Nutritional Assessment Methods

• Significance of nutritional assessment

“Nutritional assessment is the first step in the treatment and
prevention of malnutrition.
•
An optimal scheme of nutritional assessment enables the clinician to
quickly detect the presence of malnutrition and provides guidelines
for nutritional therapy.

• Although advanced cases of malnutrition are often obvious to

inspection, nutritional assessment provides an objective
characterization for the detection of pre morbid states.”
 TYPE OF ASSESSMENT METHODS

1-Nutritional Requirements
3-Biomarkers : Clinical Method, Anthropometric
measurements and chemical or biochemical
agents
 Nutrition problems in the past

Typical deficiency syndromes

• Protein energy malnutrition
• Iron deficiency anemia
• Goiter

– Short latent periods

– Can be reversed within days or weeks
 Major diseases throughout the world
None Communicable Chronic Diseases/NCD/ : Irreversible
health problems
• Heart disease
• Cancer
• Osteoporosis
• Cataracts
• Stroke
• Diabetes
• Hypertension
• Congenital malformations
– latent for long period of years
– Can not be reversed
• Throughout the world there are differences in food
consumption related to socioeconomic conditions, food
availability, and cultural dictates.
In developing countries
Macronutrients : Protein-Energy (Calorie) Malnutrition
(PEM/PCM)
Micronutrients: Iron, iodine and vitamin A (and of course
Zn) are the nutrients most lacking and cause several
disorders

Developed countries and countries in transition: NCD

• Epidemiology and Nutritional Transition discus the major

nutritional related health problems.
2. Biomarkers:
A biomarker is a biological characteristic that can be
objectively measured and that serves as an indicator
of normal biological processes, pathogenic processes,
or responses to therapeutic interventions .

• Biomarkers can be broadly characterized into 3 groups:

A. measureable physiologic function and future clinical
risk (test of night vision, cognitive assessment) or.
B. physical (anthropometric indexes)
C. chemical or biochemical agents in the biological
system (plasma retinol, iron, zinc), and
A. Anthropometrics
ƒHeight (Ht)
ƒTypically affected by chronic states
I. Growth hormone deficiency
II. Chronic malnutrition
ƒPredicts maternal and obstetric risks (Ht <150cm LBW,
<145cm CPD).

Weight (Wt )
ƒReflective of body fat, skeletal, and lean body mass
ƒRepresentative of both acute and chronic in overall health
and nutritional status
predicts birth outcome (e.g. Wt <45kg increases the risk of
LBW)
• Index : Combination of two (Wt and Ht)
measurements with age of the child

I. Height for age(HA) : Low HA is stunting (Chronic malnutrition)

a. Percentiles / %/ H/A = Child Height X 100
Ht of the reference child of the same age
b. Z- score H/A = Observed height – Median reference* height
Reference SD in height

II. Weight for height (W/H): Low WH is wasting ( acute malnutrition)

a. Percentiles / %/ W/H = Child weight X100
wt of the reference child of the same Ht
b. Z- score W/H= Observed weight – Median reference* wt
Reference SD in weight
III. Weight for age: Low W/A is underweight
a. Percentiles / %/ W/A = Child Weight X 100
Wt of the reference child of the same age
b. Z- score =Observed weight – Median reference* wt
Reference SD in weight

Body Mass Index (BMI) = Weight (kg)/(Height in meters)2

Best for measuring adult nutritional status
18.5 – 24.9 kg/m2: Normal
A. Future clinical risk(Clinical indicators)
Nutrition deficiency states appear with clinical manifestations.
Acute onset
ƒKwashiorkor:
I. Rapidly developing, catabolic state typically secondary to stress
II. Adequate caloric intake with a relative protein deficiency
III. Depletion of visceral proteins and preservation of adipose tissue
ƒChronic onset
ƒMarasmus: Retarded growth
I. Chronic condition
II. Deficiency in intake and/or utilization of nutrients
III. Wasting of somatic proteins and adipose tissueƒ
Mixed Kwashiokor-Marasmus
I. Chronically ill, acutely stressed
II. Wasting of somatic proteins, adipose tissue, and decreased
synthesis of visceral protein
• Other terms of PEM are
• Multi-deficiency syndrome
• Failure to thrive

• The term PEM/PCM/PED has been used to describe

– A range of disorders primarily characterized by growth failure or
retardation in children
• Growth deficit is catalogued based on Clinical forms as
– Marasmus
• Retarded growth with wasting of subcutaneous fat
• Chronic onset

– Kwashiorkor
• Growth failure with wasting of muscles and preservation of
subcutaneous fat and
• pitting type edema
• Acute onset

– Mixed: Marasmus-Kwashiorkor (MK)

• Edema of kwashiorkor with wasting of marasmus
Differences Between the two Forms PEMs
Classification of moderate and severe malnutrition
Malnutrition
Classification of PEM Moderate Severe

Symmetric edema No Yes

(bilateral pitting edema) (edematous malnutrition or
kwashiorkor)
Weight for Height
• SD Score • –2 to – 3 • < -3 severe wasting
• % Median • 70 to 79 • < 70 or marasmus

Length (Height) for age

• SD Score • –2 to – 3 • < -3 severe stunting
• % Median • 85 to 89 • < 85
 Milder to moderate forms of PEM
• Wasting :thinness, assessed by using weight for height
(W/H)measurement.
• Stunting: linear growth retardation, assessed by using height for age
(H/A)measurement
• Underweight : A result of wasting and/or stunting , assess using
(W/A) measurement.
I. Gomez classification : Employs weight for age

% of NCHS reference Level of malnutrition

>= 90 Normal

75 - 89 Mild (Grade I)

60 – 74 Moderate (Grade II)

< 60 Severe (Grade III)

– Disadvantage of Gomez Classification

• Edema is ignored and yet it contributes to weight
• Age is difficult to know accurately in developing countries
(where illiteracy is common)
II. Welcome classification :Employs weight-for-age
In clinical setups in order to clearly distinguish the different clinical
forms (Marasmus, Kwashiorkor or mixed)
Level of malnutrition

%NCHS Edema No Edema

60 - 79 Kwashiorkor Undernourished

< 60 Mixed Marasmus

– Disadvantage
• Doesn’t differentiate acute from chronic malnutrition
III. Water low classification
– Weight-for-height and height-for-age are used together in a two
by two table
– In field (community) set ups, the water low setup is used to
distinguish the acute and chronic forms of malnutrition

Water low Weight for height

classification
>= 80% < 80%

Height for >= 90% Normal Wasted

age
< 90% Stunted Wasted and
stunted
• MUAC/ maid upper arm circumference /
– Useful in the diagnosis of PEM
– MUAC for age can differentiate normal children from those with
PEM as reliably.
– used for screening for PEM in emergencies such as famines and
refugee crises
– In emergency situations, the measurement of weight or height may
not be feasible and ages of children are often uncertain
– A single cutoff of 12cm in Ethiopia has been used for children <5
year as a proxy for low weight for height (wasting)
. > 12 cm = normal ;
. 11 -11.5cm = at risk;
. < 11 cm = marasmic
Anthropometric assessment of body composition
• It is based on a model in which the body consists of two chemically
distinct compartments
• Fat and fat free mass ( skeletal muscle, non-skeletal muscle, and soft
lean tissue and the skeleton)
 Measured By:
A. Skin fold thickness
A-Skin fold thickness
• Provides an estimate of the size of subcutaneous fat depot
• Assumptions:
- Thickness to the subcutaneous adipose tissue reflects a constant
proportion of the total body fat
B. Waist-to-hip circumference ratio

Used to distinguish lower trunk ( hip and buttocks) and fatness in

upper trunk (waist and abdomen)

Waist to hip circumference ratio

It is the circumference of the waist measured mid-way between the
lowest rib cage and anterior superior illiac spine and

divided by the circumference of the hip measured at the level of the

greater trocanter of the fumer.

If the ratio is > 1 in male, and > 0.87 in female there is high risk of
coronary heart disease
• Therapeutic Feeding Program (TFP) for the management of SAM

• Integrates the management of Severe Acute Malnutrition (SAM) into

hospitals, health facilities and medical universities

• SAM management includes two approaches

I-Acute stabilization phase

Therapeutic Feeding unit (In patient care) for children with SAM and
complications

The main focus is treatment of infections and other complications

such as dehydration, hypothermia, hypoglycemia& other electrolyte

imbalances (see protocol from the MOH)

 OTP – First Contact, Appetite test

Uncomplicated
• Phase 1. Patients without an adequate appetite and/or a
major medical complication are initially
• admitted to an in-patient facility for Phase 1 treatment.
Inpatient Management
• 1. Manage Danger signs and infection
• 2. Prevent and Manage Medical complications as indicated
• 3. Start therapeutic feeding according to the national SAM
guidelines
• The formula used during this phase (F75) promotes
recovery of normal metabolic function and nutrition-
electrolytic balance.
• Rapid weight gain at this stage is dangerous, that is why
F75 is formulated so that patients do not gain weight during
this stage.
- Transition Phase. A transition phase has been introduced for in-
patients because a sudden
• change to large amounts of diet, before physiological function is
restored, can be dangerous and lead to electrolyte disequilibrium.

• During this phase the patients start to gain weight as F100 or RUTF is
introduced.

• The quantity of F100 given is equal to the quantity of F75 given in

Phase 1 or an equivalent amount of RUTF.

• As this is resulting in a 30% increase in energy intake the weight gain

should be around 6 g/kg/day; this is less than the quantity given, and
rate of weight gain expected, in Phase 2.
 II-Rehabilitation phase
Required for
• On the restoration of the lost tissue and promotion of catch up growth
• Whenever patients have good appetite and no major medical
complication they go through

• Out-patient therapeutic program (OTP) indicated for children with

uncomplicated SAM and with good appetite

• In Phase 2 RUTF or F100 used in both in-patient and out-patient

settings) according to look-up tables.
 Inpatient Care
Phase II
Phase I Stabilization
Rehabilitation

Treatment Antibiotic, Anti-malarial, Vitamin A, etc.

Care Attend to complications (e.g. shock, hypoglycemia)

F-100 Therapeutic Milk

Feed F-75 Therapeutic Milk
(RUTF)

Quantity 135ml/kg/day 200ml/kg/day

Time 1-7 Days, 3 to 4 Weeks

 Rehabilitation phase…….
• How much to give?
– The synthesis of new tissues requires protein and other nutrients.
– Synthesis also requires a considerable amount of energy.

• Aim is to provide all necessary nutrients so that none limits the

rate of recovery
• Normal rate of growth of children is such that they gain weight
of 1g/kg/day by
-taking 105 kcal/kg/day and
-0.78 g of protein/kg/day
• *: Stick to the current guidelines from the MOH
• Assess progress
– Patients should be weighed at least weekly, preferably daily and
the weights plotted

– Failure to maintain rapid catch-up may signal an undiagnosed

infection and/or inadequate intake

– Keeping a record of the child’s food intake helps to elucidate the

cause of poor weight gain

– Management of PEM see on table teaching aid of MOH

Prevention of PEM (options for intervention)
1. Dietary diversification
• Production of food stuffs at the back yard garden and
intensification of horticultural activities
2. Nutrition education
• Focuses on educating mothers/care givers and fathers on the
importance of having a balanced diet through diversification of
food
• On job training to DAs
• Inclusion of nutrition courses in curriculum
3. Economic approach
• Aims at improving the incomes of the target community as a
solution to their nutritional problems
• Different methods in this approach
– Food for work, food subsidy, income generating projects
4. Dietary modification
• Focuses on modifying the energy, protein and micronutrient content of
the complementary foods.
• In order to reduce dilution of the energy and protein contents of the
complementary foods and their level of contamination,
• These need to educate mothers and demonstrate to them the benefits
of sprouting (germination) and fermentation.
Fermentation
• Renders the food less contaminated probably because of the formation
of acid
Germination
Using sprouted (germinated) flour otherwise known as “power flour”
or amylase rich flour (ARF) makes the complementary food more
liquid but less dilute
5. Supplementation
– Could also be considered based on the local needs
• Undernutrition has a series of public health consequences that
diminish the individual quality of life and the prospects for social
progress

• Susceptibility to mortality (death)

• Undernutrition is associated with greater mortality rates from most
childhood diseases.
• Undernutrition accounts for 33-60% child deaths world wide

• Susceptibility to acute morbidity (disease)

- more likely to contract diarrheal, malarial and respiratory infections
and more likely to suffer from these illnesses for longer duration
• Decreased cognitive development
Specific nutrient deficiencies also impaired cognitive development
(e.g. iodine)
Decreased economic productivity
People of larger stature and musculature are more efficient and
accomplish more physical labor

Prompt and complete recovery from infectious diseases that is

promoted by adequate nutritional status increases economic
productivity

Susceptibility to chronic diseases in later life

There is early appearance and greater prevalence and severity of
obesity, hypertension, stroke and cardiac ischemia and diabetes in
people with low birth weight and nutritional problems in early life
C. Chemical or biochemical agents in the biological
system (plasma vitamins, minerals)