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ASSESSMENT OFASSESSMENT OF
NUTRITIONAL STATUSNUTRITIONAL STATUS
Developed By:Developed By: AQAQ
LEARNING OBJECTIVESLEARNING OBJECTIVES
By the end of this lecture the reader
should be able to:
To know the different methods for
assessing the nutritional status
To understand the basic
anthropometric techniques,
applications, & reference standards
INTRODUCTIONINTRODUCTION
The nutritional status of an individual is
often the result of many inter-related
factors.
It is influenced by food intake, quantity &
quality, & physical health.
The spectrum of nutritional status spread
from obesity to severe malnutrition
Nutritional Assessment WhyNutritional Assessment Why??
The purpose of nutritional assessment isThe purpose of nutritional assessment is
to:to:
Identify individuals or population groups
at risk of becoming malnourished
Identify individuals or population groups
who are malnourished
Nutritional Assessment Why?Nutritional Assessment Why?
To develop health care programs that
meet the community needs which are
defined by the assessment
To measure the effectiveness of the
nutritional programs & intervention once
initiated
Methods of Nutritional Assessment
Nutrition is assessed by two types of
methods; direct and indirect.
The direct methods deal with the
individual and measure objective criteria,
while indirect methods use community
health indices that reflects nutritional
influences.
Direct Methods of Nutritional
Assessment
These are summarized as ABCDThese are summarized as ABCD
 Anthropometric methods
 Biochemical, laboratory methods
 Clinical methods
 Dietary evaluation methods
Indirect Methods of
Nutritional Assessment
These include three categories:
Ecological variables including crop
production
Economic factors e.g. per capita income,
population density & social habits
Vital health statistics particularly infant &
under 5 mortality & fertility index
CLINICAL ASSESSMENT
It is an essential features of all nutritional
surveys
It is the simplest & most practical method
of ascertaining the nutritional status of a
group of individuals
It utilizes a number of physical signs,
(specific & non specific), that are known to
be associated with malnutrition and
deficiency of vitamins & micronutrients.
CLINICAL ASSESSMENT/2
Good nutritional history should be obtained
General clinical examination, with special
attention to organs like hair, angles of the
mouth, gums, nails, skin, eyes, tongue,
muscles, bones, & thyroid gland
Detection of relevant signs helps in
establishing the nutritional diagnosis
CLINICAL ASSESSMENT/3
ADVANTAGES
Fast & Easy to perform
Inexpensive
Non-invasive
LIMITATIONS
Did not detect early cases
Clinical signs of nutritional
deficiency
HAIRHAIR
Spare & thin Protein, zinc, biotin
deficiency
Easy to pull out Protein deficiency
Corkscrew
Coiled hair
Vit C & Vit A
deficiency
Clinical signs of nutritional
deficiency
MOUTH
Glossitis Riboflavin, niacin, folic acid,
B12 , pr.
Bleeding & spongy gums Vit. C,A, K, folic acid & niacin
Angular stomatitis,
cheilosis & fissured
tongue
B 2,6,& niacin
leukoplakia Vit.A,B12, B-complex, folic
acid & niacin
Sore mouth & tongue Vit B12,6,c, niacin ,folic acid
& iron
Clinical signs of nutritional
deficiency
EYES
Night blindness,
exophthalmia
Vitamin A
deficiency
Photophobia-
blurring,
conjunctival
inflammation
Vit B2 & vit A
deficiencies
Clinical signs of nutritional
deficiency
NAILS
Spooning Iron deficiency
Transverse lines Protein
deficiency
Clinical signs of nutritional
deficiency
SKIN
Pallor Folic acid, iron, B12
Follicular
hyperkeratosis
Vitamin B & Vitamin C
Flaking dermatitis PEM, Vit B2, Vitamin
A, Zinc & Niacin
Pigmentation,
desquamation
Niacin & PEM
Bruising, purpura Vit K ,Vit C & folic
acid
Clinical signs of nutritional
deficiency
Thyroid gland
 In mountainous
areas and far from
sea places Goiter is
a reliable sign of
iodine deficiency.
Clinical signs of nutritional
deficiency
Joins & bones
Help detect signsHelp detect signs
of vitamin Dof vitamin D
deficiencydeficiency
(Rickets) & vitamin(Rickets) & vitamin
C deficiencyC deficiency
(Scurvy)(Scurvy)
Anthropometric Methods
Anthropometry is the measurement
of body height, weight & proportions.
It is an essential component of
clinical examination of infants,
children & pregnant women.
It is used to evaluate both under &
over nutrition.
The measured values reflects the
current nutritional status & don’t
differentiate between acute &
chronic changes .
Other anthropometric Measurements
Mid-arm circumference
Skin fold thickness
Head circumference
Head/chest ratio
Hip/waist ratio
Anthropometry for children
Accurate measurement of height and
weight is essential. The results can
then be used to evaluate the physical
growth of the child.
For growth monitoring the data are
plotted on growth charts over a period
of time that is enough to calculate
growth velocity, which can then be
compared to international standards
Growth Monitoring ChartGrowth Monitoring Chart
Percentile chartPercentile chart
Measurements for adults
Height:Height:
The subject stands erect & bare
footed on a stadiometer with a
movable head piece. The head
piece is leveled with skull vault
& height is recorded to the
nearest 0.5 cm.
WEIGHT MEASUREMENT
Use a regularly calibrated
electronic or balanced-beam scale.
Spring scales are less reliable.
Weigh in light clothes, no shoes
Read to the nearest 100 gm (0.1kg)
Nutritional Indices in Adults
 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)
 Evidence shows that high BMI (obesity
level) is associated with type 2 diabetes &
high risk of cardiovascular morbidity &
BMI (WHO - Classification(
 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)
Waist/Hip Ratio
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
Waist circumference predicts mortality
better than any other anthropometric
measurement.
It has been proposed that waist
measurement alone can be used to assess
obesity, and two levels of risk have been
identified
MALES FEMALE
LEVEL 1 > 94cm > 80cm
LEVEL2 > 102cm > 88cm
Waist circumference/2
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 &
CVS complications.
Hip Circumference
Is measured at the point of greatest
circumference around hips & buttocks to
the nearest 0.5 cm.
The subject should be standing and the
measurer should squat beside him.
Both measurement should taken with a
flexible, non-stretchable tape in close
contact with the skin, but without
indenting the soft tissue.
Interpretation of WHR
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 & CVS
disorders.
A WHR below these cut-off levels is
considered low risk.
ADVANTAGES OF
ANTHROPOMETRY
Objective with high specificity &
sensitivity
Measures many variables of
nutritional significance (Ht, Wt, MAC,
HC, skin fold thickness, waist & hip
ratio & BMI).
Readings are numerical & gradable
on standard growth charts
Readings are reproducible.
Non-expensive & need minimal
Limitations of Anthropometry
Inter-observers errors in
measurement
Limited nutritional diagnosis
Problems with reference standards,
i.e. local versus international
standards.
Arbitrary statistical cut-off levels for
what considered as abnormal
values.
DIETARY ASSESSMENT
Nutritional intake of humans is
assessed by five different methods.
These are:
24 hours dietary recall
Food frequency questionnaire
Dietary history since early life
Food dairy technique
Observed food consumption
24Hours Dietary Recall
A trained interviewer asks the
subject to recall all food & drink
taken in the previous 24 hours.
It is quick, easy, & depends on
short-term memory, but may not be
truly representative of the person’s
usual intake
Food Frequency
Questionnaire
In this method the subject is given a
list of around 100 food items to
indicate his or her intake (frequency
& quantity) per day, per week & per
month.
inexpensive, more representative &
easy to use.
Food Frequency Questionnaire/2
Limitations:
 long Questionnaire
 Errors with estimating serving size.
 Needs updating with new commercial
food products to keep pace with
changing dietary habits.
DIETARY HISTORY
It is an accurate method for
assessing the nutritional status.
The information should be collected
by a trained interviewer.
Details about usual intake, types,
amount, frequency & timing needs
to be obtained.
Cross-checking to verify data is
important.
FOOD DAIRY
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.
Reliable but difficult to maintain.
Observed Food Consumption
 The most unused method in clinical practice,
but it is recommended for research purposes.
 The meal eaten by the individual is weighed
and contents are exactly calculated.
 The method is characterized by having a high
degree of accuracy but expensive & needs
time & efforts.
Interpretation of Dietary Data
1. Qualitative Method
 using the food pyramid & the basic
food groups method.
 Different nutrients are classified
into 5 groups (fat & oils, bread &
cereals, milk products, meat-fish-
poultry, vegetables & fruits)
 determine the number of serving
from each group & compare it with
minimum requirement.
Interpretation of Dietary Data/2
2. Quantitative Method
 The amount of energy & specific nutrients
in each food consumed can be calculated
using food composition tables & then
compare it with the recommended daily
intake.
 Evaluation by this method is expensive &
time consuming, unless computing
facilities are available.
Initial Laboratory Assessment
Hemoglobin estimation is the most
important test, & useful index of the
overall state of nutrition. Beside
anemia it also tells about protein &
trace element nutrition.
Stool examination for the presence
of ova and/or intestinal parasites
Urine dipstick & microscopy for
albumin, sugar and blood
Specific Lab Tests
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
micro-nutrients.
Advantages of Biochemical Method
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 Method
Time consuming
Expensive
They cannot be applied on large
scale
Needs trained personnel & facilities

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10. assessment of nutritional status

  • 1. ASSESSMENT OFASSESSMENT OF NUTRITIONAL STATUSNUTRITIONAL STATUS Developed By:Developed By: AQAQ
  • 2. LEARNING OBJECTIVESLEARNING OBJECTIVES By the end of this lecture the reader should be able to: To know the different methods for assessing the nutritional status To understand the basic anthropometric techniques, applications, & reference standards
  • 3. INTRODUCTIONINTRODUCTION The nutritional status of an individual is often the result of many inter-related factors. It is influenced by food intake, quantity & quality, & physical health. The spectrum of nutritional status spread from obesity to severe malnutrition
  • 4. Nutritional Assessment WhyNutritional Assessment Why?? The purpose of nutritional assessment isThe purpose of nutritional assessment is to:to: Identify individuals or population groups at risk of becoming malnourished Identify individuals or population groups who are malnourished
  • 5. Nutritional Assessment Why?Nutritional Assessment Why? To develop health care programs that meet the community needs which are defined by the assessment To measure the effectiveness of the nutritional programs & intervention once initiated
  • 6. Methods of Nutritional Assessment Nutrition is assessed by two types of methods; direct and indirect. The direct methods deal with the individual and measure objective criteria, while indirect methods use community health indices that reflects nutritional influences.
  • 7. Direct Methods of Nutritional Assessment These are summarized as ABCDThese are summarized as ABCD  Anthropometric methods  Biochemical, laboratory methods  Clinical methods  Dietary evaluation methods
  • 8. Indirect Methods of Nutritional Assessment These include three categories: Ecological variables including crop production Economic factors e.g. per capita income, population density & social habits Vital health statistics particularly infant & under 5 mortality & fertility index
  • 9. CLINICAL ASSESSMENT It is an essential features of all nutritional surveys It is the simplest & most practical method of ascertaining the nutritional status of a group of individuals It utilizes a number of physical signs, (specific & non specific), that are known to be associated with malnutrition and deficiency of vitamins & micronutrients.
  • 10. CLINICAL ASSESSMENT/2 Good nutritional history should be obtained General clinical examination, with special attention to organs like hair, angles of the mouth, gums, nails, skin, eyes, tongue, muscles, bones, & thyroid gland Detection of relevant signs helps in establishing the nutritional diagnosis
  • 11. CLINICAL ASSESSMENT/3 ADVANTAGES Fast & Easy to perform Inexpensive Non-invasive LIMITATIONS Did not detect early cases
  • 12. Clinical signs of nutritional deficiency HAIRHAIR Spare & thin Protein, zinc, biotin deficiency Easy to pull out Protein deficiency Corkscrew Coiled hair Vit C & Vit A deficiency
  • 13. Clinical signs of nutritional deficiency MOUTH Glossitis Riboflavin, niacin, folic acid, B12 , pr. Bleeding & spongy gums Vit. C,A, K, folic acid & niacin Angular stomatitis, cheilosis & fissured tongue B 2,6,& niacin leukoplakia Vit.A,B12, B-complex, folic acid & niacin Sore mouth & tongue Vit B12,6,c, niacin ,folic acid & iron
  • 14. Clinical signs of nutritional deficiency EYES Night blindness, exophthalmia Vitamin A deficiency Photophobia- blurring, conjunctival inflammation Vit B2 & vit A deficiencies
  • 15. Clinical signs of nutritional deficiency NAILS Spooning Iron deficiency Transverse lines Protein deficiency
  • 16. Clinical signs of nutritional deficiency SKIN Pallor Folic acid, iron, B12 Follicular hyperkeratosis Vitamin B & Vitamin C Flaking dermatitis PEM, Vit B2, Vitamin A, Zinc & Niacin Pigmentation, desquamation Niacin & PEM Bruising, purpura Vit K ,Vit C & folic acid
  • 17. Clinical signs of nutritional deficiency Thyroid gland  In mountainous areas and far from sea places Goiter is a reliable sign of iodine deficiency.
  • 18. Clinical signs of nutritional deficiency Joins & bones Help detect signsHelp detect signs of vitamin Dof vitamin D deficiencydeficiency (Rickets) & vitamin(Rickets) & vitamin C deficiencyC deficiency (Scurvy)(Scurvy)
  • 19. Anthropometric Methods Anthropometry is the measurement of body height, weight & proportions. It is an essential component of clinical examination of infants, children & pregnant women. It is used to evaluate both under & over nutrition. The measured values reflects the current nutritional status & don’t differentiate between acute & chronic changes .
  • 20. Other anthropometric Measurements Mid-arm circumference Skin fold thickness Head circumference Head/chest ratio Hip/waist ratio
  • 21. Anthropometry for children Accurate measurement of height and weight is essential. The results can then be used to evaluate the physical growth of the child. For growth monitoring the data are plotted on growth charts over a period of time that is enough to calculate growth velocity, which can then be compared to international standards
  • 22. Growth Monitoring ChartGrowth Monitoring Chart Percentile chartPercentile chart
  • 23. Measurements for adults Height:Height: The subject stands erect & bare footed on a stadiometer with a movable head piece. The head piece is leveled with skull vault & height is recorded to the nearest 0.5 cm.
  • 24. WEIGHT MEASUREMENT Use a regularly calibrated electronic or balanced-beam scale. Spring scales are less reliable. Weigh in light clothes, no shoes Read to the nearest 100 gm (0.1kg)
  • 25. Nutritional Indices in Adults  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)  Evidence shows that high BMI (obesity level) is associated with type 2 diabetes & high risk of cardiovascular morbidity &
  • 26. BMI (WHO - Classification(  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)
  • 27. Waist/Hip Ratio 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.
  • 28. Waist circumference Waist circumference predicts mortality better than any other anthropometric measurement. It has been proposed that waist measurement alone can be used to assess obesity, and two levels of risk have been identified MALES FEMALE LEVEL 1 > 94cm > 80cm LEVEL2 > 102cm > 88cm
  • 29. Waist circumference/2 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 & CVS complications.
  • 30. Hip Circumference Is measured at the point of greatest circumference around hips & buttocks to the nearest 0.5 cm. The subject should be standing and the measurer should squat beside him. Both measurement should taken with a flexible, non-stretchable tape in close contact with the skin, but without indenting the soft tissue.
  • 31. Interpretation of WHR 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 & CVS disorders. A WHR below these cut-off levels is considered low risk.
  • 32. ADVANTAGES OF ANTHROPOMETRY Objective with high specificity & sensitivity Measures many variables of nutritional significance (Ht, Wt, MAC, HC, skin fold thickness, waist & hip ratio & BMI). Readings are numerical & gradable on standard growth charts Readings are reproducible. Non-expensive & need minimal
  • 33. Limitations of Anthropometry Inter-observers errors in measurement Limited nutritional diagnosis Problems with reference standards, i.e. local versus international standards. Arbitrary statistical cut-off levels for what considered as abnormal values.
  • 34. DIETARY ASSESSMENT Nutritional intake of humans is assessed by five different methods. These are: 24 hours dietary recall Food frequency questionnaire Dietary history since early life Food dairy technique Observed food consumption
  • 35. 24Hours Dietary Recall A trained interviewer asks the subject to recall all food & drink taken in the previous 24 hours. It is quick, easy, & depends on short-term memory, but may not be truly representative of the person’s usual intake
  • 36. Food Frequency Questionnaire In this method the subject is given a list of around 100 food items to indicate his or her intake (frequency & quantity) per day, per week & per month. inexpensive, more representative & easy to use.
  • 37. Food Frequency Questionnaire/2 Limitations:  long Questionnaire  Errors with estimating serving size.  Needs updating with new commercial food products to keep pace with changing dietary habits.
  • 38. DIETARY HISTORY It is an accurate method for assessing the nutritional status. The information should be collected by a trained interviewer. Details about usual intake, types, amount, frequency & timing needs to be obtained. Cross-checking to verify data is important.
  • 39. FOOD DAIRY 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. Reliable but difficult to maintain.
  • 40. Observed Food Consumption  The most unused method in clinical practice, but it is recommended for research purposes.  The meal eaten by the individual is weighed and contents are exactly calculated.  The method is characterized by having a high degree of accuracy but expensive & needs time & efforts.
  • 41. Interpretation of Dietary Data 1. Qualitative Method  using the food pyramid & the basic food groups method.  Different nutrients are classified into 5 groups (fat & oils, bread & cereals, milk products, meat-fish- poultry, vegetables & fruits)  determine the number of serving from each group & compare it with minimum requirement.
  • 42. Interpretation of Dietary Data/2 2. Quantitative Method  The amount of energy & specific nutrients in each food consumed can be calculated using food composition tables & then compare it with the recommended daily intake.  Evaluation by this method is expensive & time consuming, unless computing facilities are available.
  • 43. Initial Laboratory Assessment Hemoglobin estimation is the most important test, & useful index of the overall state of nutrition. Beside anemia it also tells about protein & trace element nutrition. Stool examination for the presence of ova and/or intestinal parasites Urine dipstick & microscopy for albumin, sugar and blood
  • 44. Specific Lab Tests 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 micro-nutrients.
  • 45. Advantages of Biochemical Method 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.
  • 46. Limitations of Biochemical Method Time consuming Expensive They cannot be applied on large scale Needs trained personnel & facilities