Built and nutrition - assessment, patient examination and interpretation

1. C H A I R P E R S O N - D R . B A S A V A R A J B A L I G A R
M D D M C A R D I O L O G Y
S T U D E N T - D R . C H E T H A N . Y
BUILT AND NUTRITIONAL
ASSESSMENT

2. INTRODUCTION
 Nutritional assessment is defined by the American Society for
Parenteral and Enteral Nutrition as “a comprehensive approach to
diagnosing nutrition problems that uses a combination of the following:
medical, nutrition, and medication histories; physical examination;
anthropometric measurement; and laboratory data

3.  Nutritional Assessment Methods
 Four different methods are used to collect data used in assessing a
person’s nutritional status:
 Anthropometric
 Clinical
 Biochemical
 Dietary

4.  Importance of Nutritional Assessment
 Nutrition can have a profound influence on health,
affecting growth and development of infants, children, and
adolescents; immunity against disease; morbidity and
mortality from illness or surgery; and risk of such diseases
as cancer, coronary heart disease, and diabetes.

5.  Nutritional assessment is important in identifying persons
at nutritional risk, in determining what type of nutrition
intervention, if any, may be appropriate to alter nutritional
status, and in monitoring the effects of nutrition
intervention.

6. ANTHORPOMETRY
 Anthropometry is the measurement of body size, weight,
and proportions
 Anthropometric measures can be used to evaluate
nutritional status, whether it be obesity caused by
overnutrition or emaciation resulting from protein-energy
malnutrition

7. HEIGHT :
 Stature, or standing height, can be measured for
subjects 2 to 3 years of age and older who are cooperative
and able to stand without assistance
 In nonambulatory persons (those unable to walk) or
those who have such severe spinal curvature that
measurement of height would be inaccurate, stature can
be estimated from knee height.

10. SHORT STATURE
Height below 3rd centile or more than 2SD below the median height
for age and sex.
 Normal variant
 Familial short stature
 Constitutional growth delay
 Pathological
Proportionate
 Prenatal
 1. Intrauterine growth retardation
 2. Antenatal infection in mother (TORCH*, syphilis, AIDS)
 3. Antenatal consumption of alcohol, tobacco, heroin
 4. Chromosomal disorders (Down’s syndrome, Turner’s syndrome).

11. Postnatal
 1. Malnutrition (Protein-energy malnutrition, anorexia nervosa)
 2. Endocrine disorders (growth hormone deficiency, hypothyroidism,
congenital adrenal hyperplasia, precocious puberty)
 3. Cardiovascular disorders (cyanotic and acyanotic congenital heart
disease, early onset rheumatic heart disease)
 4. Respiratory disorders (Kartagener’s syndrome, cystic lung disease,
childhood asthma)
 5. Renal disorders (renal tubular acidosis, renal rickets, nephrotic syndrome,
chronic pyelonephritis)

12.  Disproportionate
 Rickets
 Skeletal dysplasia (kyphosis, lordosis, scoliosis)
 Defective bone formation (osteopetrosis, osteogenesis imperfecta)
 Defective cartilage growth (achondroplasia, multiple cartilagenous
exostosis

14. WEIGHT
 Body weight, though not an accurate measure of fat, is a widely used index.
 Diurnal variations (cyclical changes occurring throughout the day) in
weight of about 1 kg in children and 2 kg in adults are known to occur. For
this reason, it is a good practice to also record the time weight was
measured.
 Ideally, children and adults should be weighed after voiding and dressed in
an examination gown of known weight or in light underclothing with the
scales placed where adequate privacy is provided

15.  For the age interval 2 to 20 years, the charts give percentile
curves for stature-for-age, weight-for-age, body mass
indexfor- age, and weight-for-stature.

17.  Percentile Cut-Off Value( FOR 2-20 YEARS)
 < 5th percentile
 5th and < 85th percentile
 85th and < 95th percentile
 95th percentile or 30 kg/m 2 (whichever is smaller)

18. Classification of Overweight and Obesity by Body Mass Index
(BMI) in Adults
 Underweight <18.5 <18.5
 Normal weight 18.5-24.9 18.5-22.9
 Overweight 25-29.9 23-24.90
 Obesity Class 1 30-34.9 25-29.90
• (PRE OBESE)
 Obesity Class 2 35-39.9 >30
(OBESE)
 Extreme Obesity Class 3 >40

19. INDICATORS
 Body mass index (Quetelet's index) = Weight (kg)/ Height(m)(2)
 Ponderal index = Height (cm) /Cube root of body weight (kg)
 Brocca index = Height (cm) -100
(For example, if a person's height is 160 cm, his idealweight
is (160-100) = 60 kg)

20. SKINFOLD THICKNESS
 A large proportion of total body fat is located just under the skin.
 Since it is most accessible, the method most used is the measurement of
skinfold thickness.
 It is a rapid and "noninvasive“ method for assessing body fat.
 Several varieties of callipers (e.g., Harpenden skin callipers) are
available for the purpose.

23.  The measurement may be taken at all the four sites - mid-
triceps, biceps, subscapular and suprailiac regions.
 The sum of the measurements should be less than 40 mm in
boys and 50 mm in girls
 Further, in extreme obesity, measurements may be
impossible.
 The main drawback of skinfold measurements is their poor
repeatability.

24. WAIST CIRCUMFERENCE AND WAIST :
HIP RATIO (WHR)
 Waist circumference is measured at the mid point between the lower
border of the rib cage and the iliac crest.
 It is a convenient and simple measurement that is unrelated to height.
 Correlates closely with BMI
 WHR and is an approximate index of intra - abdominal fat mass and
total body fat.

25.  Changes in waist circumference reflect changes in risk factors for
cardiovascular disease and other forms of chronic diseases.
 There is an increased risk of metabolic complications for men with a
waist circumference > 102 cm,and women with a waist circumference >
88 cm
 High WHR (> 0.95 in men and > 0.80 in women) indicates abdominal
fat accumulation.

26. SL.N
O
ETHNICITY WAIST CIRCUMFERENCE
1
Europeans
Men >94 cm (>37 in)
Women >80 cm (>31.5 in)
2 South Asians
and Chinese
Men >90 cm (>35 in)
Women >80 cm (>31.5 in)
3 Japanese Men >85 cm (>33.5 in)
Women >90 cm (>35 in

27.  TYPES OF OBESITY
 Generalised obesity:Over eating is the most common cause. It is
characterised by the presence of a ‘double chin’.
 Android obesity: It is a type of obesity, which is characterised by
excess deposition of fat over the region of the waist. (GREATER
RISK)
 Gynoid obesity: It is a type of obesity, which is characterised by
excess deposition of fat over the region of the hips and thighs.
 Superior or central type of obesity:

29. CLINICAL APPLICATION

30. CLINICAL ASSESMENT

31. HISTORY
 Ask about usual weight, peak weight, and deliberate weight loss.
 A 4.5 kg (10-lb) weight loss over 6 months is noteworthy and a weight
loss of >10% of usual body weight is prognostic of clinical outcomes

32.  Medical and surgical conditions; chronic disease
 Look for medical or surgical conditions or chronic disease that can
place one at nutritional risk secondary to increased requirements, or
compromised intake or assimilation
 Constitutional signs/ symptoms :Fever or hypothermia can indicate
active inflammatory response. Anorexia is another manifestation of
inflammatory response and is also often a side effect of treatments and
medications.

33.  Eating difficulties/ gastrointestinal complaints : Poor dentition
or problems swallowing can compromise oral intake. Vomiting, nausea,
abdominal pain, abdominal distension, diarrhea, constipation, and
gastrointestinal bleeding can be signs of gastrointestinal pathology that
may place one at nutritional risk.
 Medication use : Many medications can adversely affect nutrient
intake or assimilation. Review potential drug–drug and drug–nutrient
interactions.

34.  Dietary practices and supplement use : Look for dietary practices
including therapeutic, weight reduction, vegetarian, macrobiotic, and fad
diets. Also record use of dietary supplements, including vitamins, minerals,
and herbals
 Influences on nutritional status : Ask about factors such as living
environment, functional status (activities of daily living and instrumental
activities of daily living), dependency, caregiver status, resources, dentition,
alcohol or substance abuse, mental health (depression or dementia), and
lifestyle.

38. PHYSICAL EXAMINATION
 The first of the three elements of the physical examination
is LOSS OF SUBCUTANEOUS FAT.
 The four anatomic areas (shoulders, triceps, chest, and
hands) should be checked for loss of fullness or loose-fitting
skin.
 Loss of subcutaneous fat should be noted as normal (0),
mild loss (1+ ), moderate loss (2 + ), or severe loss (3 + )

39.  The PRESENCE OF MUSCLE WASTING (the
second element of the physical examination) is best
assessed by examining the deltoid muscles (located
at the sides of the shoulders) and the quadriceps
femoris muscles (the muscles of the anterior thigh).

40.  Loss of subcutaneous fat in the shoulders and deltoid
muscle wasting gives the shoulders a squared-off
appearance.

41.  The presence of edema at the ankle or sacrum can also be
assessed as absent, mild, moderate, or severe. The
presence of “pitting” edema can be checked by
momentarily pressing the area with a finger and then
looking for a persistent depression (more than 5 seconds)
where the finger was.
 When considerable edema or ascites are present, weight
loss is a less important variable.

42.  SUBJECTIVE GLOBAL ASSESSMENT
 SGA depends on the clinician’s subjectively combining
the various elements to arrive at an overall, or global,
assessment.
 Patients with weight loss > 10% that is continuing, poor
dietary intake, and severe loss of subcutaneous fat and
muscle wasting fall within the severely malnourished
category (class C rank).

43.  Patients with at least a 5% weight loss, reduced dietary
intake, and mild to moderate loss of subcutaneous fat and
muscle wasting fall within the moderately
malnourished category (class B rank).
 A class A rank would be given to patients having a recent
increase in weight (that is not fluid retention), even if their
net loss for the past 6 months was between 5% and 10%.

44.  It is regarded by many as the most reliable and efficient
method to assess nutritional status at the bedside and is
considered the gold standard for bedside assessment tools.

47.  PROTEIN ENERGY MALNUTRITION
 PEM is the disease caused by prolonged inadequate energy and protein
consumption— starvation—with consequent depletion of the BCM and
body fat.
 The body normally adapts to starvation by reducing energy expenditure
and curtailing protein catabolism, partly by hormone- and nervous
system-regulated alterations in cellular metabolism, and partly by
reducing its muscle mass.

48.  These adaptations enable prolonged survival during sub-lethal
starvation, but survival comes at a cost that includes lethargy, a
tendency to hypothermia, muscle atrophy (including of the cardiac and
respiratory muscles), skin thinning, and functional disability.
 The cardinal diagnostic features of PEM—generalized muscle atrophy
and subcutaneous adipose tissue depletion—are easy to detect by
simple physical examination

49.  Starvation-Related Malnutrition (Uncomplicated
Protein- Energy Malnutrition)
 Chronic Disease-Related Malnutrition and
Cachexia
 Acute Disease-Related Malnutrition

50.  PROTEIN ENERGY MALNUTRITION

54.  EATING DISORDERS
 ANOREXIA NERVOSA
 Anorexia nervosa is characterized by a refusal to maintain a
minimally normal body weight, an intense fear of gaining weight
that is not alleviated by losing weight, and a distorted perception
of body shape or size in which a person feels overweight (either
globally or in certain body areas) despite being markedly
underweight.

55.  A prominent clinical feature of persons with anorexia
nervosa is marked weight loss, which in some instances
can become extreme and life threatening.
 In postmenarcheal females, amenorrhea—i.e., the
absence of at least three consecutive menstrual cycles (a
woman is considered to have amenorrhea if her periods
occur only following hormone administration—e.g.,
estrogen)

57.  BULIMIA NERVOSA
 BINGE Eating, in a discrete period (e.g., within any 2-hour
period), an amount of food that is definitely larger than
most people would eat during a similar period of time and
under similar circumstances
 A sense of lack of control over eating during the episode
(e.g., a feeling that one cannot stop eating or control what
or how much one is eating)

58.  Recurrent inappropriate compensatory behavior in order to
prevent weight gain, such as self-induced vomiting; misuse
of laxatives, diuretics, enemas, or other medications;
fasting; or excessive exercise
 The binge eating and inappropriate compensatory
behaviors both occur, on average, at least twice a week for 3
months.

60.  HEAD TO TOE EXAMINATION
FOR NUTRITIONAL STATUS

61. HAIR EXAMINATION
 Hair loss in protein, folate and vit B12 deficiency

62.  D/D for ALPOPECIA
 Cicatricial Alopecia
 Trauma
 Burns
 Infections: folliculitis, herpes zoster, gumma, lupus vulgaris
 Morphea, lichen planus, sarcoidosis, DLE
 Cutaneous neoplasms: basal cell Ca
 Drugs—mepacrin

63.  Non-cicatricial Alopecia:
 Alopecia areata (most common)
 Physiologic: Androgenic alopecia
 Systemic diseases: SLE, hyperthyroidism, hypothyroidism,
 ACRODERMATITIS ENTEROPATHICA, PERNICIOUS ANAEMIA and
Down’s syndrome.
 Infection: Moth eaten type in syphilis and fungal infections.
 Drugs: Antimetabolites, cytotoxics, heparin, carbimazole, iodine, bismuth, vitamin
A, allopurinol and amphetamines.
 Telogen effluvium: Systemic illness (typhoid, measles, pneumonia) post-partum and
post-surgical, MALNUTRITION
 Radiation.

64. VITAMIN B9
Recommende
d
Daily Enteral
Intake
Signs and
Symptoms
Populations
At Risk for
Deficiency
Signs and
Symptoms of
Toxicity
Status
Evaluation
400 mcg Bone marrow
suppression,
macrocytic
megaloblastic
anemia,
glossitis,
diarrhea Can be
precipitated by
Sulfasalazine
and
Phenytoin
Alcoholics,
celiac or tropical
sprue, chronic
sulfasalazine use
PO: May lower
seizure
threshold in
those taking
anticonvulsants
Folic
acid(serum),
RBC folic
acid(plasma)

66. VITAMIN B12
Recommende
d
Daily Enteral
Intake
Signs and
Symptoms
Populations
At Risk for
Deficiency
Signs and
Symptoms of
Toxicity
Status
Evaluation
2.4 mcg Bone marrow
suppression,
macrocytic
megaloblastic
anemia,
glossitis,
diarrhea
posterolateral
column
demyelination,
AMS,
depression,
psychosis
Vegetarians,
atrophic
gastritis,
pernicious
anemia, celiac
sprue, Crohn's
disease, patients
postgastrectomy
or ileal resection
None Cobalamin
(B12)(serum),
methylmalonic
acids (plasma)

69.  BRITTLE HAIR – BIOTIN DEFICIENCY

70. VITAMIN B7
Recommended
Daily Enteral
Intake
Signs and
Symptoms
Populations At
Risk for
Deficiency
Signs and
Symptoms of
Toxicity
Status
Evaluation
30 mcg Mental status
changes, myalgias,
hyperesthesias,
anorexia,(excessive
egg white
consumption
results
in avidin-mediated
biotin inactivation)
Alcoholics None Biotin(plasma),
methyl-
citrate(urine)

72.  CHANGE OF COLOUR – ZINC DEFICIENCY

73.  Colour of Hair
 White - hair albinism (due to absence of pigment).
 Grey hair is a sign of ageing.
 Poliosis patchy loss of pigmentation of hair in the
region of an adjoining vitiligo.
 Flag sign brownish discolouration of hair, with
interspersed normal colour of hair, is seen in protein
energy malnutrition.
 ZINC DEFICINECY

74. ZINC
Nutrient Recommended
Daily Enteral
Intake
Signs and
Symptoms
Populations At
Risk for
Deficiency1,4
Signs and
Symptoms of
Toxicity4
Status
Evaluation4,5
Zinc 11 mg Poor wound
healing,
diarrhea (high
fistula risk),
dysgeusia,
hypogonadism,
infertility,
acro-oroficial
skin lesions
(glossitis,
alopecia),
behavioral
changes
Intrinsic:
Acrodermatitis
enteropathica
Chronic
diarrhea,
cereal-based
diets,
alcoholics, any
intestinal
malabsorptive
states, fistulas/
nephrotic
syndrome,
diabetes, post–
gastric bypass/
anorexia,
pregnancy
Intrinsic:
Acrodermatitis
enteropathica
PO: Nausea,
vomiting,
gastritis,
diarrhea, low
HDL, gastric
erosions,
Competition
with GI
absorption can
precipitate
Cu21 deficiency
Inhaled:
Hyperpnea,
weakness,
diaphoresis
Zinc,S,P,
alkaline
phosphatases
(good for those
on TPN, but in
general
Zincs,p, hair,
RBC, WBC
levels can be
misleading)
Zinc
radioisotope
studies (most
accurate tests
at present;

76.  FLAG SIGN- PROTEIN MALNUTRITION

77.  Dry hair – vit A and vit E deficiency
 Easily pluckable hair in zinc, biotin and protein
deficiency

78.  Coiled and corkscrew hair – vit A and vit C deficiency

79. EYE EXAMINATION
 Bitots spot – vit A deficiency

82. Recommended
Daily Enteral
Intake
Signs and
Symptoms
Populations At
Risk for
Deficiency
Signs and
Symptoms of
Toxicity
Status
Evaluation
900 mcg
VITAMIN A
Conjunctival
xerosis,
keratomalacia,
follicular
hyperkeratosis,
night blindness,
Bitot spots,
corneal , retinal
dysfunction
Any
malabsorptive
state involving
proximal small
bowel,
vegetarians,
chronic liver
disease
Acute:
Teratogenic, skin
exfoliation,
intracranial
hypertension,
hepatocellular
necrosis
Chronic: Alopecia,
ataxia, cheilitis,
dermatitis,
conjunctivitis,
pseudotumor
cerebri,
hyperlipidemia,
hyperostosis
Retinol(serum),
retinol
esters(plasma),
electroretinogram,
liver biopsy
(diagnostic for
toxicity), retinol
binding protein
(useful in ESRD,
accurately assesses
blood levels)

84.  WHO Classification of Vitamin A Deficiency
 1. Primary
 X-1A Conjunctival xerosis
 X-1B Conjunctival xerosis + Bitot’s spots
 X-2 Corneal xerosis
 X-3A Corneal ulcer—< 1/3 of cornea involved
 X-3B Corneal ulcer—> 1/3 of cornea involved—
 keratomalacia
 2. Secondary
 X-N Night blindness
 X-F Xerophthalmic fundus
 X-S Corneal scars

85.  ANGULAR PALPEBERITIS – RIBOFLAVIN
DEFICIENCY

86. Recommende
d
Daily Enteral
Intake
Signs and
Symptoms
Signs and
Symptoms
Populations
At Risk for
Deficiency
Signs and
Symptoms of
Toxicity
Status
Evaluation
1.3 mg
RIBOFLAVIN
Cheilosis,
angular
stomatitis,
glossitis,
seborrheic
dermatitis,
normocytic
normochromic
anemia
Alcoholics,
severely
malnourished
None RBC glutathione
reductase
activity(plasma)

88. PERIORAL EXAMINATION
 Angular somatitis and chelitis : deficiency of Iron,
vitamin B complex and protein

90.  Glossitis – niacin, folate and vit B 12 deficiency,
riboflavin, pyridoxine

91. Pale tongue

92. ATROPHIC LINGUAL PAPPILAE
 Deficinecy Of IRON
 Riboflavin, niacin, folate, vitamin B12,
 protein

93. Red beefy tongue in vit B12 deficiency

94. SCARLET RED TONGUE

95. MAGENTA coloured tongue

96.  Magenta tongue – riboflavin deficiency

97.  Bleeding gums – vit C deficiency

98.  D/D OF BLEEDING GUMS:
 Ill fitting Dentures and other dental appliances
 Bleeding disorders
 Improper flossing
 Gingivitis
 Leukemia
 Vitamin c def
 Use of anticoagulants
 Vit k deficiency

99.  Manifestations
 Infancy and Childhood
 Painful swelling over the long bones due to subperiosteal haemorrhage
 Gingivitis, swollen, spongy gums if teeth have erupted
 Lassitude, anorexia and pain in limbs
 Inward sinking of sternum with sharp elevation of costochondral junctions
(scorbutic rosary)
 Purpura and echymoses may appear in the skin
 Painful joint swelling due to haemorrhage into the joint cavities.
 Retrobulbar, subarachnoid and intracerebral hemorrhages

101.  ADULTS:
 Swollen, spongy gums
 Perifollicular hyperkeratosis with haemorrhage
 Haemorrhage into the muscles of the arms and legs
 Petechial haemorrhages in the viscera and echymoses
 Delayed wound healing
 Other clinical manifestations are icterus, oedema,
 fever, convulsions and hypotension
 Vitamin C deficiency causes normochromic
 normocytic anaemia

102. Recommended
Daily Enteral
Intake
Signs and
Symptoms
Populations
At Risk for
Deficiency
Signs and
Symptoms of
Toxicity
Status Evaluation
90 mg
VIT C
Scurvy,
ossification
abnormalities
Tobacco
lowers plasma
and WBC
vitamin C
Sudden
cessation of
high dose
vitamin C
can
precipitate
scurvy
Fruit-deficient
diet, smokers,
ESRD
Nausea,
diarrhea,
increased
oxalate
synthesis
(theoretical
nephrolithiasis
risk)
Ascorbic
acid(plasma),
leukocyte ascorbic
acid

105. SKIN EXAMINATION
 Skin desquamation – riboflavin deficiency

106.  Cellophane appearance and Cracking (flaky
paint or crazy pavement dermatosis) –
protein deficiency

107.  Yellow pigmentation of skin (sparing sclera)
–carotene excess

108.  Petechiae – vit A and vit C deficiency

109.  D/D for petichiae (<3mm)
 Physical trauma :
 repeated bout of coughing, vomitting
 Asphyxiation
 Sun burn
 Hickey
 NON INFECTIOUS
 VIT C VIT K DEF
 Thrombocytopenia
 Leukemia
 Von villebrands disease
 Aplastic anemia

110.  Infectious
 Dengue ,Chickungunya , Influenza, Ebola, Cmv,
 Infectious Mononucleosis
 Malaria
 Syphylis
 Endocarditis
 Meningococciemia
 Scarlet Fever
 Typhus

111.  Ecchymosis – vit K and vit C deficiency

112. Recommended
Daily Enteral
Intake
Signs and
Symptoms Signs
and Symptoms
Populations At
Risk for
Deficiency
Signs and
Symptoms of
Toxicity
Status
Evaluation
120 mcg
VITAMIN K
Hemorrhagic
disease of
newborn,
coagulopathy
Any malabsorptive
state involving
proximal small
bowel, chronic
liver disease
In utero:
Hemolytic anemia,
hyperbilirubinemi
a, kernicterus IV:
flushing, dyspnea
hypotension
(possibly related to
dispersal agent)
Prothrombin time
(plasma)

115.  Perifollicular hemorrhage – vit C deficiency

116.  Ecchymosis and perifollicular hemorrhage in
vit C deficiency

117.  Aceniform lesions in vit A deficiency

118.  Follicular keratosis in vit A deficiency

119.  Xerosis – essential fatty acid deficiency , VIT
A def

120.  Pigmentation, cracking and crusting – niacin
deficiency (CASTELS NECKLACE)

121. Recommende
d
Daily Enteral
Intake
Signs and
Symptoms
Signs and
Symptoms
Populations
At Risk for
Deficiency
Signs and
Symptoms of
Toxicity
Status
Evaluation
16 mg/40 mg
VITAMIN B3
Pellagra
dysesthesias,
glossitis,
stomatitis,
vaginitis,
vertigo,
diarrhea,
dementia
Intrinsic:
Hartnup disease
Alcoholics,
malignant
carcinoid
syndrome,
severely
malnourished
Flushing,
hyperglycemia,
hyperuricemia,
hepatocellular
injury
N-methyl-
nicotinamide(ur
ine)

123. HARTNUPS DISEASE

124. GENERALISED HYPERPIGMENTATION: VIT
B12 FOLATE DEF

125.  D/D for generalised hyperpigmentation
Endocrinopathies
 Addison’s disease
 Nelson syndrome
 Ectopic ACTH syndrome
 Hyperthyroidism
Metabolic
 Porphyria cutanea tarda
 Hemochromatosis
 VITAMIN B12, FOLATE DEFICIENCY
 PELLAGRA
 Malabsorption, including Whipple’s disease
 Melanosis secondary to metastatic melanoma

126. Autoimmune
 Biliary cirrhosis
 Systemic sclerosis (scleroderma)
 POEMS syndrome
 Eosinophilia-myalgia syndromed
 Drugs (e.g. cyclophosphamide) and metals (e.g. silver

127.  Acro-orificial dermatitis – zinc deficiency

128. NAIL EXAMINATION
 KOILONYCHIA – IRON DEFICIENCY ANEMIA

129.  D/D OF KOILONYCHIA
 Iron deficiency Anemia
 Hemochromatosis
 Raynauds syndrome
 Porphyria
 Inherited

130. IRON
Recommended
Daily Enteral
Intake/
Parenteral
Intake
Signs and
Symptoms
Signs and
Symptoms
Populations At
Risk for
Deficiency
Signs and
Symptoms of
Toxicity
Status Evaluation
8 mg Fatigue,
hypochromic
microcytic
anemia
glossitis,
koilonychia
Reproductive age
females, pregnant
females, chronic
anemias,
hemoglobinopath
ies post–gastric
bypass/
duodenectomy,
alcoholics
PO or IV:
hemosiderosis,
followed by
deposition in liver,
pancreas heart and
glands Intrinsic:
Hereditary
hemochromatosis
Ferritins, TIBCs %
Transferrin saturation,
serum iron

132.  WHITE NAILS AND TRANSVERSE RIDGING
OF NAILS – HYPOALBUMINEMIA

133.  D/D OF WHITE NAILS
 Anemia
 Hypoalbumunaemia
 Diabetes
 CCF
 RA
 Malignancy

134. Bones, Joints
 Beading of ribs, epiphyseal swelling, bowlegs
–VIT D deficiency.

136. VITAMIN D
Recommended
Daily Enteral
Intake
Signs and
Symptoms
Signs and
Symptoms
Populations At
Risk for
Deficiency
Signs and
Symptoms of
Toxicity
Status
Evaluation
5–15 mcg Rickets/osteomal
acia
Any malabsorptive
state involving
proximal small
bowel, chronic liver
disease Of note:
Those with higher
skin melanin
content (i.e., darker
skin) have low
baseline 25-OH
vitamin D levels; it
is unclear whether
this merits their
inclusion as an “at
risk” population
Hypercalcemia,
hyperphosphatemi
a, which can lead
to CaPO4
precipitation,
systemic
calcification +/-
AMS +/-AKI
25-OH vitamin D
serum levels is Of
note: lively debate
between IOM and
Endocrine Society
regarding
definitions of
deficiency, goal
serum 25-OH
levels, and at risk
populations

137. 15

140.  Tenderness (subperiosteal hemorrhage in child) –
Vit C deficiency

141. NEUROLOGICAL EXAMINATION
 Dementia - Niacin, vitamin B12
 Confabulation, disorientation Thiamin (Korsakoff’s
psychosis).
 WERNICKES encephalopathy – Thiamine
 Peripheral neuropathy - Thiamin, pyridoxine,
vitamin B12
 Tetany - Calcium, magnesium

142. VITAMIN B1
Recommende
d
Daily Enteral
Intake
Signs and
Symptoms
Signs and
Symptoms
Populations
At Risk for
Deficiency
Signs and
Symptoms of
Toxicity
Status
Evaluation
1.2 mg Irritability,
fatigue,
headache
Wernicke's
encephalopathy,
Korsakoff
psychosis,
“Wet ” beri-beri ,
“Dry ” beri-beri
Alcoholics,
severely
malnourished
IV: Lethargy and
ataxia
RBC
transketolase
activity(blood),
thiamine(blood
and urine)

144. VITAMIN B6
Recommended
Daily Enteral
Intake
Signs and
Symptoms
Signs and
Symptoms
Populations
At Risk for
Deficiency
Signs and
Symptoms of
Toxicity
Status
Evaluation
1.3–1.7 mg Cheilosis,
stomatitis,
glossitis,
irritability,
depression,
confusion,
normochromic
normocytic
anemia
Alcoholics,
diabetics celiac
sprue, chronic
isoniazid or
penicillamine
use
Peripheral
neuropathy,
photosensitivity
Pyridoxal
phosphate(plas
ma)

146. OTHERS
 Parotid enlargement – Protein def (also consider bulimia)
 Heart failure - Thiamin (wet beriberi), phosphorus def
 Sudden heart failure, death - Vitamin C def
 Edema - Protein, thiamin def
 Poor wound healing, pressure ulcers - Protein, vitamin C,
zinc

147. CHROMIUM
Recommende
d
Daily Enteral
Intake
Signs and
Symptoms
Signs and
Symptoms
Populations
At Risk for
Deficiency
Signs and
Symptoms
of Toxicity
Status Evaluation
30–3 5 mcg Glucose
intolerance
peripheral
neuropathy
None PO: gastritis
IV: skin
irritation
Cr61: (steel,
welding) lung
carcinogen if
inhaled
Chromium (serum)

149. COPPER
Recommended
Daily Enteral
Intake
Signs and
Symptoms Signs
and Symptoms
Populations
At Risk for
Deficiency
Signs and
Symptoms of
Toxicity
Status
Evaluation
900 mcg Hypochromic
normocytic or
macrocytic anemia
(rarely microcytic)
neutropenia,
thrombocytopenia,
diarrhea,
osteoporosis
pathologic fractures
Intrinsic:
Menkes‘disease
Chronic
diarrhea high
zinc/low
protein diets
PO: gastritis, nausea,
vomiting, coma,
movement/
neurologic
abnormalities,
Wilsons disease.
Copper
,Ceruloplasmin

151. IODINE
Recommended
Daily Enteral
Intake
Signs and
Symptoms
Signs and
Symptoms
Populations
At Risk for
Deficiency
Signs and
Symptoms of
Toxicity
Status Evaluation
150 mcg Thyroid
hyperplasia
(goiter)
functional
hypothyroidism
Intrinsic in utero:
cretinism, poor
CNS
development,
hypothyroidism
Those without
access to
fortified salt
grain, milk, or
cooking oil
Hypothyroidism
blocks thyroxine
synthesis OR
hyperthyroidism
Excess
supplementation
in severe
deficiency
TSH(serum),
iodine(urine) (24 hr
intake or iodine: Cr ratio
are more representative
than a single sample)
Thyroglobulins

152. GOITER

154. MANGNESE
Nutrient Recommende
d
Daily Enteral
Intake/
Parenteral
Intake
Signs and
Symptoms
Signs and
Symptoms
Population
s At Risk
for
Deficiency
Signs and
Symptoms
of Toxicity
Status
Evaluation
Manganese 2.3 mg Hypercholes
terolemia,
dermatitis,
dementia,
weight loss
Chronic liver
disease, iron
deficient
populations
PO: None
Inhalation:
Hallucinatio
n,
Parkinsonian
-type
symptoms
No reliable
markers
Manganeses
does not
reflect bodily
stores,
especially in
the CNS

156. SELENIUM
Nutrient Recommend
ed
Daily Enteral
Intake
Signs and
Symptoms
Signs and
Symptoms
Populations
At Risk for
Deficiency
Signs and
Symptoms of
Toxicity
Status
Evaluation
Selenium 55 mcg Myalgias
cardiomyopath
y Intrinsic:
Keshan's
disease
(Chinese
children),
Endemic areas
of low soil
content include
certain parts of
China and New
Zealand
PO: Nausea,
diarrhea, AMS,
irritability,
fatigue,
peripheral
neuropathy,
hair loss, white
splotchy nails,
halitosis
(garlic-like
odor)
Selenium(seru
m), glutathione
peroxidase
activity(blood)

158. KESHANS DISEASE

159. MOLYBDENUM
Nutrient Recommende
d
Daily Enteral
Intake/
Parenteral
Intake
Signs and
Symptoms
Signs and
Symptoms
Populations
At Risk for
Deficiency
Signs and
Symptoms of
Toxicity
Status
Evaluation
Molybdenum 45 mcg/45 mcg CNS toxicity,
hyperoxypurine
mia,
hypouricemia,
low urinary
sulfate excretion
(also reported
with parenteral
sulfite infusion)
Intrinsic:
Molybdenum
cofactor
deficiency,
isolated sulfite
oxidase
deficiency
None PO or any
exposure:
Hyperuricemia
gout Inhaled:
Pneumoconiosi
s (industrial
exposure)
Molybdenum

161. VITAMIN B5
Recommende
d
Daily Enteral
Intake
Signs and
Symptoms
Signs and
Symptoms
Populations
At Risk for
Deficiency
Signs and
Symptoms of
Toxicity
Status
Evaluation
5 mg Fatigue,
abdominal pain,
vomiting,
insomnia,
paresthesias
Alcoholics PO: Diarrhea Pantothenic
acid(urine)

165.  THANK YOU