NUTRITION STATUS

ASSESSMENT
Section Objectives
• By the end of this section you will be able to:
1.Define nutrition status.
2.Explain the purpose of nutrition assessment.
3.Describe methods of nutrition status assessment.
4.Explain the nutrition assessment and interventions in
emergencies
Definition of Nutrition Status
• Nutrition status is a state of intake and utilisation
of nutrients which is manifested in good or bad
health. The state of balance between nutrients
supply (intake) and demand (requirement). An
imbalance between the two can result in
over/under nutrition.
Purpose of Nutrition status assessment
• To determine the overall nutritional status of a patient or
client in order to initiate appropriate interventions.
• To identify at risk patients or clients for malnutrition.
• To determine the current health care needs, physical
and psychosocial as well as personal; metabolic
abnormalities that influence nutrition status and the
effects of medication on nutrition.
• To assess growth and development in children.
• To monitor and evaluate therapy and client progress.
 Methods of Nutritional Status
Assessment
These methods include:
• Anthropometric measurements
• Biochemical measurement
• Clinical examination
• Dietary evaluation and personal history
Anthropometric Measurements
• These are measurements in relation to assessment of different
areas of the body such as weight, height and circumferences
(mid-upper arm, head and chest).
Weight

• Taking weight and interpreting it in terms of age is called weight

for age (WFA). You know when a child is healthy and has a
normal physical growth, the body weight increases regularly
with increase in age. However, if the child falls sick there is a
sudden weight loss.
• WFA gives a mixture of both current and past nutritional
experience. It is useful in growth monitoring because it indicates
underweight (Z score below two standard deviation or have
bilateral oedema) and severe underweight (Z score below three
standard deviation or with bilateral oedema).
Weight cont…
• You can measure weight using different types of weight scales
such as a Salter scale, measuring scale and bathroom scale.
The weight is measured in 0.01kgs.
• In measurements of weight in children ensure minimal clothing,
calibration of the weight scale, two readings and an average
obtained, the scale should be flat on the ground while a Salter
scale should hang freely from a tree or hook.
Height
• Like weight, height of a child also increases with age. However,
unlike weight, the change in height is relatively slow. Even when
there is under nutrition, height never decreases. At a given age, a
child is expected to have attained a particular height (height for
age-HFA).
• HFA is generally a reflection of cumulative past nutritional
inadequacy. Z score below two standard deviation indicates
stunting while Z score below three standard deviation indicates
severely stunted.
• Height measurements are obtained by use of a height meter for
older children and adults. The client should stand straight, bare
feet, feet should be parallel with heels, buttocks, shoulders and
back of the head touching the wall; the head should be erect with
the eyes looking straight in front. A flat horizontal sliding board is
then moved downwards till it touches the top of the head. The
Height cont…
• For infants instead of height you measure length. The linear
measurement taken from the head to heel in lying position is the
length of an infant. Lying on a length board with the head
touching the fixed head piece, the legs are extended at the
knees and the movable sliding piece is moved up to the soles of
the feet to take the reading up to 0.01cm.
• When it is extremely difficult to get the correct age of individuals
then weight for height nutrition indicator is used. Weight and
height increases with age, an individual should have attained a
particular weight to be designated as normal. If one fails to
attain this weight at that height based on reference values; then
this is considered as undernourished ‘wasting’.
Body Mass Index
• The international standard for assessing body size in adults is
the body mass index (BMI). BMI is computed using the
following formula: BMI = Weight (kg)/Height (m²)
• Classifications
• BMI < 18.5 = Under Weight
• BMI 18.5-24.5= Healthy weight range
• BMI 25-30 = Overweight (grade one obesity)
• BMI >30-40 = Obese (grade two obesity)
• BMI >40 =Very obese (morbid or grade three obesity)
Mid-Upper Arm Circumference (MUAC)
Arm circumference increases with age, but from the first to fifth
birth day, it does not change much. Normally nutrients stored
under the skin accounts for this circumference; inadequate diet
leads to depletion of stores leading to loosening and wrinkling of
the skin. MUAC indicates muscle wasting (bone, subcutaneous
fat and muscle protein).
MUAC is very simple and quick and is used:
• When the child’s age is over one and under five years
• When weighing scales are not available
• As a screening method in outpatient work
• In community nutrition surveys
• When road to health charts are out of stock
•
Head and Chest Circumference
• Normally when a child is born, the head is larger than the chest.
As the child grows, the head becomes proportionately smaller
to the chest.
• The circumference helps to assess the brain growth and
development in infants and children under the age of two. If the
head circumference remains more than the chest circumference
beyond one year of age, it indicates PEM.
• Measure the roundness of the head covering the forehead in
front and maximum end at the back. The chest circumference is
measured at the level of the nipple. Avoid taking these
measurements when the child is crying, screaming or deep
breathing.
Head and Chest circumference
cont…
• Between six months and five years if the chest circumference is
less than the head circumference, there is failure to develop or
a wasting of muscle and fat from the chest wall which is
indicative of protein calorie malnutrition.
Waist-Hip Ratio (WHR)
Waist Circumference
• Waist circumference is measured at the level of the umbilicus to
the nearest 0.5cm. The subject stands erect with relaxed
abdominal muscles, arms at the side and feet together. The
measurement should be taken at the end of a normal expiration.
• Waist circumference predicts mortality better than any other
anthropometric measurement since it is a valuable indicator of
fat distribution. It is therefore used to assess obesity and two
levels of risk have been identified. The following table shows
waist circumference.
Waist circumference cont..
Males Females

Level one > 94 cm >80 cm

Level two > 102 cm > 88 cm

Waist circumference cont..
• Level one is the maximum acceptable waist circumference
irrespective of the adult age and there should be no further
weight gain.
• Level two denotes obesity and requires weight management to
reduce the risk of type two diabetes and CVS complications.
Hip Circumference
• Hip circumference is measured at the point of greatest
circumference around hips and buttocks to the nearest 0.5cm. The
subject should be standing and the person measuring should
squat beside the person being measured.
Waist to Hip Ratio
• The ratio is meant to assess abdominal obesity. High risk WHR=
>0.80m for females and >0.95m for males that is waist
measurement >80% of hip measurement for women and >95% for
men indicates central (upper body) obesity and is considered high
risk for diabetes and CVS disorders.
• A WHR below these cut-off levels is considered low risk.
Skin Folds Thickness or Measurements

• Using a standard millimetre skin fold callipers, measure the

amount of subcutaneous fat over the triceps, biceps or scapula.
The amount of body fatness and the presence of excess body
fat can be determined since the volume of subcutaneous fat is
related to the volume of body fat.
• Hence, the measurement provides a good estimate of total
body fat. Note that if a person gains body fat, the skinfold
increase proportionately; if the person loses at, it decreases.
Advantages of Anthropometric
Measurements
• Non-expensive and need minimal training.
• Objective with high specificity and sensitivity.
• Measures many variables of nutritional significance.
• Readings are numerical and gradable on standard growth
charts.
• Readings are reproducible.
Limitations
• Inter-observers errors in measurement.
• Limited nutritional diagnosis.
• Problems with reference standards, that is local versus
international standards.
Biochemical Analysis or Laboratory
Test
• These tests help to determine what is happening to the body
internally. Biochemical measurements assess organ function,
fluid status and electrolyte balance. they also confirm nutritional
deficiencies and monitor the adequacy of nutritional therapies.
Useful baseline laboratory data includes basic chemistries (for
example electrolytes, glucose, BUN and creatinine), liver
function tests, hemogram and albumin.
• These are conducted on tissues such as liver, kidney, blood,
urine, stool, hair and bones. Various nutrients are present in the
body fluid; during illness this normal range gets deranged,
resulting in an abnormal increase or decrease of specific
nutrients. These are used to determine the nutrition status of an
individual.
Biochemical Analysis or Laboratory
Test cont…
Examples of biochemical tests include:
• Haemoglobin estimation is the most important test, and useful index of
the overall state of nutrition. Beside anaemia it also tells about protein
and trace element nutrition.
• Stool examination for the presence of ova and/or intestinal parasites.
• Urine dipstick and microscopy for albumin, sugar and blood.
• Measurement of individual nutrient in body fluids (for example serum
retinol, serum iron, urinary iodine, vitamin D).
• Detection of abnormal amount of metabolites in the urine (for example
urinary creatinine/hydroxyproline ratio).
• Analysis of hair, nails and skin for micronutrients.
Advantages of Biochemical Analysis
• It is useful in detecting early changes in body metabolism and
nutrition before the appearance of overt clinical signs.
• It is precise, accurate and reproducible.
• Useful to validate data obtained from dietary methods for
example comparing salt intake with 24 hour urinary excretion.

Limitations of Biochemical Analysis

• Time consuming.
• Expensive in terms of facilities and personnel.
• They cannot be applied on large scale.
• Interpretation of the data requires skilled manpower.
Clinical or Physical Examination
• This involves assessing an individual by examining the clinical
indicators (signs and symptoms) of nutrition status. The major
advantage is that it is simple and quick. However, some of the
clinical signs are not specific to a nutrition deficiency and one
sign overlaps for more than one deficiency disorder.
Dietary Evaluation and Personal History or Dietary
Survey

This is a systematic study of dietary intake of an individual or

groups of individuals, whose aim is to estimate:
• Intake of nutrients consumed.
• Measure food consumption in terms of quality (variety) and
quantity.
• Estimate intake of non-nutrients.
There are various ways of conducting dietary surveys including
the following:
Twenty Four Hour Recall

• A trained interviewer asks the subject to recall the food and

drink taken in the previous 24 hours and enters them in the
table below
Twenty four hour Recall
MEAL Menu Ingredien Amount Amount
ts
Cooked Raw
Breakfast
Lunch
Evening
Tea
Dinner
Any other
Weighted Intake
• In the previous method you ask the individual to recall what they
have eaten in the previous 24 hours. For this method you are
actually present when the individual is eating and you weigh the
amount of all the food items served as well as the foods not
eaten.
• The amount of food eaten in grams is equal to the amount of food
served in grams) subtract the amount of food not eaten in grams.
• Weighted intake gives the most accurate picture of food eaten
however, it is time consuming and the individual may resist
showing the interviewer the foods.
Food Frequency
• In this method the subject is given a food list of around 100 food
items to indicate the frequency of consumption.
Food Diary
• Food intake (types and amounts) should be recorded by the
subject at the time of consumption. The length of the collection
period range between one to seven days
Dietary and Personal History
During the nutrition interview, data collection will include questions
about the individual's lifestyle including:
• The number of meals eaten daily.
• Where they are eaten and who prepared the meals.
• Information about allergies, food intolerances and food
avoidances.
• Caffeine and alcohol use.
• Exercise frequency and occupation help to identify the need for
increased calories.
• Asking about the economics of the individual or family.
Risk Factors to Developing, or Denoting the
Presence of Nutrient Deficiencies or
Malnutrition
• Age < 18 years or > 65 years (increased risk age >75 years)
• Recent significant, unintentional weight loss
• Excessive alcohol intake, other substance abuse
• Homelessness, limited access to food
• Limited capacity for oral intake (dysphagia, odynophagia,
stomatitis, mucositis)
• Nil per oral > three days
Risk Factors to Developing, or Denoting the Presence
of Nutrient Deficiencies or Malnutrition cont…
• Increased metabolic demands: extensive burns, major surgery,
trauma, fever, infection, draining, abscesses, wounds, fistulae,
pregnancy
• Protracted nutrient losses: malabsorption syndrome, short gut
syndrome, draining abscesses, wounds, fistulae, effusions,
renal dialysis
• Intake of catabolic drugs: corticosteroids, immunosuppressants,
antineoplastics
• Protracted emesis: anorexia nervosa, bulimia, hyperemesis
gravidarum, radiation, cancer chemotherapy
• Chronic disease (especially AIDS, diabetes, cystic fibrosis,
Interpretation of Dietary Information
The interpretation usually takes two forms, the qualitative and
quantitative methods.
• Qualitative Method -You recall that the food pyramid suggests
portion sizes and the number of servings from each food group
to be consumed on a daily basis and can also be used as a
reference to evaluate dietary intake. Different nutrients are
classified into five groups (fat and oils, bread and cereals, milk
products, meat-fish-poultry, vegetables and fruits).
• You determine the number of serving from each group reported
by the individual and compare it with the minimum requirement
based on the pyramid. You also determine whether the foods
consumed daily are balanced and diversified in nutrients.
Interpretation of Dietary Information
cont…
• Quantitative Method - The amount of energy and specific
nutrients in each food consumed can be calculated using food
composition tables and then compared with the recommended
daily intake. Evaluation by this method is expensive and time
consuming, unless computing facilities are available.
Assessment and Interventions in
Emergency Nutrition Response
• Important components of any response to a humanitarian crisis in
this nation are health and nutrition activities geared towards a
resident population, an internally displaced population and a
refugee population.
• For any emergency, an initial assessment is conducted to
understand the situation and to be able to analyse the extent of
threat to life, dignity, health and livelihoods. A multisectoral
assessment to understand the different factors affecting
malnutrition: basic, underlying and immediate causes of
malnutrition are done to ensure a holistic approach to the treatment
of acute malnutrition. An initial screening utilises MUAC
measurements for children between 6-59 months. MUAC < 13.5cm
and presence of oedema are referred to a health or feeding centre
Assessment and Interventions in
Emergency Nutrition Response cont..
• A second screening is conducted at the health or feeding centre
by taking weight and height or length measurements and
interpretation of weight for height indicator of wasting is done.
Nutrition Interventions
There are three types of nutrition interventions:
• General feeding programme; this programme provides a food
ration to household highly affected by food insecurity. General
food rations are usually provided as dry rations for people to
cook at home.
• Supplementary feeding programme; this programme provides
supplementary food ration which is highly nutritious. The aim of
the programme is to rehabilitate individuals affected by
moderate acute malnutrition or at risk of becoming
malnourished.
• Therapeutic feeding programme; this deals with the
management of severe acute malnourished patients as
inpatient or outpatient.