Part Two

Nutrition Assessment
Outline

•Anthropometric
assessment
•Biochemical assessment
•Clinical assessment
•Dietary assessment
Nutritional Assessment
• A detailed evaluation and interpretation of multiple
parameters that includes anthropometric, biochemical,
clinical and dietary data to determine whether a person or
groups of people are well nourished or malnourished
• Importance:
• Helps to detect potential health and nutrition problems early
• Provides information on current nutritional status
• Detects dietary habits that increase the risk of malnutrition/disease
• Identifies local food resources
• Tracks growth and weight trends
• Helps identify appropriate nutrition counseling and other
interventions
Anthropometric Assessment
• Anthropometry – the technique of human body
measurement in order to assess the nutritional status of
individuals. It is the most accessible, universally
applicable, cheap, simple, and noninvasive method
• Common anthropometric measurements:
• Weight
• Height/length
• Mid-upper arm circumference (MUAC)
• Head circumference
• Waist circumference
• Skinfold thickness
Anthropometric Assessment
• Head Circumference – reflects the brain size
• At birth, HC averages 35cm and increases an average of 1 cm/month
during the first yr
• Measured using a flexible, non-stretchable measuring tape
• Useful in assessing chronic nutritional problems
• Length/height
• Measured using a wooden sliding board in recumbent position in children
<2 yrs old to the nearest 1mm and always greater than height by 1–2cm

• Height: measured in standing position in children >2 yrs old and adults
and a stadiometer or portable anthropometer can be used for measuring
heights
Anthropometric Assessment
• Weight: Weighing scale is used for measurement of
weight in children and adults
• 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
• Used as a measurement for acute malnutrition
• Accurate age determination
• Can be determined from official documents (health card,
immunization card, birth certificate, etc.) if not available, use
a local calendar
Commonly Used Anthropometric Equipment

Mechanical, Beam, Table Electronic, fitness,

Mechanical, spring,
with digital display
hanging pediatric scale

Mechanical balance, column type

with height measurement
Baby Height Measuring Rod (Infantometer) MUAC Measuring Tape
Weight and length/height measurement

Measuring Weight Measuring Length/Height

• Weight of a child should be • Measure using recommended boards
measured as soon as possible • Children under 2 yrs should be
measured while they are lying down
after the child arrives at a • Children 2 yrs or older are measured
health facility using a height board, with the child
standing
• Place the scale on a hard, flat • If age cannot be determined, children
surface, making sure the scale 87cm or greater are measured standing
is level • Place the board horizontally/vertically
• Make sure the scale is set at on a flat surface
zero before each measurement • Remove shoes or sandals and any
head covering
Measuring Weight
Measuring Length/Height

Measuring length Measuring height

 MUAC Measurement
• Simple to measure using color-coded tapes, both
in the clinic and in the community
• Measured on the upper left arm, at a point midway
between tip of the shoulder and the elbow
• Do not pull or tighten too loose the tape
• A proxy measure of nutrient reserves in muscle
and fat, independent of height
• Used to measure nutritional status of children >6
months, adolescents, and adults
• MUAC should always be used instead of BMI to assess
nutritional status of pregnant women or up to 6 Months
postpartum
Growth Monitoring and Promotion
(GMP)
• When growth slows or stops, we say growth ‘falters’
A sign that something is wrong with the child and must be
discovered at the earliest, and set right actions

• Weight for Age is the single best parameter for

assessing physical growth
Growth Monitoring and Promotion (GMP)
• A preventive and promotional
strategy aimed to raise awareness of
mothers/care givers and promote
appropriate actions before malnutrition
occurs
• A behavior change strategy that
Principles enables mothers/care givers and service
providers to achieve adequate growth of
of GMP the children through family and
community actions
• A holistic approach to the total
environment of the growing child in
comprising not only food but also health,
physical environment, psychological
development and intellectual stimulation
Growth Chart
• A chart which indicates the state of the child's health,
nutrition and wellbeing
• Uses:
• A diagnostic tool for early identification of growth failure (‘high
risk’ children)
• For planning and policy making
• An educational tool for mothers and care takers
• A tool for action – helps health workers with the type of
interventions needed
• For evaluation of the effectiveness of corrective measures and
the impact of the program or of special intervention
 Growth Chart
Weight-for-age BOYS Weight-for-age GIRL S
Birth to 6 months (z-scores) Birth to 2 years (z-scores)

11 3 11 17
3 17

16 16
10 10
2 15 2 15

14 14
9 9

13 13

8 0 8 12 12
0
11 11

W eight (kg)
W eight (kg)

7 7
10 10

-2 -2
9 9
6 6
-3 8
-3 8

5 5 7 7

6 6

4 4
5 5

4 4
3 3
3 3

2 2 2 2

Weeks 0 1 2 3 4 5 6 7 8 9 10 11 12 13 Months 1 2 3 4 5 6 7 8 9 10 11 1 2 3 4 5 6 7 8 9 10 11
Months 3 4 5 6 Birth 1 year 2 years
Age (com plet ed w eeks or mont hs) Age (com plet ed m ont hs and years)
W H O Child Grow t h Standards
W H O Child Grow t h St andards
Anthropometric Indices
• Anthropometric measurements (weight or height/length)
alone do not provide enough information to determine
nutritional status
• They have to be used in combination to form anthropometric
indices (also referred to as the building blocks) to provide
important nutritional information

• Classification of nutritional status using anthropometric

indices
• Under-nutrition
• Normal status
• Over nutrition
 Anthropometric Indices
Weight for Compares a child’s weight to the expected weight of a healthy child of
Age (WFA) the same age and sex
 Measures UNDERWEIGHT
Weight for Determines a child’s nutritional status by comparing a child’s weight to
Height (WFH) the expected weight of a child of the same length/height and sex
 Measures WASTING
Height for Determines a child’s nutritional status by comparing a child’s height to
Age (HFA) the expected height of a healthy child of the same age and sex
 Measures STUNTING
Body Mass An indicator of body fatness and used to measure malnutrition in adults
Index (BMI) 19 years and older:
 Body weight (Kg)/height (m2)
BMI for Age An indicator of body fatness and used to measure malnutrition in
children 5 years to 19 years
MUAC An indicator for children under five yrs of age and for pregnant &
lactating women
 Classification of Nutritional Status
Using BMI Cut-off points
BMI kg/m2 Classification
< 16.0 Severe acute malnutrition
16.0 – 16.9 Moderate acute malnutrition
17.0 – 18.4 At risk/mild malnutrition
18.5 – 24.9 Normal nutritional status
25.0 – 29.9 Overweight
> 30.0 Obesity
Reference Standards
• These references use standard deviations (SD) of the
median reference known as Z-scores
• Weight for Age Z-Score (WAZ)
• Used to determine nutritional status of children under 2 yrs,
specifically whether they are underweight, and is used in GMP
programs
• Weight for Height Z-Score (WHZ)
• Used to identify acute malnutrition (wasting) as well as being
overweight and is key to the management of MAM and SAM
• Height/Length for Age Z-Score (HAZ)
• Used to identify stunting which indicates chronic malnutrition
 MUAC and MUAC Cut-offs
Group SAM MAM Normal
Children (6-59 >11.5cm to
<11.5cm >12.5cm
months age) <12.5cm
Adolescents (10-19
<20.5cm
years)/Pregnant
Pregnant or post-
<23cm >23cm
partum women

BMI for Age Cut-off

SAM Moderate At Risk/Mild Normal Overweight Obese
<-3 ≥-3 to <-2 -2 to -1 ≥-1 to ≤+1 >+1 to >+2
≤+2
Biochemical Assessment
It involves measurement of either the total amount of the nutrient in the
body, or its concentration in a particular storage organ, blood, urine,
saliva, and stool
Levels of Approach Laboratory Evaluation
Minimal level (HC &  Hemoglobin, urinalysis, and blood sugar
primary hospitals)
Mid-level (general  Serum albumin, serum iron and total iron-binding capacity (TIBC),
hospitals, and regional vitamin A and β-carotene
research laboratories)  RBC indices, blood urea nitrogen (BUN), zinc, cholesterol
 Glucose, inflammatory markers, helminths
In-depth (specialized/  Blood tests: folate and vitamin C; alkaline phosphatase; RBC
referral hospitals and transketolase; RBC glutathione; lipids
national research  Urine: creatinine; nitrogen; zinc; thiamine; riboflavin; loading tests
laboratories) (xanthurenic acid/FIGLU)
 Hair root: DNA; protein; zinc; other metals
Clinical Assessment
• Involves a detailed history, a thorough physical examination,
and the interpretation of the signs and symptoms associated
with malnutrition
• Medical history – required because nutritional problems
may be caused by underlying medical conditions

• Physical examination
• Focuses on signs of nutrient deficiency or excess which usually
appear only when the deficiency is advanced, and are not
expected in marginal deficiencies
• Starts with a general visual assessment of the patient (wasting,
overweight, or obese)
 Typical clinical signs for nutritional
deficiencies (1)
Deficiency Clinical signs
Wasting (acute ● Emaciation (loss of muscle and fat tissue), bone and skin
malnutrition) ● Dermatosis: abnormally light or dark in color, shedding of skin in scales or sheets,
and ulceration of the skin of the perineum, groin, limbs, behind the ears, and in
the armpits that could be seen in children with acute malnutrition:
o + (mild): discoloration or a few rough patches of skin
o + + (moderate): multiple patches on arms and/or legs
o + + + (severe): flaking skin, raw skin, fissures (openings in the skin)
● Bilateral pitting edema
o Grade +: below the ankle
o Grade ++: below the knee
o Grade +++: generalized edema
Protein deficiency Dry and scaly skin, cellophane appearance
Protein, calories ● Interosseous muscle atrophy
(protein energy ● Squaring of shoulders
deficiency) ● Poor hand grip and leg strength
Vitamin D deficiency Bowlegged, musculoskeletal deformity, rachitic rosary (pigeon chest)
 Typical clinical signs for nutritional
deficiencies (2)
Deficiency Clinical signs
Zinc deficiency Hair loss, changes in their nails
Vitamin A deficiency ● Bitot’s spots (superficial foamy white spots on the conjunctiva (white part of the
eye)
● Night blindness
● Follicular hyperkeratosis
● Corneal clouding: opaque appearance of the cornea (the transparent layer that
covers the pupil and iris
● Corneal ulceration: a break in the surface of the cornea (a sign of severe vitamin A
deficiency)
Niacin deficiency Skin pigmentation changes
Vitamin C deficiency ● Petechiae
● Lassitude, weakness, irritability, weight loss, and vague myalgias and arthralgias
may develop early
● Symptoms of scurvy (related to defects in connective tissues) develop after a few
months of deficiency
Vitamin C, vitamin K Purpura – discoloration of skin or mucus due to hemorrhage in small vessels
deficiency
 Typical clinical signs for nutritional
deficiencies (3)
Deficiency Clinical signs
Iron, vitamin B12, Palmar pallor
folate deficiency
Iron Pale tongue
Iron, vitamin B12, Conjunctiva pallor
folate
Iodine Goiter
Riboflavin, Angular stomatitis/cheilosis (dry, cracking, ulcerated lips)
pyridoxine, niacin
Riboflavin, niacin, B Glossitis (inflammation and swelling of the tongue)
vitamins, iron,
folate
Vitamin C, Bleeding gums
riboflavin
Riboflavin and Red tongue
Dietary Assessment
• Provides information on dietary quantity, quality, frequency, eating
patterns, identification of cultural and religious patterns, and reasons
for inadequate and/or excessive food and nutrients intake
• Results compared with recommended dietary practices and recommended
dietary allowance (RDA)
• Commonly used dietary assessment tools:
• 24-hr dietary recall – information is used to characterize the mean intake
• Weighed food record – subjects instructed to weigh all foods and beverages
consumed over a specified time
• Dietary history – estimates the usual food intake and meal pattern over a
relatively long time (often a Month).
• Food frequency questionnaire – asks respondents to report the usual
frequency of consumption of each food from a list of foods for a specific
period of time
 Dietary Assessment Indicators (1)
Indicator Definition Remark
Introduction of solid, Percentage of infants 6–23 months of age Amount
semisolid, or soft who consumed solid, semi-solid or soft Diversity
foods foods during the previous day Consistency/Thickness
[6–23 months] Frequency
Responsive feeding
WASH practices
Minimum dietary Percentage of children 6–23 months of age The food groups are:
diversity [6–23 who consumed foods and beverages from 1. Breast milk
months] at least five out of eight defined food 2. Grains, roots/tubers, & plantains
groups during the previous day 3. Pulses (beans, peas, lentils, chick-peas,
kidney bean), nuts & seeds
4. Dairy products (milk, yogurts, cheese)
5. Flesh foods (meat, fish, poultry, organ
meats)
6. Eggs
7. Vitamin-A rich fruits & vegetables
8. Other fruits and vegetables
 Dietary Assessment Indicators (2)
Indicator Definition Remark
Minimum meal Percentage of children 6–23 Minimum number of feeds per day
frequency [6–23 months of age who consumed Breakfast, morning snack, lunch,
months] solid, semi-solid or soft foods for afternoon snack and dinner
breastfeeding children and milk Breast milk and other milk will not
feeds for non-breastfed children be counted for the child feeding
the minimum number of times or
More during the previous day)
Minimum Percentage of children 6–23 Optimal meal frequency
acceptable diet months of age who consumed a Optimal dietary diversity
[6–23 months] minimum acceptable diet during
the previous day
 Dietary Assessment Indicators (2)
Indicator Definition Remark
Minimum Dietary The proportion of WRA who achieve The ten food groups are
Diversity for the minimum of five food groups out 1. Grains, white roots, and tubers &
Women (MDD_W) of ten in a population plantains (varieties of banana and
[WRA (15-49)] false banana)
2. Pulses (beans, peas, chickpea, kidney
beans and lentils)
3. Nuts and seeds
4. Milk and milk products
5. Meat, poultry, and fish
6. Eggs
7. Dark green leafy vegetables
8. Other vitamin A-rich fruits &
vegetables
9. Other vegetables
10.Other fruits
Assessing for Key Clinical Signs &
Symptoms of Malnutrition (2)
• History taking – ask and check about:
• Recent unintentional weight loss (≥5 kg body weight)
• Signs of severe wasting
• Any illness the client has had
• Any medication/treatment the client is on
• Any symptoms the client has been experiencing
• Dietary history – ask the client about eating habits (e.g.,
quantity of food eaten at each meal, food groups eaten each
day, frequency and consistency, in particular for children
under 2 yrs)
• Physical assessment – check for physical changes caused
by malnutrition
Assessing for Oedema
• Oedema – a condition of abnormally large fluid volume in the circulatory
system or in tissues between the body’s cells
• Can be caused by malnutrition, congestive heart disease, lymphatic disorders and
kidney diseases
• Oedema is of nutritional significance only if it is bilateral and is pitting
• Test for oedema with thumb pressure, not just by just looking
• Grading of oedema
• No edema (0) No pitting
• Mild/(+): Both feet (below ankles)
• Moderate/(++): Both feet, plus lower legs, hands, or lower arms (below knees)
• Severe/(+++) Generalized oedema including feet, legs, hands, arms and
face
• Any client with bilateral pitting oedema should be classified as having SAM,
regardless of any other anthropometric measurements
Examining Bilateral Pitting Oedema
In Summary
• Nutrition • Nutritional assessment enables health care
providers to classify clients’ nutritional status
assessment and choose appropriate interventions,
methods including counseling and referral
• The commonly used anthropometric
•A– equipment includes
Anthropometry • weighing scales , height/length boards and MUAC
• B – Biochemical tapes for all age groups
• Growth is the Most sensitive indicator of a
• C – Clinical child’s health
• D – Dietary • Nutritional status can be under-nutrition,
normal and over nutrition