NUTRITIONAL
ASSESSMENT
INTRODUCTION:
• Nutrition assessment includes taking anthropometric measurements and
collecting information about a client’s medical history, clinical and biochemical
characteristics, dietary practices, current treatment, and food security situation.
• A detailed examination of metabolic, nutritional & functional variables by
an expert clinician, dietitian or nutrition nurse is called as nutritional
assessment.
Nutritional assessment goals:
• To establish nutritional status.
• To identify people at risk of malnutrition for early intervention or
referral before they become malnourished.
• To identify malnourished clients for treatment— malnourished
people who are not treated early have longer hospital stays,
slower recovery from infection and complications, and higher
morbidity and mortality.
• To track child growth.
• To identify medical complications that affect the body’s
ability to digest food and utilize nutrients.
• To detect practices that increase the risk of
malnutrition and infection
• To do nutrition education and counseling wherever
necessary
Factors that affect the nutritional status:
• Age, gender, physical activity
• Presence of malnutrition
• Presence of acute / chronic diseases.
• Acute medical conditions – infections / trauma / surgery.
• Medications.
• Environmental factors.
• Dietary factors of an individual.
How often should nutrition assessment be done?-
• The frequency of nutrition assessment depends on a client’s age
and pregnancy and disease status and on national policies.
• Pregnant/postpartum women: On every antenatal visit
• Infants 0–< 6 months of age: At birth and on every scheduled
postnatal visit
• Infants 6–59 months of age: During monthly growth monitoring
sessions for children under 2 and every 3 months for older children
• Children 5 years of age and over: On every clinic visit
• Adolescents and adults: On every clinic visit
• People with HIV: On every clinic visit and when initiating or
changing antiretroviral therapy (ART)
Nutrition assessed by 2 methods: Direct & Indirect method.
• Direct method: Anthropometry, Biochemical test, Clinical methods,
Dietary evaluation method.
• Indirect methods – Ecological variables – agriculture crops production.
Economic factors – household income, population
density, food
availability.
Cultural & social habits.
Vital health statistics – morbidity, mortality, maternal
& child health care
Components of nutritional assessments:
1) Medical history
2) Physical examination
3) Anthropometric measurements
4) Dietary intake & energy requirement
5) Body composition
6) Biological parameters
1)Medical & diet history:
• Diet history: appetite, composition of typical meals,
food preference & aversion, food allergy &
intolerance.
• dietary assessments: dietary records, 24 hour
recalls, food-frequency questionnaire, intake
observations.
2) ANTHROPOMETRY
• Anthropometry is the measurement of the size, weight, and
proportions of the body. Common anthropometric
measurements include weight, height, MUAC, head
circumference, and skinfold thickness.
• Body mass index (BMI) and weight-for-height are
anthropometric measurements presented as indexes.
• Each of these indexes is recorded as a z-score. Z-scores are
measured in standard deviations (SD), and describe how far and in
what direction an individual’s anthropometric measurement deviates
from the measurement for a healthy person of the same age and sex
Anthropometric measurements indicates the present
nutritional status & not used to identify specific nutritional deficiency.
• Height and weight for age
• BMI
• Mid upper arm circumference – measured at the midpoint of
upper arm with arm relaxed. It is indicative of muscle mass &
subcutaneous fat.
• Others like mid fore-arm circumference, mid calf & mid thigh
circumference, head circumference & waist-hip ratio will be
assessed same way using an measuring tape.
Weight:
• Weight Weighing is usually the first step in
anthropometric assessment and a prerequisite for
finding weight-for-height z-score (WHZ) for children
and BMI for adults.
• Measured- calibrated electronic or balanced-beam
scale, spring scale for children.
• Low pre-pregnancy weight and inadequate weight gain
during pregnancy are the most significant predictors of
intrauterine growth retardation and low birth weight.
• The main anthropometric measurement used for newborns is birth weight.
• The most common anthropometric measurements used for infants under 6
months are weight-for-length, weight-for-age, and head
circumference. Weight-for-length is used to measure acute malnutrition,
along with other clinical signs.
• Infants under 6 months should be weighed using a balance beam scale or
a digital UNISCALE that measures infant weight by weighing the mother
and infant together and subtracting the weight of the mother.
Length and height:
• Measuring length or height requires a height board or
measuring tape marked in centimeters (cm).
• Measure length for children under 2 years of age or less than
87 cm long.
• Measure height for children 2 years and older who are more
than 87 cm tall and for adults.
Height measured using – stadiometer with a movable head
piece.
Weight-for-height:
• WHZ is an index that is used to assess the nutritional status of
children from birth to 59 months of age.
• It compares a child’s weight to the weight of a child of the same
length/height and sex in the WHO Child Growth Standards to
classify the child’s nutritional status.
• The Standardized Monitoring and Assessment of Relief and
Transitions (SMART) Emergency Nutrition Assessment (ENA) tool,
available from the NutriSurvey website, calculates WHZ
automatically.
MUAC:
• MUAC is the circumference of the left upper arm measured at the mid-
point between the tip of the shoulder and the tip of the elbow, using a
measuring or MUAC tape.
• MUAC is a measure of nutrient reserves in muscle and fat that are
unaffected by pregnancy and independent of height.
• MUAC is used to measure all pregnant women and women up to 6
months postpartum.
• MUAC is also an appropriate alternative for measuring children (instead of
WHZ), adolescents (instead of BMI-for-age), and non-pregnant/
postpartum adults whose weight and height cannot be measured.
• NOTE: MUAC is not currently recommended for infants under
6 months and should not be used to assess nutritional status
in people with edema.
• It has a relatively strong association with low birth weight.
• Both MUAC and WHZ are imperfect proxy indicators for the
complex clinical condition of acute malnutrition.
BMI:
• BMI is an anthropometric indicator based on weight to-height
ratio. It is used to classify malnutrition in nonpregnant/non-
postpartum adults. BMI is not an accurate indicator of nutritional
status in pregnant women or adults with edema.
• Calculation
MALNUTRITION ASSESSMENT:
• The British Association for Parenteral and Enteral Nutrition
(BAPEN) has a Malnutrition Universal Screening Tool
(MUST) that uses weight, height, BMI, weight loss, and acute
disease score to determine risk of malnutrition.
• BMI-for-age z-score: BMI-for-age is the preferred
• Waist circumference – measured just above the umbilicus, taken
during end of normal expiration.
mild risk – males 94-102cm , female 80-88cm (WHO)
high risk – males >102cm, female > 88cm.(WHO)
• Hip circumference – measured at point of greatest circumference
around hips & buttocks.
• Ratio – females > 0.80 , males > 0.95 are at risk (WHO)
• According to international
MENdiabetes federation
WOMENcut offs for risk of
EUROPIDS >94CM >80CM
metabolic disorder are-
SOUTH ASIANS, >90CM >80CM
CHINESE, JAPANESE
American diabetic association
SKIN FOLD THICKNESS:
• A skinfold caliper is used to assess the skinfold thickness, so that a prediction of the
total amount of body fat can be made. This method is based on the hypothesis that
the body fat is equally distributed over the body and that the thickness of the
skinfold is a measure for subcutaneous fat.
To estimate the total amount of body fat, four skinfolds are measured:
• Biceps skinfold (front side middle upper arm)
• Triceps skinfold (back side middle upper arm)
• Subscapular skinfold (under the lowest point of the shoulder blade)
• Supra iliac skinfold (above the upper bone of the hip)
Skin fold thickness :
• It is measured by thickness caliper,
usually 3 times.
SKIN FOLD
THICKNESS
Reliability:
• Of all skinfold measurements, the triceps skinfold is the most reliable
one to assess, because oedema is not often seen in the upper arm.
• The measurements are less reliable in elderly people, due to their weak
skin and muscles.
Body composition:
• Dual energy X-ray absorptiometry (DXA) – used to determine
bone mineral content, lean tissue mass and FM
• Bio-electrical impedance analysis (BIA) – 2 electrodes placed at
hand & opposite foot and current (AC) is passed through the
body. It is used to determine body water & can also test for
FFM.
• Air – plethysmography – uses air displacements for
measuring………
5) Biological parameters/Biochemical assessment:
• Specific nutrients (according to history & examination)
• Immune function – Total Lymphocyte count/ delayed
cutaneous hypersensitivity.
• Protein metabolism – nitrogen balance, protein turn over
studies, plasma protein.
• Urinary metabolites – creatinine, 3-methyl histidine.
• Biochemical assessment
means checking levels of
nutrients in a person’s blood,
urine, or stools. Lab test
results can give trained
medical professionals useful
information about medical
problems that may affect
appetite or nutritional status.
CLINICAL ASSESSMENT
• Clinical assessment includes checking for visible signs of nutritional
deficiencies such as bilateral pitting edema, emaciation (a sign of wasting,
which is loss of muscle and fat tissue as a result of low energy intake and/or
nutrient loss from infection), hair loss, and changes in hair color.
• Assessment of nutritional status in infants under 6 months involves
checking for clinical signs of acute malnutrition such as visible
wasting, bilateral pitting edema, inability to suckle, ineffective
breastfeeding, and recent weight loss or failure to gain weight, as
well as risk factors such as insufficient breast milk or absence of the mother.
• Some medications can interfere with nutrient absorption,
digestion, metabolism, and utilization. Likewise, nutritional
status and diet can affect how medications work.
• For children, clinical assessment may also include history of
growth patterns, onset of puberty, and developmental
history.
• Bilateral pitting edema, also called nutritional edema, is
swelling in both feet or legs (bilateral) caused by the
accumulation of excess fluid under the skin in the spaces within
tissues.
• Edema is a sign of severe malnutrition ONLY if it exists in both
Physical examination/ Clinical assessment:
Manifestations Possible aetiology
General Underweight/ overweight/ oedema/ short Calorie or protein
stature/ apathy/ irritability malnutrition/ calorie excess
Skin & mucous Pallor/ dryness/ dermatitis/ petechiae/ Iron/ zinc/ thiamine/ ascorbic
membranes delayed wound healing acid/ EFA deficiency
Subcutaneous Decreased/ oedema Caloric deficit/ excess PEM
tissue
Muscle tissue Wasting & pain/ reduced muscle mass PEM / thiamine deficiency /
sedentary lifestyle
Hair & nails Alopecia/ thin hair/ koilonychia/ spoon Zinc/ iron/ biotin/ vitamin A/
shaped nails niacin/ EFA deficiency
Lips & gums Cheilitis/ stomatitis/ gingivitis/ bleeding B vitamins / ascorbic acid
deficiency
Eyes Dryness/ keratomalacia/ photophobia Vitamin A, E / riboflavin/ zinc
deficiency
Teeth & tongue Caries/ abnormal enamel/red/ pale/ painful Deficiency / excess fluoride/
niacin/ riboflavin/ vitamin
B12 deficiency
DIETARY ASSESSMENT
• It provides information on dietary quantity and quality,
changes in appetite, food allergies and intolerance, and
reasons for inadequate food intake during or after illness.
• The results are compared with recommended intake such as
recommended dietary allowance (RDA) to counsel clients on how
to improve their diets to prevent malnutrition or treat conditions
• If diet is to be assessed for a country or region, and data are to be collected at an
aggregate level, the choice of method will be dictated largely by government
decisions concerning information collected from growers, producers, importers,
exporters, food processors and manufacturers, and those responsible for food
storage.
• At the household and individual level, however, issue concerning literacy and
level of education will be important in the choice of method.
• Information from the finer levels of measurement (individual, household or
institution) can be built up to provide a picture of consumption at regional or
national level.
Domestic food production (level I):
• Most governments require farmers and food producers to report how much food
they produce. This is part of ongoing food surveillance which provides an
overview of the adequacy of the national food supply.
• Useful in planning food supplies and meeting requirements.
Total food available (level II):
• Of far greater use in estimating a country’s food supply and utilization are
food balance data published on a regular basis by the Food and Agriculture
Organization of the United Nations (FAO 2001).
• Food balance sheets provide information on a country’s food system through
three components: • domestic supply of food commodities in terms of
production, imports, and stock changes • domestic food utilization
including feed, processing, waste, export, and other uses. • per capita
values for the supply of all food commodities (in kilograms per person
per year)
Measurements at household level (levels III and IV):
• There are four main techniques used to assess food consumption
at the household level: food accounts inventories, household
recall, and list recall.
• Food accounts: here, household members keep a detailed record
of either the quantity or cost (or both) of all household food
acquisitions (food entering the household, including purchases,
gifts, home-produced food from gardens or allotments, food in
kind, takeaway foods eaten at home, etc).
• Menu records of food and drink provided may be used to estimate
the proportion of diet consumed away from home.
Inventory:
• The inventory method is similar in nature to the food account method,
in that respondents are asked to keep records of all foods coming into
the house. In addition, inventory of stored food is carried out at the
beginning and end of the survey period.
Household record:
• In the household record method, the foods presented for consumption
to household members (whether raw or processed) are weighed or
estimated in household measures. Preparation waste is deducted (e.g.
discarded outer leaves, peel, trimmed fat, etc.). Any food consumed by
visitors is estimated and subtracted from the total, and an allowance is
made for food waste
• The technique is useful in countries where much of the diet is home
produced rather than purchased or preprocessed.
List recall:
• This is a structured survey in which the respondent is asked to recall the
amount and cost of food obtained for household use over a given period,
usually one week. In addition to food purchases and acquisitions, it takes
into account the use of food. Therefore it can be used to provide an estimate
of food costs as well as net household consumption of both foods and
nutrients.
• The technique is well suited to populations in which most food is purchased
rather than home produced. It is relatively quick and cheap, as it requires
only a single interview.
Assessment at individual level:
Prospective methods- Weighed diary or record, Household
measures or unweighed diary or record, duplicate diet method, food
checklist
Retrospective methods- 24 hour recall, FFQ, diet history method.
• Weighed diary or record: Subjects keep a record of all food and
drink consumed. Each item is weighed prior to consumption using
portable food weighing scales. Left-over items are also weighed.
• Household measures or unweighed diary or record The
method is similar to the weighed diary, except that subjects record
• Duplicate diet method: This technique requires subjects
to weigh and record their food consumption at the time of
eating. At the same time, they put aside an exact duplicate
portion of each food consumed which is analysed
chemically for energy and nutrient content.
• Food checklist : Respondents are provided each day with
a preprinted list of foods and drinks and asked to tick a box
each time an item is consumed. A space is usually provided
to record items consumed but not listed
24 hour recall: During a recall, a client is asked to remember
in detail every food and drink consumed during the previous 24
hours. The method can be repeated on several occasions to
account for day-to-day variation in intake.
• to estimate portion sizes by looking at household measures,
food models, household utensils, photographs, or actual food.
Food frequency
questionnaire
• A food frequency questionnaire
is designed to obtain information
on overall dietary quality rather
than nutrient composition and
intake. The food frequency
questionnaire examines how
often someone eats certain
foods, and sometimes the size of
the portions
CONTI..
Food group
questionnaire:
• Another way to do dietary
assessment is to show
clients pictures of different
food groups (often available
from national nutrition
authorities) and ask
whether they ate or drank
any of those foods the
previous day.
• Food security
assessment:
USAID defines food security as
“having, at all times, both
physical and economic access
to sufficient food to meet
dietary needs for a productive
and healthy life.” This definition
includes food availability
(sufficient quantities of food
available consistently to all
people in a country, region, or
household through domestic
production, imports, and/or
food assistance), food access
and food
utilization/consumption
DURATION OF DIETARY ASSESSMENT:
• The recording is usually conducted over a period of 1–7 days.
• Recording for one day is not suitable for individual assessment,
because of the large intra-individual variability in daily food
intake.
• Given that eating and drinking patterns vary between weekdays
and weekend days and across seasons, assessments should be
made with this in mind to provide representative coverage.
Tables of food composition and dietary analysis
software:
• Calculation of the energy and nutrient content of foods and
drinks consumed in dietary surveys is performed using tables of
food composition. It is essential that food composition data is
updated regularly to include new foods and drinks introduced on
the market, and to update the nutritional value of foods and
drinks that may have changed in composition over time.
• Dietary analysis software links the food item and code to the
nutrient composition, and converts the amount reported to
FUNCTIONAL ASSESSMENT:
• Handgrip dynamometry, physical performance measures such as timed gait and chair
stands, as well as activities of daily living tools such as the Katz Index, Lawton Scale,
and Karnofsky Scale Index.
• Handgrip dynamometry-
• The purpose of using a
hand dynamometer is
to measure the maximum
isometric strength of the
hand and forearm
muscles.
• Gait & chair stand:
Gait speed, maximum grip strength and chair stand test are quick, reliable measures of
functional capacity in older adults.
THE LAWTON IADL Scale
•The current scale assesses independent living skills in 8 domains of function.
•This current assessment is ideal for older adults post stroke.
•The tool is most useful for identifying an individual's functioning at a present time, and
for identifying improvement or deterioration over time.
•Easy to Administer, provides self reported information about function skills necessary for
living.
• A summary score ranges from 0 (low function, dependent) to 8 (high function,
independent) for women, and 0 through 5 for men.
KARNOFSKY
SCALE
INDEX
REFERENCES:
• NACS-Users-Guide-Module2-May2016.pdf
• https://www.researchgate.net/publication/318779321_Nutritional_Asses
sment_Methods
.
