Nutritional Assessment
By, Nigatu T.(PHO, MPH)
March, 2024
Learning objectives
At the end of the chapter students should be acquainted with
Different nutritional assessment system
Direct and indirect nutritional assessment methods
Various approaches to assess food consumption at national,
household and individual level
Anthropometric nutritional assessment method, its weakness,
strength and way of interpretation.
Clinical, laboratory and dietary nutritional assessment
methods their weakness and strength
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Definitions
Nutritional status
Health status of an individual as influenced by intake and
utilization of nutrients(Undernourished Well nourished Over
nourished)
Assessment: a process of gathering, analyzing and interpreting
information
Nutritional assessment:
Gathering, analyzing and interpreting of information from
dietary, biochemical, anthropometric and clinical studies to
determine the nutritional status of individuals and groups.
Nutritional assessment system
Nutrition surveys:
Data collected only once
Establish baseline nutritional status of a population
Identify geographic areas and/or sub-population
groups at risk for chronic malnutrition
Formulate policies
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Nutritional Assessment ---
• Nutrition surveillance:
– Data collected over time on same groups
– Can identify both acute & chronic malnutrition
– Seasonal differences identified
– Possible causes of malnutrition for intervention
programs
– Important for monitoring policies and evaluating
nutrition interventions
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Nutritional Assessment ---
Nutritional screening :the process of identifying
individuals at risk of malnutrition through quick, safe
and cheap method so that more extensive nutrition
assessment can be done.
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Uses of Nutritional Assessment
Aim at discovering facts to guide actions intended to
improve nutrition and health
Diagnostic tool (individual and group)
Does a problem exist – identify
Type of problems
Magnitude of the problem
Who are affected by the problem
Uses of Nutritional Assessment…
Monitoring tool (individuals and group)
Requires repeated assessment over time
Has the situation changed?
Direction and magnitude of change
Evaluation tool (individual or group)
To what extent has the intervention, treatment, or
program had the intended effect (impact)
Methods for assessing nutritional status
I. Direct methods
1. Anthropometry: assesses functional disturbances
• Growth
• Body composition-fat & fat-free mass
2. Laboratory: identifies biochemical & functional
disturbances
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Methods for assessing…
3. Clinical: assesses clinical signs / symptoms
4. Dietary: assesses risk of inadequate intakes
– Food consumption patterns
– Nutrient intakes &
– Major food sources of nutrients
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Methods for assessing…
II. Indirect Methods
Include the following three categories
1. Ecological variables
Crop production, meteorological data (rainfall data),
production pattern and distribution pattern,
predominance of cash crops, etc
2. Economic factors
Per capita income, population density, income levels,
market price of foods, etc
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Indirect Methods…
3. Vital health statistics
Infant & under 5 mortality, fertility, cause specific
mortality rates, rate of nutritionally relevant
infections, etc.
Assessment of indicators of the food and nutrition
situations in the area/region of interest by looking at
certain data that are closely related to malnutrition
or which are aggravated by malnutrition
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Anthropometric assessment
Anthropometry: anthropo (human), metry (measurement)
Measurements of the variations of physical dimensions &
gross composition of the human body at different age
levels & degrees of nutrition
Anthropometric assessment –types
Assessment of growth-children & adolescents
Assessment of body composition
Can be used in field or clinical setting
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Advantages Limitations
Simple, safe, non-invasive technique Insensitive: cannot detect
disturbances over short
period of time
Inexpensive equipment: portable, durable, Limited nutritional
purchased locally diagnostic relevance
Precise & accurate methods if techniques are Can be affected by genetics
standardized & personnel are trained
Identifies mild, moderate & severe malnutrition;
give gradable results
Can be used to screen persons at high risk to
under- or over- nutrition & monitor change
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Terminologies
•Raw measurements
Weight, height, head circumference
•Indices (singular: index)
Constructed from raw measurements
Necessary for interpretation of measurements
weight-for-length: wasting; height-for-age: stunting
• Indicator : index + a cut-off point
Comparison of indices in relation to cutoffs
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Terminologies---
Cutoff points
Generally based on ranges associated with clinical signs, or
impairment in a biochemical or physiological function
Used to classify the severity of nutritional status
Stunting - H/A z score of less than -2
Trigger levels
Level of an indicator at which there is public health concern
Example: Stunting in children < 5 years > 20%
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Anthropometric Measurements
1. Growth
– Head circumference
– Length/height
– Weight
2. Body fat
–Skin fold thicknesses
–Hip circumference
–Waist circumference
–MUAC
–Body mass index
3. Fat-free mass
– Mid-upper arm Ms circumference
– Mid-upper arm muscle area
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ANTHROPOMETRIC MEASUREMENT
OF GROWTH
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Head Circumference (HC)
HC should be measured along the supra orbital ridge
anteriorly & occipital prominence posteriorly
Measuring tape should be flexible, non-stretchable
Frankfurt position by facing left side; arms relaxed
Tape at same level on each side of head; tight to
compress hair
Measure to nearest mm
HC-for age: index of chronic under nutrition for < 2 y
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Head Circumference---
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Measurement of Height/Length
Length:
< 85cm (~ <2 years)
Need:
>2 examiners for measurement
Recumbent length board
If subject restless, then only left leg used
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Measurement of Height/Length…
Recumbent length
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Measurement of height/length…
Height: > 2 yrs
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Measurement of weight
For small children:< 2 year
weigh naked
Use suspended scale; or scale pan
If necessary, weigh mother with her child & calculate
child’s weight by subtraction/special scale
Record to nearest 10 g
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Measurement of weight…
For older:
Empty bladder first
Beam balance or electronic scales can be used
Place balance on flat surface
Measure with minimum clothing & subtract clothing wt
Record to nearest 0.1 kg
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Indices of growth
Length/height-for-age:
Low ht-for-age = shortness -reflects stunting
Weight-for-age:
Low wt-for-age = lightness -reflects underweight
Weight-for-length/height:
Low wt-for-ht = thinness -reflects wasting
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Indices of growth---
• Head circumference-for-age:
Low HC-for-age = reflects chronic PEM in children
< 2 yr
• Body mass index: weight/height 2
Chronic energy deficiency (BMI < 18.5)
Overweight (BMI >25)
obesity (BMI > 30)
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Indices of growth…
In undernutrition, weight is affected more quickly
whereas growth failure will take longer
Indices sensitive to acute changes to nutritional status
are wt-for-age & wt-for-ht
Ht-for-age of children indicates nutritional status in the
long run
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ANTHROPOMETRIC
MEASUREMENTS OF BODY
COMPOSITION
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Anthropometric Measurements of Body Composition
Linear growth ceases at around the age of 25-30
years.
Therefore, the main purpose of nutritional assessment
of adults using anthropometry is determination of the
changes of body weight & body composition.
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Body Composition
Most anthropometric methods used to assess body
composition are based on a model in which the
body consists of two chemically distinct
compartments
• Fat mass
• Fat-free mass
Fat mass
Fat is one of our body’s main components and is
the main storage form of energy in the body and
is sensitive to acute malnutrition.
A healthy body fat percentage ranges
10 to 22 % for men and
20 to 32 % for women,
Measures of body fat
Skin folds:
Estimate size of subcutaneous fat
Thickness of subcutaneous adipose
tissue reflects proportion of total
body fat
Sites: triceps; subscapular;
suprailiac
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Skin fold thickness …
• Single skin folds
No agreement on best site as index of total body fat
Triceps is the most frequent site
Distribution of body fat depends on: ethnicity, age, &
sex
• Multiple skin folds
– For total body fat: one limb skin fold (e.g., triceps)
plus one trunk skin fold (subscapular)
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Subscapular Skinfold
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Suprailiac skin fold
• Landmark
– Immediately above
the iliac crest (top of
hip bone), on the
most lateral aspect
(side).
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WHR
Indices of Body composition
Assessment of body fat
Total body fat, regional fat distribution
Limb fat area
Weight in relation with height
Multiple skin fold thicknesses
Waist to hip circumference ratio*
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Waist to hip circumference ratio
Divide the waist measurement by the hip measurement to
obtain the WHR
It is an effective way to examine regional fat distribution
WC -“high risk”- >40 in. males & > 35 in. females
WHR - “high risk”->0.95 in males & >0.80 in females
*Hip: Measure at the maximum circumference of the buttocks
Elevated WHR strongly associated w/increased risk of CHD, stroke,
type 2 DM
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Body mass index (BMI)
To assess CED in adults
To classify overweight & obesity in adults
Correlates with laboratory-based measures of adiposity
Used in large-scale surveys, B/C it is:
Easy, quick, non-invasive
More precise than skin folds
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Body mass index…
• High BMI can be due to excessive:
Adiposity
Muscularity; or
Edema
• It is the best method for assessing adult nutritional status
except during pregnancy.
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quiz
• Derese is heavy weight champion, his weight
is 128kg and height is 168cm.
– A. calculate BMI
– B. is he obese?
– C. why?
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Cut-off point of BMI
Cut-off points-Adult
Normal-healthy/low risk – 18.5-24.9
Overweight– 25> Underweight-18.5<
Obese (class I)-30-34.9 Mild CED-17-17.9
Obese (class II)-35-39.9 Moderate CED-16-16.9
Extremely/morbidly obese-40> Severe CED-16 <
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Measures of fat-free mass
Measuring Mid-upper arm circumference (MUAC):
Subject in Frankfurt plane & sideways to measurer/left side
Arms hanging loosely at side with palm facing inward
Taken at marked mid-point (b/n acromion process & tip of
olecranon) of upper left arm
Do not squeeze arm; use flexible non-stretchable tape
Decrease in MUAC may reflect loss in muscle mass or
subcutaneous fat or both
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Interpretation of MUAC (NCHS)
For children taller/greater than 65 cm
New WHO standards recommend MUAC < 115 mm as
criteria for severe malnutrition among children of age 6
months and above
Nutritional status MUAC (NCHS)
Severe acute malnutrition (SAM) < 11 cm
Moderate acute malnutrition (MAM) 11 – 12 cm
Satisfactory nutritional status > 12 cm
Laboratory Assessment
Laboratory assessment is used primarily to detect
subclinical deficiency states or to confirm a clinical
diagnosis
Most objective and quantitative method of nutritional
assessment
Main drawback is that several factors may confound
interpretation of test results
Advantages and disadvantages of
Biochemical tests
• Advantages
– Detect sub-clinical Malnutrition
– Give gradable nutritional Information
– Are more objective
• Disadvantages
– Many quality control problems during sample taking, carrying
out the test, analysis. Etc
– Need sophisticated instruments
– Need highly trained staff
– Involve invasive procedures 55
Clinical Assessment
To detect & record symptoms & physical signs
associated with malnutrition
Detect nutrient deficiency/excess by observing &
interpreting clinical signs & symptoms
Medical History & Physical Examination
Useful during advanced nutritional depletion; when
overt disease is present
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Clinical Assessment
Sign/ symptom Nutritional abnormality
- Inability to see during the evening or dim light Vitamin A deficiency: Night blindness
- Xerophthalmmia
- Easy bruising of skin Scurvy (vitamin C deficiency)
- Spongy bleeding gums
- Pale: palms, conjunctiva, tongue Anemia: Which may herald, deficiency of: Iron,
- Easy fatigability, loss of appetite shortness of Vitamin B12, Folic acid, copper, protein (main
breath causes of nutritional anemia)
- Dental carries & frequent dental cavity Fluoride deficiency or increased consumption of
formation carbohydrates or decreased intake of fluoride
which decreases the pH of the mouth below
critical level i.e. 5.5 causing the enamel to
dissolve
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Dietary Assessment
Assess food consumption patterns; nutrient intakes
from foods & major food sources of nutrients
Risk of nutrient inadequacy through assessing
inadequate intakes
Dietary data could be gathered at
National
Household or
Individual levels
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Measuring food consumption at national level
Food balance sheet
The most widely used method to assess the national
food availability.
FAO definition: ‘a national account of the annual
production of food, changes in stock, imports and
exports and distribution of food over various users
with in the country’.
Balance between:
-imported food +domestic food production
-exported food +non-food uses +manufacturing,
storage and distribution loses
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Food Balance Sheet cont.….
Nutrient available per capital are estimated based on the
appropriate food composition table.
The FAO has published food balance sheet for world
countries since 1949.
Advantage :
It can be used to compare the available food supply
across countries and time.
Can be uses to formulate food and agriculture policies.
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Food Balance Sheet cont.….
Disadvantage/ Limitations:
Measures of food available for consumption but not
necessarily consumed.
Liable to incomplete measurement of food
production.
Doesn’t show seasonal, and socio-economic
distribution of food.
No deduction is made for household food waste or
loss of nutrients during food preparation.
Usually doesn’t consider that nutrient requirements
vary across segments(based on age, sex) of the
population.
Dietary Assessment…
Measuring food consumption at the household level
1. Food account method
Daily recorded by house holder of all foods entering to the
HH,either purchased , as gift or produced in specific period
Usually the period is 7 days
2. HH food record method
Completed over one week period either by the house holder
or field worker
The amount of all meal consumed at each meal is recorded
separately either by weight or house hold measure
Most accurate but increase respondent burden
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Dietary Assessment…
Measuring food consumption at individual/group level
1. Methods used to assess current intake
– Estimated food record method, weighed/observed
weighed record method, food diary method
2. Methods used to assess past intake
– Twenty-four-hour recall method, dietary history,
food frequency questionnaire
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Dietary Assessment…
Measuring food consumption at individual/group level
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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Dietary Assessment…
A. Weighed record method
Weighing & recording all foods consumed including drinks both
portion sizes consumed & left over
For mixed recipes weighed amount of food both before &
after cooking
Advantage
More accurate
No respondent memory loss
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Dietary Assessment…
Weighed record method---
– Disadvantages
High respondent burden
change of the dietary habit during the survey
Needs literate & numerate respondents
Costly
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Dietary Assessment…
B. 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
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
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Dietary Assessment…
C. 24 hours dietary recall
Subjects/care takers are asked to recall the exact food intake
during the previous 24hrs
Including all beverages, snacks, supplements ...
Portion sizes are estimated by different methods
Advantage
-Relatively cheap; quick
-Less respondent burden
-No chance for the respondents to change dietary habit
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Dietary Assessment…
24 hours dietary recall…
Disadvantage
- Respondent memory lapse;
- Social desirability bias
- Less precision; accuracy; depends on the respondent’s
ability to estimate portion sizes
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Dietary Assessment…
D. 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
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
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Dietary Assessment…
Dietary History---
Disadvantages
Very difficult to validate
Needs a very highly trained interviewer
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Dietary Assessment…
E. Food Frequency Questionnaire
Aims to assess the frequency of 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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Dietary Assessment…
Food Frequency Questionnaire---
Advantages
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 & numerate subjects
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Steps in assessment of nutrient intakes
1. Measuring food intake
2. Converting foods to nutrients using food composition values
3. Evaluating dietary adequacy
Comparing with dietary recommendations for the specific
nutrient
Adequacy of intake for individual/group
Prevalence of inadequate intake
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Errors in dietary surveys
• Interviewer bias • Wrong frequency of
• Coding & computation consumption
errors • Response bias
• Reporting errors • Sampling bias
• Wrong weight of foods • Change in dietary habit
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Thank you!!!
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