Nutrition Assessment for Modern Medicine professionals

1. Assessment of
Nutrition
Dr.Benny PV
Professor & HOD
Department of Community Medicine

2. Nutritional status
š Nutritional status is the current
body status, of a person or a
population group, related to their
state of nourishment (the
consumption and utilization of
nutrients)

3. Nutritional status
š Determined by a complex
interaction between
internal/constitutional factors and
external environmental factors
š Internal or constitutional factors (Age,
sex, nutrition, behaviour, physical
activity and diseases)
š Environmental factors (Food safety,
cultural, social and economic
circumstances)

4. An ideal nutritional status
š An ideal nutritional status
occurs when the supply of
nutrients balance the
requirements

5. Healthy Diet
š Healthy diets are more
meaningful in terms of
quality and right balance
of nutrients they provide
š Not solely on the type of
food eaten or the amount
of caloric intake

6. Optimal nutrition
š Spectra of nutritional
status
š Under-weight -> normal ->
overweight/obesity

7. The nutritional status and its role
š Optimal nutritional status is a
powerful factor for health and
well being
š It is a major, modifiable element
in promoting health, preventing
and treating diseases and
improving the quality of life
š Both under and over nutrition
affect health and well-being

8. Purpose of nutritional assessment
š Identify individuals or population
groups at risk of becoming
malnourished
š Identify individuals or population
groups who are malnourished

9. Purpose of nutritional assessment
š To develop health care programs
that meet the community needs
which are defined by the
assessment
š To measure the effectiveness of
the nutritional programs &
interventions once initiated

10. Methods of Nutritional Assessment
Direct methods
š Deal with the individuals,
and measures objective
criteria
Indirect methods
š Uses community indices that
reflect the community
nutritional status/needs

11. Direct Methods of Nutritional Assessment
š Summarized as ABCD
šAnthropometric methods
šBiochemical (Lab)
šClinical methods
šDietary evaluation methods

12. Indirect Methods of Nutritional Assessment
š Ecological variables including
agricultural crops production
š Economic factors
š Cultural and social habits
š Vital health statistics: morbidity,
mortality and other health
indicators

13. Anthropometric
Methods

14. Anthropometric Methods
š Anthropometric
measurements are a series of
quantitative measurements
of the muscle, bone, and
adipose tissue used to assess
the composition of the body

15. Elements of anthropometry
š The core elements of anthropometry
š Height
š Weight
š Body mass index (BMI)
š Waist circumferences
š Other elements
š Skinfold thickness
š Mid-arm circumference
š Head circumference
š Head/chest ratio
š Hip/waist ratio

16. Height Measurements in adults
š The subject stands erect & bare
footed on a stadiometer with a
movable head piece
š The head piece is levelled with
skull vault & the height is
recorded to the nearest 0.5 cm

17. Height in Infants & Children
Measuring Recumbent length in infants & standing height in children

18. Weight measurement in adults
š Use a regularly calibrated
electronic or balanced-
beam scale
š Spring scales are less reliable
š Weigh in light clothes, no
shoes. Read to the nearest
100 gm (0.1kg)

19. Weighing
infants and
young
children
Spring Scale Electronic and Balance Beam
Infant Scales

20. Body Mass Index
(BMI)
š The international standard for
assessing body size in adults is
the body mass index (BMI)
š BMI is computed using the
formula: BMI = Weight in kg/
Height in m²

21. Classification of undernutrition
Gomez Classification
(uses weight- for-age measurements)
Weight-for-Age(% ) Status
90-100 Normal
75-90 1st degree
60-75 2nd degree
<60 3rd degree

22. Classification of undernutrition
Wellcome Classification
(wt loss in terms of wt for age(%) & presence or absence
of edema)
Weight-for-Age(% ) Oedema No Oedema
80-60 Kwashiorkor Undernutrition
60 Marasmic-
kwashiorkor
Marasmus

23. Classification of undernutrition
Waterlow Classification
(Adopted by WHO; can distinguish between deficits of weight-for-
height%:wasting) & height-for-age%: stunting)
Normal Mild Moderate Severe
Weight-for-Age(% ) >95 90-95 80-90 <80
Weight-for-Height(%) >90 80-90 70-80 <70

24. Waist circumference
š Waist circumference is measured
at the level of the umbilicus to
the nearest 0.5 cm
š The subject stands erect with
relaxed abdominal muscles, arms
at the side, and feet together
š The measurement should be
taken at the end of a normal
expiration

25. Waist circumference
š Waist circumference predicts
mortality better than any other
anthropometric measurement
š Males/ Females
š LEVEL 1 > 94 cm/ > 80 cm
š LEVEL 2 > 102 cm/ > 88 cm

26. Hip Circumference
š Is measured at the point of
greatest circumference around
hips & buttocks to the nearest 0.5
cm
š The subject should be standing
š Waist and hip measurements
should be taken with a flexible,
non-stretchable tape in close
contact with the skin, but without
indenting the soft tissue

27. Interpretation
of Waist / Hip
ratio (WHR)

28. Mid-upper arm circumference (MUAC)
>13.5cm
GREEN COLOUR
Indicates that the child is well nourished
12.5cm to 13.5cm
YELLOW COLOUR
Indicates that the child is at risk for acute malnutrition and
Should be counselled and followed-up for Growth Promotion
and Monitoring (GPM)
11.0cm to12.5cm
ORANGE COLOUR
Indicates Moderate Acute Malnutrition (MAM)
The child should be immediately referred for
supplementation
<11.0cm)- RED
COLOUR
Indicates Severe Acute Malnutrition (SAM)
The child should be immediately referred for treatment

29. Body Mass Index for Children and Teens
š The criteria used to interpret the
meaning of the BMI for children
and teens are different from
those used for adults
š Age- and sex-specific percentiles
are used for two reasons
š The amount of body fat changes
with age
š The amount of body fat differs
between girls and boys

30. Body Mass
Index for
Children
and Teens

31. Advantages of Anthropometry
š Objective with high specificity &
sensitivity
š Measures many variables of
nutritional significance (Ht, Wt,
MAC, HC, skin fold thickness,
waist & hip ratio & BMI)
š Readings are numerical &
gradable on standard growth
charts
š Readings are reproducible
š Non-expensive & need minimal
training

32. Limitations of Anthropometry
š Inter-observers errors in
measurement
š Limited nutritional diagnosis
š Problems with reference
standards, i.e. local versus
international standards
š Arbitrary statistical cut-off levels
for what considered as abnormal
values

33. Clinical assessment of
nutrition

34. Clinical assessment of nutrition
š It is an essential feature of all
nutritional surveys
š It is the simplest & most practical
method of ascertaining the
nutritional status of a group of
individuals

35. Clinical assessment of nutrition
š It utilizes a number of physical
signs, (specific & non-specific),
that are known to be associated
with malnutrition and deficiency
of vitamins & micronutrients

36. Clinical assessment of nutrition
š Good nutritional history should be
obtained
š General clinical examination,
with special attention to organs
like hair, angles of the mouth,
gums, nails, skin, eyes, tongue,
muscles, bones & thyroid gland
š Detection of relevant signs helps
in establishing the nutritional
diagnosis

37. Clinical assessment
of nutrition
Specific clinical features for
specific nutritional deficiencies
Scurvy
Iodine
deficiency
Vit-A
deficiency
Berry-berry

38. Clinical assessment
of nutrition
Specific clinical features for
specific nutritional deficiencies Vitamin B2
Deficiency
(Ariboflavinosis)
Pellagra
Vitamin B3 (
Niacin)
Deficiency
Rickets
(Vitamin D
deficiency)
Marasmus-PEM

39. Advantages of clinical assessment
š Fast & Easy to perform
š Inexpensive
š Non-invasive

40. Limitations of Clinical assessment
š Early detection is not
feasible in clinical
assessment
š Only after signs and
symptoms developed

41. Biochemical
(laboratory) methods

42. Laboratory methods
š Initial Laboratory Assessment
š Laboratory tests based on blood
and urine can be important
indicators of nutritional status, but
they are influenced by non-
nutritional factors as well
š Lab results can be altered by
medications, hydration status,
and disease states or other
metabolic processes, such as
stress

43. Laboratory methods
š Haemoglobin estimation is the
most important test & useful
index of the overall state of
nutrition
š Beside anaemia it also talks
about protein & trace element
nutrition
š Stool examination for the
presence of ova and/or intestinal
parasites
š Urine dipstick & microscopy for
albumin, sugar and blood

44. Specific Lab Tests
š Estimation of Vitamins and
minerals in blood
š Detection of abnormal quantity
of metabolites in the urine
(urinary creatinine/
hydroxyproline ratio etc)
š Analysis of hair, nails & skin for
micro-nutrients

45. Advantages of Biochemical Methods
š It is useful in detecting early
changes in body metabolism &
nutrition before the appearance
of overt clinical signs
š It is precise, accurate and
reproducible

46. Dietary assessment

47. Dietary assessment of nutrition
š 24 hr Recall method (Questionnaire method)
š Food Frequency Questionnaire method (FFQ Method)
š Diet History
š Food balance sheet method
š Inventory method
š Weighment method
š Dietary Score method
š Duplicate Sample/ Chemical analysis method
š Expenditure pattern method
š Recording method

48. 24 Hours Dietary Recall
š The interviewer asks the homemaker to recall all the foods
consumed by the family in the past 24 hours
š Assuming that the interview is done during late morning
hours (e.g. 11 AM to 12 PM)
š The individual is asked to think back in time and recall what
was cooked and consumed for the breakfast on the day of
the interview, for the dinner last night, and the lunch on the
previous day
š In short, it meant enquiring about all the food consumed
after the previous morning's breakfast

49. 24 Hours Dietary Recall
š The recall should begin from the most recent meal and
proceed backward in time
š In the first step, the individual is asked to recall the items
consumed during the last 24 hours
š After this, the amount that was consumed is probed
š This must take to account the leftover portion which is to be
deducted from the total amount cooked

50. 24 Hours Dietary Recall
š In the third step, the amount of each raw ingredient that
went into cooking of the items is asked
š Food models and household measuring instruments can be
used to guess the portion sizes more accurately
š Also, she/he can be asked to demonstrate the spoon and
cups which were used to measure the particular ingredient
š The interviewer can assess the volume by filling it with water
and pouring the same in a measuring cup

51. 24 Hours Dietary Recall
š It is a good idea to carry measuring spoons set and other
measuring instruments such as measuring cups and
cylinders
š Also examine the packages of the pre-packaged food
items consumed
š Read the nutritional information per unit provided on these
and note down the amount actually consumed out of
these packets

52. 24 Hours Dietary Recall
š Explain to the homemaker that you need to know only what
was eaten
š Do not express either approval or disapproval of any food
item that is mentioned, either by way of words or by facial
expressions
š Do not appear to be judgmental about any dietary item
being “good” or “bad” No one can eat only the approved
foods all the time

53. 24 Hours Dietary Recall
š Do not ask leading questions that may suggest the
homemaker that the family “should” have consumed a
certain item and lead her/ him to say, “Yes, we did”

54. 24 Hours Dietary Recall
š Some items such as chapattis and bread slices can be listed
in terms of the number consumed
š The homemaker can also be requested to display the
amount of flour that she would usually use for making 10
typical chapattis
š One can guess the raw flour weight used for one chapatti
š The number of calories in each chapatti consumed in the
family can then be calculated based on this amount

55. 24 Hours Dietary Recall
š For bread slices, the amount and ingredients can be read
off the label
š The amount of rice, wheat flour, pulses, vegetables, etc., is
entered in a table

56. Recording
During a 24-
Hour Recall
(Questionnaire)
Method of
Dietary Survey

57. 24 Hours Dietary Recall
š This is repeated for one “dietary cycle” which is of 7 days
š All the days must be different days of the week
š This is done to avoid the effect of any atypical food
consumption on a particular day of the week like weekly
fasts or feasts
š If it is not possible to cover 7 days, an undergraduate
student is expected to repeat for at least 3 different days of
the week

58. 24 Hours Dietary Recall
š The average intake per day by the family is calculated by
adding up the quantities consumed on each day and then
dividing the sum by the number of days of survey
š In the next step, the average daily intake of food stuff is
converted into
š Principal food categories, e.g., grams of cereals per day,
grams of pulses per day, and grams of leafy vegetables per
day by the family

59. 24 Hours Dietary Recall
š Amount of nutrients consumed by the family in a day
š Nutrients which are calculated are calories (energy),
proteins, fat, vitamins, calcium, and iron consumed per day
š For this step, help is taken from the food tables given in the
ICMR publication Nutritive Value of Indian Foods

60. 24 Hours Dietary Recall
š Once the family's average daily intake is obtained, the next
step is to calculate the number of Consumption units (CUs)
in the family and
š Divide the average amount of each food item and nutrient
by the CUs to obtain the intake per CU by the family
š The energy consumption of an average male doing
sedentary work is taken as one
š One Consumption Unit (CU) corresponds to an energy
requirement of 2400 kcal/day

61. Consumption
Unit (CU)-
ICMR

62. 24 Hours Dietary Recall
š Calculation of the Total Consumption Units of the Family
š Allot the appropriate CU (as per the above table) to each
family member. Add up the CUs and the total will be the
number of CUs in the family
š Example
š HOF- Male, 31 years old, clerk (sedentary worker): CU = 1
š Wife of the HOF, 28 years old, housewife (mod worker): CU = 0.9
š Elder child, 12-year-old, male: CU = 1
š Younger child, 8-year-old, male: CU = 0.7
š Total CUs in the family 1 + 0.9 + 1 + 0.7 = 3.6

63. Other dietary
methods

64. Food Frequency Questionnaire
š 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
š It is inexpensive, more representative & easier to use
Limitations
š Long questionnaire
š Errors with estimating serving size
š Needs updating with new commercial food products to
keep pace with changing dietary habits

65. Diet history method
š Aims to discover the usual food intake pattern of individuals
over a relatively long period of time
š It is an interview method composed of two parts
š The first part establishes the overall eating pattern and
includes a 24hr recall
š Questions such as What did you have for breakfast
yesterday? coupled with What do you usually have for
breakfast? following through the entire day in this way
š Subjects are asked to estimate portion sizes in household
measures with the aid of standard spoons and cups, food
photographs or food models.

66. Diet history method
š The second part is known as cross-check questions
š This is a detailed list of foods that are checked with the
subject
š Questions concerning food preferences, purchasing and
the use of each food serve to verify and clarify information
given in the first part
š Questions about purchasing can also provide a check on
portion estimates

67. Food Diary
š Food intake (types & amounts) should be recorded by the
subject at the time of consumption
š The length of the collection period range between 1-7 days
š Reliable but difficult to maintain

68. Food frequency questionnaires (FFQs)
š Designed to assess habitual diet by asking about the frequency with which food items or
specific food groups are consumed over a reference period
š This method can be used to gather information on a wide range of foods or can be
designed to be shorter and focus on foods rich in a specific nutrient or on a particular
group of foods e.g. fruit and vegetables

69. Dietary
outcomes
assessed by
food
frequency
questionnaire

71. Thank you