend to be the foods that have the most trans fat.4.When at a restaurant, avoid the deep fried options. Thecooking oil, after being used again and again (which is the case at most restaurants), ends up being loaded with trans fat. Grilled, broiled, or sautéed foods are much better options.

The Great Debate: Margarine vs. Butter

•For years, Americans have been confused about whether butter or

margarine is a better choice. This is because we have known about

the dangers of saturated fat for years, so doctors and dietitians were

telling everyone: “avoid butter like the plague, eat margarine!”

•But we now know that trans fat is even worse than saturated fat.

Stick margarine has more trans fat than butter. Now these same

people are telling everyone to eat butter and avoid margarine.

Who is right?

•Neither butter nor margarine are the healthiest of options and

both raise cholesterol quite a bit. In the last few years, a large

number of healthier and great-tasting spreads have been released

(Olivio, Smart Balance, and Benecol for example are spreads

made from olive oil).

•Also, many margarines are now made ‘trans-fat free’. Now that

these healthy alternatives are available, these healthy spreads are

the best choice.

The Great Debate: Margarine vs. Butter

TRANS FATS

•• A study conducted at Harvard University, A study conducted at Harvard University,

which appeared in The Journal of Nutrition, which appeared in The Journal of Nutrition,

set out to find out whether trans fat simply set out to find out whether trans fat simply

increases cholesterol, or whether it is also increases cholesterol, or whether it is also

propro--inflammatory.inflammatory.

•• They found the more trans fats someone ate, They found the more trans fats someone ate,

the more inflammation was happening in the more inflammation was happening in

their body. This association was their body. This association was

independent of other possible causes of independent of other possible causes of

inflammation (e.g. saturated fat intake or inflammation (e.g. saturated fat intake or

obesity).obesity).

High Glycemic Index Foods

The higher the GI, thefaster blood glucose rises.


�� Low GI diets have been shown to lower the risk of Low GI diets have been shown to lower the risk of many chronic diseases that have an inflammatory cause many chronic diseases that have an inflammatory cause (i.e. obesity, diabetes, back pain and heart disease).(i.e. obesity, diabetes, back pain and heart disease).

�� When you eat a high GI food, you get a When you eat a high GI food, you get a ““spikespike”” in blood in blood sugar. In response, your body has to release a ton of sugar. In response, your body has to release a ton of insulin to get your blood glucose under control. Insulin insulin to get your blood glucose under control. Insulin is a hormone that your body makes to get glucose out of is a hormone that your body makes to get glucose out of your blood and into your cells where they belong. If a your blood and into your cells where they belong. If a spike in insulin happens occasionally, your body has no spike in insulin happens occasionally, your body has no problem adapting. problem adapting.

�� However, if this occurs again and again, your body has However, if this occurs again and again, your body has a tougher time keeping up. Your bodya tougher time keeping up. Your body’’s response to this s response to this is increasing inflammation.is increasing inflammation.


•• Another study conducted at Harvard Another study conducted at Harvard

University, that appeared in the journal The University, that appeared in the journal The

American Journal of Clinical Nutrition showed American Journal of Clinical Nutrition showed

a diet of high GI foods increases inflammation.a diet of high GI foods increases inflammation.

•• They found that the higher the CRP They found that the higher the CRP

(inflammation), the higher GI the diet tended (inflammation), the higher GI the diet tended

to be. to be. ““Dietary glycemic index is significantly Dietary glycemic index is significantly

and positively associated with plasma CRP.and positively associated with plasma CRP.””

Source: Liu S. Relation between a diet with a high glycemic loadSource: Liu S. Relation between a diet with a high glycemic load and plasma concentrations and plasma concentrations

of highof high--sensitivity Csensitivity C--reactive protein in middlereactive protein in middle--aged women. Am J Clin Nutr. 2002 aged women. Am J Clin Nutr. 2002

Mar;75(3):492Mar;75(3):492--88

Glycemic Index

Foods High In GIFoods High In GI

•• •• Sugary (i.e. candy)Sugary (i.e. candy)

•• •• Processed (i.e. white Processed (i.e. white

bread)bread)

•• •• Low in Fiber (i.e.. Low in Fiber (i.e..

white rice)white rice)

•• •• Low in Protein (i.e.. Low in Protein (i.e..

rice cakes)rice cakes)

Foods Low in GIFoods Low in GI

•• Produce (i.e. most fruits Produce (i.e. most fruits

and vegetables)and vegetables)

•• Minimally Processed Minimally Processed

(i.e. whole wheat bread)(i.e. whole wheat bread)

•• High in Fiber (i.e. beans)High in Fiber (i.e. beans)

Foods that Heal: Omega-3 Fats

�� Extensive research indicates that OmegaExtensive research indicates that Omega--3 fatty 3 fatty acids reduce inflammation and help prevent risk acids reduce inflammation and help prevent risk factors associated with chronic disease.factors associated with chronic disease.

OMEGAOMEGA--3s3s

�� Reduced risk of coronary heart diseaseReduced risk of coronary heart disease

�� Reduced blood triglyceridesReduced blood triglycerides

�� Reduced risk of certain cancersReduced risk of certain cancers

�� Decreased chronic inflammationDecreased chronic inflammation

�� Reduced CrohnReduced Crohn’’s disease s disease ““flareflare--upsups””

�� Increasing HDL (Good Cholesterol)Increasing HDL (Good Cholesterol)

�� Increase Cell FluidityIncrease Cell Fluidity A healthy cell membrane isdependent on omega-3s.

What Are Omega-3s?

There are three main types of OmegaThere are three main types of Omega--3 fats:3 fats:

1. Eicosapentaenoic acid (EPA)1. Eicosapentaenoic acid (EPA)

2. Docosahexaenoic acid (DHA)2. Docosahexaenoic acid (DHA)

3. Alpha3. Alpha--linolenic acid (ALA)linolenic acid (ALA)

�� OmegaOmega--3s are a type of fat categorized as an 3s are a type of fat categorized as an ““essential fatty acidessential fatty acid””. It is called this because, . It is called this because, unlike other types of fats, your body cannot unlike other types of fats, your body cannot make Omegamake Omega--3s.3s.

�� EPA and DHA are the best choices because EPA and DHA are the best choices because your body turns these into active antiyour body turns these into active anti--inflammatory compounds better than ALA.inflammatory compounds better than ALA. Fish are an excellent

source of omega-3s

Omega-3 Fats

•• The research published in the journal Surgical The research published in the journal Surgical

Neurology showed a safe alternative to NSAID Neurology showed a safe alternative to NSAID

for treatment for back pain was fish oil.for treatment for back pain was fish oil.

•• They gave fish oil capsules instead of NSAIDs They gave fish oil capsules instead of NSAIDs

to patients with chronic low back pain.to patients with chronic low back pain.

•• 80% of patients were satisfied with their 80% of patients were satisfied with their

improvement and 88% said that they would improvement and 88% said that they would

continue taking the supplements.continue taking the supplements.

Source: Maroon JC. OmegaSource: Maroon JC. Omega--3 fatty acids (fish oil) as an anti3 fatty acids (fish oil) as an anti--inflammatory: an alternative to nonsteroidal inflammatory: an alternative to nonsteroidal

antianti--inflammatory drugs for discogenic pain. Surg Neurol. 2006 Apr;65inflammatory drugs for discogenic pain. Surg Neurol. 2006 Apr;65(4):326(4):326--31.31.

Best non-fish sources of Omega-3s

•• Flax seeds Flax seeds

•• WalnutsWalnuts

•• TofuTofu

•• BeansBeans

•• SoybeansSoybeans

•• Winter SquashWinter Squash

To get the maximum benefit from Omega-3s, you should eat 4g (4000mg) at the very least on a daily basis.

Omega 6 to Omega 3 Ratio

•• The typical OmegaThe typical Omega--6 to Omega6 to Omega--3 ration in 3 ration in

the average American diet is about 15:1the average American diet is about 15:1

•• Research is not clear on the Research is not clear on the ““bestbest”” ratio of ratio of

these two fatty acidsthese two fatty acids

•• Currently most recommendations should be Currently most recommendations should be

as close to 1:1 as possible.as close to 1:1 as possible.

What About All That Mercury?

�� Certain types of fish contain high levels of certain toxins Certain types of fish contain high levels of certain toxins (specifically heavy metals).(specifically heavy metals).

So isnSo isn’’t eating too much fish dangerous?t eating too much fish dangerous?

�� The recommendation by the EPA and FDA to limit fish consumption The recommendation by the EPA and FDA to limit fish consumption is meant for pregnant women and young children.is meant for pregnant women and young children.

�� Also, those recommendations advise expecting mothers and childreAlso, those recommendations advise expecting mothers and children n to avoid certain types of fish: large, predatory fish like sharkto avoid certain types of fish: large, predatory fish like shark, , swordfish, and king mackerel are very high in mercury.swordfish, and king mackerel are very high in mercury.

�� Other fish, such as salmon, pollock and catfish, are extremely lOther fish, such as salmon, pollock and catfish, are extremely low in ow in mercury.mercury.

�� Experts agree: Experts agree: ““The dangers of not eating fish, including tuna, The dangers of not eating fish, including tuna, outweigh the small possible dangers from mercuryoutweigh the small possible dangers from mercury””..

�� The bottom line: unless you are pregnant, eating fish (or takingThe bottom line: unless you are pregnant, eating fish (or taking fish fish oil capsules) is the best way to get pain fighting Omegaoil capsules) is the best way to get pain fighting Omega--3s.3s.

VITAMIN D

•• Vitamin D has the unique property of being Vitamin D has the unique property of being

made in your skin with the help of sunlight. made in your skin with the help of sunlight.

This is why it is commonly referred to as the This is why it is commonly referred to as the

““Sunshine vitaminSunshine vitamin””..

•• ““Vitamin D deficiency is an unrecognized Vitamin D deficiency is an unrecognized

epidemic in both children and adults epidemic in both children and adults

throughout the world.throughout the world.””

Vitamin D Influences

•• Cell GrowthCell Growth

•• Insulin Resistance (Diabetes)Insulin Resistance (Diabetes)

•• ImmunityImmunity

•• Muscle FunctionMuscle Function

•• Nervous SystemNervous System

•• Cardiovascular SystemCardiovascular System

•• Blood PressureBlood Pressure

•• InflammationInflammation

•• Low Back PainLow Back Pain

Uric Acid

•• Is produced from the natural breakdown of body's cells and Is produced from the natural breakdown of body's cells and

from the foods we eat.from the foods we eat.

•• High levels of uric acid in the blood can cause gout , kidney High levels of uric acid in the blood can cause gout , kidney

stonesstones

•• A uric acid blood test is done to:A uric acid blood test is done to:

•• Help diagnose goutHelp diagnose gout

•• Check to see if kidney stones may be caused by high uric Check to see if kidney stones may be caused by high uric

acid levels in the bodyacid levels in the body

•• Check to see if medicine that decreases uric acid levels is Check to see if medicine that decreases uric acid levels is

workingworking

•• Check uric acid levels in people who are Check uric acid levels in people who are

undergoingundergoing chemotherapychemotherapy oror radiation therapy. These radiation therapy. These

treatments destroytreatments destroy cancercancer cells that then may leak uric cells that then may leak uric

acid into the bloodacid into the blood

High uric acid values may be caused by:High uric acid values may be caused by:

•• Conditions, such as:Conditions, such as:

•• Kidney disease or kidney damageKidney disease or kidney damage

•• Increased breakdown of body cells Increased breakdown of body cells

•• some types of cancer (includingsome types of cancer (including leukemia,leukemia, lymphoma, andlymphoma, and multiple multiple

myeloma)myeloma)

•• cancer treatmentscancer treatments

•• Hemolytic anemia,Hemolytic anemia, sickle cell anemia, orsickle cell anemia, or heart failure.heart failure.

•• Disorders, such asDisorders, such as alcohol alcohol

dependence,dependence, preeclampsia,preeclampsia, liverliver disease disease

(cirrhosis),(cirrhosis), obesity,obesity, psoriasis,psoriasis, hypothyroidism, and low blood levels hypothyroidism, and low blood levels

of parathyroid hormoneof parathyroid hormone

•• Starvation, malnutrition, lead poisoning.Starvation, malnutrition, lead poisoning.

•• A rare inherited gene disorder called LeschA rare inherited gene disorder called Lesch--Nyhan syndromeNyhan syndrome

•• Medicines, such as someMedicines, such as some diuretics,diuretics, vitamin C, lower doses of aspirin (75 to vitamin C, lower doses of aspirin (75 to

100 mg daily),100 mg daily), niacin, warfarin,niacin, warfarin, cyclosporine, levodopacyclosporine, levodopa

•• Eating foods that are very high inEating foods that are very high in purines, such as organ meats (liver, purines, such as organ meats (liver,

brains), red meats (beef, lamb), some seafood (sardines, herringbrains), red meats (beef, lamb), some seafood (sardines, herring), game ), game

meat, dried beans, dried peas, mushrooms meat, dried beans, dried peas, mushrooms

Collaborative Care•• Dietary measuresDietary measures

•• Weight reductionWeight reduction

•• Avoidance of alcoholAvoidance of alcohol

•• Avoidance of foods high in purinesAvoidance of foods high in purines

•• High: Sardines, anchovies, herring, High: Sardines, anchovies, herring,

mussels, liver, kidney, goose, venison, mussels, liver, kidney, goose, venison,

meat soups, sweetbreads, beer & winemeat soups, sweetbreads, beer & wine

•• Moderate: Chicken, salmon, crab, veal, Moderate: Chicken, salmon, crab, veal,

mutton, beefmutton, beef

Collaborative Care

•• Prevention of renal stonesPrevention of renal stones

•• Increase fluid intake to maintain adequate Increase fluid intake to maintain adequate

urine outputurine output

•• AllopurinolAllopurinol

•• ACE inhibitor losartin (Cozar) ACE inhibitor losartin (Cozar) ––

promotes urate diuresispromotes urate diuresis

Stool Exam

•• Occult BloodOccult Blood

•• OvaOva

•• ParasiteParasite

•• Undigested food in fecesUndigested food in feces

Thyroid Function Tests (TFT)

•• T3T3

•• T4T4

•• T3UPT3UP

•• TSHTSH

•• AntiAnti-- TPOTPO

Total T4 & Free T4

Total T4Total T4

�� Most of the thyroxine (T4) in the blood is attached to Most of the thyroxine (T4) in the blood is attached to thyroxinethyroxine--binding globulin. Less than 1% of the T4 is binding globulin. Less than 1% of the T4 is unattached. A total T4 blood test measures both bound unattached. A total T4 blood test measures both bound and free thyroxine and free thyroxine

Free T4Free T4

�� Free thyroxine affects tissue function in the body, but Free thyroxine affects tissue function in the body, but bound thyroxine does notbound thyroxine does not

�� Free thyroxine (T4) can be measuredFree thyroxine (T4) can be measured

◦◦ directly (FT4)directly (FT4)

◦◦ calculated as the free thyroxine index (FTI)calculated as the free thyroxine index (FTI)

�� The FTI tells how much free T4 is present compared to The FTI tells how much free T4 is present compared to bound T4. The FTI can help tell if abnormal amounts of bound T4. The FTI can help tell if abnormal amounts of T4 are present because of abnormal amounts of T4 are present because of abnormal amounts of thyroxinethyroxine--binding globulinbinding globulin

Triiodothyronine (T3)

•• Most of the T3 in the blood is attached to Most of the T3 in the blood is attached to

thyroxinethyroxine--binding globulin. Less than 1% of the binding globulin. Less than 1% of the

T3 is unattached. T3 is unattached.

•• A T3 blood test measures both bound and free A T3 blood test measures both bound and free

triiodothyronine.triiodothyronine.

•• T3 has a T3 has a greater effect greater effect on the way the body on the way the body

uses energy than T4, even though T3 is normally uses energy than T4, even though T3 is normally

present in present in smaller amounts smaller amounts than T4.than T4.

TSH

•• Screening for thyroid dysfunctionScreening for thyroid dysfunction

•• Serum TSH normal Serum TSH normal —— no further testing no further testing

performedperformed

•• Serum TSH high Serum TSH high —— free T4 added to determine free T4 added to determine

the degree of hypothyroidismthe degree of hypothyroidism

•• Serum TSH low Serum TSH low —— free T4 and T3 added to free T4 and T3 added to

determine the degree of hyperthyroidismdetermine the degree of hyperthyroidism

•• We measure serum free T4 if the patient has We measure serum free T4 if the patient has

convincing symptoms of hyperconvincing symptoms of hyper-- or or

hypothyroidism despite a normal TSH resulthypothyroidism despite a normal TSH result

T3UP

•• Hyperthyroidism Hyperthyroidism —— high serum total T4, high serum total T4,

high T3high T3--resin uptake, high free T4 indexresin uptake, high free T4 index

•• TBG excess TBG excess —— high serum total T4, low high serum total T4, low

T3T3--resin uptake, normal free T4 indexresin uptake, normal free T4 index

•• Hypothyroidism Hypothyroidism —— low serum total T4, low low serum total T4, low

T3T3--resin uptake, low free T4 indexresin uptake, low free T4 index

•• TBG deficiency TBG deficiency —— low serum total T4, high low serum total T4, high

T3T3--resin uptake, normal free T4 indexresin uptake, normal free T4 index

Micronutrients

�� SodiumSodium

�� PotassiumPotassium

�� CalciumCalcium

�� PhosphorousPhosphorous

�� MagnesiumMagnesium

�� CeruloplasminCeruloplasmin

�� CopperCopper

�� ZincZinc

�� 25(OH)D 25(OH)D -- 1,25(OH)D1,25(OH)D

�� RetinolRetinol

�� FolateFolate

�� B12B12

Others

•• HormonesHormones

•• InsulinInsulin

•• ACTHACTH

•• CortisolCortisol

•• Serum protein electrophoresisSerum protein electrophoresis

Assessment of Hydration Status

•• Dehydration: a state of negative fluid balance Dehydration: a state of negative fluid balance caused by decreased intake, increased losses, or caused by decreased intake, increased losses, or fluid shiftsfluid shifts

•• Overhydration or edema: increase in extracellular Overhydration or edema: increase in extracellular fluid volume; fluid shifts from extracellular fluid volume; fluid shifts from extracellular compartment to interstitial tissuescompartment to interstitial tissues

•• Caused by increase in capillary hydrostatic Caused by increase in capillary hydrostatic pressure or permeabilitypressure or permeability

•• Decrease in colloid osmotic pressureDecrease in colloid osmotic pressure

•• Physical inactivityPhysical inactivity

•• Use laboratory and clinical data to evaluate ptUse laboratory and clinical data to evaluate pt

Hypovolemia

Isotonic fluid loss from the extracellular space Isotonic fluid loss from the extracellular space caused bycaused by

•• Fluid loss (bleeding, fistulas, nasogastric Fluid loss (bleeding, fistulas, nasogastric drainage, excessive diuresis, vomiting and drainage, excessive diuresis, vomiting and diarrhea)diarrhea)

•• Reduced fluid intakeReduced fluid intake

•• Third space fluid shift, when fluid moves out Third space fluid shift, when fluid moves out of the intravascular space but not into of the intravascular space but not into intracellular space (abdominal cavity, pleural intracellular space (abdominal cavity, pleural cavity, pericardial sac) caused by increased cavity, pericardial sac) caused by increased permeability of the capillary membrane or permeability of the capillary membrane or decrease on plasma colloid osmotic pressuredecrease on plasma colloid osmotic pressure

Symptoms of Hypovolemia

•• Orthostatic Hypotension (caused by change in Orthostatic Hypotension (caused by change in position)position)

•• Central venous and pulmonary pressures Central venous and pulmonary pressures ↓↓

•• Increased heart rateIncreased heart rate

•• Rapid weight lossRapid weight loss

•• Decreased urinary outputDecreased urinary output

•• Patient cool, clammyPatient cool, clammy

•• Decreased cardiac outputDecreased cardiac output

•• Ask the medical team!!Ask the medical team!!

Treatment of Hypovolemia

•• Replace lost fluids with fluids of similar Replace lost fluids with fluids of similar

concentrationconcentration

•• Restores blood volume and blood pressureRestores blood volume and blood pressure

•• Usually isotonic fluid like normal saline or Usually isotonic fluid like normal saline or

lactated Ringerlactated Ringer’’s solution given IVs solution given IV

Hypervolemia

•• Excess of isotonic fluid (water and sodium) Excess of isotonic fluid (water and sodium) in the extracellular compartmentin the extracellular compartment

•• Osmolality is usually not affected since Osmolality is usually not affected since fluid and solutes are gained in equal fluid and solutes are gained in equal proportionproportion

•• Elderly and those with renal and cardiac Elderly and those with renal and cardiac failure are at riskfailure are at risk

Causes of Hypervolemia

•• Results from retention or excessive intake of Results from retention or excessive intake of

fluid or sodium or shift in fluid from fluid or sodium or shift in fluid from

interstitial space into the intravascular spaceinterstitial space into the intravascular space

•• Fluid retention: renal failure, CHF, cirrhosis of Fluid retention: renal failure, CHF, cirrhosis of

the liver, corticosteroid therapy, the liver, corticosteroid therapy,

hyperaldosteronismhyperaldosteronism

•• Excessive intake: IV replacement tx using Excessive intake: IV replacement tx using

normal saline or Lactated Ringernormal saline or Lactated Ringer’’s, blood or s, blood or

plasma replacement, excessive salt intakeplasma replacement, excessive salt intake

Causes of Hypervolemia

•• Fluid shifts into vasculature caused by Fluid shifts into vasculature caused by

remobilization of fluids after burn tx, remobilization of fluids after burn tx,

administration of hypertonic fluids, use of administration of hypertonic fluids, use of

colloid oncotic fluids such as albumincolloid oncotic fluids such as albumin

Symptoms of Hypervolemia

•• No single diagnostic test, so signs and symptoms No single diagnostic test, so signs and symptoms

are keyare key

•• Cardiac output increases Cardiac output increases

•• Pulse rapid and boundingPulse rapid and bounding

•• BP, CVP, PAP and pulmonary artery wedge BP, CVP, PAP and pulmonary artery wedge

pressure risepressure rise

•• As the heart fails, BP and cardiac output dropAs the heart fails, BP and cardiac output drop

•• Distended veins in hands and neckDistended veins in hands and neck

Symptoms of Hypervolemia

•• Anasarca: severe, generalized edemaAnasarca: severe, generalized edema

•• Pitting edema: leaves depression in skin when Pitting edema: leaves depression in skin when

touchedtouched

•• Pulmonary edema: crackles on auscultationPulmonary edema: crackles on auscultation

•• Patient SOB and tachypneicPatient SOB and tachypneic

•• Labs: low hematocrit, normal serum sodium, Labs: low hematocrit, normal serum sodium,

lower K+ and BUN (or if high, may mean renal lower K+ and BUN (or if high, may mean renal

failure)failure)

•• ABG: low O2 level, PaCO2 may be low, ABG: low O2 level, PaCO2 may be low,

causing drop in pH and respiratory alkalosiscausing drop in pH and respiratory alkalosis

Treatment of Hypervolemia

•• Restriction of sodium and fluid intake Restriction of sodium and fluid intake

•• Diuretics to promote fluid loss; morphine Diuretics to promote fluid loss; morphine

and nitroglycerine to relieve air hunger and and nitroglycerine to relieve air hunger and

dilate blood vessels; digoxin to strengthen dilate blood vessels; digoxin to strengthen

heart heart

•• Hemodialysis or CAVHHemodialysis or CAVH

Dehydration

•• Excessive loss of free waterExcessive loss of free water

•• Loss of fluids causes an increase in the Loss of fluids causes an increase in the

concentration of solutes in the blood (increased concentration of solutes in the blood (increased

osmolality)osmolality)

•• Water shifts out of the cells into the bloodWater shifts out of the cells into the blood

•• Causes: prolonged fever, watery diarrhea, failure Causes: prolonged fever, watery diarrhea, failure

to respond to thirst, highly concentrated feedings, to respond to thirst, highly concentrated feedings,

including TFincluding TF

Symptoms of Dehydration

•• ThirstThirst

•• FeverFever

•• Dry skin and mucus membranes, poor skin turgor, Dry skin and mucus membranes, poor skin turgor, sunken eyeballssunken eyeballs

•• Decreased urine outputDecreased urine output

•• Increased heart rate with falling blood pressureIncreased heart rate with falling blood pressure

•• Elevated serum osmolality; elevated serum Elevated serum osmolality; elevated serum sodium; high urine specific gravitysodium; high urine specific gravity

Treatment of Dehydration

•• Use hypotonic IV solutions such as D5WUse hypotonic IV solutions such as D5W

•• Offer oral fluids Offer oral fluids

•• Rehydrate graduallyRehydrate gradually

Laboratory Values and Hydration: BUN

Lab TestLab Test HypoHypo--

volemiavolemia

HyperHyper--

volemiavolemia

Other factors influencing Other factors influencing

resultresult

BUNBUN

Normal: Normal:

1010--20 20

mg/dlmg/dl

IncreasesIncreases DecreasesDecreases Low: inadequate dietary Low: inadequate dietary

protein, severe liver protein, severe liver

failurefailure

High: prerenal failure; High: prerenal failure;

excessive protein intake, excessive protein intake,

GI bleeding, catabolic GI bleeding, catabolic

state; glucocorticoid state; glucocorticoid

therapytherapy

Creatinine will also rise Creatinine will also rise

in severe hypovolemiain severe hypovolemia

Adapted from Charney and Malone. ADA Pocket Guide to Nutrition Assessment, 2004.

Laboratory Values and Hydration

Status: BUN:Creatinine Ratio


volemiavolemia

HyperHyper--

volemiavolemia

Other factors Other factors

influencing resultinfluencing result

BUN: BUN:

creatinine creatinine

ratioratio

Normal: Normal:

1010--15:115:1

IncreasesIncreases DecreasesDecreases Low: inadequate dietary Low: inadequate dietary

protein, severe liver protein, severe liver

failurefailure

High: prerenal failure; High: prerenal failure;

excessive protein intake, excessive protein intake,

GI bleeding, catabolic GI bleeding, catabolic

state; glucocorticoid state; glucocorticoid

therapytherapy


Laboratory Values and Hydration: HCT


volemiavolemia

HyperHyper--

volemiavolemia


resultresult

HematoHemato--

critcrit

Normal: Normal:

Male: Male:

4242--52%52%

Female: Female:

3737--47%47%

IncreasesIncreases DecreasesDecreases Low: anemia, hemorrhage Low: anemia, hemorrhage

with subsequent with subsequent

hemodilution (occurring hemodilution (occurring

after approximately 12after approximately 12--24 24

hours)hours)

High: chronic hypoxia High: chronic hypoxia

(chronic pulmonary (chronic pulmonary

disease, living at high disease, living at high

altitude, heavy smoking, altitude, heavy smoking,

recent transfusion) recent transfusion)


Laboratory Values and Hydration: Alb,

Na+Lab TestLab Test HypoHypo--

volemiavolemia

HyperHyper--

volemiavolemia


resultresult

Serum Serum

albuminalbumin

↑↑ ↓↓ Low: malnutrition; acute Low: malnutrition; acute

phase response, liver phase response, liver

failurefailure

High: rare except in High: rare except in

hemoconcentrationhemoconcentration

Serum Serum

sodiumsodium

TypicalTypical--

ly ly ↑↑

can be can be

normal normal

or or ↓↓

↓↓, , normal normal

or or ↑↑

Serum sodium generally Serum sodium generally

reflects fluid status and not reflects fluid status and not

sodium balancesodium balance



Status

Lab TestLab Test

normalnormal

HypoHypo--

volemiavolemia

HyperHyper--

volemiavolemia


resultresult

Serum Serum

osmolalityosmolality

(285(285--295 295

mosm/kg)mosm/kg)

Typically Typically

↑↑ but can but can

be be normal normal

or or ↓↓

Typically Typically

↓↓ but can but can

be be normal normal

or or ↑↑

Urine sp. Urine sp.

GravityGravity

1.0031.003--1.0301.030

↑↑ ↓↓

Urine Urine

osmolality osmolality

(200(200--1200 1200

mosm/kg)mosm/kg)

↑↑ ↓↓ Low: diuresis, Low: diuresis,

hyponatremia, sickle cell hyponatremia, sickle cell

anemiaanemia

High: azotemia, High: azotemia,



Status


volemiavolemia

HyperHyper--

volemiavolemia


resultresult

Serum Serum

albuminalbumin

↑↑ ↓↓ Low: malnutrition; acute Low: malnutrition; acute

phase response, liver phase response, liver

failurefailure

High: rare except in High: rare except in

hemoconcentrationhemoconcentration

Serum Serum

sodiumsodium

Typically Typically

↑↑can be can be

normal or normal or

↓↓

↓↓, ,

normal normal

or or ↑↑


Hypokalemia (K+< 3.5 mEq/L)

•• ↑↑ renal losses (diuresis)renal losses (diuresis)

•• ↑↑ GI losses (diarrhea, vomiting, fistula)GI losses (diarrhea, vomiting, fistula)

•• K+ wasting meds (thiazide and loop K+ wasting meds (thiazide and loop

diuretics, etc)diuretics, etc)

•• Shift into cells (anabolism, refeeding, Shift into cells (anabolism, refeeding,

correction of glucosuria or DKA)correction of glucosuria or DKA)

•• Inadequate intakeInadequate intake

Hyperkalemia (K+>5.0 mEq/L)

•• Decreased renal excretion as in acute or Decreased renal excretion as in acute or

chronic renal failurechronic renal failure

•• Medications, e.g. potassium sparing Medications, e.g. potassium sparing

diuretics, beta blockers, ACE inhibitorsdiuretics, beta blockers, ACE inhibitors

•• Shift out of cells (acidosis, tissue necrosis, Shift out of cells (acidosis, tissue necrosis,

GI hemorrhage, hemolysis)GI hemorrhage, hemolysis)

Serum Calcium

•• Normal serum 9.0Normal serum 9.0--10.5 mg/dL (includes 10.5 mg/dL (includes ionized calcium and calcium bound to ionized calcium and calcium bound to protein, primarily albumin, and ions)protein, primarily albumin, and ions)

•• Ionized calcium: 4.5Ionized calcium: 4.5--5.6 mg/dL5.6 mg/dL

•• Normal levels maintained by hormonal Normal levels maintained by hormonal regulation using skeletal reservesregulation using skeletal reserves

•• Ionized calcium is more accurate, especially Ionized calcium is more accurate, especially in pt with hypoalbuminemia; evaluate in pt with hypoalbuminemia; evaluate before repleting Ca+before repleting Ca+

Charney and Malone, 2004, p. 89

Hypocalcemia (serum calcium <9.0

mg/dL; ionized Ca+ <4.5 mg/dL)

•• HypoalbuminemiaHypoalbuminemia

•• HypoparathyroidismHypoparathyroidism

•• HypomagnesemiaHypomagnesemia

•• Renal failure, renal tubular necrosisRenal failure, renal tubular necrosis

•• Vitamin D deficiency or impaired Vitamin D deficiency or impaired

metabolismmetabolism

Hypercalcemia (serum calcium >10.5

mg/dL; ionized Ca+ >5.6 mg/dL)

•• HyperparathyroidismHyperparathyroidism

•• Some malignancies, especially breast, lung, Some malignancies, especially breast, lung, kidney; multiple myeloma, leukemia, kidney; multiple myeloma, leukemia, lymphomalymphoma

•• Medications: thiazide diuretics, lithium, Medications: thiazide diuretics, lithium, vitamin A toxicityvitamin A toxicity

•• ImmobilizationImmobilization

•• HyperthyroidismHyperthyroidism


Serum Phosphorus (normal 3.0-4.5

mg/dL)

•• Serum phos a poor reflection of body stores Serum phos a poor reflection of body stores

because <1% is in ECFbecause <1% is in ECF

•• Bones serve as a reservoirBones serve as a reservoir

Hypophosphatemia (<3.0 mg/dL)

•• Impaired absorption (diarrhea, Vitamin D Impaired absorption (diarrhea, Vitamin D deficiency, impaired metabolism)deficiency, impaired metabolism)

•• Medications: phosphate binding antacids, Medications: phosphate binding antacids, sucralfate, insulin, steroids)sucralfate, insulin, steroids)

•• Alcoholism, especially during withdrawalAlcoholism, especially during withdrawal

•• Intracellular shifts in alkalosis, anabolism, Intracellular shifts in alkalosis, anabolism, neoplasmsneoplasms

•• Refeeding syndromeRefeeding syndrome

•• Increased losses: hyperparathyroidism, renal Increased losses: hyperparathyroidism, renal tubular defects, DKA recovery, hypomagnesemia, tubular defects, DKA recovery, hypomagnesemia,


Hyperphosphatemia (>4.5 mg/dL)

•• Decreased renal excretion: acute or chronic renal Decreased renal excretion: acute or chronic renal failure (GFR<20failure (GFR<20--25 mL/min); 25 mL/min); hypoparathyroidismhypoparathyroidism

•• Increased cellular release: tissue necrosis, tumor Increased cellular release: tissue necrosis, tumor lysis syndromelysis syndrome

•• Increased exogenous phosphorus load or Increased exogenous phosphorus load or absorption, phosphorus containing laxatives or absorption, phosphorus containing laxatives or enemas, vitamin D excessenemas, vitamin D excess

•• AcidosisAcidosis

Hypomagnesemia <1.3 mEq/L

(normal 1.3-2.1 mEq/L)

•• Decreased absorption: prolonged diarrhea, intestinal or Decreased absorption: prolonged diarrhea, intestinal or biliary fistula, intestinal resection or bypass, steatorrhea, biliary fistula, intestinal resection or bypass, steatorrhea, ulcerative colitis; upper GI fluid loss, gastric suctioning, ulcerative colitis; upper GI fluid loss, gastric suctioning, vomitingvomiting

•• Renal losses: osmotic diuresis, DM with glucosuria, Renal losses: osmotic diuresis, DM with glucosuria, correction of DKA, renal disease with magnesium wasting, correction of DKA, renal disease with magnesium wasting, hypophosphatemia, hypercalcemia, hyperthyroidismhypophosphatemia, hypercalcemia, hyperthyroidism

•• AlcoholismAlcoholism

•• Inadequate intake: malnutritionInadequate intake: malnutrition

•• MedicationsMedications

•• Intracellular shift: acute pancreatitisIntracellular shift: acute pancreatitis

•• Refeeding syndromeRefeeding syndrome

Hypermagnesemia (>2.1 mEq/L)

•• Acute or chronic renal failureAcute or chronic renal failure

Assessment for Protein-Calorie

Malnutrition

•• Hormonal and cellHormonal and cell--mediated response mediated response

to stressto stress

•• Negative acuteNegative acute--phase respondentsphase respondents

•• Positive acutePositive acute--phase respondentsphase respondents

•• Nitrogen balanceNitrogen balance

Assessment for Protein-Calorie

Malnutrition–cont’d

•• Hepatic transport proteinsHepatic transport proteins

•• AlbuminAlbumin

•• TransferrinTransferrin

•• PrealbuminPrealbumin

•• RetinolRetinol--binding proteinbinding protein

•• CC--reactive proteinreactive protein

•• CreatinineCreatinine

•• ImmunocompetenceImmunocompetence

Hormonal and Cell-Mediated Response

to Inflammatory Stress

•• Acute illness or trauma causes Acute illness or trauma causes

inflammatory stressinflammatory stress

•• Cytokines (interleukinCytokines (interleukin--1, interleukin1, interleukin--6 6

and tumor necrosis factor) reorient and tumor necrosis factor) reorient

hepatic synthesis of plasma proteinshepatic synthesis of plasma proteins

•• Although proteinAlthough protein--energy malnutrition can energy malnutrition can

occur simultaneously, interpretation of occur simultaneously, interpretation of

plasma proteins is problematicplasma proteins is problematic

Hormonal and Cell-Mediated Response

to Inflammatory Stress

•• Negative acuteNegative acute--phase respondents phase respondents

(albumin, transthyretin or prealbumin, (albumin, transthyretin or prealbumin,

transferrin, retinoltransferrin, retinol--binding protein) binding protein)

decreasedecrease

•• Positive acutePositive acute--phase reactants (Cphase reactants (C--reactive reactive

protein, orosomucoid, fibrinogen) protein, orosomucoid, fibrinogen)

increaseincrease

•• The change in these proteins is The change in these proteins is

proportional to the physiological insultproportional to the physiological insult

Nitrogen Balance Studies

•• Oldest biochemical technique for Oldest biochemical technique for

assessment protein statusassessment protein status

•• Based on the fact that 16% of protein is Based on the fact that 16% of protein is

nitrogennitrogen

•• Nitrogen intake is compared to nitrogen Nitrogen intake is compared to nitrogen

output, adjusted for insensible losses output, adjusted for insensible losses

(skin, hair loss, sweat) (skin, hair loss, sweat)

Nitrogen Balance Studies

•• Nitrogen balance in healthy adults is 0Nitrogen balance in healthy adults is 0

•• Nitrogen balance is positive in growing Nitrogen balance is positive in growing

children, pregnant women, adults gaining children, pregnant women, adults gaining

weight or recovering from illness or injuryweight or recovering from illness or injury

•• Nitrogen balance is negative during Nitrogen balance is negative during

starvation, catabolism, PEMstarvation, catabolism, PEM

Nitrogen Balance Calculations

•• Nitrogen balance = nitrogen intake (g/24 Nitrogen balance = nitrogen intake (g/24

hours) hours) ––(urinary nitrogen [g/24 hours) + 2 (urinary nitrogen [g/24 hours) + 2

g/24 hoursg/24 hours

•• Use correction of 4 g/24 hours if urinary Use correction of 4 g/24 hours if urinary

urea nitrogen is usedurea nitrogen is used

•• Nitrogen intake = (grams protein/24 Nitrogen intake = (grams protein/24

hours)/6.25hours)/6.25

Nitrogen Balance Challenges

•• Urea nitrogen is highly variable as a Urea nitrogen is highly variable as a

percent of total nitrogen excretedpercent of total nitrogen excreted

•• It is nearly impossible to capture an It is nearly impossible to capture an

accurate nitrogen intake for patients accurate nitrogen intake for patients

taking food potaking food po

•• Most useful in evaluating the Most useful in evaluating the

appropriateness of defined feedings, e.g. appropriateness of defined feedings, e.g.

enteral and parenteral feedingsenteral and parenteral feedings

Visceral Proteins:

Serum Albumin

•• Reference range: 3.5Reference range: 3.5--5.2 g/dl5.2 g/dl

•• Abundant in serum, stable (halfAbundant in serum, stable (half--life 3 weeks)life 3 weeks)

•• Preserved in the presence of starvation Preserved in the presence of starvation (marasmus)(marasmus)

•• Negative acute phase reactant (declines with the Negative acute phase reactant (declines with the inflammatory process)inflammatory process)

•• Large extravascular pool (leaves and returns to Large extravascular pool (leaves and returns to the circulation, making levels difficult to the circulation, making levels difficult to interpret)interpret)

•• Therefore, albumin is a mediocre indicator of Therefore, albumin is a mediocre indicator of nutritional status, but a very good predictor of nutritional status, but a very good predictor of morbidity and mortalitymorbidity and mortality

Visceral Proteins:

Plasma Transferrin•• Reference range: 200Reference range: 200--400 mg/dl400 mg/dl

•• HalfHalf--life: 1 weeklife: 1 week

•• Negative acute phase respondentNegative acute phase respondent

•• Increases when iron stores are depleted Increases when iron stores are depleted

so affected by iron status as well as so affected by iron status as well as

proteinprotein--energy statusenergy status

•• Responds too slowly to be useful in an Responds too slowly to be useful in an

acute settingacute setting

Visceral Proteins:

Transthyretin (Prealbumin)

•• Reference range: 19Reference range: 19--43 mg/dl43 mg/dl

•• HalfHalf--life: 2 dayslife: 2 days

•• Negative acuteNegative acute--phase reactantphase reactant

•• Zinc deficiency reduces levelsZinc deficiency reduces levels

•• Due to short halfDue to short half--life, it is useful in life, it is useful in monitoring improvements in proteinmonitoring improvements in protein--energy status if baseline value is obtained energy status if baseline value is obtained near the nadir as inflammatory response near the nadir as inflammatory response waneswanes

Visceral Proteins:

Retinol-Binding Protein

•• Reference range: 2.1Reference range: 2.1--6.4 mg/dl6.4 mg/dl

•• HalfHalf--life: 12 hourslife: 12 hours

•• Negative acuteNegative acute--phase proteinphase protein

•• Unreliable when vitamin A (retinol) status Unreliable when vitamin A (retinol) status

is compromisedis compromised

•• Elevated in the presence of renal failure, Elevated in the presence of renal failure,

regardless of PEM statusregardless of PEM status

Visceral Proteins:

C-Reactive Protein

•• Positive acutePositive acute--phase reactantphase reactant

•• Increases within 4Increases within 4--6 hours of injury or illness6 hours of injury or illness

•• Can be used to monitor the progress of the Can be used to monitor the progress of the

stress reaction so aggressive nutrition support stress reaction so aggressive nutrition support

can be implemented when reaction is subsidingcan be implemented when reaction is subsiding

•• Mildly elevated CRP may be a marker for Mildly elevated CRP may be a marker for

increased risk for cardiovascular diseaseincreased risk for cardiovascular disease

Inflammation

•• hshs--CRPCRP

•• HomocysteineHomocysteine

Urinary Creatinine

•• Formed from creatine, produced in muscle Formed from creatine, produced in muscle

tissuetissue

•• The bodyThe body’’s muscle protein pool is directly s muscle protein pool is directly

proportional to creatinine excretionproportional to creatinine excretion

•• Skeletal muscle mass (kg) = 4.1 = 18.9 x 24Skeletal muscle mass (kg) = 4.1 = 18.9 x 24--

hour creatinine excretion (g/day)hour creatinine excretion (g/day)

•• Confounded by meat in dietConfounded by meat in diet

•• Requires 24Requires 24--hour urine collection, which is hour urine collection, which is

difficultdifficult

Markers of Malabsorption

•• Fecal fatFecal fat

•• FatFat--soluble vitaminssoluble vitamins

•• Vitamin DVitamin D

laboratory data in nutrition assessment...

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