INTRODUCTION

The nutritional status of an individual is often the

result of many inter-related factors.

It is influenced by food intake, quantity & quality,

& physical health.

The spectrum of nutritional status spread from

obesity to severe malnutrition
Nutritional Assessment Why?

The purpose of nutritional assessment is to:

Identify individuals or population groups

at risk of becoming malnourished

Identify individuals or population groups

who are malnourished
Nutritional Assessment Why? 2
To develop health care programs that meet the
community needs which are defined by the
assessment

To measure the effectiveness of the nutritional

programs & intervention once initiated
Methods of Nutritional Assessment
Nutrition is assessed by two types of methods;
direct and indirect.

The direct methods deal with the individual and

measure objective criteria, while indirect
methods use community health indices that
reflects nutritional influences.
Direct Methods of Nutritional Assessment
These are summarized as ABCD
 Anthropometric methods
 Biochemical, laboratory methods
 Clinical methods
 Dietary evaluation methods
Indirect Methods of Nutritional
Assessment
These include three categories:
Ecological variables including crop production
Economic factors e.g. per capita income,
population density & social habits
Vital health statistics particularly infant & under 5
mortality & fertility index
CLINICAL ASSESSMENT
It is an essential features of all nutritional surveys
It is the simplest & most practical method of
ascertaining the nutritional status of a group of
individuals
It utilizes a number of physical signs, (specific & non
specific), that are known to be associated with
malnutrition and deficiency of vitamins &
micronutrients.
CLINICAL ASSESSMENT/2
Good nutritional history should be obtained
General clinical examination, with special
attention to organs like hair, angles of the mouth,
gums, nails, skin, eyes, tongue, muscles, bones, &
thyroid gland.
Detection of relevant signs helps in establishing
the nutritional diagnosis
CLINICAL ASSESSMENT/3
 ADVANTAGES
 Fast & Easy to perform
 Inexpensive
 Non-invasive
 LIMITATIONS
 Did not detect early cases
Clinical signs of nutritional deficiency
HAIR
Spare & thin Protein, zinc, biotin
deficiency

Easy to pull out Protein deficiency

Corkscrew Vit C & Vit A

Coiled hair deficiency
Clinical signs of nutritional deficiency
MOUTH
Glossitis Riboflavin, niacin, folic acid,
B12 , pr.
Bleeding & spongy gums Vit. C,A, K, folic acid & niacin
Angular stomatitis, B 2,6,& niacin
cheilosis & fissured
tongue
leukoplakia Vit.A,B12, B-complex, folic
acid & niacin
Sore mouth & tongue Vit B12,6,c, niacin ,folic acid
& iron
Clinical signs of nutritional deficiency
EYES

Night blindness, Vitamin A deficiency

exophthalmia

Photophobia- Vit B2 & vit A

blurring, deficiencies
conjunctival
inflammation
Clinical signs of nutritional deficiency
NAILS

Spooning Iron deficiency

Transverse lines Protein deficiency

Clinical signs of nutritional deficiency
SKIN
Pallor Folic acid, iron, B12
Follicular Vitamin B & Vitamin C
hyperkeratosis
Flaking dermatitis PEM, Vit B2, Vitamin A,
Zinc & Niacin
Pigmentation, Niacin & PEM
desquamation
Bruising, purpura Vit K ,Vit C & folic acid
Clinical signs of nutritional deficiency
Thyroid gland
 in mountainous
areas and far from
sea places Goiter is a
reliable sign of
iodine deficiency.
Clinical signs of nutritional deficiency

Joins & bones

 Help detect signs of
vitamin D deficiency
(Rickets) & vitamin C
deficiency (Scurvy)
Anthropometric Methods
Anthropometry is the measurement of body
height, weight & proportions.
It is an essential component of clinical
examination of infants, children & pregnant
women.
It is used to evaluate both under & over nutrition.
The measured values reflects the current
nutritional status & don’t differentiate between
acute & chronic changes .
Other anthropometric Measurements

 Mid-arm circumference

 Skin fold thickness

 Head circumference

 Head/chest ratio
 Hip/waist ratio
Anthropometry for children
Accurate measurement of height and weight is
essential. The results can then be used to
evaluate the physical growth of the child.

For growth monitoring the data are plotted on

growth charts over a period of time that is
enough to calculate growth velocity, which can
then be compared to international standards
Growth
Percentile chart
Monitoring Chart
Measurements for adults
Height:
The subject stands erect & bare
footed on a stadiometer with a
movable head piece. The head piece
is leveled with skull vault & height
is recorded to the nearest 0.5 cm.
WEIGHT MEASUREMENT
Use a regularly calibrated electronic or balanced-
beam scale. Spring scales are less reliable.

Weigh in light clothes, no shoes

Read to the nearest 100 gm (0.1kg)

Nutritional Indices
The international in Adults
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)
 Evidence shows that high BMI (obesity level) is
associated with type 2 diabetes & high risk of
cardiovascular morbidity & mortality
BMI (WHO - Classification)
BMI < 18.5 = Under Weight
BMI 18.5-24.5= Healthy weight range
BMI 25-30 = Overweight (grade 1
obesity)
BMI >30-40 = Obese (grade 2 obesity)
BMI >40 =Very obese (morbid or
grade 3 obesity)
Waist/Hip Ratio
 Waist circumference is measured at
the level of the umbilicus to the
nearest 0.5 cm.
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
Waist
than anycircumference
other anthropometric measurement.

It has been proposed that waist measurement

alone can be used to assess obesity, and two
levels of risk have been identified
MALES FEMALE
LEVEL 1 > 94cm > 80cm
LEVEL2 > 102cm > 88cm
Waist circumference/2
Level 1 is the maximum acceptable waist
circumference irrespective of the adult age and
there should be no further weight gain.

Level 2 denotes obesity and requires weight

management to reduce the risk of type 2 diabetes
& CVS complications.
Hip Circumference
Is measured at the point of greatest
circumference around hips & buttocks to the
nearest 0.5 cm.
The subject should be standing and the
measurer should squat beside him.
Both measurement should taken with a
flexible, non-stretchable tape in close contact
with the skin, but without indenting the soft
tissue.
Interpretation of WHR
High risk WHR= >0.80 for females & >0.95 for
males i.e. waist measurement >80% of hip
measurement for women and >95% for men
indicates central (upper body) obesity and is
considered high risk for diabetes & CVS disorders.
A WHR below these cut-off levels is considered
low risk.
ADVANTAGES OF ANTHROPOMETRY
 Objective with high specificity & sensitivity
 Measures many variables of nutritional significance
(Ht, Wt, MAC, HC, skin fold thickness, waist & hip
ratio & BMI).
 Readings are numerical & gradable on standard
growth charts
 Readings are reproducible.
 Non-expensive & need minimal training
Limitations of Anthropometry
Inter-observers errors in measurement

Limited nutritional diagnosis

Problems with reference standards, i.e.

local versus international standards.

Arbitrary statistical cut-off levels for

what considered as abnormal values.
DIETARY ASSESSMENT
 Nutritional intake of humans is assessed by five
different methods. These are:

 24 hours dietary recall

 Food frequency questionnaire
 Dietary history since early life
 Food dairy technique
 Observed food consumption
24 Hours Dietary Recall

A trained interviewer asks the subject to recall all

food & drink taken in the previous 24 hours.
It is quick, easy, & depends on short-term
memory, but may not be truly representative of
the person’s usual intake
Food
In thisFrequency Questionnaire
method the subject is given a list of around
100 food items to indicate his or her intake
(frequency & quantity) per day, per week & per
month.

inexpensive, more representative & easy to use.

Food Frequency Questionnaire/2
Limitations:
 long Questionnaire

 Errors with estimating serving size.

 Needs updating with new commercial food products

to keep pace with changing dietary habits.
DIETARY HISTORY
It is an accurate method for assessing the
nutritional status.
The information should be collected by a trained
interviewer.
Details about usual intake, types, amount,
frequency & timing needs to be obtained.
Cross-checking to verify data is important.
FOOD DAIRY
Food intake (types & amounts) should be
recorded by the subject at the time of
consumption.

The length of the collection period range between

1-7 days.

Reliable but difficult to maintain.

 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 &
efforts.
Interpretation of Dietary Data
1. Qualitative Method
 using the food pyramid & the basic food groups
method.
 Different nutrients are classified into 5 groups
(fat & oils, bread & cereals, milk products,
meat-fish-poultry, vegetables & fruits)
 determine the number of serving from each
group & compare it with minimum
requirement.
Interpretation of Dietary Data/2
2. Quantitative Method
 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.
 Evaluation by this method is expensive & time
consuming, unless computing facilities are
available.
Initial Laboratory Assessment

Hemoglobin estimation is the most important

test, & useful index of the overall state of
nutrition. Beside anemia it also tells about
protein & trace element nutrition.
Stool examination for the presence of ova and/or
intestinal parasites
 Urine dipstick & microscopy for albumin, sugar
and blood
Specific Lab Tests
Measurement of individual nutrient in
body fluids (e.g. serum retinol, serum
iron, urinary iodine, vitamin D)
Detection of abnormal amount of
metabolites in the urine (e.g. urinary
creatinine/hydroxyproline ratio)
Analysis of hair, nails & skin for micro-
nutrients.
Advantages of Biochemical Method
It is useful in detecting early changes in body
metabolism & nutrition before the appearance of
overt clinical signs.
It is precise, accurate and reproducible.
Useful to validate data obtained from dietary
methods e.g. comparing salt intake with 24-hour
urinary excretion.
Limitations of Biochemical Method

Time consuming

Expensive

They cannot be applied on large scale

Needs trained personnel & facilities