Assessment of Nutritional Status

INTRODUCTION

- The nutritional status of an individual is often the

result of many interrelated factors
- It is influenced by food intake, quantity & quality,
& physical health
- The spectrum of nutritional status spread from
obesity to severe malnutrition

PURPOSE OF NUTRITIONAL ASSESSMENT

- Identify individual or population groups at risk of

becoming malnourished piece. The head piece is leveled with
- Identify individuals or population groups who are skull vault & height is recorded to the
malnourished nearest 0.5 cm
- To develop health care programs that meet the ii. Weight measurement
community needs which are defined by the a. Use a regularly calibrated electronic
assessment or balanced-beam scale. Spring scales
- To measure the effectiveness of the nutritional are less reliable
programs & intervention once initiated b. Weight in light clothes, no shoes
c. Read to the nearest 100gm (0.1kg)
METHODS OF NUTRITIONAL ASSESSMENT
 Nutritional Indices in Adults
- Nutrition is assessed by two types of methods:
- The international standard for assessing body size
direct and indirect
in adults is the body mass index (BMI)
o Direct – deal with the individual and
- BMI is computed using the following formula:
measure objective criteria
o BMI = weight (kg)/ height (m2)
o Indirect – methods use community
- Evidence shows that high BMI (obesity level) is
health indices that reflects nutritional
associated with type 2 diabetes & high risk of
influences
cardiovascular morbidity & mortality
- BMI (WHO – Classification
DIRECT METHODS OF NUTRITIONAL ASSESSMENT

Summarized as ABCD BMI < 16.0 Severe thinness

BMI 16.0-16.9 Moderate thinness
I. Anthropometric methods BMI 17.0-18.49 Mild thinness
o Is the measurement of body height, BMI 18.5-24.9 Healthy weight average
weight & proportions BMI ≥25.0 Overweight
BMI 25.1-29.9 Pre-obese
o Is an essential component of clinical
BMI 30.0-34.9 Obese (grade/class 1
examination of infants, children &
obesity)
pregnant women
BMI 35.0-39.99 Obese (grade/class 2
o Is used to evaluate both under & over obesity)
nutrition BMI ≥ 40 Very obese
o The measured values reflects the (morbid/grade/class 3
current nutritional status & don’t obesity)
differentiate between acute & chronic
changes  Waist/Hip Ratio
o Other anthropometric measurements - Waist circumference is measured at the level of
 Mid-arm circumference the umbilicus to the nearest 0.5cm
 Skin fold thickness - The subject stands erect with relaxed abdominal
 Head circumference muscles, arms, at the side, and feet together
 Head/chest ratio - The measurement should be taken at the end of a
 Hip/waist ratio normal expiration
- It has been proposed that waist measurement
 Anthropometry for Children alone can be used to assess obesity, and two levels
- Accurate measurement of height and weight of risk have been identified.
essential. The results can then be used to evaluate
the physical growth of a child MALES FEMALES
- For growth monitoring the data are plotted on LEVEL 1 >94cm >80cm
growth charts over a period of time that is enough LEVEL 2 >102cm >88cm
to calculate growth velocity, which can then be - Level 1 is the maximum acceptable waist
compared to international standards. circumference irrespective of the adult age and
there should be no further weight gain
 Measurements for Adults - Level 2 denotes obesity and requires weight
i. Height management to reduce the risk of type 2 diabetes
a. Subject stands erect & bare footed on & CVS complications
the stadiometer with a movable head
 non-lactating) below 12g/ 100ml
blood indicates anemia.
 Hip Circumference o Similarly, severity of iodine deficiency
- Is measured at the point of greatest circumference in individuals can be assessed from
around hips & buttocks to the nearest 0.5cm the iodine concentration in their
- The subject should be standing and the measurer urine.
should squat beside him o The presence of worms such as round
- Both measurements should be taken with a worm, hook worm etc. can be
flexible, non-stretchable tape in close contact with determined from the stool specimens
the skin, but without indenting the soft tissue of individuals.
o Selection of biochemical test depends
 Interpretation of WHR on the purpose and the availability of
- High risk WHR = >0.80 for females and >0.95 for resources such as trained personnel,
males laboratory facilities and money etc.
- Example: o Proper collection, storage and
o Waist measurement >80% of hip transportation of blood/urine samples
measurement for women and >95% are extremely important for the
for men indicate central (upper body) accuracy of assessment.
obesity and is considered high risk for o Moreover, reference values and cut-
diabetes and CVS disorders off points for levels of nutrients in
- A WHR below these cut-off levels is considered body fluids/ tissues should be
low risk available for comparison and
diagnostic purposes.
 Advantages of Anthropometry
- Objective with high specificity & sensitivity  Initial Laboratory Assessment
- Measures any variables of nutritional significance - Hemoglobin estimation is the most important test,
(ht, wt, MAC, HC, skin fold thickness, WHR, & BMI) & useful index of the overall state of nutrition.
- Readings are numerical & gradable on standard Beside anemia it also talks about protein & trace
growth charts element nutrition.
- Readings are reproducible - Stool examination for the presence of ova and/or
- Non-expensive & need minimal training intestinal parasites
- Urine dipstick & microscopy for albumin, sugar
 Limitations of Anthropometry and blood
- Inter-observers’ errors in measurement
- Limited nutritional diagnosis  Specific Lab Tests
- Problems with reference standards like local - Measurement of individual nutrient in body fluids
versus international standards (e.g. serum retinol, serum iron, urinary iodine,
- Arbitrary statistical cut-off levels for what vitamin D)
considered as abnormal values - Detection of abnormal amount of metabolites in
the urine (e.g. urinary creatinine/hydroxyproline
II. Biochemical, laboratory methods ratio)
o This method of assessing nutritional - Analysis of hair, nails & skin for micro-nutrients.
status involves laboratory tests that
measure levels of nutrients and their
metabolites in body tissues and fluids
as these are consequence of the
variations in quantity and nutrient
composition of food consumed and
utilized by the body.
o Biochemical tests are sensitive to even
small changes in nutritional intake
and therefore, provide the earliest
indication to malnutrition.
o Biochemical assessment also confirms
clinical diagnosis of nutritional status
and/ or risk for a disease. There are
several biochemical tests that can be
done on bones, hair, nails,
subcutaneous fat, liver etc., however,
in community settings most
commonly, these tests are conducted
on blood, urine and stool samples.
o For example, measuring hemoglobin
(Hb) level in blood indicates iron
deficiency anemia. In adult males Hb
level below 13g/100ml of blood and
in adult females (non-pregnant and
  Advantages of Biochemical Method -Sore mouth & niacin, folic acid
- It is useful in detecting early changes in body tongue & iron
metabolism & nutrition before the appearance of Eyes -Night -Vit A deficiency
overt clinical signs. blindedness,
- It is precise, accurate and reproducible. exophthalmia
- Useful to validate data obtained from dietary -Photophobia- -Vit B2 & Vit A
methods such as comparing salt intake with 24- blurring, deficiency
conjunctival
hour urinary excretion
inflammation
Nails -Spooning -Iron def.
 Limitations of Biochemical Method
-Transverse -Protein def.
- Time consuming lines
- Expensive Skin -Pallor -Folic acid, iron,
- They cannot be applied on large scale B12
- Needs trained personnel & facilities -Follicular -Vit B & C
hyperkeratosis
III. Clinical methods/assessment (A skin condition
o It is an essential features of all characterized by
nutritional surveys excessive
o It is the simplest & most practical development of
method of ascertaining the nutritional keratin in hair
follicles,
status of a group of individuals
resulting in
o It utilizes a number of physical signs,
rough, cone-
(specific & non-specific), that are shaped, elevated
known to be associated with papules)
malnutrition and deficiency of -Flaking -PEM, Vit B2, A,
vitamins and micronutrients dermatitis zinc, & niacin
o Good nutritional history should be (Flaking skin
obtained (dandruff) on
o General clinical examination, with your scalp, hair,
special attention to organs like hair, eyebrows, beard
or mustache.)
angles of the mouth, gums, nails, skin,
-Pigmentation, -Niacin & PEM
eyes, tongue, muscles, bones, &
desquamation
thyroid glands (The peeling or
o Detection of relevant signs helps in flaking process
establishing the nutritional diagnosis is your skin's
way of
 Clinical Signs of Nutritional Deficiency recovering or
healing from
Hair -Spare & thin -protein, zinc, some type of
biotin deficiency damage)
-Easy to pull out -protein -Bruising, -Vit K, C & Folic
deficiency purpura Acid
-Corkscrew -Vit C & A Thyroid Gland -in mountainous -Iodine def.
coiled hair deficiency areas & far from
Mouth -Glossitis -Riboflavin, sea places.
(inflammation of niacin, folic acid, (Goiter)
the tongue) B12, pr. Joints & Bones -Rickets -Vit D def.
(imperfect
calcification,
-Bleeding & -Vit C, A, K, folic softening and
spongy gums acid & niacin distortion of the
-Angular -B2, 6 & 9 bones.)
stomatitis -Scurvy
(inflammation of -Vit C def.
the mucous
membrane of the  Advantages of Clinical Assessment
mouth), - Fast & easy to perform
cheilosis - Inexpensive
(inflammatory - Non-invasive
condition that
causes cracking,
 Limitations of Clinical Assessment
crusting &
- Did not detect early cases
scaling corners
of the mouth) &
fissured tongue -Vit A, B12, B- IV. Dietary evaluation methods
-Leukoplakia complex, folic o Nutritional intake of humans is
(white patches acid & niacin assessed by five different methods:
on tongue, gums
& inside of the
cheek) -Vit B12, 6, C, 1. 24 hours dietary recall
 A trained interviewer asks the subject to recall all - Fast and easy to perform
food and drink taken in the previous 24 hours - Inexpensive and quick to administer
 It is quick, easy, depends on short-term memory - Non-invasive
but may not be truly representative of a person’s - Requires only short-term memory as the food
usual intake eaten only on the previous day has to be recalled.
- There is an element of surprise in this method and
2. Food frequency questionnaire the individuals are therefore, less likely to
 In this method, the subject is given a list of around deliberately modify their eating patterns.
100 food items to indicate his or her intake - It is well accepted by individuals as they are not
(frequency & quantity) per day, per week and per required to keep a record of food consumed; and
month their expenditure of time and effort is also
 Inexpensive, more representative & easier to use relatively low.
 Limitations: - It is useful for assessing average usual intakes of a
o Long questionnaire large population.
o Errors with estimating serving size
o Needs updating with new commercial  Limitations of Dietary Assessment
food products to keep pace with - Did not detect early cases
changing dietary habits - Not suitable for elderly
- May withhold or alter information
3. Dietary history since early life - Does not give actual intake
 It is an accurate method for assessing the
nutritional status INDIRECT METHODS OF NUTRITIONAL ASSESSMENT
 The information should be collected by a trained
interviewer Includes three categories:
 Details about usual intake, types, amount,
1. Ecological variables including crop production
frequency & timing needs to be obtained
2. Economic factors such as per capital income,
 Cross-checking to verify data is important
population density & social habits
3. Vital health statistics particularly infant & under 5
4. Food diary technique
mortality & fertility index
 Food intake (types and amounts) should be
recorded by the subject at the time of
consumption
 The length of the collection period range
between1-7 days
 Reliable but difficult to maintain

5. Observed food consumption

 The most unused method in clinical practice, but it
is recommended for research purposes
 The meal eaten by the individual is weighed and
contents are exactly calculated
 The method is characterized by having a high
degree of accuracy but expensive & needs time
and efforts

 Interpretation of Dietary Data

1. Qualitative Method
a. Using the food pyramid and the basic
food groups method
b. Different nutrients are classified into
5 groups (fats & oils, bread & cereals,
milk products, meat-fish-poultry,
vegetables & fruits)
c. Determine the number of serving
from each group & compare it with
minimum requirement
2. Quantitative Method
a. The amount of energy & specific
nutrients in each food consumed can
be calculated using food composition
tables & then compare it with the
recommended daily intake
b. Evaluation by this method is
expensive & time consuming, unless
computing facilities are available

 Advantages of Dietary Assessment