Mosby's Guide to Physical Examination, 7th Edition

CHAPTER 3. Nutrition and Growth and Measurement

EQUIPMENT

image Tape measure with millimeter markings

image Standing platform scale with height attachment

image Devices for measuring weight and height for infants

image Calculator

image Skinfold caliper

EXAMINATION

TECHNIQUE

FINDINGS

ANTHROPOMETRICS

Measure height and weight

imageEstimate desirable body weight (DBW)

Add 10% for large frame; subtract 10% for small frame.

EXPECTED:Women: 100 pounds for first 5 feet, plus 5 pounds for each inch thereafter. Men: 106 pounds for first 5 feet, plus 6 pounds for each inch thereafter.

Use growth charts for pediatric patients available at www.cdc.gov/growthcharts.

EXPECTED:Child is following a growth curve pattern for height and weight. Height and weight are approximately same percentiles.

imageCalculate percent weight change 

image

UNEXPECTED:Weight loss that equals or exceeds 1% to 2% in 1 week, 5% in 1 month, 7.5% in 3 months, 10% in 6 months.

imageCalculate body mass index (BMI) kg/m2 

image

EXPECTED:18.5 to 24.9 for men and women.

UNEXPECTED:BMI less than 18.5 is classified as undernutrition. BMI of 25 to 29.9 is classified as overweight. BMI of 30 to 39.9 is obesity. BMI of 40 and higher is extreme obesity.

or
See nomogram below. Also, see an interactive BMI calculator on the 
image website.

 

Nomogram for body mass index (kg/m2). Draw a line from the patient’s height to the patient’s weight. The BMI or weight/height2 is read from the central scale. The ranges suggested as “desirable” are from life insurance data.

image

From Thomas AE et al, 1976.

TECHNIQUE

FINDINGS

Calculate waist-to-hip circumference ratio

Using tape measure with millimeter markings, measure waist at a midpoint between the costal margin and the iliac crest. Then measure hip at the widest part of the gluteal region. Divide waist circumference by hip circumference to obtain the ratio.

EXPECTED:Ratio less than 0.9 in men and 0.8 in women.

UNEXPECTED:Ratios of greater than 1.0 in men and greater than 0.85 in women indicate increased central fat distribution and increased risk of disease.

DETERMINE DIET ADEQUACY

24-hour diet recall

 

Food diary

Use the MyPyramid guide at www.mypyramidtracker.gov to track and analyze individual eating patterns and to generate a dietary plan based on age, gender, and physical activity level.

DETERMINE NUTRITIONAL ADEQUACY

Calculate estimates for energy needs

Use actual weight for healthy adults.

Calories

Kcal/kg

Weight loss

25

Use adjusted weight for obese patients.

Weight maintenance

30

Weight gain

35

 

Hypermetabolic/malnourished

35-50

Estimate fat intake

 

25% to 35% of the daily calories consumed should come from fat, with a distribution of less than 7% saturated fat, less than 10% polyunsaturated fat, and the rest in monounsaturated fat (U.S. Department of Health and Human Services and U.S. Department of Agriculture, 2005).

Estimate protein intake

 

An average of 0.8 g per kilogram body weight is sufficient to meet needs. Approximately 15% of daily calories consumed should come from protein.

Estimate carbohydrate intake

 

50% to 60% of the total calories consumed should come from carbohydrates, with selections predominantly coming from complex carbohydrates including grains, fruits, and vegetables.

Estimate fiber intake

 

14 g per 1000 calories consumed (U.S. Department of Health and Human Services and U.S. Department of Agriculture, 2005). In children ages 3 to 18 years, the formula “age +5 g” should be used to determine fiber needs.

SPECIAL PROCEDURES

Measure mid–upper arm circumference (MAC)

Place measuring tape around upper right arm, midway between tips of olecranon and acromial processes. Hold tape snugly and make the reading to nearest 5 mm.

EXPECTED:Between 10th and 95th percentiles.

UNEXPECTED:Less than 10th or greater than 95th percentile (see table on p. 25).

Percentiles for Midarm Circumference, Midarm Muscle Circumference, and Triceps Skinfold Thickness

image

This measurement is used along with the triceps skinfold thickness to calculate midarm muscle circumference (MAMC).

 

Measure triceps skinfold (TSF) thickness

Have patient flex right arm at a right angle. Find midpoint between tips of olecranon and acromial processes on the posterior arm, and make a horizontal mark. Then draw a vertical line to intersect. With arm relaxed, use your thumb and forefinger to grasp and lift triceps skinfold about image inch proximal to intersection marks. Place caliper at skinfold and measure without making an indentation. Make two readings to nearest millimeter, and derive an average. This measurement is used along with the MAC to calculate MAMC.

EXPECTED:Between 10th and 95th percentiles.

UNEXPECTED:Less than 10th or greater than 95th percentile (see table above).

image

 

Calculate midarm muscle circumference (MAMC)

image

EXPECTED:Between 10th and 95th percentiles.

Compare measurement with table for percentiles.

UNEXPECTED:Less than 10th or greater than 95th percentile (see table on p. 25).

BIOCHEMICAL MEASUREMENTS

Obtain biochemical measures as indicated

Hemoglobin

Hematocrit

Serum albumin

Transferrin saturation

Serum glucose

Triglycerides

Cholesterol

High-density lipoprotein (HDL) cholesterol

Cholesterol/HDL ratio

Low-density lipoprotein (LDL) cholesterol

Hemoglobin A1c

Serum folate

EXPECTED:See reference ranges established by your particular laboratory.

AIDS TO DIFFERENTIAL DIAGNOSIS

ABNORMALITY

DESCRIPTION

Obesity

Subjective Data:Excessive caloric intake, weight gain, decrease in physical exercise, recent life change or stress, medications.

 

Objective Data:BMI—overweight 25 to 29.9; obesity 30 to 39.9, extreme obesity greater than 40; excess fat located in breasts, buttocks, thighs; may have pale striae or acanthosis nigricans.

Anorexia nervosa

Subjective Data:Use of weight control measures (e.g., voluntary starvation, purging, vomiting, diet pills, laxative abuses, and diuretic use); possible excessive exercise, unusual eating habits.

 

Objective Data:Weight at less than 85% of ideal body weight for age and height, BMI 17.5 or less; dry skin, lanugo hair, brittle nails, bradycardia, hypothermia, orthostatic hypotension, loss of muscle mass and subcutaneous fat; may have hypoglycemia, elevated liver enzymes, and thyroid hormone abnormalities.

Bulimia

Subjective Data:Binge-eating episodes on an average of two times per week followed by purging (e.g., vomiting, laxatives, diuretics); bloating, fullness, abdominal pain, heartburn.

 

Objective Data:Body weight may be normal, underweight, or overweight; knuckle calluses, and dental enamel erosion, salivary gland enlargement; may have metabolic alkalosis, hypokalemia, or elevated salivary amylase.

Nutrient deficiencies

See table on p. 28 for signs and symptoms of various nutrient deficiencies.

Clinical Signs and Symptoms of Various Nutrient Deficiencies

Body Part or System

Sign/Symptom

Deficiency

Eyes

Xerosis of conjunctiva

Vitamin A

 

Keratomalacia

Vitamin A

 

Bitot spots

Vitamin A

 

Corneal vascularization

Riboflavin

Gastrointestinal tract

Nausea, vomiting

Pyridoxine

Diarrhea

Zinc, niacin

 

Stomatitis

Pyridoxine, riboflavin, iron

 

Cheilosis

Pyridoxine, iron

 

Glossitis

Pyridoxine, zinc, niacin, folate, vitamin B12

   

Riboflavin

   

Vitamin C

   

Protein

Skin

Dry and scaling

Vitamin A, essential fatty acids, zinc

 

Petechiae/ecchymoses

Vitamin C, vitamin K

 

Follicular hyperkeratosis

Vitamin A, essential fatty acids

 

Nasolabial seborrhea

Niacin, pyridoxine, riboflavin

 

Atopic dermatitis

Niacin, zinc

Hair

Alopecia

Zinc, essential fatty acids

 

Easy pluckability

Protein, essential fatty acids

 

Lackluster

Protein, zinc

 

“Corkscrew” hair

Vitamin C, vitamin A

 

Decreased pigmentation

Protein, copper

Extremities

Subcutaneous fat loss

Calories

 

Muscle wastage

Calories, protein

 

Edema

Protein

 

Osteomalacia, bone pain, rickets

Vitamin D

 

Arthralgia

Vitamin C

Neurologic

Disorientation

Niacin, thiamin

 

Confabulation

Thiamin

 

Neuropathy

Thiamin, pyridoxine, chromium

 

Paresthesia

Thiamin, pyridoxine, vitamin B12

Cardiovascular

Congestive heart failure, cardiomegaly, tachycardia

Thiamin

 

Cardiomyopathy

Selenium

Pediatric Variations

EXAMINATION

TECHNIQUE

FINDINGS

Measure head circumference

Wrap tape measure snugly around infant’s head at occipital protuberance and supraorbital prominence.

Refer to the growth charts available at www.cdc.gov/growthcharts. for infants and children for appropriateness of head circumference size for age.

Calculate estimates for energy needs

imagePediatric patients:

EXPECTED:1000 kcal plus 100 kcal per year of age, up to 12 years. Fat intake: Ages 2 to 3 years, 30% to 35% of daily calories, ages 4 to 18, 25% to 35% of daily calories (U.S. Department of Health and Human Services and U.S. Department of Agriculture, 2005).

SAMPLE DOCUMENTATION

Subjective.A 45-year-old businessman with steady weight gain over the past 5 years seeks nutrition counseling for weight loss plan. Eats three full meals each day with snacking in between; eats breakfast and dinner at home, where wife prepares meals. Often eats lunch (fast foods) on the run. Alcohol intake: 1 to 2 glasses of wine daily with dinner. No regular exercise. Has never kept a meal log. No change in lifestyle; moderate stress.

Objective.Height: 173 cm (68 inches). Weight: 90.9 kg (200 pounds), 123% of desirable body weight; BMI: 30.5; triceps skinfold thickness: 20 mm, 90th percentile; midarm circumference: 327.8 mm; midarm muscle circumference: 26.5 cm, 25th percentile; waist circumference: 42 inches; hip circumference: 41 inches; waist-to-hip ratio: 1.02; 2200 calories daily estimated for appropriate weight loss.