﻿ Nutrition and Growth and Measurement - Mosby's Guide to Physical Examination, 7th Edition

## Mosby's Guide to Physical Examination, 7th Edition

### CHAPTER 3. Nutrition and Growth and Measurement

EQUIPMENT

Tape measure with millimeter markings

Standing platform scale with height attachment

Devices for measuring weight and height for infants

Calculator

Skinfold caliper

EXAMINATION

 TECHNIQUE FINDINGS ANTHROPOMETRICS Measure height and weight Estimate 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. Calculate percent weight change 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. Calculate body mass index (BMI) kg/m2 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. orSee nomogram below. Also, see an interactive BMI calculator on the  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. 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

 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  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). Calculate midarm muscle circumference (MAMC) 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 Pediatric 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.

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