NUTRITIONAL ASSESSMENT

Objective
After Completing this chapter the students is able to

 Define nutritional assessment

 List nutritional assessment methods

 Describe nutritional assessment method

 Describe advantages and disadvantages of each methods

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Introduction
 Nutritional assessment is
gathering, analyzing and
interpreting of anthropometric,
biochemical (laboratory),
clinical and dietary survey data
to tell whether a person/ group of
people is well nourished or
malnourished (Over nourished or
under nourished). 4
Methods of Nutritional Assessment
 There are direct and indirect methods of assessing
Nutritional status.

1. Direct methods - ABCD

1. Anthropometry: assesses functional disturbances

2. Biochemical: assess biochemical & functional disturbances

3. Clinical: assesses clinical signs / symptoms

4. Dietary: assesses risk of inadequate intakes

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Methods of Nutritional Assessment…

2. Indirect methods

 Indicators of the food & nutrition situations in the

area/region of interest

 By examining certain data closely related to malnutrition

or aggravated by malnutrition
 Income levels  Rate of nutritionally relevant
 Market price of foods infections
 Cause specific mortality rates  Meteorological data (rainfall data )
 Production pattern & distribution
 Age specific mortality rates
pattern
 Health service statistics 6
 Predominance of cash crops
Anthropometric Assessments
 Anthropometry comes from two Greek words:
Anthropo = Human, and Metry/metron = measurement.

 Definition:- Anthropometry refers to measurement of

variations of physical dimension and gross composition of
human body at different levels and degrees of nutrition.

 Anthropometric assessment can be used in field or clinical

setting.

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Anthropometric Assessments…
Purposes of Anthropometric Measurements

 Anthropometric measurements are performed with two

major purposes in mind:

 In children: to assess physical growth

 In adults: to assess changes in body composition or weight

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Anthropometric Assessments…
 Growth
 Head circumference
 Length/height
 Weight
 Fat-free mass
 Mid-upper Arm Circumference (MUAC)
 Mid Upper Arm Muscle Circumference (MUAMC)
 Mid Upper Arm Muscle Area (MUAMA)
 Body fat
 Skin fold thicknesses
 Hip circumference
 Waist circumference 9
Head Circumference
 Measured using flexible
measuring tape around 0.6cm
wide to the nearest 1mm.
 It is the circumference of the head
along the supra orbital ridge
anteriorly and occipital
prominence posteriorly.
 HC is useful in assessing chronic
nutritional problems in under
two children.
 But after 2 years as the growth of
the brain is sluggish it is not
useful.
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Length
Recumbent length

 Measured in children:
 Younger than 24 months
 Less than 85cm long if age is not known
 Who are too ill to stand

 Correct measurement of length requires that:

 Child is relaxed with no shoes on
 Child lies parallel to the long axis of the board
 Crown of the head is against the fixed board
 Movable board is brought up against the heels
 One assistant is needed in taking the measurement 11
Length…

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Height
Standing height

 Measured in children:
 Over 24 months of age
 85 -110 cm tall if age is not known
 To measure height, the:
 Head should be in the Frankfurt plane during measurement,
knees should be straight and the heels buttocks and the shoulders
blades and occiput , should touch the vertical surface of the
stadiometer ( anthropometer) or wall.

 Child stands barefoot wearing little clothing 13

Height…

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Weight
 Weight can be measured with a :

 Hanging spring scale (< 2 years children)

 Beam balance (> 2 years)

 Portable electronic scale

 Calibration needed after every measurement

 Remove or make allowance for clothing

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Weight…

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Weight…

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Indices of Growth Measurements
 Indices are constructed from two or more raw
anthropometric measurements or a measurement plus
age.

 The following are few of them: -

 Head circumference-for age

 Weight -for-age

 Height-for age

 Weight for height 18

Weight for Age (WFA)
 An index of acute malnutrition in children 6 months to
seven years of age when the measurement of length is
difficult especially during infancy.

𝒘𝒆𝒊𝒈𝒉𝒕 𝒐𝒇 𝒕𝒉𝒆 𝒄𝒉𝒊𝒍𝒅

𝑾𝑭𝑨 = 𝑿 𝟏𝟎𝟎
𝒘𝒆𝒊𝒈𝒉𝒕 𝒐𝒇 𝒕𝒉𝒆 𝒓𝒆𝒇𝒆𝒓𝒆𝒏𝒄𝒆 𝒄𝒉𝒊𝒍𝒅 𝒐𝒇 𝒕𝒉𝒆 𝒔𝒂𝒎𝒆 𝒂𝒈𝒆

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Height for Age (HFA)
 An index of past or chronic malnutrition (stunting) : a
slowing of skeletal growth and of stature due to reduced rate
of linear growth.

𝒉𝒆𝒊𝒈𝒉𝒕 𝒐𝒇 𝒕𝒉𝒆 𝒄𝒉𝒊𝒍𝒅

𝑯𝑭𝑨 = 𝑿 𝟏𝟎𝟎
𝒉𝒆𝒊𝒈𝒉𝒕 𝒐𝒇 𝒕𝒉𝒆 𝒓𝒆𝒇𝒆𝒓𝒆𝒏𝒄𝒆 𝒄𝒉𝒊𝒍𝒅 𝒐𝒇 𝒕𝒉𝒆 𝒔𝒂𝒎𝒆 𝒂𝒈𝒆

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Weight for Height (WFH)
 A sensitive index for the assessment of current nutritional
status (acute malnutrition)

 Relatively independent of age between one and ten years(

Age uncertain).

𝒘𝒆𝒊𝒈𝒉𝒕 𝒐𝒇 𝒕𝒉𝒆 𝒄𝒉𝒊𝒍𝒅

𝑾𝑭𝑯 = 𝑿 𝟏𝟎𝟎
𝒘𝒆𝒊𝒈𝒉𝒕 𝒐𝒇 𝒕𝒉𝒆 𝒓𝒆𝒇𝒆𝒓𝒆𝒏𝒄𝒆 𝒄𝒉𝒊𝒍𝒅 𝒐𝒇 𝒕𝒉𝒆 𝒔𝒂𝒎𝒆 𝒉𝒆𝒊𝒈𝒉𝒕

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 Relative Usefulness of Different Growth
Indices

WFH HFA WFA

Usefulness in populations 1 4 4
where age is unknown or
uncertain
Usefulness in identifying 1 4 3
wasted children
Sensitivity to weight changes 1 4 2
over a short period of time
Usefulness in identifying 4 1 2
stunted children

Scale from 1 (excellent) to 4 (poor). Gorstein (1994)

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 Classification of Moderate and
Severe Malnutrition
Malnutrition
Moderate Severe
Symmetric edema (bilateral No Yes (edematous
pitting edema) malnutrition or
kwashiorkor)

Weight for SD Score –2 to –3 < -3 severe wasting

age
% Median 70 to 79 < 70 or marasmus

Length SD Score –2 to –3 < -3 severe stunting

(Height) for
age % Median 85 to 89 < 85

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 Classification of Moderate and
Severe Malnutrition

Acute Percentage of the Z-scores Edema

malnutrition median
using WFH
Severe < 70% < -3 z score Yes/no

Moderate < 80% to >=70% < -2 z-score to ≥ -3 z No

scores

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 Prevalence of Malnutrition &
Interpretation Levels
 The following classifications for malnutrition have been
established by WHO as levels for interpreting WFH, HFA
and WFA z-scores (WHO2002).

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Body Mass Index (BMI)
 Body mass index the best method for assessing adult
nutritional status of adults as they are assumed to be highly
correlated with obesity.

 Measure body weight corrected for height, but cannot

distinguish between excessive weight produced by
adiposity, muscularity, or edema

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Body Mass Index (BMI)
 Relatively unbiased by height
 To classify overweight & obesity in adults
 To assess Chronic Energy Deficiency in
adults
 Used in large-scale surveys:
 Easy, quick, non-invasive
 More precise than skinfolds
 Does not distinguish b/n weight
associated w/muscle vs. body fat
 High BMI can be due to
 excessive adiposity;
 muscularity; or edema
 No indication of distribution of body fat 27
Body Mass Index (BMI)…
 WHO classifies the nutritional status of adults according to
their BMI as follows:

 Underweight ≤ 18.50,

 Normal range = 18.5–24.99,

 Overweight = 25.00 –29.99,

 Obese ≥ 30.00,

 Very severely obese ≥ 40.00

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Assessment of Body Composition
 Linear growth ceases at around the age of 20-25 years.

 In assessing body composition we consider the body to made

up of two compartments:

 The fat mass and the fat free mass.

 Total body mass = Fat mass + fat free Mass

 Therefore different measurements are used to assess these

two compartments:

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Measurements Used to Assess Fat Mass

 Waist to Hip circumference ratio

 Skin fold thickness

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Waist to Hip Circumference Ratio
 It is the circumference of the waist measured mid-way
between the lowest rib cage and anterior superior iliac
spine divided by the circumference of the hip measured
at the level of the greater trochanter off the femur ( both
are measured to the nearest 0.5 cm)

 If the ratio is > 1 in male, and > 0.87 in female there is high
risk of coronary heart disease.

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Waist to Hip Circumference Ratio…

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Skin Fold Thickness
 Common sites for measuring skin
fold thickness include :
 Triceps
 Biceps
 Sub -scapular
 Supra iliac , and
 Mid axillary (on the maxillay line at
the level of Xiphoidprocess)

 No consensus exists on the best

single or combination of skin fold
sites to assess body fat. 33
Measurements Used for Assessing Fat Free Mass

 Mid-upper Arm Circumference (MUAC)

 Mid Upper Arm Muscle Circumference (MUAMC)

 Mid Upper Arm Muscle Area (MUAMA)

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Mid Upper Arm Circumference (MUAC)

 Is used for screening purposes especially in emergency

situations where there is shortage of human resource, time
and other resources as it is less sensitive when compared to
the other indices.

 It is measured half way between the olecranon and

acromion process using non stretchable tap.

 It is a sensitive indicator of risk of mortality.

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Mid Upper Arm Circumference (MUAC)…

Target MUAC Malnutrition

Groups
Moderate acute
Under five 11-11.9 cm
malnutrition (MAM)
years old
children Severe acute
<11 cm
malnutrition (SAM)
17 to <21cm
Moderate
18 to < 21 cm with recent malnutrition
Pregnant weight loss
women/
Adults < 17 cm
<18 cm with recent weight Severe malnutrition
loss 36
Mid Upper Arm Circumference (MUAC)…

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Errors in Anthropometry
 Random measurement errors: affect precision. It is
minimized by:
 Training personnel
 Using standardized techniques: multiple measurements
 Calibrated equipment

 Systematic measurement errors

 Affect accuracy of the measurement
 Commonly occurs due to the equipment (equipment bias)
 (e.g. different skin fold calipers on the same person (compression of springs,
surface area)
 There is no reference in anthropometry to know the true value. This
is instead estimated by comparing them with those made by a
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criterion anthropometrist.
Errors in Anthropometry…
Other sources of error

 Errors from changes in tissue composition and properties

 Variation in tissue hydration with menstrual cycle

 Variation in skin-fold compressibility and thickness with

age, gender, level of tissue hydration

 Demineralization of bone with aging;

 Changes in body water with aging

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Pros and Cons Anthropometric Measurements

Pros Cons
 Quick  Difficult in selecting
 Cheaper appropriate cut-off
 Give gradable results point
 More accepted by the community  Limited diagnostic
 Not invasive relevance
 Can be accurate and precise  Considerable potential
provided that standardized methods for inaccuracy
are used  Need for reasonably
 Can be used in evaluation of precise age
changes in nutritional status
 Used in screening tests 40
Biochemical/Laboratory Methods
 This involves measurement of either total amount of the
nutrient in the body, or its concentration in a particular
storage site (organ) in the body or in the body fluids.

 The depletion could be detected by biochemical tests and/or

by tests that measure physiological or behavioral functions
dependent on specific nutrient.

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Types of Biochemical /Laboratory Assessment

1. Static biochemical tests: This involves measurement a

nutrient or its metabolites in pre-Selected biological
material (blood, body fluids, urine, hair, fingernails etc.)
 E.g. Serum ferritin level, Serum HDL, Erythrocyte Folate, Tissue
stores of Vitamin A and D.

2. Functional tests: diagnostic tests are used to determine the

sufficiency of host nutrition to permit cells , tissues , organs
to perform optimally the intended nutrient dependent
biological functions. 42
Clinical Methods
 Used to detect deviations from the normal state of
nutrition by observing and interpreting clinical signs and
symptoms of deficiency or excess.

 To detect and record symptoms and physical signs associated

with malnutrition

 Medical History and Physical Examination

 Useful during advanced nutritional depletion; when overt

disease is present
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Clinical Methods…
 Advantage
 It does not require elaborate equipment or laboratory;
several can be done by minimally trained personnel.

 Limitation:
 Specificity is low; many of the signs are associated with a
number of nutritional disorders as well as non-nutritional
disorders.

 Sensitivity is low; sign may appear in the recovery as

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well as the deficiency state
Clinical Methods…

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Dietary Methods
 These methods include assessment of past or current
intakes of nutrients from food by individuals or a group in
order to know their nutritional status.

 Dietary data could be gathered at

 National

 Household or

 Individual levels

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Dietary Methods…
Measuring Food Consumption At Individual/Group Level
1. Methods used to assess current intake
 Estimated food record method,
 Weighed/observed food record method
 Food diary method
2. Methods used to assess past intake
 Twenty-four-hour (24hrs) recall method,
 Dietary history,
 Food frequency Questionnaire
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Dietary Methods…
1. Quantitative Methods

 Estimated/weighed/observed food record method

 Twenty-four-hour recall method

2. Qualitative Methods

 Food diary method

 Dietary history

 Food frequency questionnaire

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Weighed Food Records
 Weighing and recording all foods consumed including
drinks both portion sizes consumed and left over.

 Most precise method for assessing food intakes of

individuals.

 Respondent or research assistant weighs all foods and

drinks (including snacks) consumed during a specified
period of time.

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Weighed Food Records…
Advantage
 More accurate; no respondent memory loss

Disadvantages
 High respondent burden; change of the dietary habit during
the survey due fear of burden

 Needs literate & numerate respondents

 Invasive (observed WR); change of the dietary habit

during the survey

 Costly 50
24 Hours Dietary Recall
 Subjects/care takers are asked to recall the exact food
intake during the previous 24hrs/preceding day.

 Including all beverages, snacks, deserts, supplements ...etc.

 Portion sizes are estimated by different methods.

51
24 Hours Dietary Recall…
Advantage
 Relatively cheap; quick; less respondent burden

 No chance for the respondents to change dietary habit

Disadvantage
 Respondent memory laps;

 Social desirability bias

 Less precision; accuracy; depends on the respondent’s ability to

estimate portion sizes

52
Food Diary Method
 Subject is asked to record what ever he/she ate including
beverages for specified period of time with estimation of
the portion sizes consumed.

53
Food Diary Method…
 Advantage

 May give relatively accurate estimate of the nutrient intake

if done properly.

 Disadvantage

 High respondent burden; literacy & numeracy of subjects

needed; high coding burden.

54
Dietary History
 Attempts to estimate the usual food intake & meal pattern
over a relatively long period of time.

 Usually to see the association between diet & disease.

55
Dietary History…
 Advantages
 Give the dietary habits over a longer periods of time

 Can target questions to specific dietary habits or intake of specific

nutrients of interest (e.g. Alcohol intake, fat intake)

 Less respondent burden

 Disadvantages
 Over emphasizes the regularity of the dietary pattern

 Needs a very highly trained interviewer

 Gives just a relative if not an absolute information

56
Food Frequency Questionnaire
 Describes how often a client eats each of a variety of foods

 Aims to assess the frequency with which food items/food

groups are consumed during a specified time period.

 Questionnaire based on the local staple diet & its

administration to determine frequency of consumption of a
particular nutrient.

 Provide descriptive qualitative information about usual

food consumption pattern.
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Food Frequency Questionnaire
Advantages
 Usually used for areas with geographically widely scattered
population.

 It is less costly especially if self administered.

 Less respondent burden

 Disadvantages
 Very difficult to develop especially in multi-cultural society where
different staple foods are consumed.

 It needs literate and numerate subjects.

58
 Errors During The Collection of
Dietary Data
 Interviewer and/or respondent biases: all methods

 Respondent memory lapses: for recalls, FFQ, DH only

 Incorrect estimation of portion sizes: for recalls, FFQ, DH

only.

 Errors in converting portion sizes to weight equivalents

 Errors in food composition database

 Sampling bias

 Change in dietary habit 59

Introduction

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