Nutritional Assessment

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Nutritional Assessment
Learning Objectives
At the end of this session you should be
able to:

oDefine nutritional assessment.

oIdentify
the forms of nutritional
assessment.

oIdentify
methods of nutritional
assessment.
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Introduction
•What is nutritional assessment?
o It is the interpretation of information from
dietary, laboratory, anthropometric and clinical
studies.
oUsed to determine the nutritional status of
individuals or population groups as influenced by
the intake and utilization of nutrients.
oHistorically….used in
oSchools: to identify those who need supplementary
feeding
oMilitary: to identify those ‘fit’ from the
‘unfit’
oNow used in community and clinical settings
o Can take one of four forms:
- Surveys 3
1. Nutrition Survey

 Is a cross-sectional asst of nutritional status of a

selected population group.
Uses:
– Establish baseline nutritional data &/ ascertain
overall nutritional status of the popn
– Identify population ‘at-risk’ to chronic
malnutrition
– To make fair allocation of resources to those in
need
– To formulate nutritional -related policies
Limitations:
– Less likely to identify acute malnutrition
– Not suitable to study causes of malnutrition 4
2. Nutritional surveillance

Continuous monitoring of the nutritional

status of selected population groups.
Uses:
– Identify possible causes of malnutrition
– Help to formulate and initiate
interventions at population or sub/popn
level
– Formulate predictions based on
current trends
Nutritional surveillance carried out on
selected individuals is called ‘Monitoring’ 5
3. Nutrition screening

• Identification of malnourished individuals

requiring intervention

• Involves a comparison of individual’s mx

with predetermined risk levels or ‘cut-off’
points

• Can be done at individual or popn level

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4. Intervention

◦ Targets population subgroups identified

as “at risk” during nutrition survey or by
nutrition screening.

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There are two methods of assessing Nutritional
status:
1. Direct method
2. Indirect method

Indirect methods
- assessment of indicators of the food and
nutrition situations in the area of interest by
looking at certain data that are closely related
to malnutrition or which are aggravated by
malnutrition.
- These include:
- Cause specific mortality rates
- Age specific mortality rates
- Health service statistics
- Rate of nutritionally relevant infections 8
Cont’…

-Meteorological data (rainfall data )

- Production pattern and distribution

pattern

- Income levels

- Market price of foods

- Predominance of cash crops

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Direct methods
Involve the direct mx of body dimensions
and proportions, determination of tissue or
- body fluid concentrations of nutrients,
dietary intake, appearance of the clinical
symptoms and signs related to a specific
nutrient dependent functional impairment.
abbreviated as the ABCDs

A=Anthropometry
B= Biochemical/Biophysical
C= Clinical
D= Dietary
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Development of nutrient
deficiency
Inadequate dietary
intake-primary/secondary
↓
Gradual tissue desaturation of the nutrient
↓
Biochemical lesion arising from major
defect in a metabolic pathway
↓
Functional changes
Clinical signs & symptoms
Generalized scheme for development
of nutritional deficiency

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A. Anthropometric assessments

Anthropometry comes from two words:

- Anthropo = Human, and
- Metry = measurement.

Definition: - Anthropometry refers to

mx of variations of physical dimension
and gross composition of human body at
d/t levels and degrees of nutrition

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 Anthropometric
Measurements…
1. Growth
– Head circumference
– Length/height
– Weight
2. Body composition
2.1. Body fat
– Skin fold thicknesses
– Hip circumference
– Waist circumference
2.2. Fat-free mass
– Mid-upper arm circumference
1. Head circumference (HC)
Mx using flexible measuring tape around
0.6cm wide to the nearest 1mm.

Itis 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.
HC-for age: index of chronic under nutrition
for < 2 y

But after 2 years as the growth of the brain is

sluggish it is not useful. 15
Measurement of head
circumference…
2. Length
o A wooden measuring board (also called
sliding board) is used for measuring
length.

o It is measured in recumbent position in

children <2 yrs old to the nearest 1mm.
o An assistance of two people is needed in
taking the measurement.

o Measurement is read to the nearest mm.

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3. Height
 Is measured in children > 2 yrs and adults
in standing position to the nearest 0.1
cm.
 The head should be in the Frankfurt plane
during Mx, knees should be straight and
the heels, buttocks and the shoulders
blades, should touch the vertical wall.

 Stadiometeror portable anthropometer

can be used for measuring.

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4. Weight

• Weighing sling (spring balance) also

called salter scale is used for Mx of
weight in children < 2 years.

• In children < 2 years the Mx is performed

to the nearest 10g.

• In adults and children >2 years, beam

balance is used and the Mx is performed
to the nearest 0.1 kg.

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Indices derived from these
measurements
 What is an index? It is a combination of
two Mxs or a Mx plus age.
 The following are few of them: -
 Head circumference-for age: Reflects
chronic PEM in children < 2 yr.
 Weight -for-age :Low wt-for-age = lightness-
reflects underweight.
 Height/length-for age: Low ht-for-age =
shortness-reflects stunting.
 Weight for height: Low wt-for-ht = thinness-
reflects wasting

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Meanings of the indices derived from
growth
measurements

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 INDICATOR
An indicator is an index + a cut-off point.
E.g.
- W F A < 60% = is indicator of severe
malnutrition
- BMI < 16 kg/m2 = >> of severe
chronic energy deficiency
- W F H < 7o% = is indicator of severe
wasting
o Uses of cut-off points
o Cut-off points are used for identifying
those children suffering from or at a
higher risk of adverse outcomes.
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Classification of nutritional status
based anthropometric indicators

I. Gomez classification (weight-for-age)

(Gomez et al, 1956)

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Disadvantages of Gomez classification

 The cut off point 90% may be too high as many

well-nourished children are below this value,

 Edema is ignored and yet it contributes to

weight and
 It does not indicate the duration of malnutrition

 Age is difficult to know in developing countries

(agrarian society).
 It does not also differentiate between
kwashiorkor and marasmus.
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2. Well-come classification (weight-
for-age)

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Disadvantages

 Thismethod does not differentiate :

- Acute malnutrition (for emergency
planning
- Chronic malnutrition( for food security
planning)

 Depends on knowledge of the child’s age

 Doesnot take height differences in to

account
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Waterlow Classification ( Waterlow
JC,1972)

Index % of NCHS reference Level of Malnutrition

90-94% Mild Stunting
Height 85-89% Moderate (Chronic
For < 85% Sever malnutrition)
Age

Wasting
In adults
Weigh for 80- 89 (Acute
Mild
Height Malnutrition)
70-79 Moderate
<70% Sever

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In general,

 In the clinical setups it is preferable to

use welcome classification in order to
clearly distinguish the d/t severe forms.

 However, in the field (community) set

ups the milder forms of malnutrition like
stunting and wasting are very rampant.
Therefore, it is preferable to use Water
low classification.

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Assessment 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 and body
composition.

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1. Mid upper arm circumference(MUAC)
 Is used for screening purposes especially in emergency
situations where there shortage of human resource,
time and other resources as it is less sensitive
 It is measured half way between the olecranon
process and acromion process using non
stretchable tap.
• New MUAC for children
– RED (severe) Mx of 115 mm or less is considered
SEVERELY MALNOURISHED and high mortality risk.
– ORANGE (moderate) Mx of 116 – 124 and is read as
MODERATELY MALNOURISHED.
– YELLOW (mild) Mx of 125 – 134 means AT RISK, but
not malnourished.
– GREEN (normal) Mx of 135mm or above is NOT
malnourished.
• Pregnant/lactating women are severely malnourished if
their MUAC is less than 170 mm
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MUAC…

It
is a sensitive indicator of risk of
mortality.

Useful
for screening of children for
community based nutrition interventions.

Useful for the assessment of nutritional

status of pregnant women.

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Measurements used to assess fat
mass:

Body mass index

 Waist to Hip circumference ratio

Skin fold thickness

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1. Body mass Index(BMI)

Body mass index the best method

for assessing adult nutritional status

Therefore, it is most frequently used

for assessing adult nutritional status.

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Cut-off points for BMI

• > 40 kg/m2 = very obese

• 30-40 kg/m2 = obese
• 26-30 kg/m2 = overweight
• 18.5-25kg/m2 = Normal
• 17-17.9 kg/m2 = mild chronic energy
deficiency
• 16-16.9kg/m2 = Moderate chronic energy
deficiency
• < 16 kg/m2 = severe chronic energy
deficiency
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This classification is based on the
mortalities and morbidities associated
with either extremities

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2. Skin fold thicknesses

Skin fold thickness is done at the

following anatomical sights:
 Biceps skin fold
 Triceps skin fold
 Subscapular skin fold
 Suprailliac skin fold
 Mid axillary skin fold
 Thigh skin fold
 Calf skin fold

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Skin fold measurement

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Triceps skin fold

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Sub scapular skin fold

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3. 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
trochantor off the femur( both are
measured to the nearest 0.5 cm)

 Ifthe ratio is > 1 in male, and > 0.87 in

female there is high risk of coronary heart
disease.
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Advantages and disadvantages of
Anthropometric measurements

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B. Biochemical/ biophysical
(laboratory)
methods
This involves Mx 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.

This group includes those that are

indicative of defect in intermediary
metabolism in other words they occur
when there is a biochemical lesion
(Depletion).
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This involves measuring a nutrient or its
metabolites in pre-Selected biological
material (blood, body fluids, urine, hair,
fingernails etc.)

E.g. Biochemical Tests (laboratory)

1. Serum ferritin level
2. Serum HDL
3. Erythrocyte Folate
4. Tissue stores of Vit. A, Vit D,
5. T3,T4, TSH , Urine iodine level =
for Iodine deficiency
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Advantages and disadvantages
of biochemical tests

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C. Clinical methods
This are detection of deviations from the
normal state of nutrition just by observing
and interpreting clinical signs and
symptoms of deficiency or under intake,
Sign/ symptom Nutritional abnormality
for instance, see the following.
 Inability to see during the evening or dim Vitamin A deficiency:
light (Night blindness also called nyctalopia)
 Bitot’s spots
 Easy bruising of skin Scurvy (vitamin C deficiency)
 Spongy bleeding gums
 Pale: palms, conjunctiva, tongue Anemia: Which may herald,
 Easy fatigability, loss of appetite shortness deficiency of: Iron, Vitamin
of breath B12, Folic acid, copper,
protein (main causes of
nutritional anemia)
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Cont’…

Advantages
– Fast & Easy to perform
– Inexpensive
– Non-invasive

Limitations
– Did not detect early cases
– Trained staff needed
- Not specific

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D. 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.
At national level:-
 Food balance Sheet
 also called National food disappearance
data or food going in to consumption.
At a household level
 HH food inventory method
 Food count method
 List recall method
 HH food record method
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Methods used to assess current intake
(at a group or individual level)

I. Weighed record method: In this method

the subject will be asked to weigh whatever
he/she consumes including drinks both before
cooking and after cooking and the portion sizes
he consumed and the left over.
Advantages:
o It is more accurate
o There is no respondent memory loss
Disadvantages
 High respondent burden
 Change of the dietary habit during the survey
due fear of burden
 Needs literate and numerate respondents
 Costly 58
Cont’…

2. Observed weighed method

 In this method the investigator him/herself records

the amount and type of food consumed by the
study subjects over specified period of time.

 This method is usually applied for disabled people,

infants and small children, mentally ill people or
institutionalized elderly people or patients
admitted to a hospital.

Advantage VS disadvantages

 The same as the observed weighed

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Cont’…
3. Food Diary method

In this method the subject/s are asked to

record what ever they eat 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 and numeracy of subjects
needed
◦ High coding burden 60
Methods Used to assess past intake

1. 24 hours dietary recall

the subjects are requested to remember

whatever they consumed within the last 24
hours.
This involves all beverages, snacks deserts
etc. That have been ingested from x time
yesterday to x time today.
The portion sizes consumed during this time
should also be determined by the respondents
by assessing them to use either photographs
or the common food being consumed at
different sizes or by using a line graph etc.
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Advantages and disadvantages of
24 hrs dietary recall method

Advantages Disadvantages
 Relatively cheap A single day 24 hrs
 Quick recall does not
 Less respondent indicate the usual
burden intake of individuals
 No chance for the  Respondent memory
respondents to change laps
their dietary habit  Social desirability bias
 The usual intake of a (the flat slop
group can be
determined from a
syndrome)
single 24 hrs recall  Has less precision
 Accuracy depends on
the respondent’s 62
Reasons why a single day
assessment does not give the
true mean intake

Day of the week effect

Seasonal effects

Consecutive /nonconsecutive data

Holiday effects(feasts and fasts)

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2. Dietary history
This method is used to assess the
nutrient intake of an individual or a group
from food over a longer period of time,
usually to see the association between
diet and disease.
Advantages Disadvantages
 It gives the dietary habits  It over emphasizes
of an individual or a group the regularity of the
of people over a longer dietary pattern
periods of time  It is very difficult to
 It is possible to target the validate
dietary questions to
 It needs a very
specific dietary habits or
intake of specific highly trained
nutrients of interest interviewer
 Less respondent burden  It gives just a relative
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3. Food frequency questionnaire

• This is based on the preparation of a food

frequency questionnaire, which is based on the
local staple diet to determine the frequency of
consumption of a particular nutrient.
• This could be achieved through self or
interviewer administration of the
questionnaire.
• Sometimes the quantities consumed could be
included, in such circumstances, the FFQ is
called semi quantitative FFQ.
• The following table indicates the frame of a
food frequency questionnaire.

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Example of semi quantitative
FFQ for Vitamin A friendly foods

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Advantages and Disadvantages
of FFQ
Advantages Disadvantages
 Itis usually used for  It is very difficult to
areas where there is a develop especially in
geographically widely multi-cultural society
scattered study where different
population
staple foods are
consumed
 It is less costly
especially if self
administered  Itneeds literate and
numerate subjects
 Less respondent burden

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