Nutritional Assessment of

Community
 Purpose
• To teach the determination of the
nutritional status of patients and healthy
individuals by using the methods used in
determining the nutritional status of the
individual and the society and the
nutritional status

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 Content

It includes providing information

about community nutrition, public
health dietician, nutritional
epidemiology, methods used in
determining nutritional status,
anthropometric measurements and
their application, clinical symptoms,
biochemical and biop

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 LEARNING
OUTCOMES Defines the concepts of community nutrition and nutrition epidemiology and explains the
working areas, importance and duties of the public health dietitian.

Learns and applies the methods of screening and detecting nutritional status individually and
socially.

Interpret and apply anthropometric measurements, body composition and some biophysical
methods

ınterprets biochemical findings and clinical signs.

Defines food consumption recording methods, applies food consumption records and uses
related computer programs.

Defines food consumption recording methods, applies food consumption records and uses
related computer programs.

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DETAILED COURSE OUTLINE
• Determination of Nutritional Status
• Anthropometric Measurements
• Anthropometric Measurements
• Body Composition Determination Methods
• Biochemical Methods I
• Biochemical Methods II
• Clinical Symptoms
• Food Consumption Survey I
• Food Consumption Survey II
• Nutrition Software (Practice)
• Nutritional Status Screening Tests
• Health Statistics and Ecological Factors
• Community Nutrition and Nutrition Epidemiology, Working Areas and Duties of Community Nutrition Dietician,
Food Taking Standarts.
 Nutritional Assesment
Nutritional imbalances are a serious public
problem that lead to a significant increase in the
risk of mortality and morbidity.
Bir bireyin beslenme durumu besinlerin yeterli
tüketilmesi yeterli besin öğesi alabilmesi yeme
örüntüsü ve sedanter yaşam tarzından etkilenir.
All this is a factor of occurrence of chronic
diseases such as cardiovascular diseases,
Diabetes mellitus, stroke and cancer

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 Improving public health, preventing LOW birth
weight children and malnutrition are important
In order to improve public health, it is necessary to
define the effect of bad eating patterns on chronic
diseases and to determine the nutritional status of
individuals, families and societies.
Public health measures also reduce the cost.
Obesity: $245 billion U.S.

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 ABCD OF NUTRITION ASSESSMENT
• ANTHROPOMETRY
• BIOCHEMICAL

• CLINICAL EXAMINATION
• DIET ASSESSMENT

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 Anthropometry • It refers to the measurement of the human body. As an early
tool of physical anthropology, it was used in
paleoanthropology to understand human physical diversity
and to identify various attempts to establish relationships
between physical, racial, and psychological characteristics.

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 Biochemical

• It refers to the use of laboratory

or biochemical data obtained
through blood and urine samples
(among others) to assess the
nutritional status of an individual.

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 Clinical
evaluation

• A physical examination is a
medical examination or clinical
examination is the process by
which a medical professional
investigates a patient's body for
signs of disease.
• Visible aspects of overall body
composition include assessment
of overall muscle, fat mass and
fluid status

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 Diet Assessment

• Dietary Assessment is a
comprehensive assessment of a
person's food consumption.
• Nutrition assessment methods
• It includes 24-hour recall, food
consumption frequency
questionnaire, diet history, food
consumption diary, food
consumption observation.

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 • Preliminary evaluation
Nutrition and
• Assessment of nutritional status is the first step
Health in identifying nutrition-related problems that
arise from nutrient deficiencies and cause
chronic diseases and malnutrition.

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 • 1700 Scottish Dr James Lind, Scurvy
Nutrient • The first to be encountered in sailors
Deficiencies : • C vit deficiency
Historical • -1900s germs, malaria, tuberculosis withdrawal
Perspective studies, pellegra (B3 vit (niacin)), beriberi (B1 vit
(thiamine)) and rickets (D vit)
• -1912 vitamins were isolated. Rickets, pelegra,
scurvy treatments
• -1940 first dietary guidelines
• 1950, relationship of excessive intake of energy, fat,
sugar, sodium with diseases

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• 1974 Malnutrition is a serious problem
• 1995 – Mandatory nutrition screening in hospitals (within 24 hours)
• 2012- Etiological view of malnutrition, acute, chronic diseases and hunger
 Major Causes of
Death and Chronic
Diseases
• Heart Conditions
• Cancer
• Chronic Lower Respiratory Tract
Diseases
• Accidents
• Paralysis
• Alzheimer's Disease
• Diabetes
• Influenza and Pneumonia
• Nephritis Nephrotic syndrome
• Suicide

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 Nutrition Screening
And Nutrition
Assessment Tools

• DETECTION SCREENING TOOLS

DESIGNED TO QUICKLY SCAN
NUTRITIONAL STATUS.
• Nutritional assessment tools
define malnutrition.

• Nutrition screening tests can be

done individually and socially.
Individuals at risk are referred to
primary care physicians.

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 • Height and weight
Basic principles of
• A history of weight gain or weight loss
nutrition
• Change in appetite
screening
• Lifestyle changes
• Disorders of the digestive system
• Laboratory criteria (blood, urine, or both)
• Family history, previous medical history

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Widely Used Nutrition Screening Tools

Widely Used Nutrition

Screening Tools

Malnutrition screening tool

Mini nutrition assessment
(MNA)
Universal Screening Tool for
Malnutrition (MUST)
Nutritional Risk Assessment
(NRS 2002)
Nutrition Screening Patient Population Risk Screening Parameters Measures for Malnutrition Risk
Tool Adults hospitalized for acute Recent weight loss 0-1 score for recent food intake
Malnutrition care, oncology patients Recently deficient nutrient 0-4 points for recent weight loss
screening too intake Total score: ≥2= malnutrisyon
riski altında

Universal Screening Adult patients receiving acute RDA 0-3 for each parameter
Tool for Malnutrition medical care, serious patients Weight loss (%) Total score: > 2 high risk
(MUST) hospitalized for medical surgery Acute illness 1=medium risk

Mini Nutrition For subacute and outpatient Recent food intake Total score of 0-3 points for each
Assessment (MNA) patients Recent weight loss parameter
Mobility < 11= at risk of malnutrition
Recent acute illness or
physiological stress
Neuropsychological problems
RDA
NRS 2002 Patients hospitalized for Recent weight loss(%) 0-3 points for each
acute care hospitalized RDA parameter
for medical surgery Severity of the disease Total score >3= start
Old age (>70 years) nutritional support
Food intake or eating
problems, skipping meals
 https://www.bapen.org.uk/pdfs/must/must_full.pdf

• https://www.mna-elderly.com/sites/default/files/2021-10/mna-mini-english.pdf
• https://dosyaism.saglik.gov.tr/Eklenti/71685/0/hbfr13-nutrisyonel-risk-skoru-nrs-2002-
degerlendirme-formupdf.pdf
• https://wwwn.cdc.gov/nchs/nhanes/nhanes3/anthropometricvideos.aspx
 • After the Subjective Global
Assessment (SGA) form, which
was initially used for malnutrition
screening, an accepted diagnostic
tool began to be used.

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 STANDARD METHODS USED • Anthropometric measurements method
TO ASSESS NUTRITIONAL • Anthropometry shows bone muscle adipose
STATUS tissue in humans.

• Weight, foot length length, horizontal length,

skin fold thicknesses, limb lengths, wrist width
and head, chest and waist circumference are
some of the anthropometric measurements.
• Thanks to these measurements, many indices
are found. FOR EXAMPLE, BMI

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WHO BMI FORMULA Weight (kg)/ Height2
(meters)

Application
Below 18.5 Underweight

18.5–24.9 Normal weight

25.0–29.9 Pre-obesity

30.0–34.9 Obesity class I

35.0–39.9 Obesity class II

Above 40 Obesity class III

 • Anthropometric data for infants and children reveal
overall health status and dietary adequacy, and their
growth and development trends are examined. The
collected data formed the reference standards and
growth charts
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Biochemical Measurements Method

• Differences in the amount and composition of a person's diet are reflected in the concentration and metabolites of chemicals in tissues and
body fluids. However, laboratory results are insufficient to make a diagnosis.alone.
• Biochemical results are also influenced by non-nutritional factors such as medications, hydration, disease, stress.
• Widespread deficiencies determined by biochemical results;
• Iron, folic acid, B6- B12
• Thiamine, riboflavin, niacin, C vit
• All Fat-soluble vitamins, (A,,D, E, K)
• Iron
• Iodine
• Cholesterol
• Triglycerides blood lipids
• Glucose
• Enzymes related to heart conditions
 Clinical Method: Clinical history usually includes information such as
medical diagnosis, recent hospitalizations,
History and medications, changes in nutrient and fluid intake,

Physical food supply and ability to prepare, and weight

changes.

After obtaining an anamnesis, a nutrition-oriented

physical examination should be performed

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 • Dietary assessment methods collect information on the
food supply and the nutrients consumed by individuals
and groups
• . FAO IN USA, LABOR FORCE STATISTICS

• Turkiye=TBSA
• Real food intake data, diet questionnaires are made with
nutrient diaries, 24-hour reminder, food consumption
frequency questionnaires, food habit questionnaires

Diet Assessment
methods
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• NHANES is an example of a long-running survey program designed to assess the health and
nutritional status of adults and children in the United States. This questionnaire also conducted a
physical and history evaluation.
Signs and Symptoms of Nutritional Deficiency
Body Signs and Nutrition Element
system Symptoms Shortage
General stunted Energy
Appeara
nce
Skin Rash Many vit, zinc
Rash on the sun- essential fatty
exposed place acids
Bruising easily Niacin (pellegra)
C or K vit
Hair and Thinning or hair Protein
nails loss in the hair Selenium
strand, iron
early graying of
the hair
Spoon nail
Eyes Night Vision Impairment A vit
Corneal keratomalacia
Mouth Cleft lip and glossy Riboflavin, niacin, pridoxin, demir, C vit,
Bleeding gums riboflavin
Ekstremiteler Oedema Protein
Neurological Sock glove style paresthesia or numbness Thiamine (Beriberi)
TetanCognitive and sensory deficits Calcium, magnezyum
Thiamine, niacin, pridoxin, vitamin b12

Skeletal System Muscle Loss Protein, Dvit kalsiyum, c vit

Bone deformation
Joint pain, swelling

Gastrointestinal Diarrhea Protein, niacin, folate, b12

Diarrhea and dysgeusia Zinc
Dysphagia and odynophagia Iron

Endocrine Tiromegali Iodine

 2nd week
Nutritional Assesment
Phd © Fatma Özsel ÖZCAN ARAÇ
 • Nutritional Epidemiology
• It deals with the causes of diseases in
societies and how diseases develop and
spread. By definition, it is the study of
health-related events and events in certain
communities (locality, school, city, state..)
based on scientific and systematic data.

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 Last WEEK QUİZZZ

The main difference between a nutrition

screening form and a nutrition assessment form
is:
a) Screening forms provide screening for
malnutrition
b) Screening forms determine the risk of
malnutrition
c) Screening forms diagnose chronic disease
d) Screening forms measure weight gain

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 • Which of the following does the
information contained in the
Clinical History not include?
• Drug treatment
• Changes in food intake
• Medical diagnosis
• Laboratory tests

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 • The most reliable indicator of
poor nutritional status,
• A) weight loss

• B) low albumin concentrations

• C) low nutrient intake
• D) Poor clutch strength

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 Anthropometric
Anthropometric assessment also shows us the loss of muscle mass and the distribution
of adipose tissue
Values derived from some measurements are used to determine body composition
(body fat percentage)

In the evaluation of body fat, anthropometric measurements such as bki, der, fold
thickness were evaluated using dual energy x ray – dual x ray DXA) as a reference. It is
said that skin fold thickness is a better method of body fat

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 Breakpoints were created by applying statistical analyses
Anthropometric Anthropometric indicators and cut-off points are assessed by height, weight and
Indicators and age.

Breakpoints A cut-off point is called the point at which individuals or populations need
intervention
The application of universal breakpoints facilitates cross-ethnic comparisons.
Helps to analyze changes and trends in society
EG: In order to classify central obesity in children as well as in different ethnic
groups, the waist height ratio point has been proposed as 0.5.

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 • In growth references, z-scores
and percentages are designated
as cut-off points to classify
nutritional status.
• In pediatrics, the measurements
required up to 2 years of age are
length, head circumference and
weight according to length. Over
3 years old are height, weight and
BMI

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 Çocuklarda Boy ve
Uzunluk

• In order to accurately measure a

child's height, children who are
too young to stand should first be
laid on their backs on the board.

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• For children who are unable to stand for reasons other than age, alternative methods are used,
including knee height or upper arm length. Knee height is measured with a special caliper from the
top of the patella to the bottom of the foot when both the knee and foot are at a 90 degree angle.
Race- and gender-specific formulas are used for the height of a child aged 6-18 years
• White children = Boy height: 40,54+(2,22xknee height)
• Girl:height= 43,21 +(2,15xknee height)
These values should be compared with specific standard curves specified for knee height
calculations.
 • For patients aged 2-20 years,
weight, height and body mass
index should also be drawn.
Shortness in height is determined
when the average height and age
of the fence is more than two
standard deviations or less than
the third percentile. Children
older than two years old are
measured with a wall-mounted
stadiometer.

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Percentiles and Z scores

• Two indicators commonly used to assess children's nutritional status and growth performance are
the percentiles and the Z score.
• The percentile is defined as the position of an individual on a given 100-point reference
distribution. Indicate the percentage that should fall below a percentile value. There is a growing
consensus on the use of BMI percentiles instead of weight according to height in the evaluation of
overweight and obesity in children older than two years of age
• There are several considerations that support the use of Z
scores. The first is calculated both the mean and standard
deviation from the distribution of the reference
population, and the second is that the z scores are
comparable measurements between age, sex and
measurements. Third, a group Z score is continuously
variable.
• When drawing and interpreting curves in children, a ruler
should be used at each doctor's visit to draw a line from
the age after the child's age is on the horizontal axis.
Then there is a specific measurement (weight, height,
height and head circumference) on the vertical axis, and
a line is drawn at the intersection of age and
measurement to determine the percentile value.
• https://www.who.int/tools/child-growth-standards/standards/weight-for-age
Height growth rate

• It is used to detect growth abnormalities in the course of chronic diseases If a child is over two
years of age and the height growth rate is lower than 4 cm/year, they should be evaluated for
nutritional deficiencies 95% of children are more than 4 cm Height growth increases most in
adolescence boys 6-12 cm/year girls 5-10 cm/year
 Stature in adults
• For height measurement is done with a standard meter of
accuracy keisin with a fixed vertical ruler or adjustable
sliding horizontal head.

• The person being measured is expected to stand upright on

a hard surface, face the face with his arms at his side in a
comfortable position, stand straight with his legs adjacent
straight, and stand with his feet flat and heels together.

• The measurement is made in the frankurt plane, where the

head, lower eyelid or socket is at the same level as the
upper part of the ear

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 • If the individual is unable to
stand or is bed-bound, hand
opening, knee height, or forearm
length are measured for the
individual's
• The hand open measurement is
measured from the sternal notch
between the middle and upper
fingers to the net, and the knee
height is measured with a caliper
when both the knee and ankle
are 90 degrees.

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•
 • Forearm length is measured with an
anthropometric tape measure with the
individual's left arm straight on the chest
and fingers bent over the chest pointing
to the right shoulder.
• FROM THE TIP OF THE DEAD ELBOW
(OLECRANON protrusion) should be
performed on a bare arm up to the
styloid protrusion (the prominent bone
of the wrist). It's low-cost but Asians and
blacks find it wrong for the size.

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 • As people get older, their height shortens,
so these measurements can answer. In the
same way, postral posture disorders also
affect

• half arm length decreases like standing

height and is a good for calculate BMI,
especially over 65 years of age

• Knee height may be sufficient to measure

height especially in bed-bound people.

• If BMI is to be used in the evaluation of

malnutrition in the calculation of forearm
length, it is recommended to add 1.8
kg/m2.

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 HEAD CIRCUMFERENCE
• In children under 3 years of age, head
circumference measurement, known as the
frontal-occipital environment, is important
because this period coincides with the fastest
brain growth period.
• Accurate measurement requires a flexible tape
measure to be applied with a maximum head
diameter along the supraorbital ridge at the
back of the head. The value should be shifted to
the nearest cm and also marked in the growth
table.

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 For accurate follow-up, at least 3-6 intervals, preferably 6-12 months2
measurements are required. Head measurement is rarely applied after 16
years of age
Head circumference is clinically associated with both height and weight,
especially in tall and short children, measurement is important. THE MOST
IMPORTANT GROUP IS NEWBORNS
The development of head circumference is influenced by ethnicity. Age,
gender and population comparisons above 2 standard deviations of the mean
and being under macracephaly suggest microcephaly.
The condition caused by increased pressure on the brain due to excess
cerebrospinal fluid indicates hydrocephalia.

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• Cranioosteonosis is determined by negative standard deviation and refers to the premature closure
of skull sutures.
• Adult weight measurements are made only with little clothing. There are special scales and scales
for bed-bound people. Especially in malnutrition weight follow-ups, weight weighing should be
done at the same time of the day.
• Adjustments should be made using a factor that estimates the percentage of weight for amputees.
• - (Weight/100-%amputation)x100
 • Ideal weight or ordinary body weight can be used in nutritional status calculations.
• Estimating Energy Needs: Indirect Calorimeter
• It is more reliable but more expensive than the use of estimated equations in energy
calculation in the clinical setting. Stress is able to calculate trauma factors.
• It is used in equations such as Harris Benedict, Mifflin-St. To use these equations, the
correct kg and height and age are needed. Then we need to add factors such as
activity, stress, fever, malnutrition to calculate the total energy. (1.2-1.5 times) Both
equations consider energy reductions due to aging: The possible mistake is the lack
of lean mass separation. It is known that the Harris Benedict equation can
overestimate the energy calculation by 5-15%. It is known that it should not be used
in critically ill patients and recommended by the Academy of Nutrition and Dietetics.

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Expected Normal BMI’S

• 9-24 years: 19-24 BMI

• 25-34 years: 20-25 BMI
• 35-44 years: 21-26 BMI
• 45-54 years: 22-27 BMI
• 55-64 years: 23-28 BMI
• 65 years and older: 24-29 BMI
 Waist-to-Height Ratio

• Waist to height ratio is an indicator of the

risk of central obesity and cardiovascular
diseases.
• It can also be used to assess cardiometabolic
risks in children.

• It is obtained by dividing the waist size by the

length.

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Body Mass Index
• Central obesity works as a complex endocrine
hormone that produces various hormones and
cytokines
• It is involved in inflammatory , metabolic
processes through various mechanisms,
including hepatic lipogenesis and hepatic insulin
resistance and the release of free fatty acids
from adipocytes.
• BMI is a valid predictor of adiposity. It depends
on the variables gender, age, height
 • Compared to other methods such
as triceps and skin fold thickness is
a stronger data for estimating the
percentage of fat in children and
adolescents. A child with a BMI of
85 percentile and above is
overweight and 95 and above is
obese, while a child with a BMI
below 5 is underweight (Z scores
and percentiles)
• The relationship between BMI and
muscle mass may vary in people of
the same height. Bodybuilders,
those who play power-related
sports can be misjudged.
Overweight can be calculated
while typically having a lower fat
content.

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 • Low BMI in adults is effective in the diagnosis of sarcopenia. In sarcopenia there are
losses in lean mass (fat free mass FFM)
• Waist circumference
• Adiposity, a marker of cardiovascular disease and type 2 diabetes
• The waist circumference measurement place is very confused ??
• -the bottom or bottom of the floating rib
• The midpoint between the iliac wing and the floating rib
• -Visually the narrowest point of the abdomen

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 • The WHO says that at BMI level, there are
ethnic groups that may reflect more body fat
around the waist. Research shows that in Chi
Japan India Korea Huney Asia, higher body
fat percentage in lower BMI has higher body
fat than the white race. Blacks have lower fat
mass and higher muscle mass

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 Skin fold thickness
Another method used to estimate body fat percentage (CALIPER)

Skin fold thickness measurements are assumed to account for

50% of total body fat

Skin fold thickness (DKK) measurements,

Subscapular

Triceps

Biceps

Suprailiac

It is taken from at least 3 and at most 9 regions of the body,

including the abdominal

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 • Ensure that you take the skinfold in a rotational order (circuit) and do
not complete consecutive readings at each skinfold site
• Grasp the skinfold firmly between your thumb and index finger of
your left hand. The skinfold is lifted 1 cm and recorded with the
callipers held in the right hand
• Keep the fold elevated while the measurement is recorded
• Take the skinfold measurement 4 seconds after the calliper pressure is
released
• Take a minimum of two measurements at each site. The acceptable
range between repeated measures is 1mm. If the values vary by more
than 1mm take an additional measurement and use the average of the
three measurements
• Skinfold measurements should not be taken when the skin is wet or
after exercise
• Remember age, size and state of hydration may affect skinfold
measurement

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• The most commonly used skinfold test is the Durnin & Womersley four site test, devised in 1974
This test uses the sum of the triceps, biceps, subscapula and suprailiac skinfolds to produce an
estimate of body fat for males and females.
•
Once you have completed and recorded the measurements of the four sites, refer to the following
tables for the conversion of the sum of the four skinfolds to % body fat and for a rating of the sum
of the four skinfolds for males and females of normal and athletic ability.
• Abdominals: Pinch a vertical fold of skin one inch to the right of your belly button.
• Biceps: Pinch the skin vertically halfway between the elbow and shoulder on the front of your arm.
• Calf: Pinch the skin vertically on the inside of the largest part of the right calf.
• Lower back: Pinch the skin horizontally about 6 inches above the waist and 2 inches to the right of the
spine.
• Midaxillary: Pinch the skin vertically directly below the armpit at the same height as the base of your
breastbone.
• Pectoral: For men, pinch a diagonal skinfold halfway between the front edge of your armpit and your right
nipple. For women, pinch a diagonal skinfold about two-thirds of the way from your right nipple to the front
edge of your right armpit (i.e. closer to your armpit than your nipple).
• Subscapular: Pinch the skin diagonally an inch beneath the middle of your shoulder blade (about three
inches to the right of your spine and six inches above your waist).
• Suprailiac: Pinch the skin diagonally directly above the bony protrusion on the front of the right hip (the iliac
crest).
• Thigh: Pinch the skin vertically halfway between the top of the kneecap and the top of the front of your
thigh.
• Triceps: Pinch the skin vertically halfway between the elbow and shoulder on the back of your arm.
• For men, chest, abdomen, thighs are recommended, while for women, triceps, suprailiac and thigh
measurements are recommended.
• Once you have recorded the skinfolds at each site you could simply use these measurements to
compare with subsequent measurements to show change in the clients skinfold over time (which
we recommend), alternatively you can add the sum of the four sites together to work out an
estimate of your clients body fat percentage using the following table.
• *Measurements can be answered in the elderly, (skin elasticity)
 Use the table below for the conversion of
the sum of the four skinfolds (biceps,
triceps, subscapula and suprailiac) in mm
into % body fat.

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• Lean Tissue weight = Total body weight - (total body weight x body fat percentage)
 Upper Middle Arm
Circumference
• Malnutrition is one of the ways to evaluate protein energy
reserves. This measurement is used at any age after 2 years
of age
• In children, UOC was associated with mortality
• The person uses an inelastic tape measure to measure the
back surface of the left upper arm when both feet are
balanced and the person taking the measure is in the
position with his back to the person being measured The
elbow of the left arm is bent at a 90 degree angle, the left
palm is facing up. Then the upper arm length is measured
and the tape measure is placed on the acromion protrusion
(shoulder blade). And the olecranon (elbow) is extended to
the protrusion of the tape measure placed at the center
point and measured.

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 • In aneroxic adolescents, the use of upper
middle arm circumference is
recommended.
• Upper Middle Arm Muscle Area

• Used to find muscle competence

• Middle Arm Muscle = Upper Middle Arm
Arm Thickness – (3.14 TRICEPS SKIN FOLD
THICKNESS)

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 • Calf/Lower Leg
• The National Institute of Aging recommends it – it also indicates muscle atrophy.
• In the literature, cutting values from 29 cm to 33 cm in men and from 27 cm to 31 cm in
women are indicated.
• A general cut-off point of 31 cm is indicated for disability, sarcopenia, reduced bone
mineral density for both sexes.
• Inverse proportion between high calf circumference and fragility

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 • Thigh/Upper Leg Circumference
• Detects muscle mass (an
indicator of a bone fracture).

• There is an inverse relationship

between thigh circumference and
cardiovascular risk. In those with
a thigh < 55 cm, the risk increases
to 2 times.

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 • Limitations of anthropometric
measurements,
• May vary depending on the time
of day (why)
• The measurement location must
be marked for consistent
repeated measurements.
• The quality of the tape measure
can vary.

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3 rd week
 • To understand an individual's nutritional
status, body composition, including
adiposity (body fat), FFM (bone and lean
mass), and water, needs to be evaluated

Body and measured.

Composition
• In the literature, direct, indirect and double indirect
methods are used to measure body composition.

• Methods are used. These methods can be easy and

cheap field methods, or they can be complex and
expensive.

• Laboratory methods may also be available. The only way

to directly measure body composition is cadaver studies.
 470 × 357

• “"Hydrostatic Weighing" or "Hydrodensitometry"

and "Air Displacement Plethismography", which are
considered to be the "gold standard", are often
used to determine body density or to develop
regression formulas. In addition, body composition
can be determined by imaging methods involving
advanced technologies
• Bu yöntemlerde vücut kompozisyonu
bileşenlerinin daha detaylı belirlenmesi
amacıyla Dual Energy X-ray
Absorptiometri (DXA), İsotope Dilusyonu,
Potasyum 40 sayımı, Nötron Aktivasyonu
Analizi, Yakın Kızılötesi İnteraktans (Near
Infrared Interactance-NIR), Manyetik
Rezonans görüntüleme (MRI) ve
Biyoelektrik İmpedans Analizi (BİA)
yöntemleri kullanılmaktadır
• The determination of body composition is
usually divided into two parts, considered as fat
mass and lean body mass. For a more detailed
determination of lean body mass; At the
elemental level, at the chemical level, with
anatomical variables and at the liquid metabolic
level, models are also used,

• In the literature of body composition models, the

terms "compartment" or "component" are used
to describe the chemical structures or parts of
the body
• The 2-Component model evaluates
body composition by basically dividing
the body into two masses. These are "Fat
Mass" and "Lean Body Mass". 2-After
calculating the body density for the
component model, the amounts of body
fat mass and lean body mass can be
easily calculated.
• In the 2-Component Model, body composition regression
formulas were often obtained by using DXA and hydrostatic
weighing methods as reference methods. The disadvantage
of the hydrostatic weighing method, in which the 2-
component model is used, is that it does not provide
information about the distribution of fat in the body.
• In 3-B3-Component models, body composition is examined as fat mass, water and lean
body mass. Lean body mass can be examined in two different ways, either as chemical or
anatomical components (Toomey et al., 2015). In the anatomical model, which is often
used in determining body composition, it is assumed that body water and lean body
mass are constant. With a different approach, body composition can also be examined in
3-Component models, including fat mass, bone mineral content, and non-fat mass (all
mineral-free tissues such as organs). This type of 3-Component model, which requires
the measurement of bone mineral content, requires the DXA method (Toomey et al.,
2015).
• Body composition differs between men and
women. Men have more lean mass, and women
have more fat mass than men. Men are more
likely to accumulate adipose tissue around the
trunk and abdomen, whereas women usually
accumulate adipose tissue around the hips and
thighs.
Total body potassium has been discussed in the
past as an important component in assessing
nutritional status and composition. Potassium is
found in 70% skeletal muscles
Hand grip Strength
• Determination of hand grip strength (ECG) is a valid method used to
determine nutritional status in clinical and epidemiological studies.

• There is evidence that in the presence of malnutrition, muscle function is impaired and
muscle strength decreases

• The earliest malnutrition occurs in muscle cells, thus affecting muscle cell function.
Measurement of muscle strength is therefore a sensitive method of assessing nutritional
status
• Hand grip strength (ECG) has been used in the clinic in
musculoskeletal, neurological muscle diseases, before and after
surgery, in the elderly population and in cardio-vascular diseases

• Grip strength should be assessed while the patient is sitting in

the chair. The elbows are held close to the body and in 90°
flexion. The wrist is neutral. The person to be measured is
asked to grasp the dynamometer and squeeze it as strongly as
possible. The test result is determined by calculating the
average of the three measurements. Norm values for
measurement: 47-40kg in men aged 20-69 years (left hand
less than 2 kg) 30-24kg in women (left hand 1.5-2kg less)
BIOELECTRİC IMPEDANCE ANALYSİS (BIA)

• Bioelectrical impedance analysis (BIA) has been proposed for

measuring fat-free mass, total body water, percent fat, body
cell mass, intracellular water, and extracellular water: a
veritable laboratory in a box

• BIA assumes that the body consists of two compartments, fat

and FFM (Body weight=Fat+FFM). BIA is best known as a
technique for the measurement of percent body fat although
it has more recently been used for estimating skeletal muscle
mass too.
 BIOELECTRİC IMPEDANCE ANALYSİS (BIA)

Experts generally agree that the

accuracy of the measurement Hydration level: Dehydration
Body weight: Bioelectrical
depends, in part, on the quality may cause fat-free mass (muscle
impedance analysis may be less
of the device. In addition, other and bone) to be
accurate in people with obesity.
factors may affect a reading underestimated.
when you use a BIA scale

Training load: Some scales

Recent food or drink
Recent exercise activity: High- have a setting for athletes who
intake: The results of a study
intensity exercise may affect the train more often. The settings
suggest that BIA may be more
accuracy of BIA readings. are intended to increase
accurate after overnight fasting.
accuracy.
• Some researchers also say that
ethnicity can affect the accuracy
of BIA measurements. Overall,
studies show that this method is
not very accurate although it may
be able to track change over time,
your results are unlikely to reflect
your actual body composition.
Evaluation Methods: Biochemical
Evaluation
• Biomarkers play a critical role in improving the diagnosis, follow-up, course
and treatment development of the disease and in larger biomedical
research initiatives. Understanding the relationship between measurable
biological processes and clinical outcomes is vital to expanding treatment
options for all diseases and deepening our understanding of normal,
healthy physiology.

• Biomarkers should be inexpensive, easily available, reproducible and

objective. The aim of clinical practice should be to reduce morbidity and
mortality. It should offer treatment options for patients with the same
diagnosis, providing clear and unambiguous data that has the potential to
definitively show whether interventions are effective and safe.
• Types of Biological Material

• ● BLOOD Capillary blood Artery blood Vena blood Blood samples; It can be
examined in the form of whole blood, plasma and serum. ● Gaita ● Gastric sap
● Urine ● Amniotic fluid ● Semen ● Saliva ● Sweat ● Kidney and gallstones ●
Tissue fragments ● Fluids collected in pathological states; Acid fluid Cystic
fluids Fissure fluids Aspiration material
• The laboratory finds many reasons that affect the test results

• Effect of posture

• The blood volume in a standing person is 600-700ml less than in a lying person.
The real reason is that the protein-free fluid of the blood passes between the
tissues, causing a significant difference in plasma volume. In parallel, the
concentration of all proteins, including enzymes and protein hormones,
calcium, bilirubin and protein-bound drugs partially bound to proteins is
affected.
• In the transition from a reclining to a
seated state:

• – AST, ALT – Albumin, Alk.fos., – Amylase,

Igs – Cholesterol, Triglycerides – Ca,
Thyroxine

• Varies between 3-11%

• Aldosterone (provides Na-C balance)

• In a lying state; Reference range of 3-10

ng/dl, Seated; Female: 5-30 ng/dl Male:
6-22 ng/dl'
• In case of prolonged bed rest; Total
protein Albumin decreases

• Calcium excretion in the urine increases

• It takes three weeks for the disturbed

balance of calcium and nitrogen to be
restored.
EXERCISE
Glucose (drops in heavy exercise)
, • ALT: 41% • AST: 31% • Creatinine: 17% • Phosphorus: 12% • Acid
phosphatase: 11% • LDH • CK • Urea • Creatinine • Transferrin
increases
It should be taken into account that plasma renin activity,
aldosterone, growth hormone reach pathological levels.
• Travel:

• • After 10 hours of travel, the

circadian rhythm is disturbed. It
returns to its former state in 5 days.

• • Fluid and Na retention occurs in

long-duration flight. After 2 days, it
returns to normal.
• Fasting Fasting is particularly desirable for
some tests, such as blood glucose
measurement, and 10-12 hours of fasting
is desirable for sampling in terms of
standardization and techniques of
laboratory procedures. This should not be
longer than 16 hours.
Hunger-long hunger
● Aldosterone ↑, ● In the blood: : K ↓ : Mg ↓ : Ca ↓ ● Branched
chain, amino acids 100% ↑, ● Uric acid ↑, glomerular filtration ↓

Growth hormone can be up to 15 times higher during

prolonged fasting. It returns to its former state after 3 days.

● T3 and free T3 50% on the third day of fasting ↓

The effect of nutrients

• Some plasma building blocks are affected by foods that have been eaten and
drunk recently. The fact that the serum is lipemic may affect the methods used
for measurements.

• For vegetarians:

• – Urea 50% from normal diets ↓,

• – Cholesterol, triglycerides 2/3 of those who eat a normal diet,

• – Total lipid, LDL, VLDL and B12 ↓

• Two cups of coffee contain free fatty acids ↑% less↑, glycerol, total lipids and
lipoproteins less ↑

• Avocado affects the release of insulin, OGTT is disrupted.

• The mannoheptulosis contained in avocado has been found to inhibit both

insulin synthesis and release
• -bananas, tomatoes, avocado:5
HIAA ↑

• • Caffeine, theophylline
catecholamine ↑

• • Purin-rich food: uric acid ↑

• • Protein: urea nitrogen ↑

 • -Retinal-binding globulin,

• ● Transferrin,

• ● Prealbumin

• The decrease in their value is indicative

Malnutrition of malnutrition
• Cortisol ↑, thyroid hormones significantly ↓↓

• Fe is not affected by malnutrition.

• ● Erythrocyte count ↓,B12 vit and Fe normal

• Excessive Protein Diet Urea, Phosphorus and Uric acid remain high for 12 hours,
Cholesterol and Growth hormone for one hour
• Excess Fat Diet BUN and Uric acid ↓

• ↓. Dietary cholesterol intake of 50% more increases blood

cholesterol by only 5-10%

• Smoking

• Cholesterol and Triglycerides ↑ HDL-K ↓

• GH can exceed 10-fold ↑ Carboxyhemoglobin 10% of total

hemoglobin within 30 minutes after smoking a cigarette.
Erythrocytes ↑. ↑ Leukocytes up to 30%.
• Büyüme hormonu uykuya daldıktan kısa bir süre sonra ↑

• ● Oysa bazal plazma insülini, sabah ve akşam daha yüksek düzeydedir.

• ● ACTH ve Kortizol gece saatlerinde minimal düzeydedir.

• ● İdrar hacmi ve kreatinin atılımı gece ↓

Isoniazid: Hepatitis (Isoniazid may increase the incidence of hepatitis. Patients with chronic
liver disease and severe renal failure should be closely monitored while using Isoniazide.)
High doses of vitamins C: Glucose ↓ Antioxidant vitamins have an important role in the
regulation of insulin secretion.

Morphine and meperidine: AST, ALT, GGT, Amylase, Lipase ↑

Increased AST activity may be high enough to suggest myocardial infarction.

Diuretics: Often K and Na'u ↓. Thiazides: Hyperglycemia, Hyperuricemia Phenytoin: FSH

improves sperm count and fertility ↓ T3 and T4 ↓.

There may be a folate deficiency. Vitamin B12 ↓ in 10%.

Oral kontraseptifler

• Antitrombin III ve Folat belirgin derecede düşer.

Pıhtılaşma faktörleri • Kolesterol • Demir • Total demir bağlama

kapasitesi (TDBK) • Na • T4 • Tiroksin bağlayıcı globulin (TBG) ARTAR.
• ↑ Erythrocyte count and Hb evident in living at high altitude. Increased number
of erythrocytes, uric acid in the urine with nucleoprotein turnover ↑.

• Biochemical parameters have certain side lives. Repeating the test before this
period will not benefit from the follow-up of the disease and will bring
additional burden to the country's economy. For this reason, it is very important
for clinicians to know the minimum recurrence time of each test
 • A complete blood count is a valuable and
relatively inexpensive test that helps the
physician approach the diagnosis.

• What values are examined in the blood test? Red

Complete blood blood cells (erythrocytes) that carry oxygen in

our body and white blood cells (leukocytes) that

count analysis allow us to defend against diseases are counted

(hemogram)
and their size is examined. As you know,
hemoglobin proteins are found in red blood
cells. The protein that carries oxygen is
hemoglobin. If the amount of hemoglobin
decreases, oxygen cannot be transported
• RBC (red blood cells): Red blood cells give the amount of
cells that carry oxygen. RBC↓ in anemia or blood loss

• Sitting on a high altitude floor COPD Kidney disease

Polycythemia disease (Hemoglobin more than normal
erythrocytes) INCREASES RBC
• MCV (mean corpuscular volume): It is
the average size of the cells carrying
oxygen. If the MCV is low, the
erythrocytes are smaller, if it is high,
they are more enlarged. MCV↓ in iron
deficiency anemia (erythrocytes shrink)
MCV↑ in vitamin B12 deficiency anemia
(erythrocytes are enlarged)
• Hb (Hemoglobin): Shows the total
amount of hemoglobin in the blood.
Hemoglobin in anemias ↓. MCH, mean
corpuscular hemoglobin: Indicates the
amount of hemoglobin in erythrocytes.
MCHC, Mean Corpuscular Hemoglobin
Concentration: It is the expression of
erythrocyte hemoglobin concentration as
a percentage.
• PLT (Platelets): Platelets. In other words,
it shows the cells that provide clotting.
Young platelets become larger.
Normally, 10% of platelets are large.
The number of large platelets increases
due to excessive destruction and
consumption.
• WBC (White Blood Cells-Leukocytes): White
blood cells. It shows the sum of the body's
defense and immune cells, namely leukocytes.
Normal values are between 5-10 thousand.

• Types of White Blood Cells

• 0 Neutrophils

• Basophils

• Eosinophils

• Lymphocytes

• Monocytes
BİYOKİMYASAL TESTLER NEDEN
YAPILIR
With the purpose of diagnosis: important in determining the presence or absence of any
pathological condition. Biochemical examinations can sometimes be much more sensitive than
clinical findings.

For the purpose of differential diagnosis: Although the clinical anomaly identity is known, the
specific diagnosis is unknown. When the test is selectedn ihtimal dahilinde olan hastalıklarda farklı
sonuç verenler işaretlenir.

For the purpose of monitoring treatment: It is used to monitor the outcome of treatment after the
diagnosis has been made, which is more important than the diagnosis.
They are used to indicate known, unknown side effects of treatment or another complication of
the disease.
 erken teşhis amacı ile
yapılan bu testler:
tedaviyi
kolaylaştırmaya, toksik
Tarama amaçlı toksik etki gizli bir hastalığın
etkiyi önlemeye, erken
kullanılırlar: araştırmasında, ortaya çıkarılmasında,
teşhis ile yaşamı
uzatmaya, hastalığın
ortaya çıkmasını
geciktirmeye yararlar
• The reference range of samples obtained from healthy individuals, which is
determined by each laboratory with certain statistical calculations under its own
conditions, is taken as the basis. Normal value: It is an artificial value given for
any body, indicated by lower and upper limit values.

• Example: Serum Sodium normal 135-145 meq/L means a sharp boundary

between normal and abnormal (pathological)
• Reference range: Test results generally
show the expected values in the healthy
population and reference values are used
instead of normal values today, medical
judgment is important when using these
values determined by different approaches.

• When determining the reference values,

the average and standard distributions of
the results obtained from healthy
individuals are calculated. In general, the
calculated range of + 2 SD is used for a
large number of test results.
There may be a decrease due to the circadian rhythm
● The tourniquet may be overtaken
● Diuretics may have been taken
● Diet with excessive carbohydrates
● Prolonged hunger
TO BE CONTİNUED
Sample Footer Text

4 RD WEEK

11/6/2024
PHD © Fatma Özsel ÖZCAN ARAÇ
1
Sample Footer Text

• Excretion of nutrients is
reduced. For example, its
excretion in the urine decreases,
but the pool in the body does
not change.
• The pool in the body decreases,
but its functions do not change
• Functions are disrupted and

STAGES OF
biochemical manifestations
appear. For example, enzyme
activities are reduced.

NUTRIENT • Morphological changes and

clinical manifestations of
DEFICIENCY insufficiency diseases are

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observed.

2
Sample Footer Text

Serum total protein- Albumin- Transferrin-

HOW TO Retinol binding protein- Thyroxine-
DETERMINE binding prealbumin

PROTEIN Urine creatinine, 3 methyl histidine

Nitrogen balance
LEVELS?

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3
Sample Footer Text

İdrar • Creatine is an energy-storing compound that is

collected in the liver in muscle mass synthesized from
Kreatinin amino acids (glycine, arginine, methionine).
• Creatinine, which occurs with the breakdown of
creatine, is indicative of lean body mass.
• For this purpose, creatinine excreted in the urine (24
hours) is evaluated
• The ideal urine is creatinine in the 24-hour urine;
• 23 mg/Ideal Body Weight (kg)/day for Male
• 18 mg/Ideal Body Weight (kg)/day for Female

11/6/2024
4
• A value called Creatinine Height Index (CBI) is calculated.
• BMI (%) = Measured Urine Creatinine. X100
• Ideal Urinary Creatine
•
Assessment
• 80-100% Sufficient
• 80-60% Medium
• < 60% Heavy
• muscle loss
NITROGEN IN 24-HOUR URINE
• 24-hour nitrogen intake – (24-hour urine-excreted nitrogen +2 g skin and fecal excreted nitrogen)
• The difference is an important parameter for assessing the adequacy of total protein intake. – A
positive nitrogen balance of 3-5 g/day is required for wound healing and anabolism.
• Amount of Protein = % Amount of Nitrogen x 6.25
• Nutrition with formulas containing free amino acids; With feces, nitrogen loss is reduced by 0.2 g
per day.
• Environmental factors; Increasing ambient temperature increases nitrogen loss with sweat.
• In liver and kidney failure, nitrogen balance is disturbed. In chronic renal failure, increases in blood
urea nitrogen should be taken into account.
• In cases where catabolic stress is increased, nitrogen increases in the urine.
EVALUATION OF PROTEIN INTAKE –
SKELETAL MUSCLES
• In the absence of adequate levels of protein, essential amino acids and energy from the diet, amino
acid and protein catabolism increases in skeletal muscles.
• Protein loss and metabolic changes in skeletal muscles can be monitored by urinary levels of
creatinine and 3-methylhistidine
• CREATININE URINE
• Creatinine present in urine is a metabolite that comes mainly from the catabolism of creatine
phosphate in the muscles. In cases where the amount of creatine in the muscles is considered to be
constant, the dye ratio of the amount of creatinine in the urine can be considered as an index for the
evaluation of muscle mass.
• ENHANCING FACTORS
• Obesity Heavy exercise Emotional stress Dietary intake of creatine and creatinine does not
significantly affect total protein intake, but arginine and glycine Menstruation Age Infection, fever
and trauma – non-creatinine chromogens
• MITIGATING FACTORS
• Chronic renal failure – urine volume Type I diabetes mellitus - the presence of acetoacetate in the
urine leads to an error in the method of analysis.
• URINE 3-METHYLTHIDINE
• Analysis of 3-methylhistidine in urine; A large part of the amino acid is found in the structure of
actin and myosin. When actin and myosin are catabolized, 3-methylhistidine is released and excreted
in the urine where it is not used for protein synthesis again. Based on this information, 3-
methylhistidine concentrations in adult individuals may be an indicator for muscle mass.
• FACTORS AFFECTING THE LEVEL OF URINE 3-METHYLTHIDINE
• The meat group is excluded from the diet to control the level of 3-methylhistidine in the diet for 3
days before 24-hour urine is collected.
• Not all of the 3-methylhisidine found in urine comes from skeletal muscles, but some from the heart
and smooth muscle tissue. As much as 5% of this amino acid is excreted in the form of N-acetyl,
which is not analyzed. Age ↓
• Hunger, fever, trauma and infections ↑
• Excretion of 3-methylhistidine in the urine in chronic renal failure ↑
EVALUATION OF PROTEIN INTAKE –
VISCERAL PROTEINS
• The level of visceral proteins is determined by one or more serum proteins.
• • A very large part of visceral proteins are synthesized in the liver.
• The liver is one of the organs affected by protein deficiencies in the diet as soon as possible.
• • Therefore, serum protein concentrations give information about the adequacy of daily protein
intake in the early period in a shorter time compared to other methods
• ALBUMIN
• Compared to other visceral proteins, the albumin pool is proportionally high (3-5 g/kg-
body weight) and more than 50% is found in the extravascular environment.

• Serum albumin levels can provide information about the amount of intravascular visceral
protein. It is not a good indicator of the total visceral protein pool. It is not an appropriate
method to evaluate short-term changes in protein levels, both because it has a large pool
in the body and because it has a long half-life (18-20 days)35-52 g/L
• FACTORS AFFECTING THE LEVEL OF ALBUMIN
In cases of increased excretion with urine and feces, ulcerative colitis, Chron's disease and
kidney diseases↓Conditions in which protein synthesis is reduced; liver diseases and
hypothyroidism ↓Conditions in which blood volume increases: congestive heart failure
and pregnancy ↓In traumatic injury, there is a temporary transfer of albumin from the
intravascular environment to the extavascular fluids. In such cases, parenteral albumin
administration masks nutritional deficiencies
• In short-term fasting, a transient hyperalbuminemia may be experienced since albumin
transfer from the extavascular environment into the vein and plasma volume decreases in
case of dehydration. Since the rate of protein synthesis slows down in geriatric patients,
the response to increases in protein intake is slower. Serum albumin levels decrease in the
quasiorkor, but not in marasmus
• TRANSFErrin
• Basically it is β-globulin synthesized in the liver. It is largely found in the intravascular
environment. Its main function in the organism is that it carries iron.
• Each transferrin molecule binds two molecules of iron. In organisms with adequate and
balanced nutrition, 30-40% of its transfer is used for the transport of iron. It has a
bacteriostatic effect; Because it binds iron, it prevents the increase of gram-negative
bacteria that use iron to multiply. It is a parameter that responds in a shorter time to
changes in protein level because it has a shorter half-life (8-9 days) and less pool in the
body (0.1 g/kg body weight) compared to albumin.g/L
• FACTORS AFFECTING THE LEVEL OF TRANSFER
•
ENHANCING FACTORS
• Due to increased absorption in iron deficiency, their concentration may increase for
transport. (pregnancy, estrogen therapy and acute hepatitis)
• MITIGATING FACTORS
• Diseases of the liver and gastrointestinal tract Kidney diseases Conjective heart failure
Neoplastic diseases Inflammation Conditions of reduced iron absorption High-dose
antibiotics and fungicides tetracycline If iron deficiency anemia and chronic protein-
energy malnutrition are detected, serum transferrin level is not an appropriate parameter
to determine protein level.
• RETINOL BINDING PROTEIN – RBP
•
Retinol is a carrier protein that can bind 1 molecule of retinol on the binding protein. The
RBP+ retinol complex is the smallest of the circulating proteins. This complex exists in
normal physiological conditions due to its transthyretin. Thus, the loss is prevented by
filtration from the renal glomeruli. The half-life of retinol-binding protein is approximately
12 hours and the total pool in the body is quite small (0.0002g/kg body weight). It is the
plasma protein that responds most rapidly to nutritional therapy.
FACTORS AFFECTING THE RBP LEVEL
ENHANCING FACTORS
Supplementation of vitamin A and zinc increases the concentration of RBP. The use of oral
contraceptives may increase serum RBP concentrations.
In chronic renal failure, RBP catabolism in renal tissue decreases and serum RBP level increases.
MITIGATING FACTORS
In liver diseases such as hepatitis and cirrhosis
Acute catabolic processes
Cystic fibrosisAfter surgery,
Hyperthyroidism
In vitamin A and zinc deficiency, RBP mobilization from the liver decreases due to a decrease in the
concentration of molecules to be transported.
RBP in chronic renal failure is not an
appropriate method for assessing nutritional
status.
• PREALBUMIN-TRANSITIN
Prealbumin carries thyroxine and RBP by binding. Compared to RBP, the half-life is longer
(2 days) and the pool in the body is higher (g/kg body weight)Prealbumin has a high
proportion of tryptophan and essential amino acids in its structure. It is therefore an
indicator for the assessment of the amount of essential amino acids in the body. It is a
method used to evaluate the nutritional status of patients.g/L
FACTORS AFFECTING PREALBUMIN LEVELS

ENHANCING FACTORS
Renal failure – competence can not be assessed, the difference can be assessed. Anti-
inflammatory agents, oral contraceptives and estrogen
MITIGATING FACTORS
Gastrointestinal diseases
Surgical trauma and stressInflammation and infection
Advanced stages of liver diseases are not affected by zinc, vitamin A and iron deficiency
• INSULIN-LIKE GROWTH FACTOR
It is a growth hormone-dependent growth factor synthesized in the liver.
• Also called Somatomedin C.
• In the evaluation of the results of nutritional therapy, it responds more sensitively and in a
shorter time than other serum proteins.
• As with other serum proteins, serum levels are variable in liver diseases, renal failure, some
autoimmune diseases and hypothyroidism.
• Stress doesn't change with exercise and sleep. The administration of estrogen changes the
concentration.
• PLASMA ALKALINE RIBONUCLEASE ACTIVITY
•
Plasma alkaline ribonuclease activity decreases in protein malnutrition.
• Values return to normal in 2-4 weeks after treatment.
• It is foreseen that this method can be used especially in cases where the response of
patients with malnutrition to nutritional therapy is evaluated
• PLASMA FIBRONECTIN
• Fibronectin is a glycoprotein. Apart from the liver, the organism is produced in endothelial
cells, peritoneal macrophages and fibroblasts. It has many physiological functions in the
body. Decreasing concentrations of protein malnutrition increase to normal levels with
treatment. Their levels vary with infection, trauma and burns.
• VITAMIN A is stored in the liver in the form of retinyl ester.
•
Vitamin A in serum is found in the highest ratio of RBP by forming a complex of retinol in
a 1:1 ratio. The rest is contained in the form of retinyl esters and a very small amount of
retinoic acid. Serum retinol level 0.7 μmol/LSerum retinol levels are an indication for
sufficiency when stores in the liver are depleted (0.07μmol/g liver weight) or increased
(1.05μmol/g liver weight). If the vitamin A storage in the liver is within normal limits,
serum retinol levels are checked homeostatically.
• PARAMETERS USED TO DETERMINE VITAMIN A LEVELS
•
Serum retinol level < 0.7 μmol/L is epidemiologically indicative of vitamin A deficiency.
• FACTORS AFFECTING VITAMIN A LEVELS
ENHANCING FACTORS
• Kidney diseases Estrogen Oral contraceptives
• MITIGATING FACTORS
• Low fat content in the diet Zinc deficiency Protein energy malnutrition Liver failure Cystic
fibrosis Systemic infections
VITAMIN D
It is found circulating in the forms of 25(OH) vitamin D-calcidiol and 1-25(OH)2 vitamin D
calcitriol. Normal levels in adult individuals are nmol/L. Today, the concentrations of its
metabolites are used to determine vitamin D levels in the body. Although there are
nonspecific methods when the conditions are not suitable, alkaline phosphatase activity and
serum calcium and phosphorus levels also give an idea.
• Clinical use of urine-excreted calcium and phosphorus levels for vitamin D assessment is
not recommended. 25(OH) vitamin D: has a long half-life so it is an indicator for total
vitamin D that is taken in the diet and synthesized endogenously. It indicates both the
adequacy and insufficiency of the vitamin level and the toxicity of the vitamin 25(OH)2
vitamin D: half-life is 4-6 hours. It is an indicator for short-term physiological needs.
Homeostatics are controlled. Therefore, in vitamin D deficiency, concentrations in serum
may temporarily increase.
• FACTORS AFFECTING VITAMIN D LEVELS
ENHANCING FACTORS
• Seasonal changes – the sun
• Use of oral contraceptives
• MITIGATING FACTORS
• Indoor working environment in daily life
• Cigarette
• Obesity
• Steatorrhea, malabsorptions, inflammatory bowel diseases, celiac Anticonvulsant drugs
• VITAMIN E
• Vitamin E is transported in serum in the form of 90% α-tocopherol in LDL. The most
commonly used method for assessing vitamin E levels is serum α-tocopherol
concentrations. The highest proportion in the organism is found in the liver and adipose
tissue.
PARAMETERS USED TO DETERMINE VITAMIN E
LEVELS

Serum α-tocopherolSerum α-tocopherol to cholesterol ratio: ≥2.2 μmol/mmol indicates

adequate vitamin E levels.
Erythrocyte α-tocopherol level – its use is limited, it is technically difficult to detect the level
within erythrocytes. Platelet α-tocopherol level: not affected by serum lipid concentrations.
For large studies of the universe, platelet isolation is not a practical method. Level of α-
tocopherol in adipose tissue and buccal mucosa: this is a valid method for detecting stores.
Normal levels for buccal mucosa, which is easy to apply, have not been established.
• FACTORS AFFECTING VITAMIN E LEVELS
ENHANCING FACTORS
• High total serum lipid levels
• MITIGATING FACTORS
• Cigarette
• Premature birth
• Fat absorption disorders
VITAMIN C
Ascorbic acid is used for both the molecules L ascorbic acid and dehydroascorbic acid. The
most commonly used method for determining vitamin C levels is serum or leukocyte
ascorbic acid concentrations.
After ascorbic acid is transported to the serum, almost all of it is free to bind to any
protein. Vitamin C intake before the analysis affects the values, so fasting blood samples
should be used
VITAMIN C
When the daily intake of vitamin C rises above 70 mg, plasma ascorbate levels (75 μmol/L)
plateau. When the daily intake exceeds 200 mg, it begins to be excreted in the urine. When
daily intake is in the mg range, dietary intake of vitamin C shows strong correlation with
serum or plasma ascorbic acid concentrations. Serum ascorbic acid concentrations are not
indicative for excessive vitamin C consumption.
VITAMIN C
When the daily intake of vitamin C rises above 70 mg, plasma ascorbate levels (75 μmol/L)
plateau. When the daily intake exceeds 200 mg, it begins to be excreted in the urine.
When daily intake is in the mg range, dietary intake of vitamin C shows strong correlation
with serum or plasma ascorbic acid concentrations. Serum ascorbic acid concentrations
are not indicative of excessive vitamin C consumption.
Vitamin B6
• An adult individual has a pool in his body that is rapidly depleted in case of inadequate
intake limited to mg.
• In the body, most often in muscle tissue is found the coenzyme form pyridoxal-5-
phosphate. Since clinical manifestations are non-specific, they need to be described
biochemically.
• PARAMETERS USED TO DETERMINE VITAMIN B6 LEVELS
- Plasma pyridoxal-5-phosphate – indicates tissue level.– Pregnancy ↓
• – Alcohol intake ↓
• – High plasma alkaline phosphatase activity ↓
• – Smoking ↓
• – Aerobic exercise ↑
• – Infections ↓
• – Heart diseases, breast cancer Hodgkin's Lymphoma and diabetes ↓– Bronchodilators and
antihistamines ↓
• Beta blockers and anticoagulants ↓
• PARAMETERS USED TO DETERMINE VITAMIN B6 LEVELS
In erythrocytes, alanine aminotransferase and aspartate aminotransferase indicate both
dietary daily intake and total pool level.
• Alcohol intake↓Liver and heart diseases
• Concentrations of pyridoxic acid, the breakdown product of vitamin B6 in the urine, are a
good indicator of dietary intake rather than tissue levels.
• When using the methods, the B6 content of the diet and the amount of protein should
be taken into account.