Physical examination

• Assess for clinically significant weight loss or unintentional weight loss.
• Calculate the body mass index (BMI) and waist circumference.
• Throughout the head-to-toe assessment, look for signs that suggest possible nutritional deficiency, such as muscle wasting, poor skin integrity, loss of subcutaneous tissue, and obesity.
• Other tissues that serve as physical indicators of nutrition status include the hair, skin, teeth, gums, mucous membranes, mouth and tongue, skeletal muscles, abdomen, lower extremities, and thyroid gland.
• Perform a biochemical assessment, which may include these serum and urine tests.
  • Low serum albumin and prealbumin are most often used as measures of protein deficit in adults. Liver Function Tests (LFTs) can also be useful because the liver synthesizes albumin and prealbumin.
  • Transferrin is a protein that binds and carries iron from the intestine through the serum. Low levels of transferrin can also lead to a deficiency in iron.
  • A complete blood count may show a decreased total lymphocyte count in patients who are acutely malnourished.
  • Serum electrolyte levels, along with a blood urea nitrogen (BUN), creatinine, and glucose level, provide information about fluid and electrolyte balance and kidney function.
  • A 24-hour urine collection can be utilized to calculate the creatinine/height index that assesses metabolically active tissue and indicates the degree of protein depletion.

PEARLS

• Some signs and symptoms that appear to indicate nutritional deficiency may reflect other systemic conditions, such as endocrine disorders, infection, or malignancy, or may result from impaired digestion, absorption, excretion, or storage of nutrients.
• Inadequate dietary intake in older adults may result from physiologic changes in the gastrointestinal tract, financial factors, limited ability to shop and cook, drug interactions, disease or illness such as dysphagia, and poor dentition.
• A waist circumference greater than 40 inches for men or 35 inches for women indicates excess abdominal fat.
• Decreased albumin levels may be caused by overhydration, liver or renal disease, or excessive protein loss due to burns, major surgery, infection, or cancer.