UNIT 2 NUTRITIONAL STATUS

ASSESSMENT
Contents
2.1 Introduction
2.2 Nutritional Status - A Brief Concept
2.3 Importance of Assessing Nutritional Status
2.4 Anthropometric Methods
2.5 Biochemical Methods
2.6 Clinical Assessment (Signs and Symptoms)
2.7 Dietary History
2.R Summary
2.9 References
Suggested Reading
Sample Questions
, 1.....
~

Learning Objectives ••. _

After you have read this unit, you will:

).> be aware of the methods that are being employed by researchers to document
nutritional status;

).> know the importance of studying nutritional status in a country such as India;

).> understand that WHO has evaluated the methods that can be used and has also
come up with recommendations that need to be understood;

).> realise that each method has its own merits and demerits that need to be
understood so as to use a method that is well-suited to the study model and
conditions; and

).> recognise the symptoms of different deficiency diseases and infections need to
be learnt.

2.1 INTRODUCTION
A healthy diet is required for maintaining normal growth and development. Such a
diet includes sufficient amounts of carbohydrate, protein, fat and vitamin. Balanced
diet is the key to normal growth and development. An imbalance in the dietary habit
leads to an imbalance of nutrients in the body: This results into susceptibility to
recurring infections and diseases, slow or retarded growth and eventually early death.

This Unit focusses on different methods that one can employ to assess nutritional
status. These methods are very simple, yet objective and the results are easy to
interpret and reproduce, These have been successfully utilized in various field
situations. However, each method has its own advantages and disadvantages and
the method chosen depends on the situation.

21
 Nutritional Anthropology
2.2 NUTRITIONAL STATUS - A BRIEF CONCEPT
Nutrition is an important component of preventive health care.An optimum level
of nutrition is .the amount of intake that promotes to the highest level of health.
Individual nutritional levels are closely related to the status of health and disease.
However, an excess calorie intake leads to obesity, whereas a deficit intake of
calorie results into a depletion of essential nutrients. These alterations can lead to
biochemical changes and eventually to clinical signs and symptoms. Nutritional.
requirements are influenced by many factors such as gender, age, physical activity,
physiological status" drugs and alcohol intake. Nutritional status is now recognized
as one of the prime indicators of the health of an individual.

Causes of Malnutrition
Direct Causes of malnutrition are mainly (a) low food intake and (b) frequent attack
of diseases and infections. The list of indirect causes is a long one and is as follows:

.:. Decrease in the availability of food resources due to population explosion

.:. Low production

.:. Low purchasing power

.:. Poor personal hygiene and sanitation

.:. High susceptibility to diseases and infections

.:. Lack of awareness

Of the 800 million individuals undernourished worldwide, a little under one-third

(258 million individuals) are concentrated in South Asia (Gaiha, 1997). Under-
nutrition is the principal cause of ill-health, premature mortality and morbidity
among children of the developing countries (Uthman and Aremu, 2008). About 70%
of the world's, malnourished children live in Asia, giving that region the highest
concentration of worldwide childhood malnutrition (Khor, 2005).

With its large population size and widespread poverty, a majority of individuals in
India are undernourished (Antony and Laxmaiah, 2008). Tndia shows the world's
highest prevalence of childhood under-nutrition with more than half of its children
being undernourished (Bamji, 2003). In India, the prevalence of obesity is increasing
in the urban 'areas than in the rural areas. Th is is the results of new dietary habits
and sedentary lifestyles.

We all know that

.:. Lack/excess of intake and/or faulty utilization of nutrients in the body can lead.
to malnutrition .

•:. Malnutrition is of two types: under-nutrition and over-nutrition .

.•:. The ultimate objective of nutritional assessment studies is to improve human

health and hence the quality of life of human beings.

,2.3 IMPORTANCE OF ASSESSING NUTRITIONAL

STATUS
Assessing nutritional status is very important for screening and identifying
individuals and populations that are affected by/at risk with malnutrition. This, in
turn, is very useful in the development and formulation of nutritional intervention
and awareness programmes. Such assessments also help to analyze the impact of
I 22 ' these programmes on the individuals and the community.
The World Health Organization (WHO) believes that the ultimate objective of Nutritional Status Assessment

nutritional assessments is the improvement in the quality of human health (Beghin

et al., 1988).

Nutritional assessment may be defined as a judgement of the quality and quantity

of the intake and the subsequent utilization of nutrients. The methods adopted .for
nutritional assessment can be classified into two groups: Direct Methods and Indirect
Methods (WHO, 1966).

Direct Methods are directly related with the individual and the parameters taken are
considered to be objective, whereas indirect methods are the methods which rely
on various demographic indices that are related to the community. Each method is
unique in its advantages and limitations. Ideally, the results of all the methods should
be taken together to assess nutritional status and formulate suitable intervention
programmes to improve the level of nutrition and health.

What are the direct methods?

Anthropometric measurements

Biochemical assessments

Clinical examinations

Dietary assessments

It can be remembered as "ABCD".

A for Anthropometric measurements

B for Biochemical assessments

C for Clinical examinations

D for Dietary assessments

What are the indirect methods?

These are the vital statistics data that are obtained from' the census and demographic
data. They also include data from other important sources such as per capita income
and population density.

The World Health Organization (WHO) has played a significant role in formulating
and standardizing the methods used to assess nutritional status of individuals
and populations. Very important recommendations were given by the WHO
Expert Committee on Medical Assessment of Nutritional Status in 1963. These
recommendations led to the publication of the World Health Organization Monograph
Series No. 53 entitled "The Assessment of the Nutritional Status of the Community"
in the year 1966 authored by D.B. Jelliffe.

w~o expert committee recommendation (1963):

"There is an urgent need for a standard guide which would give detailed
instructions about planning and conducting nutrition surveys, and the reporting
of results, and which would contain information of assistance to the correct
interpretation of results. The Committee strongly recommends that WHO
undertake the preparation of a manual to meet this need."

,2.4 ANTHROPOMETRIC METHODS

Anthropometry has been widely and successfully applied to the assessment of
health and nutritional risk. It is a useful technique 'to assess nutritional status and 23
Nutritional Anthropology body composition of an individual or population (WHO, 1966; Hamieda and Billot,
2002). Anthropometry is the single most universally applicable, inexpensive, and
non-invasive technique available to assess the size, proportions and composition of
the human body.

The most commonly utilized measurement are as follows:

a) Height/length

b) Weight

c) Mid-upper arm circumference (MUAC)

d) Head circumference

e) Chest circumference

f) Waist circumference

Height
Height is very important for assessing nutritional status-as a normal individual attains
a particular height at a particular age and has to be measured in a standardized
manner.

Weight
An individual has to obtain a standard weight for age to attain normal nutritional
status. Weight increases with the increase in the age of a healthy child.

There are standard range of weight of a child given age/height and standard range
of height given age. If a child falls short of the minimum values of these ranges
the child is underweight. On the other hand, if the child lies above the maximum
values of the ranges then he/she is overweight.

Mid-upper arm circumference (MUAC)

MUAC can be used for screening under-weight. It can be utilized along with BMI
to identify the preferential loss of peripheral tissue stores of fat and protein. It is
very useful to assess the nutritional status of children aged less than 5 years as
it does not change much during the age of 1 year till 5 years. It is also of great
value e pecially when a large number of children are to be covered and there is
confusion regarding their ages. MUAC coloured tape are being regularly used
during emergencies such as famines.

MUAC values below 23.0 cm and below 22.0 cm are considered to be undernourished
for adult males and females respectively (James et al., 1994). For children the cut
off point is 12.5 cm for both boys and girls. A series of MUAC cut-off points have
also now been identified to allow the screening of individual adults under extreme
conditions, e.g. during famines (Ferro-Luzzi and lames, 1996).

Head circumference
Brain size and head circumference can be affected by under-nutrition, especially in
case of protein energy malnutrition. The greatest circumference is to be measured
for head circumference.

Chest circumference
Chest circumference is a useful indicator of growth in the 2nd and 3rd years of
life. A chest/heap circumference ratio of < 1 recorded in children aged 6 months to
5 years indicates under-nutrition. If the chest circumference is more than the head
circumference among children aged 1 year to 5 year , it is an indication of protein
24 energy malnutrition.
 Waist circumference Nutritional Status Assessment

Waist measurement can be used to assess obesity, and two levels of risk have been
identified. These are:

Risk Level I: Males> 94.0 cm Females> 80.0 cm

Risk Level II: Males> 102.0 cm Females> 88.0 cm

Level I is utilized for the maximum acceptable waist circumference, while Level II
is significant for the screening of obesity and requires weight reduction management
therapy.

Commonly Used Indices to Determine Nutritional Status

The commonly used indices in this regard are the Body Mass Index (BM!),
Height-for-age, Weight-for-age, Weight-for-height, Waist-hip ratio and Waist-
height ratio, These indices are expressed in terms of Z-scores or percentiles. The
WHO recommends a comparison of these indices with an international reference
population to determine under-nutrition (Dibley et aI., 1987). The justification for
use of a reference population, is the empirical finding that well-nourished children
in all communities follow very similar growth patterns (Habicht et al., 1974). If the
measurements and indices are compatible with those of the reference standards, then
the individual is considered to be nutritionally healthy. If lower than the values, then
the individual suffers from under-nutrition. In case the observed values are higher
than those of the reference, then it is a case of over-nutrition.
International reference standards are provided by the National Centre for Health
Statistics (NCHS), USA. Indian reference standards have been complied by the
National Institute of Nutrition (NIN), Hyderabad.
The reliability of the anthropometric data depends on two important factors: accurate
age estimation and the normal reference values for comparison of the measurements
obtained.
Body Mass Index

BMI = body weight / heighf

the units being kg/mt' for BMI, kg (kilogram) for weight and m (meter) for height.
BM} is a good indicator of under-nutrition in terms of Chronic Energy Deficiency
(CED) in populations (Ferro-Luzzi and James, 1996) and isnon-invasive, inexpensive
and can be used for large-scale surveys well suited for the assessment of malnutrition
because it is.

BM! cut-off values for assessing malnutrition, according to WHO (1995)

CED Grade III BMI < 16.00 kg/m?
CED Grade II BM! 16.00 kg/m2- 16.99 kg/m?
CED Grade I BMI 17.00 kg/m? - 18.49 kg/m?
Normal BM! 18.50 kg/m2- 24.99 kg/m?
Overweight BMI 25.00 kg/m-» 29.99 kg/m!
Obese BM! 2: 30.00 kg/m?

Height-for-age

Individual height reflects the total increase in size of the person and indicates
adequate nutritional status. The height-for-age index is a long term measure of the
duration of malnutrition. Low height for age is also known as stunting, stunting
usually occurs before age two. 25
Nutritional Anthropology Weight-for-age

Changes in weight are more pronounced than height, as weight is more sensitive
to changes in individual growth patterns. The weight-for-age index is a commonly
used indicator of body size and it reflects food intake levels. This index is a good
indicator of' short-term and acute under-nutrition.
Weight-for-height

Sometimes it is difficult to ascertain the correct date of birth and subsequently the
age of the individual. Then the relation between weight and height instead of weight-
for-age can be used. This index provides an indication of thinness of the individual
and shows chronic and acute under-nutrition. Wasting refers to low weight-for-height.
Waist-hip ratio (WHR)

Waist-hip ratio = Waist circumference in cm / Hip circumference in cm.

WHR values> 0.90 in males and> 0.80 in females are considered to be high risk
for diseases such as diabetes.
Waist-height ratio

Waist-height ratio = Waist circumference in cm / height in cm.

A cut-off value of 0.5 is suggested for both sexes to a sess obesity (Hsieh et al.,
2004).
Some New Indices and Cut-Offs
The Composite Index of Anthropometric failure (CIAF)

The conventional indices of stunting, under-weight and wasting only allow for the
categorization of children into the general categories of under-nutrition and do not
provide an opportunity to determine the overall prevalence of under-nutrition that
is associated with multiple failures. The number of children suffering from under-
nutrition was being under-estimated primarily due to overlapping of the children
into multiple categories of anthropometric failure. The conventional anthropometric
indices are unable to depict the overall prevalence of under-nutrition because a
researcher has to 'choose' a certain category of anthropometric failure for assessing
nutritional status. Hence, while some stunted children may not be affected with
wasting and/or underweight, and other similar combinations, others might suffer
from all three nutritional failures of stunting, under-weight and wasting. The CIAF
is thus, an a:ggregated single anthropometric measure providing an overall estimate
of under-nourishment in children. The original model, proposed by Svedberg (2000),
comprised of 6 sub-groups of anthropometric failure (Groups A-F) to which Nandy
et al. (2005) supplemented one more sub-group (Group V).

Table 2.1: Classification of the CIAF (after Nandy et al. 2005)

Group Description Wasting Stunting Under-weight
A No failure , No No No
B Wasting only"...-- Yes No No
C Wasting and under-weight Yes No Yes
D Wasting, stunting and under- Yes Yes Yes
weight
E Stunting and under-weight No Yes Yes
F Stunting only No Yes No
26 Y Under-weight only No No Yes
 New cut-offs for definition of overweight and obesity in children Nutritional Status Assessment

Cole et al. (2007a) have developed an internationally acceptable definition of child

overweight and obesity, specifying the measurement, the reference population and
the age and sex specific cut off points.

New cut-offs for BM! for thinness

Co le et al. (2007b) also developed international cut-off points for BM! for thinness
grades 1, 2, and 3 by sex for exact ages between 2 and 18 years. These cut-off
points correspond to BMI v~~I.I~S16, 17, and 18.5 for adults."

The main advantages of tJ..,ismethod are that these are objective, precise, non-
expensive and non-irvasive. No sophisticated laboratory is required and there is no
collection and transportation of any biological tissue while the main disadvantages
. are that inter- and intra- observer errors may occur while recording the measurements
and there an; jet to be sorted out issues relating to the reference standards and cut
off values.

2.5 BIOCHEMICAL METHODS

The underlying principle of this method is that any changes in the quantity and
composition of the diet is reflected by variations in the concentrations of nutrients
or their associated compounds in different body tissues and fluids along with the
appearance or disappearance ofmetabolites. The method of biochemical assessment
estimates the concentrations of essential dietary constituents in the body to evaluate
nutritional status.

Haemoglobin estimation is the most important test to interpret the overall state of
nutrition. This indicates prevalence of anaemia and deficiencies in proteins and
trace elements. Stool examination is utilized to test for the presence of ova andl
or intestinal parasites. Urine examination can be used for albumin and sugar tests.

Vitamins and Proteins in Assessing Nutritional Status

Vitamins promote other metabolic reactions in the body' that produce energy
(Omieljaniuk et aI., 1989; Moswa et al. 1985). This in turn leads to better
maintenance of cells and tissues, along with promoting growth and development.
Hence, a determination of the levels of these vitamins of different body tissues
(biornarkers) can help to ascertain deficiencies. The important vitamins needed by
the body are vitamins A, B, C, D, E, and K.

Vitamin A deficiency is indicated by plasma B-carotene levels and fasting plasma

amino acid pattern, which in turn indicate a deficiency of plasma retino\. Deficiency
in vitamin Bl (thiamine) is determined by thiamine levels in urine. The biomarker
for riboflavin or vitamin B2 deficiency is urinary riboflavin and the function of the
enzyme red cell gluthione reductase is impaired. The biomarker for the determination
of vitamin B6 deficiency is urinary 4-pyridoxic acid, indicating plasma pyridoxal
5' phosphate dysfunction. Deficiency in vitamin B 12 is indicated in plasma
'... holotranscobalamin n levels which in turn show a deficiency in the function of
the enzymes plasma vitamin B 12 and plasma methylmalonate. Analysis of plasma
and urinary ascorbate levels is associated with a deficiency in vitamin C. There is
a cell depletion of leucocyte ascorbate in the long term. Vitamin D deficiency is
, documented by the analysis of 25-hydroxy-vitamin D in the plasma. The deficiency
results in the improper function of the enzyme plasma alkaline phophatase. The ratio
of plasma tocopherol to cholesterol plus triglyceride is the biomarkcr to determine
27
Nutritional Anthropology deficiency in vitamin E status. Vitamin K deficiency is determined by the plasma
analysis of phylloquinone. Thi deficiency re ults in the impairment in the function
of plasma prothromin,

A biomarker is an objective measure of a biological tissue that helps in the

assessment of nutritional status and health and also diagnosis of a disease;

Proteins are responsible for maintaining fluid balance, blood clotting, cell growth
and repair, and immunity. Proteins also provide fuel for the body and glucose for
the synthesis of sugar. Diets low in energy and proteins lead to a situation known
as protein-energy malnutrition (PEM) and kwashiorkor. Analysis of urinary nitrogen
indicates reduced intake of proteins.

Essential Trace Elements in Assessing Nutritional Status

Trace elements are those elements that are present in the human body in minute
quantities. Their concentrations are measured in parts per million. Essential trace
elements act as catalytic or structural components of larger molecules and they have
specific functions which are indispensable for life. These trace elements are required
by man in amounts ranging from 50 micrograms to 18 milligrams per day. The
main essential trace elements are iron, zinc, selenium, iodine, chromium and copper.

In June 1990, the Joint FAOIWHO/IAEA Expert Consultation of Trace Elements

in Human Nutrition was held in Geneva. A number of trace essential elements
along with their functions, interactions and issues relating to their deficiencies
and toxicities were discussed in the meeting.

Iron and transferrin levels in plasma are utilized for determining iron levels and
documenting iron deficiency. Plasma zinc is the best biomarker for zinc deficiency.
Plasma selenium concentra.tions together with toe nail selenium levels are the
established biomarkers of selenium status. Iodine deficiency is analyzed from the
concentrations of iodine in urine. Chromium deficiency can be assessed using urine
and plasma chromium levels. Serum or plasma copper is the most widely used
biomarker for copper deficiency.

Recent epidemiological and clinical evidence has shown that in most developing
countries deficiencies of specific micronutrients are somewhat accountable for the
morbidity and mortality in malnourished children. Zinc deficiency is a chief cause
of morbidity among young children in the developing countries, including India.
However, scant information is accessible on the global prevalence of zinc deficiency.

The World Health Organization (WHO), the United Nations Children's Fund
(UNICEF), the International Atomic Energy Agency {IAEA), and the International
Zinc Nutrition Consultative Group (IZiNCG) have together reviewed the present
methods of assessing population zinc status. They have provided the standard
recommendations for the use of specific biochemical, dietary and functional
indicators of zinc status in human populations.

The principal advantages of the biochemical method are that it is precise, accurate,
reliable and extremely useful in assessing and detecting early cases of malnutrition
before the appearance of the clinical signs. The biochemical measurements usually
reflect the immediate past intake of nutrients or the changes produced by a long-
standing deficient intake of a nutrient. The main disadvantages are that most of
the tests are still quite expensive, time consuming and not routinely done. Good
laboratory facilities and trained personnel are a pre-requisite. Often in the field
situation, it becomes difficult to collect and transport tissue samples which are
biologically active.
28
 Nutritional Status Assessment
2.6 CLINICAL ASSESSMENT (SIGNS AND
SYMPTOMS)
Clinical examination is a simple, yet objective method to assess nutritional status.
The signs and symptoms can be in the skin, mouth, gums, nails, lips, eyes and hair
of the subjects under study. Clinical examination may be defined as the method of
assessing the nutritional status of an individual by examining the clinical signs and
symptoms.

Classification of the physical signs and symptoms

The 1963 WHO Expert Committee on Medical Assessment of Nutritional Status

provided a classification of the physical signs that can be utilized for nutritional
assessment. This classification was subsequently updated in the World Health
Organization Monograph Series No. 53 entitled "The Assessment of the Nutritional
Status of the Community" published in the year 1966. The WHO classification is
very helpful when a rapid nutritional screening of a population is required within
a stipulated time frame and also for specific research studies that needs to evaluate
certain signs and symptoms.

Group I: This group constitutes those signs that are of paramount importance in
nutritional assessment studies. These signs are sometimes associated with deficiencies
in one or more micronutrients and are strongly related to malnutrition. This group
is the best suited for individual assessment of nutritional status.

Group II: This group consists of those signs that are unclear and require more precise
investigation. The signs mayor may not be related to malnutrition. The signs under
this category are usually noticed among populations in the developing countries.

Group Ill: Signs that arc not related to malnutrition are included in this group. But
the problem is that these signs can bear similarities to that of malnutrition. So, it
really needs a trained eye to differentiate between the two.

Physical Signs of Malnutrition

Physical signs and symptoms need to be recorded in a precise manner. The signs of
malnutrition can be multiple. An experienced observer should possess the inherent
capability of going for a more precise assessment of the body, after the initial
findings based on a single sign. He/she also has to take into account the physical
environment of the subject, along with the cultural features that can contribute to
malnutrition. The age of the subject also plays an important role as the signs of a
particular deficiency.

The two aspects that are vital for proper and objective diagnosis are the reliability
of the signs of symptoms and the experience of the investigator.

For convenience, the signs and symptoms are being classified into two categories.
The categories are:

a) Physical signs and general appearance (Table 2.2)

b) Internal signs (Table 2.3)

29
Nutritional Anthropology Table 2.2: Physical Signs (Appearance) Indicative of Malnutrition'

External body Signs indicative of Normal signs indicative of

area examined malnutrition absence of malnutrition
Head hair • dull, dry, thin, lack of • Shiny, firm
lustre
• good- quantity
• sparse in quantity
• normal colour
• colour reddish brown
• cannot be easily plucked
• can be easily plucked
Face • moon face, swollen, loss • uniform and healthy skin
in skin colour • pink skin colour
, • dark skin in cheeks and
under the eyes
• not swollen

• cheeks often sagging

• skin flaked in the area of
nose and mouth
Eyes • sunken in appearance • bright, clear and shiny
• pale and dry membranes eyes

• conjunctival infection • membranes healthy, moist

and pink in colour
• dry foamy triangular
spots on the temporal • no prominent blood
vessels
sides of the eyes
• unable to see in dim • no night blindness
light: night blindness
• dull and soft cornea
Lips
. • swollen, chapped, red in
colour and cracked
• smooth and not chapped
• no lesions or scars

- • corners possess angular

fissures, lesions and scars
Tongue • swelled with a oedema • deep red in appearance
• red/purple in colour • not swollen or smooth
• painful sores • no painful sores
• loss of papillae giving
tongue a smooth
appearance
Teeth • enamel may be mottled • bright shiny teeth
• enamc1may be eroded • no cavities

• teeth may erupt at a

later age or may be
abnormally erupted
• cavities
Gums • bleeding, spongy and • healthy red, no bleeding
receded
Glands • thyroid visible and
enlarged (front of the
• No enlargement of the
thyroid and parotid
neck)
• parotid enlarged (cheeks
swollen)
30
 Nutritional Status Assessment
Skin • dry skin (xerosis), skin • healthy tight skin
flaked and feels like
sandpaper
• no lesions or swellings or
spots
• swollen and dark in
colour
• normal colour

• symmetric skin lesions

(dermatosis) on the
exposed portions of the
body
• dark and light spots
Nails • spoon shaped • firm and hard
• brittle • pink in colour
• ridged
Muscular and • muscles wasted in • good muscle tone
skeletal system appearance
• normal fat
• loss of fat, thin
emancipated
• normal walking

"
• ribs, beaded, sternum
protruded
• knees bowed
• skull suture closure late
or absent
• musculo-skeletal
haemorrhage

Table 2.3: Internal Signs Indicative of Malnutrition

Internal body area Signs indicative of Normal signs

examined malnutrition indicative of absence of
malnutrition
Cardiovascular • heart beat rate very
rapid (> 100 beats/
• normal heart beat rate
and rhythm
min)
• no murmurs or
• heart rhythm having
murmurs, not normal
abnormal rhythms

• normal blood
• enlarged heart pressure for age

• blood pressure high

for age
Gastro-intestinal • liver and spleen
enlarged
• no enlargement of
organs
Nervous • mental depression,
forgetfulness, low IQ
• nonnallQ, normal
psychology

• loss of sleep,
headache
• reflexes normal

• normal orientation
• irritability and mental,
confusion

• loss of reflexes and

orientation
31
Nutritional Anthropology' Based on the Tables 2.2 and 2.3, we are now in a position to screen individuals
for normal nutrition and malnutrition. Once malnutrition has been established, the
next question is whether it can be linked to a specific nutrient or vitamin deficiency.
Table 2.4 shows how the clinical signs and symptoms are linked to the deficiency
of a particular nutrient and vitamin.
Table 2.4: Clinical Signs of Specific Nutrient and Vitamin Deficiencies
Clinical Signs Deficiency of N utrientNitamin involved

Dry and reddish brown hair Protein, zinc, biotin, vitamins A and C
Bleeding and spongy gums Vitamins A, C and K, niacin, folic acid
Glossitis in the mouth Niacin, folic acid, riboflavin, vitamin Bl2
Sore mouth and tongue Vitamins B 12, C and 6, niacin, folic, acid, iron
Fissured tongue Vitamins E2 and B6, niacin
Night blindness Vitamin A
Inflammatory conjunctivitis Vitamins A and B2
Spooned nails Iron

Transver e lines in nails Protein

Skin pallor Vitamin B12, folic acid, iron
Flaked skin Vitamin A and B 12, zinc, niacin, protein
Pigmented skin Niacin, protein

Bruised skin Vitamin C and K, folic acid

Gioter Iodine
Rickets Vitamin D
Scurvy Vitamin C

Indian Government has launched a number of nutritional intervention

programmes: Integrated Child Development Services (ICDS), Mid-Day Meal
Programme (MDMP), National Iodine Deficiency Disorder Control Programme
(NlDDCP), National Nutritional Anaemia Control Programme (NNACP) and
the National Control Programme for Prevention of Nutritional Blindness due
to Vitamin A Deficiency.

The physical signs and symptoms need to be recorded as accurately and possible.
This can only be attained by the nutritionist/health worker by constant practice. The
age of the individual under study is also related to the signs and their interpretation.
Any physical finding that is indicative of malnutrition should be a clue that needs
to be pursued more precisely. The physical signs and symptoms is strongly related
to the ethnic features of the population under study. In a diverse country such as
Jndia, this is even more evident.
The main advantages of this method are that it is inexpensive, rapid, reliable
and easy to perform in any situation. It is also non-invasive and do not require
the collection, transportation and analysis of any biologically active material. No
specialized laboratory is required as such. Whereas the main disadvantage of this
method is that it is often not possible to detect early cases of malnutrition and that
32
some of the clinical signs may not be specific to a particular nutrient deficiency Nutritional Status Assessment
and often one sign is an indicator of two or more such deficiencies. Moreover, the
prevalence of the different clinical signs of malnutrition are quite low. There also can
be differences in the assessment of the clinical signs by different observers (inter-
observer error). The physical signs and symptoms can also vary over time periods.

Physical clinical examination constitutes an inseparable portion in nutritional

assessment studies, even though some authorities have opined that it would
not be wise to interpret the clinical results alone. Used in a cautious manner in
conjunction witl the other methods of assessing nutritional status, they can provide
a comprehensive assessment of the same.

2.7 DIETARY mSTORY

The dietary data can be collected from individuals and/or families depending on
the need and the model/hypothesis. This method has assumed prime importance as
nutritionists have now recognized that nutrition has a major role to play so far as
the prevalence of obesity, heart diseases and diabetes are concerned. This prevalence
is now termed as "aetiology of common chronic diseases". Dietary surveys are
nowadays being increasingly used for both population estimates and individual
assessments. Dietary survey may be defined as the systematic study of the dietary
intake of individuals and populations/communities. The dietary methods can be both
qualitative and quantitative.

Qualitative method typically uses food pyramids to estimate food requirements,

servings and consumption and quantitative method calculates the amount of energy
and specific nutrients for each food using food consumption tables which are
subsequently compared with the RDA.

Dietary surveys are extensively used in the areas of nutritional epidemiology, clinical
assessment, population surveillance and experimental research. The dietary surveys
have some general advantages. They are inexpensive, relatively easy, objective and
yet easy to reproduce. No sophisticated laboratory is required. It is a non-invasive
method and there is no requirement of the collection, transportation and analysis of
any human tissue. However, the dietary surveys have certain general disadvantages.
The assessment of the food amount is usually done by the subjects which may be
erroneous. There may be variations in the daily diet that may not be accurately
reflected. There also could be under-reporting by the respondents and of course,
measurement errors.

Types of dietary surveys

.:. Twenty-four hour recall

.:. Weighed intake

.:. Food frequency questionnaire

.:. Food diary

.:. Dietary history

Twenty-four hour recall.method

All the food items that were consumed during the last 24 hours are recorded in the
"24-hour recall method". This method is utilized in large-scale nutritional surveys.
The subject is usually asked to recall and describe in as much detail as possible
his/her food intake during the last 24-hours either through an interview or by a
questi onnaire.
33
Nutritional Anthropology The most widely preferred subject for this method is the housewife. The investigator
asks her to recall the kind and amount of the food used, the preparations actually
made and distributed to the family members. Standard measuring containers such
as cups, glasses, aucers and spoons are used to help the subject in recalling the
information. To get proper information, the investigator may use several stages in
which each data obtained are checked and verified.

The main advantages of this method are that it is inexpensive, quick, easy and relies
on short-term memory. The 24-hour recall method for a single day is not very suited
for correlation with the biochemical or clinical findings. The 24-hour recall method
should be repeated for at 'least 2-3 consecutive days. Some individuals may find it
difficult to vividly recall the details about the last day's diet. The day of the recall
may also not be the typical normal day of the individual. Lastly, the individual being
interviewed may not be always speaking the truth.

Weighed intake method

In this case the investigator remains actually present when the subject is eating and
the food amounts are weighed before serving, during serving and subsequently the
left-over (food not consumed). The differences between the amounts of food served
and not consumed give the amount of food actually consumed by the individual.
The principal advantage of weighed intake method is that it is a very intensive
method. The main demerit of the weighed intake method is that it is time consuming.
Furthermore, there can be cultural taboos in some societies to eat in front of a
stranger or grant the investigator entry to the kitchen,

Food frequency questionnaire (FFQ)

The FFQ method tries to obtain long-term dietary habits. The individuals generally
completes the FFQ themselves. The detailed instructions are sent by post along with
the questionnaire . However, in the developing countries such as India, it is advisable
for the investigator to fill up the questionnaire after interviewing the subjects. In
the FFQ method the individual is asked about how often specific food items are
consumed. The responses of the subjects are standardized so that the subjects just
need to tick mark on the specific responses. The frequency is generally calculated
as per week/fortnight/month. The list offood items should not generally exceed 150
items. To standardize, categories ranging from never to six times per day are the
usual format. The FFQ method has been used in large epidemiological studies to
assess food patterns associated with inadequate intake of nutrients and descriptive
information of the food and diet.

The FFQ check list ha two main parts, namely, a list of different food items and
the frequency of consumption of these food items. The main advantage is that this
method is quick and inexpensive, involving more coverage of the respondents. The
data obtained can be analyzed in a very short time as the re ponses are standardized.
However, the FFQ method gives only a qualitative description and frequency of the
food items consumed. It does not indicate the amounts of food consumed. It also
becomes difficult to explain the association between the diet patterns and certain
diseases. Sometimes the questionnaire may be long and may need modifications to
.
keep pace with the changing dietary habits.
,

Food diary

The subject is required to keep a record in written form (diary) and photographs
of all the food and beverages consumed over a certain period of time. This method
generally utilized when interviewing all the members regarding their dietary intakes.
is not possible due to some practical constraints. A time period of one week can be
34 used in the diary to estimate the dietary intake. The subjects arc initially tutored

"
to describe and weigh/estimate the amount food immediately prior to eating and Nutritional Status Assessment
subsequently to record left overs, if any. Standardized bowls and utensils are given
to them prior to writing the diary. Even though the subject burden appears to be the
highest while using this method, the food diary method has been effectively used in
a number of large prospective epidemiological studies and for validating the results
obtained from other methods of dietary assessment.

This method consists of dietary records kept just at the time of eating. So there is
no question of any kind of "recall". The method is reliable as sufficient number of
days is covered by each subject. The subjects also take interest in filling up the diary.
The main disadvantage is that individuals are sometimes not able to estimate the
quantity of food consumed accurately. The subject concerned can also be illiterate.
Maintaining a diary can also be cumbersome for some individuals. Often, individuals
modify their diets so that not much information can be noted in the diary and the
records are kept to a minimum. The subject may not be writing the correct dietary
information and become biased.

Dietary history

Dietary history records the dietary practices of the respondents over a prolonged
period of time. The investigator obtains a retrospective estimate of the food
intake using this method. The time duration covered is 3 months to one year. The
information is recorded either through interviews and/or questionnaires addressed
to the subject. -This method is not used in large scale epidemiological surveys.

The main advantage is that it can be used for individual assessment. This method
is now used increasingly by dieticians in the clinical context. Since the time period
covered by this method is large, the individuals often cannot remember what they
had consumed during the last one year. Moreover, each interview takes a very long
time, often up to 90 minutes. The method is also not cost effective.

2.8 SUMMARY
Nutritional status is now recognized as a significant indicator of the health of the
individuals and/or population. It is important for screening and identification of
individuals and populations who are affected/at risk with malnutrition. This, in turn,
bears importance in formulating nutritional intervention and awareness programmes.
Nutritional status can be assessed using a number of methods. The direct methods
are anthropometry, biochemical assessment, clinical signs and symptoms, and dietary
intake. The indirect methods are based on vital statistics.

Anthropometry is a technique to assess nutritional status and body composition

of an individual or population. The most commonly utilized measurements to
assess nutritional status are height/length, weight, mid-upper arm circumference,
head circumference, chest circumference and waist circumference. The commonly
utilized indices are the body mass index, height-for-age, weight-for-age, weight-
for-height, waist-hip ratio and waist-height ratio. The method of biochemical
assessment estimates the concentrations of essential dietary constituents in the body
to evaluate malnutrition. The important tests are haemoglobin estimation, urine
and stool examination. Specific vitamins and micro-nutrients deficiencies can also
be documented using this method. Clinical signs and symptoms are observed in
the skin, mouth, gums, nails, lips, eyes and hair of the subjects. The internal signs
are in the cardio-vascular, gastro-intestinal and nervous systems. The qualitative
dietary method uses food pyramids to estimate food requirements, servings and
consumption, while the quantitative method calculates the amount of energy and
specific nutrients for each food using food consumption tables.
35
Nutritional Anthropology
2.9 REFERENCES
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Height and Weight Standard jar Preschool Children: How Relevant are Ethnic
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Hsieh, S.D., Yoshinaga, H. and Muto, T. 2004. Waist-to-height Ratio, a Simple

and Practical Index jar Assessing Central Fat Distribution and Metabolic Risk in
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Uthman, O.A. and Aremu, O. 2008. Malnutrition Among Women in Sub-Saharan Nutritional Status Assessment
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Suggested Reading
Wardlaw, G.M. and Insel, P.M. 1995. Perspectives of Nutrition. Chicago; Mosby.

Mann, J. and Truswell, A.S. (eds.). 2007. Essentials of Human Nutrition. New
Delhi; Oxford.

Sample Questions
1) What is meant by nutritional assessment? Discuss its aims.

2) What are the prevalent methods currently available for the assessment of
nutritional status in man?

3) What do you mean by biomarker? Discuss how you can use biomarkers to
document nutritional status.

4) Briefly discuss the clinical signs and symptoms of malnutrition.

37