Nutrition assessment presentation

1. Nutrition Assessment
May 24, 2017
Rates of malnutrition in Pakistan are among the highest in the world. According to the most recent
Demographic and Health (DHS) Survey for Pakistan (2012-13), approximately 45% of children
under the age of 5 are stunted, 11% are wasted and 30% are underweight. Stunting is most
common among children of less educated mothers (55%) and from poorest households (62%),
and is more common in rural areas (48%) than urban areas (37%). A large-scale country-wide
food fortification program was announced in September with the aim of improving the nutritional
status of women and children in particular. Micronutrients will be added to wheat flour, oils, and
ghee (the first time a staple food will be fortified country-wide in Pakistan). Currently, drought
(ongoing since 2013) has contributed to an increase in children under 5 with severe acute
malnutrition (SAM), particularly in Sindh province. Sources: Pakistan 2012-13 Demographic and Health Survey; Grant H.
Pakistan fights devastating malnutrition with mass food-fortifying programme. The Guardian, 16Sept2016; Relief Web South Asia update,
11Jan2017. Photos: 11-year-old Daddia with her mother and some of her siblings in Sindh province (Vicki Francis/Department for International
Development), Makeshift camp for people displaced by flooding in Sindh province, 2010 (UN Women/Asad Zaidi)
FNH 355: INTERNATIONAL NUTRITION
Pakistan
funded through USAID people selected to represent population as a whole
loss of muscle mass and weight
vitamin D added to milk in western countries
is chronic or acute malnutrition more common in pakistan?

2. Objectives for today
1. Define nutrition assessment
2. Describe, with specific examples, how
anthropometric measurements can be used to
classify malnutrition
3. Clearly define, describe, and evaluate stunting,
wasting, underweight, and body mass index (BMI)
4. Briefly describe how biochemical measurements
can be used in nutrition assessments
5. Differentiate between clinical signs and symptoms

3. Objectives for today, cont’d
6. Identify and explain important clinical signs of
malnutrition (including bilateral pitting edema)
7. Summarize the limitations of a physical examination in
the assessment of nutritional status
8. Describe strategies for assessing dietary intake
(including 24-hour recalls, food records, food frequency
questionnaires) and, based on your consideration of their
strengths and limitations, determine which method would
be most appropriate to use to assess dietary intake in
various settings
9. Apply what you have learned so far about nutrition and
nutrition assessment to evaluate a recent study from
Nigeria

4. Nutrition Assessment:
How we measure nutritional status
Why conduct nutrition assessments? To determine who is
malnourished – and to evaluate the _______ of any program
or other change – we need to measure nutritional status
Mothers waiting for children to be weighed as
part of outpatient therapeutic feeding program.
UNICEF Ethiopia
impact
Text

5. What is Nutrition Assessment?
• The science of determining nutritional status by
analyzing individual’s…
…history and current data.
A measurement of the
extent to which the
individuals
physiologic need for
nutrients is being met.
Anthropometric
Biochemical
Clinical
Dietary
is the person getting what they need in terms of nutrients and energy

6. Optimal nutritional status is a balance
depends on if we are growing, lactating, sick, pregnant, etc.
Nutrient Requirements
(what our body needs)
Nutrient Intake
(what we eat)
Nutritional status

7. Optimal nutritional status is a balance
Krauses Food, Nutrition Diet Therapy, 10th ed. Fig 16-1, p. 354
what we eat
need to consider
bioavailability
stress disturbs the
equilibrium in the body
need more nutrients
relative to body size
someone who
exercises more would
need more nutrients
than a sedentary
individual

8. Conducting Nutrition Assessments in Laos
Video
Tests:
Ñ measured height, weight, wasting
Ñ blood tests to measure Hb (iron status)
Ñ compare these to DHS data
Who was IdentiÞed as undernourished?
Ñ children
Ñ women
Ñ usually those who were poorest (crops wiped out)
-marginalized people
Ñ responses need 2 branches of activity
1. Health activity
Ñ address infection, sickness etc.
2. Livelihood opportunities
Ñ canÕt only give micronutrients etc. wonÕt help over time
Ñ try to increase economies

9. Anthropometry: Measurement of ___________
___________ and gross composition of the body
Key measurements of gross body size:
Height, weight, mid upper arm circumference (MUAC)
(Results compared to ______________in order to interpret them)
Photo: Geno Teofilo/Oxfam Photo: EC/ECHO/Anouk Delafortrie
Photo: UNICEF Ethiopia/Getachew
dimensions
physical
standard values
can use calipers to measure fat mass
measure then compare these to a standard Ñ important

10. World Health
Organization (WHO)
Multicentre Growth
Reference Study
• Tracked growth of
children raised in
Brazil, Ghana, India,
Norway, Oman, USA
• Created international
reference values for
growth
• Infants ___________
Anthropometric measurements are
compared to “standard values”…
where do standard values come from?
people from various countries were monitored for many years
measure weight and length of those who were breastfed from birth to 24 months breastfed
only

11. Do children from different ethnic groups grow differently?
Figure source: WHO Multicentre Growth Reference Study Group. Assessment of differences in linear growth among populations in
the WHO Multicentre Growth Reference Study. Acta Paediatr Suppl 2006;450:56--65.
lines essentially overlap because growth of children and babies in
early life do not depend on where theyÕre from, but what they eat
and what affects their growth
Ñ young children should have similar growth patterns
no difference in growth pattern
birth to ~2 years of age

12. Wasting:
___________________
• Reflects ______ malnutrition
• Generally result of weight
loss due to recent period of
starvation or severe disease
• Severe Acute Malnutrition
(SAM): weight-for-height is
-3 SD or more below WHO
standard
• Moderate acute malnutrition
(MAM): between -2 and -3
SD
Figure: Mwtoews via Wikimedia Commons
Source: WHO child growth standards and the identification of severe acute
malnutrition in infants and children (2009)
low weight for height
acute
undernutrition that occured in the relatively recent past
2.1% of children
decisions based on a normal distribution of values
0.1% of children have seveere acute malnutrition
ÒwastedÓ
10x likelihood
of death
wasting = emergency

13. Mid upper arm circumference (MUAC)
• Measures ____________,
correlates with total
muscle mass
– reflects _______________
– Common for field
assessment (measurement
is quick, easy, informative)
– MAM = 12.5 cm
– SAM = 11.5 cm
Another way to measure wasting and detect acute malnutrition:
MUAC being measured on Shegitu,
an 18-month-old girl undergoing
treatment for SAM (Ethiopia, 2012)
protein status
muscle conent
simple, mobile measurement with minimal discomfort
cut off used to be 11cm

14. • Major determinants of MUAC: arm muscle, subcutaneous fat
• More _______ measure of malnutrition than low body weight
• Strong predictor of risk for death
• __________ measurement to perform
• Primarily used for children aged 6 – 59 months of age
Mid upper arm circumference (MUAC)
Photo: Geno Teofilo/Oxfam
green: OK
yellow: MAM
Red: SAM
sensitive
can predict things earlier than other measurements
Easy
just before 5 y/o

15. Can MUAC be used to assess malnutrition
in adolescents and adults?
• Some studies have shown low MUAC is
correlated with poor outcomes among
adolescents and adults
– Example: MUAC 23.5 cm
in pregnant women associated
with higher risk of having baby
born with ______________in
Guatemala
• No international cut-offs exist
• Additional research is needed
Woman and child in Guatemala.
Photo: Chris Serour
do not have the same international standard for this measurement
low birth weight

16. Young girl being screened for malnutrition in Sindh, Pakistan, 2012.
Photo: Dan Casperz/DFID

17. Stunting: ___________________
• Failure to reach linear
growth potential
• Reflects chronic
malnutrition (sustained and
cumulative episodes of
undernutrition)
• Child considered “stunted”
if height-for-age is -2 SD
below WHO standard
Photo: Mercedes de Onis, WHO. AT Technical Brief, Issue 2, Sept 2010
low height for age
height they could have achieved
LT gap in caloric intake that isnÕt incapacitating them
proportions are appropriate, but overall height is not where it should be
26 months 52 months (stunted)
issue because not just a lack of height, but lack of internal development (organs), other
body parts, less cognitive development
ex: pelvis not properly formed = difÞcult to give birth

18. Recumbent length: measured if child cannot
______________________________
Photo credit: Zoriah (www.zoriah.net) Child assessed for malnutrition at Kakuma Refugee Camp in Kenya, February 1, 2009
stand erect without assistance
not an easy measurement to do
very important to do this test

19. “Our work is taking place in the
context of a malnutrition crisis in
Pakistan, where nearly half of
children are stunted and won’t be
able to participate in the economy…
Stunted kids are at a disadvantage
cognitively as well as often being the
height of a child two or even four
years younger… When these
children become adults they are
more susceptible to communicable
diseases, they are generating less
money for their families – and the
overall net effect on GDP is 3% a
year for Pakistan. So it is a much
cheaper problem to fix than to allow
to continue.”
- John Spicer, President of the Micronutrient Initiative
Regarding the large-scale fortification program being implemented in Pakistan (mentioned on the title slide):
Children returning home from school in Pakistan. Photo: Adeel Anwer
Quoted in Grant H. Pakistan fights devastating malnutrition with
mass food-fortifying programme. The Guardian, 16Sept2016
wont be able to provide for families
decrease

20. But aren’t different ethnic groups just naturally shorter? Is it
appropriate to compare height to an international standard?
Maya children in rural Guatemala Maya American children in Florida
Image source: ABC and Wuqu’ Kawoq via Flood D. Height and herencia in rural Guatemala. GlobalHealthHub.org, 2014
• Race/ethnicity has a _________ impact on preschool
growth, compared to _______________effects
environmental
SMALL
especially the case in childrenÕs growth
these children would be in normal distribution

21. Maya children in rural Guatemala Maya American children in Florida

23. Source: Victoria et al. Worldwide Timing of growth Faltering: Revisiting Implications for Interventions. Pediatrics 2010
ÒstuntedÓ children
stunting occurs early in life -typically by ~age 2
Þrst 1000 days = when people are most vulnerable

24. “Failing to grow” vs. “having failed to grow”
Boy in Changu Narayan, Nepal.
Photo: Jean-Marie Hullot
Dalit girls in Kanakpur Village, Nepal.
Photo: Heather Webb, 2012 Advocacy Project Peace Fellow, WRRP, Nepal.
ÒstuntingÓ
- it is happening right now
-chronic, over long period of time
ÒstuntedÓ
- already happened by this age

25. Stunting and wasting can occur together or independently
going on over a
period of months
going on over a
period of years

26. Underweight: ___________________
• Influenced by both height-
for-age and weight-for-
height, so interpretation
can be difficult
• Reflects chronic or acute
malnutrition (or
combination)
8-month old Hassan Hussein is weighed as part of
outpatient feeding treatment in Ethiopia, 2012.
Photo: UNICEF Ethiopia/2012/Getachew
low weight for age in children
Òred ßagÓ

27. Body mass index (BMI)
Classification BMI Category Risk of developing
(kg/m2) health problems
Underweight 18.5 Increased
Normal Weight 18.5 Ð 24.9 Least
Overweight 25.0 Ð 29.9 Increased
Obese
Class I 30.0 Ð 34.9 High
Class II 35.0 Ð 39.9 Very high
Class III ≥ 40.0 Extremely high
Note: For persons 65 years and older the ‘normal’ range may begin slightly above BMI 18.5 and
extend into the ‘overweight’ range.
Adapted from: WHO (2000) Obesity: Preventing and Managing the Global Epidemic: Report of a WHO Consultation
on Obesity.
From: Canadian Guidelines for Body Weight Classification in Adults
how we classify weight in adults (20 y/o)

28. Anthropometric measurements enable us to identify:
How do we
identify it?
What does it
mean?
Why does it
matter?
Wasting
Low weight for height
Stunting
Low height for age
Underweight
Low weight for age
review slide

29. Biochemical
methods
• Measure a
nutrient or its
metabolite in
blood, urine,
feces… or
measure other
components
related to
nutritional status
B
Kazakhstan, 2012. Photo: Maxim Zolotukhin/World Bank
ex: look at blood to detect Hb and iron levels

30. Clinical methods
• Use medical history and
physical examination to
detect and interpret the
signs and symptoms of
malnutrition
Angola, 2009. Photo: mp3ief
Sign
Observations made by qualiÞed
examiner; patient usually
unaware of them
objective
Symptom
Reported by patient, more
subjective

31. Hair
• Depigmentation of hair suggests protein deficiency
• _________ = traverse depigmentation of hair (reflects
period of undernutrition and then improvement)
Flag sign
hair that would be dark turns more orange/reddish because pigments are protein based
Ñ shows lack of protein
band depigmentation
shows inadequate
nutrition for a
period of time
overall dull hair/loss of colouration are signs of protein deÞciency, but not a clear indicator

32. A child with severe acute malnutrition in
Mazrak IDP camp in north-west Yemen,
close to border with Saudi Arabia,
September 2009. Photo: Hugh Macleod/IRIN
2 video clips:
Ñ Newest to life are the closest to death
Ñ a child dies every 6-10 min in Yemen

33. Mouth
• Swollen, retracted, bleeding gums
• Possible deficiency: __________________
Photo: Centers for Disease Control and Prevention
vitamin C

34. Eyes
• Xeropthalmia: night blindness, photophobia,
Bitots spots, corneal ulceration or scarring
• Possible deficiency: vitamin _____
Photo: Community Eye Health Journal Vol. 23 No. 72, March 2010
Distinct white-grey __________ plaques lateral to cornea
A
foamy
only on side white part of
the eye
lateral = beside

35. Bitot’s spot: Distinct white-grey foamy plaques
lateral to cornea

36. Skin
• Pallor (___________) of skin and conjunctiva
• Consider iron deficiency anemia
paleness
blood vessels are close to surface, so should be pink not this pale
can also look at inner part of lip where it joins to gum area, if that part is pale/white = iron deÞciency
mucous membrane lines inside of eyelids

37. Nails
• Traverse ridging: consider protein deficiency
across
similar to ßag sign, period of protein insufÞciency

38. Nails
• Koilonychia (spoon-shaped nails): consider iron
deficiency anemia
Photo: NHS Choices

39. Nails
• Koilonychia (spoon-shaped nails): consider iron
deficiency anemia

40. Edema
= swelling due to __________________________
Bilateral pitting edema is a sign of severe acute
malnutrition (SAM)
• How to check for bilateral pitting edema:
Photos: Somalia 2011
Geno Teofilo/Oxfam
excess ßuid accumulation
press down and see if the skin bounces back
independent of anything else
1. press gently with thumbs and hold for 3 sec
2. remove thumbs. If indent remains = pitting edema
Ñ bilateral = both sides, if pit is only on ONE side it is
NOT bilateral pitting

41. Somalia 2011
Photo: Geno Teofilo/Oxfam
How to check for bilateral pitting edema

42. Somalia 2011
Photo: Geno Teofilo/Oxfam

43. bilateral pitting

44. August 25, 2016: 11-month-old Bedru had severe acute malnutrition (SAM). This follow-
up MUAC measurement indicates his nutritional status has improved, and he is now
classified as having moderate acute malnutrition (MAM). Photo: UNICEF Ethiopia/2016/Ayene
Example:
Using MUAC and
checking for
bilateral edema to
screen for acute
malnutrition in
Ethiopia

45. Using MUAC and checking for bilateral edema to screen
for acute malnutrition in Ethiopia
Video:
Clicker Q
Which of the ßoowing is (are) the most appropriate
measurement(s) to detect severe acute malnutrition in a Ôhealth
postÕ context?
A. MUAC
B. Bilateral pitting edema
C. Weight
D. A B Ñ
E. All of the above
A B are quick and good detectors

46. 1. Physical signs are often __________ (especially if
deficiency is mild or moderate)
• Same sign could be caused by different deficiencies
• Signs may be caused by non-nutritional factors
2. Examiner inconsistencies
3. Inter-individual _________________
Limitations of physical exam
not speciÞc
example: one person may pull the band more than the other = different interpretations
variability
individual variability can change some results
*Can be hard to interpret, not using a single sign as a single indicator.

47. Dietary methods
• Measurements of foods and beverages
consumed in one day, several days, or longer
(months – years) It can be extremely difÞcult to accurately assess diet

48. 1) 24-hr recalls
1. Participant asked for quick list of
foods/beverages consumed in
the past _______________
2. Starting with the first item on the
list, the interviewer probes for
details (type, amounts, additions
or condiments, preparation
method)
3. Review details and amounts and
correct any inaccuracies
24 hours
*Multiple pass method*

49. Strengths and Limitations of 24-hr Recall
Strengths
1. Quick
2. Inexpensive
3. Easy for person to
complete
4. Can be used in variety
of settings
5. Does not _______ diet
Limitations
1. Under/over-reporting of
certain foods
2. Relies on ___________
3. Labour-intensive data
entry
4. One recall does not
represent individuals
typical intake
memory
alter
depends on diet diversity of individual
Ñ some people eat the same thing everyday
Ñ others have a wider variety of what they eat
* depends on dietary diversity*

50. An example of using 24-hour recalls to assess dietary intake:
Estimating cassava intakes and prevalence of
vitamin A deficiency in Akwa Ibom, Nigeria
• HarvestPlus (an international initiative
to develop and promote biofortified food
crops) has a provitamin A-biofortified cassava
program in Nigeria
• Biofortification: using
genetics (e.g., selective
breeding) to increase
_____________ in crop
(usually staple crop)
Biofortified (yellow) cassava containing vitamin A
and traditional (white) variety. Photo: Harvest Plus
micronutrients
yellow casava = can eat more vitamin A through
fortiÞcation

51. Women selling fufu in market, June 2015. Photo: IFPRI/Milo Mitchell

52. Using multiple pass 24-hour recalls to assess dietary
intake of women and children in Akwa Ibom, Nigeria
• Typical dietary intake estimated in mother-child pairs
from 587 households (mothers: 18-49 y, children: 6-59 mths)
• “Mother trainers” visited 2 days
before data collection to:
- explain procedure
- distribute plates/cups (to
encourage “individual eating” so
that individual portions could be
estimated)
- emphasize the importance of not
changing eating habits
• 5 mL blood samples provided by
women and children
Mother and child, Nigeria (2011).
Photo: Lindsay Mgbor/DFID De Moura et al. 2015
if donÕt see much undernutrition in children under 5, then generally the whole population has good nutrition status
can reßect typical intake
would vitamin A be a
Dietary method
Biochemical Method

53. What did they find?
• 57% of daily kcal came from _________________
• 30% of women and 8% of children had low _________
intakes
• Cassava is widely consumed: 95% of women, 92% of
children 24–59 aged months, and 66% of children aged
6–23 months had cassava on the day of the 24-hr
recall
• Red palm oil consumed by vast majority, made a
substantial contribution to vitamin A intake
• Overall dietary intakes of vitamin A were ___________
De Moura et al. Cassava intake and vitamin A status among women and preschool children in Akwa-Ibom, Nigeria. PLoS ONE.
2015:10(6);e0129436
PRO
CHO
adequate
45-65% according to AMDR, so this amount is alright
children need smaller amounts of calories than adults, so are not as great of a risk as the women
younger children (6-23 months) consume less due to breastfeeding
only 1 of 2 sources of saturated fats (coconut oil is another)
do not need the enriched casavaÕs in this region
Ñ note: biochemical indicator very important as well as dietary assessment
Ñ 24 hour recalls are difÞcult to get an accurate assessment

54. 2) Food Records
• Person records type and amount of food/beverage
consumed for a period of time
• Typically lasts ________________
• Foods and beverages are written down right after they
are eaten
1-7 days
addresses memory bias, but writing down what you
eat may affect results
3 day food records are
most popular (2
weekdays, 1 weekend)

55. Strengths and Limitations of Food Records
Strengths
1. Do not rely on memory
2. Can provide great detail
3. Can give insight into
eating habits/patterns
4. Multiple days more
_______________ of
individual’s usual intake
Limitations
1. Takes time and effort to
complete accurate record
2. Requires literacy
3. Recording diet ______diet
4. Labour-intensive data entry
and analysis
5. May not represent usual
intake
alters
representative
such as brands of beverages and cereal
food record is too much for village, is a good Þt for elite athletes
may worry what people thing, too lazy to write down etc.

56. 3) Food Frequency Questionnaires (FFQs)
• Can determine how often
person consumes a limited
number of foods
• Usually 150 or fewer items
survey administrered individually, but can be donw as an interview
portion sizes are not always indicated
indicate how often they consume the food, goes up to one year =
greater scope of # of days being assessed

57. Strengths and Limitations of FFQ
Strengths
1. Can be self-administered
2. Machine-readable
3. Inexpensive
4. May be more
representative of ______
intake
Limitations:
1. May not include foods
usually consumed by
participants
2. May not include information
on portion size
3. Requires ___________
4. If self-administered, cannot
ask clarifying questions
literacy
usual

58. Other tools in dietary
assessment
• 24-hour
recall/dietary
diversity
instrument
• Local foods
• Grouped
according to key
____________
– e.g. Vitamin A
FOOD OR BEVERAGE CHILD MOTHER
1. Milk – fresh, tinned or powdered Y N Y N
2. Tea or coffee Y N Y N
3. Coke, Sprite, Fanta or other soft drink Y N Y N
4. Juice Y N Y N
5. Beer or other alcoholic beverages Y N Y N
6. Any other liquids (e.g. broth or soup) Y N Y N
7. Maize, sorghum, millet, rice, noodles, bread Y N Y N
8. Pumpkin, yellow sweet potatoes (yams), squash or
carrots
Y N Y N
9. White potatoes, cassava or white sweet potatoes (yams) Y N Y N
10. Any dark green leaves (e.g. isombe or dodo) Y N Y N
11. Ripe (orange) mangoes or papayas Y N Y N
12. Any other fruits or vegetables (e.g. tomatoes, onions,
bananas, cabbages, pineapples, lychee)
Y N Y N
13. Liver, kidney, heart, blood, intestine or other organs Y N Y N
14. Meat such as pork (pig), cow, chicken, goat, duck (other
fowl) or other animal flesh
Y N Y N
17. Eggs Y N Y N
18. Fresh or dried fish or shellfish Y N Y N
19. Beans or foods made from beans, lentils, other pulses or
nuts (e.g. cashews or peanuts)
Y N Y N
20. Any oil, fats, butter (including foods made with any of
these)
Y N Y N
21. Red palm oil, palm nut oil Y N Y N
21. Sugar or sugary foods such as sweets, candies, cakes, or
biscuits
Y N Y N
22. Any condiments (e.g. ketchup) Y N Y N
23. Any other solid or semi-solid food Y N Y N
List other if yes to #23
nutrients
hybrid of recall and FFQ
want to include foods that reßect
vitamin A status

59. Which method is best for
measuring dietary intake?
resources
respondents
goal
setting

60. Next Class:
Malnutrition in Nepal
Sociocultural Aspects of Food
Reminders:
1. Quizzes for Readings 1 2 available until Sun May 28 at 11:59 PM
2. If you want to change the proposed grade distribution, deadline for doing so is
the end of the day today (Wednesday May 24 at 11:59 PM); see syllabus for details
“We call upon all governments to ensure free, compulsory education
all over the world for every child. We call upon all the governments to
fight against terrorism and violence. To protect children from brutality
and harm. We call upon the developed nations to support the
expansion of education opportunities for girls in the developing world.
We call upon all communities to be tolerant, to reject prejudice based
on caste, creed, sect, color, religion or agenda to ensure freedom
and equality for women so they can flourish. We cannot all succeed
when half of us are held back.”
-Malala Yousafzai, Pakistani activist for human rights and education and
youngest ever Nobel Prize laureate, in her speech to the United Nations, July 2013
(full text: www.ibtimes.com/malala-yousafzais-speech-un-full-text-1344117)