NUTRITIONAL ASSESSMENT ARE WE APPORACHES

1. NUTIRITIONAL ASSESSMENT
PRESENTING BY
LOKESH GANDHI
M.Sc NURSING PREVIOUS
BATCH 2017-2018

2. INTRODUCTION:-
The nutritional status of an individual is often the result of many interrelated factors. It is influenced
by the adequacy of food intake both in term of quantity and quality and also by the physical health of
the individual. The nutritional status of a community is the sum of the nutritional status of the
individuals who form that community. The main objective of a “comprehensive” nutritional survey is
to obtain precise information on the prevalence and geographic distribution of nutritional problem of
a given community, and identification of individuals or population groups “at risk” or in greatest need
of assistance. In the absence of this information, problem cannot be defined and policies formulated.
The purpose of nutritional assessment is to develop a health care programme that meets the need
defined by that assessment,including evaluation of effectiveness of such programmes.
A nutrition assessment is an in-depth evaluation of both objective and subjective data related to an
individual's food and nutrient intake, lifestyle, and medical history. Once the data on an individual is
collected and organized the practitioner can assess and evaluate the nutritional status of that person.

3. DEFINITION:-
• 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).
• Nutritional assessment is the interpretation of anthropometric, biochemical
(laboratory), clinical and dietary data to determine whether a person or groups of
people are well nourished or malnourished (over-nourished or under nourished).

4. CONTI…..
• The nutritional status of an individual is influenced by the adequacy of food intake
both in terms of quantity and quality and also by the physical health of the
individual. The purpose of nutritional assessment is to detect nutritional problems
and to develop the plan to meet the nutritional needs.
• Assessment of nutritional status provides information about obesity,
weight loss , undernutrition, malnutrition, deficiencies, in specific nutrients,
metabolic abnormalities, the effects of medications on nutrients, metabolic
abnormalities, the effects of medications on nutrition, and special problem
affecting patients both in hospitals and in the home and other community
settings.
Chen,2005.

5. NUTRITIONAL ASSESSMENT METHOD:-
The assessment of the nutritional status involves various techniques with different
approachs. Proper evaluation demands a many–angled approach, covering all the
different stages in the natural history of nutritional diseases, including
prepathogenesis. Stage as shown in
The assessment methods include the following:-
1. Clinical Examination 2. Anthropometric method
3. Biochemical Evaluation 4. Functional assessment
5. Assessment of dietary intake 6. Vital and health statistics
7. Ecological studies.

6. 1. CLINICAL EXAMINATION:-
• It is the simplest and the most practical method for assessment of nutritional status of individuals. It is an
essential aspect of nutritional assessment to detect the level of health status of the individual in relation to
the food consumption.
• Head to toe examination should be performed to detect the signs of nutritional deficiency states such as
hair changes, anemia, edema, xerosis, cheilosis, angular stomatitis, rachitic rosary, bleeding gums, dental
caries, toad skin, enlarged thyroid gland, etc.
Nutrition assessment schedule:-
Serial No : Date :
Name : Age :
Address : Sex :
District : Village :
History – (Dietary and illness)

7. CLINICAL EXAMINAION:-
A significant amount of information regarding nutritional
deficiencies comes from a clinical examination.
CLINICAL SIGN & SYMPTOM Nutrient
General Wasted, skinny appearance
Loss of appetite.
Calorie
Protein-energy, Zine
Skin Psoriasiform rash, eczematous scaling
Pallor
Follicular hyperkeratosis
Perifollicular petechiae
Flaking dermatitis
Bruising
Pigmentation changes
Scrotal dermatosis
Thickening and dryness of skin
Zine, vit.A, essential fatty acids.
Folate, Iron, Vit.B12, Copper.
Vit.A, & Vit.C
Vitamin C
Protein-Energy,niacin,riboflavin, zine.
Vitamin C & Vitamin K.
Niacin, protein-Energy.
Riboflavin.
Linoleic acid.
Head Temporal muscle wasting Protein-energy
Hair Sparse and thin, dyspigmented
Easy to pull out
Corkscrew hairs
Protein
Protein
Vitamin C

8. Eyes History of night blindness(also impaired visual
recovery after glare)
Photophobia,blurring,conjunctival inflammation
Corneal Vascularization
Xerosis,Bitot’s sports, Keratomalacia
Vitamin A, Zinc
Riboflavin,
vitamin A
Riboflavin
Vitamin A
Mouth Glossitis
Bleeding gums
Cheilosis
Angular stomatitis
Hypogeusia
Tongue fissuring
Tongue Atrophy
Nasolabial seborrhea
Riboflavin, niacin,folic acid, Vit.B12, pyridoxine.
Vit.C, Riboflavin.
Riboflavin, Pyridoxine, niacin.
Riboflavin, Pyridoxine, niacin.
Zine.
Niacin
Riboflavin, Niacin,Iron
Pyridoxine.
Neck Goiter
Parotid enlargement
Iodine
Protein
Throax Thoracic rosary Vitamin D

9. Abdomen Diarrhea
Distention
Hepatomegaly
Niacin, Folate, Vit.B12.
Protein-energy
Protein-energy
Extremities Edema
Softening of bone
Bone tenderness
Bone ache, joint pain
Muscle wasting and weak ness
Muscle tenderness, muscle pain
Protein, thiamine
Vita.D, Calcium, Phosphorus.
Vitamin D.
Vitamin C
Protein, calorie, Vitamin D, selenium,
Sodium chloride.
Thiamine.
Nails Spooning
Transverse lines
Iron
Protein

10. Neurologic Tetany
Paresthesias
Loss of reflexes, wristdrop, footdrop
Loss of vibratory and position sense
Ataxia
Dementia, disorientation
Calcium, magnesium.
Thiamine, VitaminB12.
Thamine.
Vitamine B12.
VitaminB12.
Niacin
Blood Anemia
Hemolysis
Vitamin B12. Folate, Iron, Pyridoxine.
Phosphorus, Vitamin E.

11. 2. Anthropometric Methods:-
Anthropometry is the measurement of body height, weight & proportions. It is an
essential component of clinical examination of infants, children & pregnant women.
There measurements are compared to the reference data (standards) of the same age
and sex group,in order to evaluate the nutritional status.
 Although they indicate the nutritional status in general, Still they are not used to identify
specific nutritional deficiencies.
 They are used to evaluate both under & over nutrition.
 The measured values reflect the current nutritional status & don’t differentiate between
acute & chronic changes.

12. Other anthropometric measurements:-
(1) Height Measurement.
(2) Weight Measurement.
(3) Body mass index (BMI).
(4) Waist Circumference.
(5) Hip Circumference.
(6) Mid – arm circumference(MAC).
(7) Skin fold thickness.
(8) Head circumference.

13. 1. Height Measurement
 The subject stands erect &
bare footed on a
 stadimeter with a movable
head piece.
The head piece is leveled with skull
vault & the height is recorded to the
nearest 0.5 cm.

14. 2. 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 100gm(0.1kg).

15. 3. BODY MASS INDEX (BMI):-
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 & mortality.
 Example:-
Weight = 68 kg, height = 165cm (1.65m)
BMI = 68 / (1.65)2 =24.98 kg/m2

16. Interpretation of BMI for adults:-
For adults 20 years old and older, BMI
is interpreted using standard weight
status categories that are the same for
all ages, and for both men and women.
BMI Weight Status
Below 18.5 Under weight
18.5 - 24.9 Normal
25.0 – 29.9 Overweight
30.0 and above Obese

17. 4. Waist Circumference:-
 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 predicts mortality better
than any other anthropometric measurement.

18. MALES FEMALES
LEVEL I >94 cm >80cm
LEVEL II >102cm >88cm
Level 1 :- Is the maximum acceptable
waist circumference irrespective of
the adult age, and there should be no
further weight gain.
level II :- Denotes obesity and requires
weight management to reduce the risk
of type 2 diabetes & CVS
complications.

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

20. 6. Mid-arm circumference (MAC) :-
Locate the mid point of the arm.
 Non-dominant arm elbow flexed at 90deg with palm facing upwards.
 Measurer stands behind the subject & locates the lateral tip of the acromion
and the most distal point of the olecranon process.
 Place a tape measure so that it passes between these 2 landmarks and mark
the midpoint.
Measure the midarm circumference.
 The subject stands erect with arms hanging freely at the sides and the palms
facing the thighs.
 Place the tape measure perpendicular to the long axis of the arm at the
marked midpoint & measure the circumference to the nearest mm.
 Provide the actual MAC in cm.

21. 7. Skin-fold measurements:-
 Approximately half of the total amount of fat tissue in the human bodyis located below the surface
of the skin.
 This makes it possible to predict total body fat from skin-fold thicknesses with a relative high
degree of accuracy using a simple two-compartmental method.
 This accuracy is confirmed by CT scan as well as ultrasonic and radiographic techniques used to
measure subcut.fat.
1. Triceps skin-fold (TSF).
2. Biceps skin-fold (BSF).
3. Subscapular skin-fold (SSF).
4. Supra-iliac skin-fold (SISF).

22. In general,when measuring skin-fold thickness,
 The assessor, using the forefinger and the thumb, grasps and lifts the subcut.tissue and skin from
the underlying muscle.
 Places the pincers of the skin-fols caliper, applying a constant pressure,2cm below the fingers at a
depth of 1cm.
 Holds this position for 3-4 seconds.
 Takes three measurements for accuracy.
 Provides the actual skin-fold thickness in mm.

23. 8. Head circumference:-
 This measurement may change slightly during the first 3 days owing to moulding during labour. It
is taken with a tape measure at the maximum circumference of the head in the occipito-frontal
diameter.
The purpose of taking these measurements are:
(i) To assess the baby’s size against known standards for the population.
(ii) To compare the size with estimated period of gestation.
(iii)To provide a baseline against which subsequent progress can be measured.

24. 3. Biochemical evaluation :-
(A). Laboratory tests:-
(i) Haemoglobin estimation :-
It is the most important laboratory test that is carried out in nutrition surveys. Haemoglobin level is a useful index
of the overall state of nutrition irrespective of its significance in anaemia. An RBC count and a haematocrit
determination are also valuable.
(ii) Stools and urine :-
Stool should be examined for intestinal parasites. History of parasitic infestation, chronic dysentery
and diarrhoea provides useful background information about the nutritional status of persons. Urine
should also be examined for albumin and sugar.

25. B. Biochemical test :-
With increasing knowledge of the metabolic functions of vitamins and minerals,
assessment of nutritional status by clinical signs has given way to more precise
biochemical test which may be applied to measure individual nutrient
concentration in body fluids (e.g., serum retinol, serum iron) or detection of
abnormal amounts of metabolites in urine(e.g., urinary iodine) frequently after a
loading dose, or measurement of enzymes in which the vitamin is a known co-
factor (for example in riboflavin deficiency) to help establish malnutrition in its
preclinical stages.

26. Some biochemical tests used in nutritional surveys:-
Nutrient Method Normal value
Vitamin A Serum retinol 20mcg/dl
Thiamine Thiamine pyrophosphate(TPP)3
stimulation of RBC transketolase
activity
1.00-1.23(ratio)
Riboflavin RBC glutathione
Reductase activity
stimulated by flavine
adenine dinucleotide
1.0-1.2(ratio)

27. Niacin Urine N-methyl
nicotinamide
(Not very reliable)
Folate Serum folate
Red cell folate
6.0mcg/ml
160mcg/L
Vitamin B12 Serum vit.B12
concentration
160mg/L
Vitamin C Leucocyte ascorbic acid 15mcg/108cells
Vitamin K Prothrombin time 11-16 seconds
Protein Serum albumin(g/L)
Transferrin(g/L)
Thyroid-binding pre-albumin(mg/L)
35
20
250

28. 4. Functional indicators :-
Static indices of nutritional status (biochemical indicators) will continue
to play an important role as they are well-established and familiar to
practitioners and public health workers. Functional indices of nutritional
status are emerging as an important class of diagnostic tools.

29. Functional indices of nutritional status
1. Structural Integrity
Erythrocyte fragility Vitamin E, Se
Capillary fragility Vitamin C
Tensile strength CU
2. Host defence
Leucocyte chemotaxis P/E, Zn
Leucocyte Phagocytic capacity P/E, Fe
Leucocyte bactericidal capacity P/E, Fe, Se
T cell blastogenesis P/E, Zn
Delayed cutaneous hypersensitivity P/E, Zn
3. Haemostasis
Prothrombin time Vitamin K
4. Reproduction
Sperm count Energy, Zn
5. Nerve function
Nerve conduction P/E, Vit B1, B12
Dark adaptation Vitamin A, Zn,
EEG P/E
6. Work capacity
Heart rate P/E, Fe
Vasopressor response Vit.C

30. 5. Assessment of dietary intake :-
The value of nutritional assessment is greatly enhanced when it is supplemented by an assessment of food consumption.
Direct assessment of food consumption involves dietary surveys which may be household inquiries or individual food
consumption surveys. Well organized survey methods for this purpose are available.
A diet survey may be carried out by one of the following methods:-
(i) WEIGHMENT OF RAW FOODS :-
This is the method widely employed in india as it is practicable and if properly carried is considered fairly accurate. The
survey team visits the households, and weight all food that is going to be cooked and eaten as well that which is wasted or
discarded. The duration of the survey may vary from 1 to 21 days, but commonly 7days which is called “one dietary
cycle”.
(ii) WEIGHTMENT OF COOKED FOODS :-
Foods should preferably be analyzed in the state in which they are normally consumed, but this method is not easily
acceptable among people.
(iii) ORAL QUESTIONNAIRE METHOD :-
This is useful in carrying out a diet survey of a large number of people in a short time. Inquiries are made retrospectively
about the nature and quantity of foods eaten during the previous 24 or 48 hours. If properly carried out, oral questionnaire
method can given reliable results. A diet survey may also include collected of data relating to dietary habits and practices.

31. (6.) Vital statistics:-
 An analysis of vital statistics – mortality and morbidity data – will identify groups at high risk
and indicate the extent of risk to the community. Mortality in the age group 1 to 4 years is
particularly related to malnutrition. In developing countries, it may be as much as 20 times
that in countries such as Australia, Denmark or france. The other rate commonly used for this
purpose are : infant mortality rate, second-year mortality rate, rate of low birth-weight babies
and life expectancy. These rates are influenced by nutritional status and may thus be indices of
nutritional status. Mortality data, however, do not provide a satisfactory picture of the
nutritional status of a population.
 Data on morbidity (e.g., hospital data or data from community health and morbidity surveys)
particularly in relation to protein energy malnutrition, anaemia, xerophthalmia and other
vitamin deficiencies, endemic goitre, diarrhoea, measles and parasitic infestations can be of
value in providing additional information contributing to the nutritional status of the
community.

32. 7. Assessment of ecological factors :-
 Malnutrition is the end result of many interacting ecological factors. In any nutrition survey it is necessary to collect
ecological information of the given community.
 A study of the ecological factors comprise the Following:
(A). Food balanced sheet:-
 This is an indirect method of assessing food consumption, in which supplies are related to census population to derive
level of food consumption in terms of per capita supply availability. The estimate refers to the country as a whole, and so
conceals differences which may exist between regions, and among economic, age and sex groups.
 The great advantage of this method is that it is cheaper and probably simpler than any method of direct assessment. Used
intelligently, this method does give an indication of the general pattern of food consumption in the country
(B). Socio economic factor :-
 Food consumption patterns are likely to vary among various socio-economic groups. Family size, occupation, income,
education, customs, cultural patterns in relation to feeding practices of child and mothers, all influence food consumption
patterns.

33. (C). Health and educational services following :-
 Primary health care services,feeding and immunization programmes should also be taken into
consideration.
(D). Conditioning influences :-
 These include parasitic, bacterial and viral infections which precipitate malnutrition. It is necessary to make
an “ecological diagnosis” of the various factors influencing nutrition in the community before it is possible
to put into effect measures for the prevention and control of malnutrition.

34. THANK YOU