presentation on nutritional status assessment covering approaches, methods, indices, indicators, growth monitoring and advantages and disadvantages

1. Assessment of Nutritional Status

 What is Nutritional Status?
 What is Nutritional Assessment?
Approaches
Nutritional assessment systems involve the interpretation ofinformation fromdietary
and nutritional biomarkers, and anthropometric andclinical studies.
Purpose
Determinethe nutritional status of individualsor population
groups as influencedby the intakeandutilization of dietary
substances andnutrientsrequired to support growth, repair, and
maintenanceof the body as awhole or in any of its parts
Nutritioninterventions
• Population subgroups identifiedas
“at-risk” duringnutrition surveys or
by nutrition screening
• micronutrient supplementation,
• food fortification,
• promotion of exclusive breast
feeding,
• dietary approaches,
• complementary feeding,and
• nutrition education
Nutritionscreening
• Comparison of measurementson individualswith
predeterminedrisk levelsor “cutoff” points using
measurementsthatare accurate, simple and
cheap.
• SubjectiveGlobal assessment (SGA)
• Malnutrition UniversalScreeningTool (MUST)
• mid-upper-armcircumference (MUAC) witha
fixedcutoff of 115mm.
Nutritionsurveillance
• Continuous monitoring of the nutritional
status of selected population groups.
• dataare collected, analyzed,andutilized
over an extendedperiodof time;
• aidlong-term planningin health and
development;
• provide input for program managementand
evaluation;
• givetimely warningof the needfor inter-
vention to prevent critical deteriorations in
food consumption
Nutritionsurveys
• cross-sectional survey;
• establish baselinenutritional
dataor
• ascertain the overall nutritional
status of the population;
• prevalence of existinghealthand
nutritional problems
• examineassociations,
• identifyanddescribe population
subgroups “atrisk” for chronic
malnutrition

2. Nutritional AssessmentMethods
 Measurements of the variations of the physical dimensions and the gross composition of the human body at different age
levels and degrees of nutrition.
Anthropometric
measurements
Biochemical/
Laboratory
tests
Clinical
evaluations
Dietary
assessment
ANTHROPOMETRY
Uses
• Related to past exposures, to present processes, or to future events;
• Used both at clinical and public health settings
At individual levels,
• diagnose failure to thrive in infants and young children,
• monitor overweight and obesity in children and adults;
At population levels,
• targeting interventions through screening;
• assessing the response to interventions;
• identifying the determinants and consequences of malnutrition;
• conducting nutritional surveillance;
• characterize and compare the health and nutritional status of populations
across countries.
• Stature (lengthor height),
• weight, and
• headcircumference;
• Skinfold thickness (sizeof the subcutaneous fat depot);
• waist circumference (intra-abdominalvisceral fat);
• mid-upper-arm circumference – MUAC (skeletalmuscle mass);
• Etc
Measurements
Body Size Body Composition

3. • Calculatedfrom two or more raw measurements;
• Essentialfor the interpretation and grouping of mea-
surements collectedin nutritional assessment;
Examples
• weight-for-age;
• height-for-age;
• weight-for-height;
• Weight-for-length;
• Body mass index (BMI);
• BMI-for age;
• waist-hipratio
• Comparing anthropometric data and or indiceswith the distri-
bution of appropriate anthropometric referencedata using
standarddeviation scores (Z-scores) or percentiles.
• thenumber and proportion of individuals(as %) with
anthropometric indicesbelow or above a predetermined
referencelimit or cutoff are often calculated;
• the indexand its associated referencelimit or cutoff become an
“indicator”
• constructed from anthropometric indices
• Z-scores isthe distanceand direction of anobservation awayfromthe
population mean.
• Itindicates how many standard deviations anobservation isawayfrom
themean inthe referencepopulation.
• Percentiles give information onthe percentage of observations that fall
below acertain value inthe referencepopulation.

4. Anthropometric Indices and respective indicators
Length/height-for-age
• reflectsattainedgrowthinlengthorheight
atthechild’sageatagiventime.
• canhelpidentifychildrenwhoarestunted
(short)duetoprolongedundernutritionor
repeatedillness.
• Childrenwhoaretallfortheiragecanalso
beidentified,buttallnessisrarelya
problemunlessitisexcessive andmay
reflectuncommonendocrinedisorders (+3
z-score).
• Between+2to-1z-scoreisconsidered
normal
• -2z-scoreindicatesstunting
• -3z-scoreindicatessevere stunting
Weight-for-age
• reflectsbody weightrelativeto thechild’sageon
agivenday.
• assesseswhethera childisunderweight,
• notusedto classifya childas overweightorobese
(+1to +3z-scores).
• cannotbereliedupon insituations wherethe
child’sagecannotbeaccuratelydetermined,such
asrefugeesituations.
• Itispossibleforunderweighttooccureither
becauseofshortlength/height(stunting) or
thinnessorboth.
• Btwmedianto -1z-scoresareconsiderednormal
• -2z-scoreindicatesunderweight
• -3z-scoreindicatessevereunderweight

5. Weight-for-length/height
• reflectsbody weightinproportion to attained growth inlength or
height.
• usefulinsituations wherechildren’s agesareunknown (e.g.refugee
situations).
• helpsidentify children withlow weight-for-height who may bewasted
or severely wasted.
• aswell ashigh weight-for-length/height who maybe atriskof
becoming overweight or obese;
• wasting isusually caused byarecent illnessor food shortage that
causesacute and severeweightloss;
• chronic undernutrition or illnesscanalso causethiscondition.
• Btw median to -1z-scores areconsidered normal;
• +3 z-score isobese;
• +2 z-score isoverweight
• +1z-score isat possible riskofoverweight
• -2z-score indicates wasting
• -3 z-score indicates severewasting
BMI-for-age
• usefulforscreeningforoverweight
andobesity;
• Btwmedianto -1z-scoresare
considerednormal;
• +3z-scoreisobese;
• +2z-scoreis overweight
• +1z-scoreis atpossibleriskof
overweight
• -2z-scoreindicateswasting
• -3z-scoreindicatesseverewasting

8.  Commonly used in healthcare systems to monitor the growth and
development of infants, children and adolescents.
 height, weight, head circumference, and body mass index (BMI),
on a standardized graph.
 track and measure a child's growth over time in order to identify
any deviations from the expected or normal growth patterns.
 Growth charts provide valuable information for parents,
healthcare providers, and researchers.
 early detection of growth disorders, nutritional deficiencies,
hormonal imbalances, or other underlying medical conditions
that could affect a child's growth.
 baseline for assessing the effectiveness of interventions or
treatments.
 identify differences in growth rates and patterns and inform
public health policies and interventions
Growth Charts
WHO Growth Charts
CDC Growth Charts
Down Syndrome Growth
Charts
Premature Infant Growth
Charts
Ethnic-Specific Growth Charts

9. WHO Growth Charts
• Developed by WHO;
• growth data from a diverse international population;
• boys and girls aged 0-5years;
• based on breastfed infants;
• preferred growth charts for infants and young
children.
CDC Growth Charts
• Developed by CDC;
• children aged 2-20years;
• Based on data from the National Health and
Nutrition Examination Survey (NHANES);
• based on a representative sample of the US
population.
Examples Examples
z-scores: girls
Girls chart- Length for age: birth to 6 months (z-scores)
Girls chart- Length for age: birth to 2 years (z-scores)
Girls chart- Length for age: 6 months to 2 years (z-scores)
Girls chart- Height for age: 2 to 5 years (z-scores)
Girls chart- Length/height for age: birth to 5 years (z-scores)
Percentiles: girls
Girls chart- Length for age: birth to 6 months (percentiles)
Girls chart- Length for age: birth to 2 years (percentiles)
Girls chart- Length for age: 6 months to 2 years (percentiles)
Girls chart- Height for age: 2 to 5 years (percentiles)
Girls chart- Length/height for age: birth to 5 years (percentiles)

10. Growth Charts Contd.
x-axis:
• Horizontal reference line at the bottom of
the graph;
• some show age and some show
length/height;
• Plot points on vertical lines corresponding
to completed age (in weeks, months, or
years and months);
• or to length or height rounded to the
nearest whole centimetre.
y-axis:
• vertical reference line at the far left of the graph.
• show length/height, weight, or BMI;
• Plot points on or between horizontal lines
corresponding to length/height, weight or BMI as
precisely as possible.
Plotted point
• point on a graph where a line extended from a
measurement on the x-axis (e.g. age) intersects
with a line extended from a measurement on the
y-axis (e.g. weight)

14. Midupper Arm Circumference
(MUAC)
• MUAC ismeasured inboth adults and children,
• sumof the muscleand subcutaneous fatintheupperarm;
• can be used as a indicator of body composition in adults and
children;
• Measured to nearest 0.1cm;
• aflexiblenon-stretch tape;
• It is measured on a straight left arm;
• mid-way between the tip of the shoulder and
the tip of the elbow;
• <12.5cmsuggestsmalnutrition;
• >13.5cmisnormal.

15. Body mass index - BMI
• ameasureofbody fatbased onheightandweightthat
appliesto adult menandwomen;
• definedasaperson’sweightin kilogramsdividedbythe
square oftheperson’sheightin metres(kg/m2);
• Forexample,anadultwhoweighs70kgandwhoseheight
is1.75 mwillhaveaBMIof22.9.
• For children and teens, BMI is age- and sex-specific;
• often referred to as BMI-for-age;
• The BMI-for-age percentile growth charts are the most
used indicator to measure the size and growth patterns;
BMI for Children and Adolescents

16. Anthropometry: Strengths and Weaknesses
Advantages
• Simple, safe, noninvasive techniques are involved, which can be used at the bedside of a single
patient, but arealso applicable to largesample sizes;
• Inexpensive equipment is required. It is portable, and durable and can be made or purchased
locally;
• Relatively unskilled personnel canperformthe measurement procedures ifadequately trained;
• Methods can be precise and accurate, if standardized techniques and trained personnel are
used;
• Retrospective information is generated on past long-term nutritional history, which cannot be
obtained with equal confidence using other techniques;
• Mild to moderate undernutrition, as well as severe states of under- or overnutrition, can be
identified;
• Changes in nutritional status over time and from one generation to the next, a phenomenon
known as the secular trend, canbeevaluated
Disadvantages
• Relativelyinsensitiveand cannotdetect
disturbances innutritional status overshort
periods oftime;
• Cannotidentifyanyspecificnutrientdefi-
ciencyand,therefore,is unableto
distinguish disturbancesin growth andbody
composition inducedby nutrientdeficiencies;
• Certainnon-nutritionalfactors(suchas
disease,geneticinfluences,diurnal
variation, andreducedenergyexpenditure)
canlowerthespecificityandsensitivityof
anthropometricmeasurements

17.  describe exposure to food and nutrient intakes as well as information on food behaviors
and eating patterns.
Uses include:
 dietary counseling and education;
 designing healthy diets for hospitals, schools, long-term care facilities and prisons;
 generate information on nutrient adequacy within a country;
 identify population groups at risk, and
 develop nutrition intervention programs;
 study relationships between diet and disease;
 formulating nutrition policy such as food-based dietary guidelines.
Dietary Intake methods

19.  FBSarecompiled byFAOannuallyandaremainlybasedoncountry-leveldatacovering acalendaryear;
 Givesinformationonavailableseeds,wastecoefficients, stockchangesandtypesofutilizationtopreparesupply/utilizationaccountinweights;
 theFAOFBSalsoprovide totalfood availabilityestimatesbyaggregatingthefood componentofallcommodities includingfisheryproducts;
 Thedataareconventionallypresentedpercapita,byadjustingforpopulationsize,e.g.availableamountoffood/energy/ nutrientsperpersonperday;
 Morespecifically, FBSpresentacomprehensivepictureofacountry’sfood supplyovertime;
 TheFBSlistfood items,i.e.primaryfoodcommodities andanumberofprocessedfoodcommodities potentiallyavailableforhumanconsumption,includingtheirsourcesofsupplyandutilization;
 Grossnationalfoodsupplyinagiven referenceperiod ofacountryiscalculatedfromthetotalquantityoffoodproducedplusthetotalquantityimported, adjustedforchangesatnationalfoodstocklevelsandexports;
 Netfood availabilityiscalculatedby subtractingtheamountsusedforanimalfeed,seeds,industrialorotherpurposesand lossesinthesupplychain;
 Thisnetvalueisthendivided by thecountry’spopulationestimatetoobtainafinalfiguredescribing theavailabilityoffoodcommodities, expressedaskilogramspercapitaperyear;
 Thispercapitainformationcanalsobe linkedtofoodcomposition dataandpresentedaspercapitaenergyintake(kilocalories perday),proteinintake(gramsperday)andfatintake(gramsperday).
Food Balance Sheets – national food availability

20.  widely used in the food and agriculture sectors to monitor global food patterns
and dietary habits;
 trends and changes in overall national food availability, and the adequacy of a
country’s supply to meet nutritional requirements;
 used to set public health priorities, formulate policies, undertake intercountry
comparisons;
 estimate the likelihood of micronutrient deficiencies. For example, FBS data was
used to identify the probability of micronutrient deficits in food supply per capita
Applications and uses of FBS

22.  Food Consumption: “the total amount of food available for consumption in the household, generally
excluding food eaten away from the home unless taken from home”
Examples
 Household Budget Survey (HBS)
 the Living Costs and Food Survey (LCFS),
 the Household Income and Expenditure Survey (HIES),
 the Living Standards Measurement Study (LSMS),
 the Household Expenditure Survey (HES);
 the Integrated Household Survey (IHS)
 The central statistical offices in countries are usually responsible for data collection.
 Household members keep records on all expenses and type of foods consumed during a specific time
period, usually one to four weeks, and preferably evenly distributed during different times in the year,
which is then provided to enumerators.
 The collected data are analysed and used to assess food consumption at household level.
Household Consumption and Expenditure Surveys – household food consumption

24.  FFQs assesses the frequency with which foods and/or food groups are eaten over a
certain time period.
 provide information that establishes usual dietary intake
 The questionnaire includes a food list (usually close-ended) and a frequency
category section, and can be self- or interviewer administered.
 Depending on the study objectives, data collection might be daily, weekly, monthly
or yearly.
 Furthermore, FFQs can include information about portion sizes and/or quantity of
food intake - semi-quantitative.
 By including portion size as part of frequency, the questionnaire allows for the
estimation of food quantities eaten and of nutrient intakes.
Food frequency questionnaire

26.  During a 24-hour recall, respondents (i.e. adults, children and their parents or caretakers) are asked, by a nutritionist or dietitian who has been
trained ininterviewing techniques, to recall and report all foods and beverages consumed over thepreceding 24hours.
 However, asingle 24-hour recall isnot enough to describe anindividual’s usualintake of food and nutrients.
 multiple nonconsecutive 24-hour recalls on the sameindividual are required inorder
 tocapturedailyvariability;
 Tobeusedasacomparison method tovalidate anFFQ;
 canincreasequality control, minimizeerrorsandmaximizereliability;
 Quantitative information on food intake, as described using portion size,allows for the calculation of energy and nutrient intakes;
 Estimation of portion sizeisfacilitated by the useof measurement aids suchas standard household measures,photo atlases, food models, etc;
 To calculate energy and nutrient intakes, the estimated portion size or the amount of food intake is multiplied by the values of nutrient content in
foods as found inthefood composition tables or databases
24-hour recall

28. Estimated food records
• Whenconductinganestimatedfoodrecord,respondentsareinstructedto documentallfoodsandbeveragesconsumedduringapredefinedperiod
(e.g.1to 7days).
• Thenumberofdays includedintheassessmentdependsonthepurpose ofthestudy;
• Duringtherecordperiod, specificdetailssuchas brandnames,timeofdaythefood orbeveragewasconsumed,thelocationandsometimesa
description oftheoccasionaredocumentedas well;
• Estimation ofthefoodportion orfood weightconsumedisnormallyaidedbyusingstandardized householdmeasures,food photographs ormodels;
• Priortodata collection,respondentsareoftenprovidedtrainingand practiceonrecording,inorderto becomefamiliarwith thesteps ofthe
assessment,especiallyforfoods eatenoutside thehome;
• Toensurethat data collectionisaccurate,ahomevisit bytrainedinterviewersonthefirstday ofrecordingishelpful;
• Afterdata collectioniscompleted,calculationofnutrientintake isdoneusingafoodcomposition database.

30.  Theweighedfoodrecordisoftenregardedasthemostprecisemethodforestimatingthefoodandnutrientintakesofindividuals.
 Theapproachadoptsthesameprinciplesastheestimatedfoodrecordmethod;
 However,inthis methodrespondents areaskedto weighusingweighingscales(e.g.adigitalelectronicscalewithatarebutton to
facilitatefoodweighing).
 Thesubjectsdirectlycopytheweightofanindividualfoodfromthescalewhileconductingadditiveweighingwithoutthenecessityof
manipulatingfigures,andthusavoiding errors;
 Allfoodandbeveragesconsumedareweighedandrecorded,alongwithadescription ofportion size,brand namesanddetailsonfood
preparation;
 apredefinedmeasurementperiod (between1to 7days)needstobeset;
 weekenddaysshouldbeincludedtoaccountforchangesinfoodintakeduring weekenddays.
 Toobtainevenmoreprecisedata,leftoverscanalsobeweighedor estimated;
Additionalconsiderationsforaccuracy
 rawingredients separatelybeforecooking,andthis isespeciallyimportant for mixeddishes;
 fulldescription ofthefoodsconsumed,theoccasionandlocationforfoodsconsumedawayfromhome;
 Prior to therecording period,therespondents shouldbeprovided withinstructions for recording, withsufficienttimeforpracticingand
remindersaboutmaintainingtypicaldietary habitsduring therecording period;
 homevisits arenormallyarrangedduring thestudyperiod toascertainthattheproceduresarecarriedoutproperly
Weighed food records

32.  Theduplicate mealmethodinvolves setting aside duplicateportions of all foods andbeverages consumed
throughout aspecifictimeperiod.
 These retained duplicateportions are set aside, weighed,either bytherespondent orfieldworker, andthen
senttoalaboratory for chemicalanalysis todetermine nutrient content.
 respondents also maintainaweighedfood diary torecord details of thefoods andbeverages consumedduring
theassessment period andprovide information onportion size expressed inweightsor household portions.
 Thefood diary canhelptoverify thecomprehensiveness of collectingduplicate foods andaccuracy of the
portion sizes of theduplicatemeal;
 Acomparison of nutrient intakes canbemadebetweenthevalues of analysed nutrients andthenutrient intake
whichiscalculated basedonthereported portion size anddatafrom afood compositiondatabase.
Duplicate meal method

34.  TheDietary Diversity Score (DDS) isaproxy tool based on the
concept that ‘dietary diversityis akeyelement of diet quality and
avaried diethelps ensure adequate intakes of essential
nutrients that promote health’
 DDS provides asimplescore whichrepresentsanumber of
differentfoods and/or food groups consumed over agiven
referenceperiod;
 There arevarious DDSs published and used for different
purposes. Theydifferinthe numberand definition of food;
 groups or food items,referenceperiods and units of analysis (i.e.
household or individual level).
Qualitative retrospective proxy tools for assessing dietary diversity
HouseholdDietaryDiversityScore(HDDS)
• isbased onthecountof12-foodgroups.
• information isextractedfromonequalitative 24-hourrecall,
excludingfoods consumedoutside thehome;
• accessesthequality offoodaccessathouseholdlevel;
• additionally, it isusefulforidentifyingemergenciesrelated
to foodsecurityandmalnutrition.
Minimum Dietary Diversity

35.  MinimumDietaryDiversity –Women(MDD-W)
 TheMDD-Windicatoraims to beusedas aglobalindicator
ofdietary diversity;
Minimum Dietary Diversity –Women (MDD-W)
• Food consumption of individuals during thepreceding 24hours isrecalled using a
qualitative 24-hour recall questionnaire, including foods that have beeneaten outside
thehome.
• Theinformation on food consumption, collected either by24-hour recall or list-based
questionnaire, that matches theitems inthe16-food group list areunderlined;
• To createtheMDD-W score,thepreliminary listof the 16-food group isaggregated into
the10-food group indicator whereone point isallocated whenever afood item contained
inthe 10-food groups hasbeen underlined inthe16-food group list.
• Evenifeachfood group hasone or more underlined food itemonly one point isallocated,
thuscontributing equally to thefinalscore.
• Thevalueof zeroisgivenifnone of thefood itemsinthe food group wereconsumed. The
sumof the consumed food groups representsthetotal DDS.
• Only food items that wereconsumed inaquantity greater than 15grams(roughly a
tablespoon) should beconsidered and included inthe 10-food group indicators.
• Acut-off point of fiveistaken asthe‘bestcut off’sinceitrecommended asareasonable
predictor of anMPA
*meanprobabilityofmicronutrientadequacy(MPA)

36.  IYCDDS isdefinedasthe “Proportion of children6–23 months
of agewho receivefoods fromfour or more food groups”
 Theindicator isbased on thecount of 7-food groups.
 consumption of any amount of food from eachfood group is
sufficientenough to beaccounted for inthe construction of
thescore, except ifanitemisonly used asacondiment;
 Thecut-off of atleast four of the above 7-food groups
indicates aminimum dietarydiversity ininfantsand young
children.
Infant and Young Child Dietary Diversity Score (IYCDDS)

37.  Laboratorymethodsareusedtomeasurenutritionalbiomarkers;
 usedtodescribestatus,function,riskofdisease,andresponsetotreatment;
 nutritionalbiomarker:abiologicalcharacteristicthatcanbeobjectivelymeasured
andevaluatedasanindicatorofnormalbiologicalorpathogenicprocesses,and/oras
anindicatorofresponsestonutritioninterventions;
 Theycanalsobeusedtodescribeexposuretocertainfoodsornutrients,whenthey
aretermed“dietarybiomarkers”
 Mostusefularenutritionalbiomarkersthatdistinguishdeficiency,adequacyand
toxicity,and
 whichassessaspectsofphysiologicalfunctionand/orcurrentorfuturehealth.
Canbemeasured using:
• biological tissuesand fluids;
• physiological or behavioral functions;
• metabolic and geneticdata that inturninfluence health, well-
being,and riskof disease.
• Laboratory tests canhelp confirm nutritional status findings
uncovered during adietary assessment and physical examination
Biochemical/Laboratory Methods