NUTRITION

ASSESSMENT
BERYL NEGESA
MSC, BSc NURSING
OBJECTIVES
By the end of this section you should be able to:
Define nutrition status
Explain the purpose of nutrition assessment
Describe methods of assessment of nutrition status
Discuss the nutrition assessment and interventions in emergencies
INTRODUCTION
Nutrition status is a state of intake and utilization of nutrients which is
manifest in good or bad health. The state of balance between nutrients
supply (intake) and demand (requirement). An imbalance between the
two can result in over/under nutrition.
PURPOSE OF NUTRITION STATUS
The purpose of nutritional assessment is to:
To determine the overall nutritional status of patient in order to
initiate appropriate interventions.
To identify at clients at risk for malnutrition.
To determine the current health care needs, physical and
psychosocial as well as personal; metabolic abnormalities that
influence nutrition status and the effects of medication on nutrition.
CONT…
To assess growth and development in children.
To monitor and evaluate therapy and client progress.
To determine nutritional status of people in different setting such as
health facilities and community.
To identify people who might require nutrition related interventions.
Monitor effectiveness of nutrition interventions.
METHODS OF NUTRITIONAL STAUS
ASSESSMENT
These methods are used to measure nutritional status of individuals or
groups and include;
Anthropometric measurements
Biochemical measurement
Clinical examination
Dietary evaluation and personal history
ANTHROPOMETRY MEASUREMENTS
METHOS
These are measurements in relation to assessment of different areas of
the body such as weight, height and circumferences (mid-upper arm,
head and chest).
Weight
Weight is a critical measurement in assessment of nutritional status. It
is used to assess the child’s growth, predict energy expenditure, protein
needs and to determine BMI. Taking weight and interpreting it in terms
of age is called weight for age (WFA).
CONT…
You know when a child is healthy and has a normal physical growth, the
body weight increases regularly with increase with age. However, if the
child falls sick there could be a sudden weight loss.
WFA gives a mixture of both current and past nutritional experience. A
useful in growth monitoring because it indicates underweight (Z score
below -2 standard deviation or have bilateral oedema) and severe
underweight (Z score below -3standard deviation or presence of
bilateral edema).
CONT…
We can measure weight using different types of weight scales such as a
salter scale (children less than five years) measuring scale, and
bathroom scale. The weight is measured in 0.01 kilograms.
In measurements of weight in children ensure minimal clothing,
calibration of the weight scale, two readings and record an average
obtained, the scale should be flat on the ground while a Salter scale
should hang freely from a tree or hook.
CONT…
Height/Length
Like weight, height/length of a child also increases with age. However,
unlike weight, the change in height is relatively slow. Even when there
is under nutrition, height never decreases. At a given age, a child is
expected to have attained a particular height or length (height for age-
HFA).
HFA is generally a reflection of cumulative past nutritional inadequacy.
Z score below 2 standard deviations indicates stunting while Z score
below 3 standard deviation indicates severely stunted.
 CONT…
Height measurements are obtained by use of a height meter for older children and adults.
The client should stand straight, bare feet, feet should be parallel with heels, buttocks,
shoulders and back of the head touching the wall; the head should be erect with the eyes
looking straight in front. A flat horizontal sliding board is then moved downwards till it
touches the top of the head. The reading is taken in 0.01 cm.
For infants instead of height you measure length. The linear measurement taken from the
head to heel in lying position is the length of an infant.
Lying on a length board with the head touching the fixed head piece, the legs are
extended at the knees and the movable sliding piece is moved up to the soles of the feet
to take the reading up to 0.01cm.
When it is extremely difficult to get the correct age of individuals then weight for height
nutrition indicator is used.
Weight and height increases with age, an individual should have attained a particular
weight to be designated as normal. If one fails to attain this weight at that height based on
reference values; then is considered undernourished ‘wasting’
CONT…
Body Mass Index
The international 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)
Classifications include:
• 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)
CONT…
Find out whether you have mastered it:
BMI = Weight (kg)/height2 m2
= 65/ (1.50)2
= 28.8 kg/m2 (overweight)
Limitations of Body Mass Index are:
It is used as a standalone measurement
It does not into account extreme body size and composition
CONT…
Mid-Upper Arm Circumference (MUAC)
Arm circumference increases with age, but from the first to fifth birth
day, it does not change much. Normally nutrient stored under the skin
accounts for this circumference; inadequate diet leads to depletion of
stores leading to loosening and wrinkling of the skin. MUAC indicates
muscle wasting (bone, subcutaneous fat and muscle protein).
CONT…
MUAC is very simple and quick and is used:
When the child’s age is over one and under five years
When weighing scales are not available
As a screening method in outpatient work
In community nutrition surveys
When road to health charts are out of stock
When visiting homes
Screening pregnant women
CONT…
The procedure involves measurement of the left upper arm at halfway
between the point of the shoulder and the elbow. The arm is allowed
to hang freely and the measuring tape is placed around the middle
portion of the left arm. The reading is taken to the nearest 0.01cm.
Table 1: The criteria to identify malnutrition using MUAC
(Wood C., et. al., 2008)

Nutrition Status Children Under Five Years Adults

At risk of malnutrition 12.5 to 13.4cm 18.5cm

Moderately malnourished 11.5 to 12.4cm

Severely malnourished Less than 11.5cm <16cm

CONT…
Head and Chest Circumference
You must have noticed that when a child is born, the head is larger than the
chest, have you? As the child grows, head becomes proportionately smaller
to the chest.
The circumference helps to assess the brain growth and development in
infants and children under age two. If the head circumference remains more
than the chest circumference beyond I year of age, it might indicate PEM.
Measure the roundness of the head covering the forehead in front and
maximum end at the back. The chest circumference is measured at the level
of the nipple. Avoid taking these measurements when the child is crying,
screaming or deep breathing.
CONT…
Between 6 months and 5 years if chest circumference is less than head
circumference by 1 cm, there is failure to develop or a wasting of muscle and
fat from the chest wall which is indicative of protein calorie malnutrition.
Waist-Hip Ratio (WHR)
Waist Circumference
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 than any other anthropometric
measurement since it’s a valuable indicator of fat distribution. It is therefore
used to assess obesity, and two levels of risk have been identified.
CONT…

Table 1: Waist Circumference

Males Female
Level 1 > 94cm > 80cm
Level2 > 102cm > 88cm
CONT…
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 and cardiovascular system complications.
People with a BMI of 25kg/m² to 34.9kg/ m² or waist circumference
greater than 102 cm has an increased health risk.
Note that combining measurements of BMI and waist circumference is
more predictive of cardiovascular disease risk than one alone.
Hip Circumference
Hip circumference is measured at the point of greatest circumference
around hips & buttocks to the nearest 0.5 cm. The individual should be
standing and the measurer should squat beside him.
CONT…
Waist to Hip Ratio
The ratio is meant to assess abdominal obesity. 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 and cardiovascular
disorders.
A WHR below these cut-off levels is considered low risk.
Skin Folds Thickness/Measurements
Using a standard millimeter skin fold callipers, measure the amount of
subcutaneous fat over the triceps, biceps or scapula. The amount of body
fatness and the presence of excess body fat can be determined since the
volume of subcutaneous fat is related to the volume of body fat.
CONT…
Advantages of anthropometric measurements include:
Non-expensive and need minimal training
Objective with high specificity and sensitivity
Measures many variables of nutritional significance
Readings are numerical and gradable on standard growth charts
Readings are reproducible.
CONT…
Limitations of anthropometric measurements include:
• Inter-observers errors in measurement
• Limited nutritional diagnosis
• Problems with reference standards, i.e. local versus international standards.
BIOCHEMICAL ASSESSMENT
METHODS
These tests help to determine what is happening to the body internally.
Biochemical measurements are useful to assess organ function, fluid
status and electrolyte balance, confirm nutritional deficiencies, and
monitor the adequacy of nutritional therapies.
Useful baseline laboratory data includes basic chemistries (e.g.
electrolytes, glucose, BUN and creatinine), liver function tests, hemogram
and albumin.
These test require an analysis of tissues such as liver, kidney, blood, urine,
stool, hair and bone. Various nutrients are present in the body fluid;
during illness this normal range gets deranged, resulting in an abnormal
increase or decrease of specific nutrients
CONT…
The analysis of specific nutrients from the body specimens are used to
determine the nutrition status of an individual and are better indicators
of nutritional status than directly measuring blood levels of nutrients
e.g. vitamin A and calcium levels excreted in urine or feces provide
useful information about their status in the body.
Examples of specimens for biochemical tests are:
Hemoglobin estimation is the most important test, and useful index
of the overall state of nutrition. Beside anemia it also tells about
protein and trace element nutrition.
Stool examination for the presence of ova and/or intestinal parasites
CONT…
Urine dipstick and microscopy for albumin, sugar and blood
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 micronutrients
Albumin in blood can be an indicator of concentration of protein
status, and a measure of a nutrient metabolism, storage, transport
compound, enzyme that depends on a vitamin or a mineral.
CONT…
Advantages of biochemical analysis include:
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 analysis include:
Time consuming
Expensive in terms of facilities and personnel.
They cannot be applied on large scale
Interpretation of the data requires skilled manpower.
CLINICAL/PHYSICAL EXAM
This involves assessing an individual by examining the clinical indicators
(signs and symptoms) of nutrition status.
The major advantage is that it is simple and quick. However, some of
the clinical signs are not specific to a nutrition deficiency and one sign
overlaps for more than one deficiency disorder.
The characteristics of health that are observed in physical assessment
help to complete the picture of nutritional health of an individual. The
nonspecific observations are clues to nutrient deficiency or excess and
can be confirmed by using biochemical assessment.
DIETARY EVALUATION AND PESONAL
HISTORY/DIETARY SURVEY
Dietary information may confirm the lack of excess of a dietary
component suggested by anthropometric, biochemical and clinical
evaluation. This is a systematic study of dietary intake of an individual
or groups of individuals, whose aim is to estimate;
Intake of nutrients consumed,
Measure food consumption in terms quality (variety) and quantity
and
Estimate intake of non nutrients
 CONT…
There are various ways of conducting dietary surveys including the
following:
Twenty four hour recall
A trained interviewer asks the subject to recall all food and drink taken in
the previous 24 hours, for example midnight to midnight and enters them
in the Table 3.
Table 3: Twenty Four Hour Diet Recall
Meal Menu Ingredients Amounts
Cooked Raw
Breakfast
Lunch
Evening tea
Dinner
Any other
CONT…
Weighted Food Intake
In the previous method you ask the individual to recall what they have
eaten in the previous 24 hours. For this method you are actually
present when the individual is eating and you weigh the amount of all
the food items served as well as the amount foods not eaten.
The amount of food eaten (g) = the amount of food served (g) - the
amount of food not eaten (g)
Weighted intake gives the most accurate picture of food eaten
however, it is time consuming and the individual may resist showing the
interviewer the foods.
CONT…
Food Frequency
In this method the individual is given a list of around 100 food items to
indicate the frequency of consumption
Food Diary/Food Records
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.
These records provide information about day to day intake of an
individual’s food and beverages that they have consumed in 3-7 days.
The method is prone to inaccuracies from memory lapses, self-reported
and time consuming.
CONT…
Dietary and Personal History
During the nutrition interview, data collection will include questions
about the individual's lifestyle including:
The number of meals eaten daily,
Where they are eaten, and who prepared the meals
Information about allergies, food intolerances, and food avoidances
Caffeine and alcohol use
Exercise frequency and occupation help to identify the need for
increased calories.
Asking about the economics of the individual or family
CONT…
Risk factors to developing, or denoting the presence of nutrient
deficiencies or malnutrition include:
Age < 18 years or > 65 years (increased risk age >75 years)
Recent, unintentional weight loss of 10% in six months.
Excessive alcohol intake, or other substance abuse
Homelessness, limited access to food
Limited capacity for oral intake (dysphagia, odynophagia, stomatitis,
mucositis)
Nil per Oral > 3 days
CONT…
Increased metabolic demands: extensive burns, major surgery, trauma,
fever, infection, draining, abscesses, wounds, fistulae, pregnancy
Protracted nutrient losses: malabsorption syndromes, short gut syndrome,
draining abscesses, wounds, fistulae, effusions, renal dialysis
Intake of catabolic drugs: corticosteroids, immunosuppressants,
antineoplastics
Protracted emesis: anorexia nervosa, bulimia, hyperemesis gravidarum,
radiation, cancer chemotherapy
Chronic disease (especially AIDS, diabetes, cystic fibrosis, stroke, cancer)
INTERPRETATION OF DIETARY
INFORMATION
The interpretation usually takes two forms, the qualitative and
quantitative methods
Qualitative Method
This involves using the food pyramid that we came across in chapter
three with its food groups. You recall that the food pyramid suggests
portion sizes and the number of servings from each food group to be
consumed on a daily basis, and can also be used as a reference to
evaluate dietary intake. Different nutrients are classified into 5 groups
(fat & oils, bread & cereals, milk products, meat-fish-poultry, vegetables
& fruits).
CONT…
We determine the number of serving from each group reported by the
individual and compare it with the minimum requirement based on the
pyramid. We also determine whether the foods consumed daily are
balanced and diversified in nutrients.
Quantitative Method
The amount of energy and specific nutrients in each food consumed
can be calculated using food composition tables and then compared
with the recommended daily intake. Evaluation by this method is
expensive and time consuming, unless computing facilities are
available.
ASSESSMENT AND INTERVENTION IN
EMERGENCY NUTRITION RESPONSE
Important components of any response to a humanitarian crisis in this nation are health
and nutrition activities geared towards a resident population, an internally displaced
population and a refugee population.
For any emergency, an initial assessment is conducted to understand the situation and
to be able to analyze the extent of threat to life, dignity, health, and livelihoods.
A multisectoral assessment to understand the different factors affecting malnutrition:
basic, underlying and immediate causes of malnutrition are done to ensure a holistic
approach to the treatment of acute malnutrition.
An initial screening utilizes MUAC measurements for children between 6-59 months.
MUAC < 13.5cm and presence of edema are referred to a health /feeding centre.
A second screening is conducted at the health/feeding centre by taking weight and
height/length measurements and interpretation of weight for height indicator of
wasting is done.
CONT…
There are three types of nutrition interventions which include:
General feeding Programme; this Programme provides a food ration
to household highly affected by food insecurity. General food rations
are usually provided as dry rations for people to cook at home.
Supplementary feeding Programme; this Programme provides
supplementary food ration which is highly nutritious. The aim of the
programme is to rehabilitate individuals affected by moderate acute
malnutrition or at risk of becoming malnourished.
Therapeutic feeding program; the management of severe acute
malnourished patients as inpatient or outpatient.
QUESTIONS??