2. Objectives
At the end of this lesson you will be able to:
• identify the most commonly used indicators of nutritional
status and of causes of malnutrition; and
• apply criteria for selecting nutrition indicators in specific
contexts.
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The principal aim of the assessment of the
nutritional status of a community is :
i) to map out the magnitude and geographical
distribution of malnutrition as a public health
problem;
ii) to discover and analyse the ecological factors
that are responsible; and
iii) to plan out and put into effective measures
which are not only for the control and eradication
of malnutrition but also subsequence of good
nutrition.
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8. Cont …
• Nutrition assessment is important in clinical
medicine because acute and chronic malnutrition are
common clinical findings.
• “A systematic process of obtaining, verifying, and
interpreting data in order to make decisions about the
nature and cause of nutrition-related problems.”
– Lacey and Pritchett, JADA 2003;103:1061-1072.
• Malnutrition is defined as the sub-optimal supply of
a nutrient that interferes with an individual’s growth,
development or maintenance of health.
• Over-nutrition is excessive intake of nutrients,
mostly macronutrients and calories which increase risk
of many chronic diseases.
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10. Nutritional Assessment -Why?
The purpose of nutritional
assessment is to:
Identify individuals or population
groups at risk of becoming
malnourished
Identify individuals or population
groups who are malnourished
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11. Nutritional Assessment –Why?
To develop nutrition and 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
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12. Nutritional
Need
Assessment
of the
Community
• Define needs, opportunities and
constraints, and prioritize solutions
Evaluate of
nutrition
programmes
• Evaluate programme impact and
improve efficiency.
Policy change
and
sustainability
• Influence decision making in strategic planning,
policy formulation and resource allocation.
• Raise community awareness and participation
to maximize long-term impact.
Nutritional Assessment
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13. Nutritional status assessment
Triple A Cycle (Source –UNICEF)
Analysis
Action
Assessment
Nutritional status
assessments measure
Anthropometric
Biochemical or
physiological
characteristics.
These assessments
combined with the
analysis of underlying
causes will result in
appropriate action.
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14. In the Triple-A Cycle model:
Indicators to assess and
analyse nutrition
The ANALYSIS stage aims to
analyse the causes of
malnutrition as represented in
the FIVIMS conceptual
framework.
The ASSESSMENT stage aims
to define the nutritional
problem in terms of
magnitude and distribution.
ASSESSMENT
of the nutritional
situation in target
population
ACTION
based on the
analysis &
available
resources
ANALYSIS
of the causes
of the
problem
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15. Food security conceptual framework in some detail.
The diagram below illustrates the FAO-FIVIMS framework (FIVIMS = Food
Insecurity and Vulnerability Information and Mapping Systems)
:
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19. Methods of Nutritional Assessment
Nutrition is assessed by two types of
methods; direct and indirect.
A. Direct methods deal with the individual
and measure objective criteria
B. Indirect methods use community
health indices that reflects nutritional
influences
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20. Nutritional Evaluation of individuals
why?
• Identify nutrition factors affecting person’s current or
future health
• May want to measure success of an intervention
• Identify people at risk for malnutrition
Sources of data used in performing Nutritional
Assessment: , B, C, D, E”
• Anthropometry
• Biochemical tests
• Clinical observation (I.e. physical examination)
• Dietary intake data
• Economic status and Educational status
NOTE:
Historical information other than dietary intake data is also
necessary to identify potential problems: -health history
-medical history
-Interference with intake and utilization
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21. DIRECT METHODS
The direct involve the direct measurement of
body dimensions and proportions,
determination of tissue or body fluid
concentrations of nutrients, dietary intake,
appearance of the clinical symptoms and
signs related to a specific nutrient
dependent functional impairment
abbreviated as the ABCDs
A=Anthropometry
B= biochemical/Biophysical,
C= Clinical,
D= Dietary
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22. Methods of Nutritional Assessment
Different anthropometrical
indices
Weight
Height
Mid upper arm
circumferences
Skin fold thickness
Demi-span or armspan
Knee height
Sitting height
Skin fold thickness
Head circumference
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23. The indirect methods #1
Indirect methods include assessment of
indicators of the food and nutrition situations
in the area/ region of interest by looking at
certain data that are closely related to
malnutrition or which are aggravated by
malnutrition.These include:
Cause specific mortality rates
Age specific mortality rates
Health service statistics
Rate of nutritionally relevant
infections
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24. The indirect methods #2
Meteorological data (rainfall data )
Production pattern and distribution pattern
Income levels
Market price of foods
Predominance of cash crops
Or Indirect Methods of Nutritional Assessment
i. Ecological variables including crop production
ii. Economic factors e.g. per capita income,
population density & social habits
iii. Vital health statistics particularly infant & under 5
mortality & fertility index
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25. A.ANTHROPOMETRIC ASSESSMENTS
#1
Anthropometry comes from two
Greek words: Anthropo = Human,
and Metry/metron = measurement.
Definition: - Anthropometry refers to
measurement of variations of physical
dimension and gross composition of
human body at different levels and
degrees of nutrition (Jelliff, 1966).
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34. 1- Anthropometry
Greek ‘anthropos’ = human, ‘metro’ = measurement
Measurement of physical characteristics e.g. height, weight,
body composition (fat!). Compare with standards for age, sex
…
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35. ANTHROPOMETRIC ASSESSMENTS #2
Anthropometric measurements could be
used both in the clinical and field set-ups.
In the clinical set-ups they are used to assess
the nutritional status of:
post-operative patient,
post traumatic patient (after acute
trauma or surgery),
chronically sick medical patient,
patient preparing for operation,
Severely malnourished patient to assess
the impact of nutritional intervention.
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36. Purposes of Anthropometric
measurements
Anthropometric measurements are
performed with two major purposes in
mind:
IN CHILDREN: to assess physical
growth
IN ADULTS: to assess changes in
body composition or weight
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37. 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 .
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39. A. 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
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40. ASSESSMENT OF NUTRITIONAL STATUS OF
CHILDREN
1. History
Dietary history of mother & child
History of height & weight changes
2. Anthropometric indicators
Evidence of deviations from average height &
weight
Evidence of depletion of fat depots
Evidence of decrease in muscle mass
3. Change in psychic reaction
4. Reaction to infection
5. Evidence of specific deficiencies
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41. HEAD CIRCUMFERENCE
(HC):
Measured using flexible measuring tape
around 0.6cm wide to the nearest 1mm.
It is the circumference of the head along the
supra orbital ridge anteriorly and occipital
prominence posteriorly.
HC is useful in assessing chronic
nutritional problems in under two
children.
But after 2 years as the growth of the brain
is sluggish it is not useful.
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42. • One of the first things to assess when evaluating the head of the
newborn is the Occipital Frontal Circumference (OFC). This simple
measurement may be the first clue to an underlying problem. The 50th
percentile for OFC of a term newborn is 34 cm, so if an infant has a
normal weight and length for a term infant (near 50th %ile for age), a
measurement of <31 cm is disproportionately small (<< 10th %ile for
age). Further evaluation is indicated; head imaging, screening for
TORCH infection, and assessment for chromosomal abnormalities
should all be considered.
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43. LENGTH
A wooden measuring board (also called
sliding board) is used for measuring
length.
It is measured in recumbent position in
children <2 yrs old to the nearest 1mm.
It is always > height by 1-2cm.
One assistant is needed in taking the
measurement
Measurement is read to the nearest mm
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47. HEIGHT
Is measured in children > 2 yrs and a adults in
standing position to the nearest 0.1 cm.
The head should be in the Frankfurt plane during
measurement, knees should be straight and the
heels buttocks and the shoulders blades, should
touch the vertical surface of the stadiometer (
anthropometer) or wall.
Stadiometer or portable anthropometer can be
used for measuring.
There is also a plastic instrument called acustat
Stadiometer that is cheaper than the conventional
Stadiometer.
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50. WEIGHT
Weighing sling (spring balance) also
called salter scale is used for measurement
of weight in children < 2 years.
In children the measurement is performed to
the nearest 10g.
In adults and children >2 years, beam
balance is used and the measurement is
performed to the nearest 0.1 kg.
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55. INDICES DERIVED FROM THESE
MEASUREMENTS
What is an index? It is a combination
of two measurements or a
measurement plus age. The following
are few of them: -
Head circumference-for age
Weight -for-age
Height-for age
Weight for height
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56. MEANINGS OF THE INDICES DERIVED
FROM GROWTH MEASUREMENTS
Weight for Age = Weight of the child x 100
Weight the normal child of
the same age
Weigh for height = Weight of the child x 100
Weight of the normal child of
the same height
Height for age = Height of the child . X 100
Height of the normal child of
the same age
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57. both weigh for age and weight for height
are indices sensitive to acute changes to
nutritional status
Height for age of children in a given
population indicates their nutritional
status in the long run.
The best example is change in the average
height of children in the industrialized countries
towards higher values following improvements
in nutrition, control of infectious problems etc.
This is called Secular change (trend) in Height
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58. Indicator
An indicator is an index + a cut-off point.
E.g.
W F A < 60% = is indicator of severe
malnutrition
MBI < 16 kg/m2 = indicator of severe
chronic energy deficiency
W F H < 70% = is indicator of severe
wasting
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59. EXPRESSING ANTHROPOMETRIC
MEASUREMENTS #1
A. Z- score which is expressed as,
Z = median of the reference population---subject’s value X100
Standard deviation of the reference
-2 Z is a cut-off point for under nutrition
B. Standard deviation score which could be expressed as,
SD =(subject’s value -- the mean of the group) 2
Number of subjects—1
- 2 SD if a cut-off point for under nutrition
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60. EXPRESSING ANTHROPOMETRIC
MEASUREMENTS #2
Percent of the median expressed as,
P = Weight or height Value of the subject X 100
(Median height or weight value of the reference of the same age)
80 % of the median is a cut-off point for under nutrition
D. Centiles, Expressed according to the value of the subject in reference to
e NCHS’s 3rd
,
5tyh, 10th
and 90th
centiles
Usually the 3rd
centiles is taken as a cut off point for labeling
malnourished
subject.
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61. What is a Percentile?
95th
5th
Major Percentile Divisions
85th
50th
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63. Relationship of conventional cut-off points for
diagnosing moderate malnutrition
Type of
standard
Height for
age
Weight for
height
Weight for
age
Z-score -2 -2 -2
Standard
deviation
-2 -2 -2
Centile 3rd
3rd
3rd
Percent of the
median
90% 80% 80%
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68. I. Gomez classification (weight-for-age)
(Gomez et al, 1956) W/A= W/W(N) x 100
Percentage (%) of NCHS
reference
Level of malnutrition
90-109 Normal
75-89 Mild(grade I)
60-74 Moderate(Grade II)
< 60 Severe (grade III)
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69. Disadvantages of Gomez classification
The cut off point 90% may be too high as many
well-nourished children are below this value,
edema is ignored and yet it contributes to weight
and
It does not indicate the duration of malnutrition
age is difficult to know in developing countries
(agrarian society).
It does not also differentiate between
kwashiorkor and marasmus
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70. II.Well-come classification (weight-for-
age)
(Welcome trust working party 1970)
Level of malnutrition
Percentage (%) of NCHS
Reference Edema No edema
60-80% Kwashiorkor Undernourished
< 60% Marasmic- kwashiorkor Marasmus
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National Center for Health Statistics (NCHS)
National Center for Health Statistics (NCHS)/WHO
international growth reference ('the NCHS reference')
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71. Disadvantages
This method does not differentiate :
Acute malnutrition (for emergency
planning
Chronic malnutrition( for food security
planning)
Depends on knowledge of the child’s age
Does not take height differences in to
account
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73. ASSESSMENT BODY COMPOSITION
Linear growth ceases at around the age
of 25-30 years.
Therefore, the main purpose of
nutritional assessment of adults using
Anthropometry is determination of
the changes of body weight and
body composition.
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74. Five levels of body composition
Assessment
1. Atomic level(C, H, N, P, Ca, O)
2. Molecular level(fat, Water, protein)
3. Cellular level(body cell mass,
intra/extra cellular water, intracellular
solids)
4. Tissue level(adipose tissue, muscle,
bone)
5. Whole body level (Weight, height,
skin folds)
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75. Three Models of Body
Composition
Adapted, by permission, from J.H. Wilmore, 1992, Body weight and body composition.
In Fasting, body weight, and performance in athletes: Disorders of modern society,
edited by R. Brownell and J.H. Wilmore (Baltimore, MD: Lippincott, Williams, and
Wilkins), 77-93.
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76. Body Composition
• Body Composition Methods measure the amount and distribution
of fat and lean body mass(protein or muscle and bone).
• These data are used to investigate the relationship between the
levels of these compartments, changes in these levels, and
health status. Loss of fat-free mass is particularly important in
malnutrition, AIDS, and cancer.
• In some of these methods, it is assumed that the body is a two-
compartment model of body fat and fat-free mass (lean
mass).
• The three-compartment model assumes the body is
composed of fat mass, lean mass and bone.
• The four-compartment model divides the body into water,
lean mass, mineral (bone) and fat.
• Methods used to determine these different components include:
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77. 1. Skinfold measurements
• Skinfold measurements: Measurement at three or
four body sites are used to estimate the percent body
fat using standard tables and equations developed for
this purpose using more exacting methods.
• Four sites that are generally suggested for skinfold
measurements include the triceps, biceps,
subscapular, and supra iliac.
• Standardization of measurement protocol is essential,
but this method is inexpensive and provides no risk
to the patient.
• Tester variability is a factor. (Clinical and research
uses.)
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78. 2. Air Displacement Plethysmography
• Air Displacement Plethysmography (ADP or Bod
Pod) determines FFM and percent body fat.
• This is a fast and easy way to measure body volume
(compared to hydrostatic weighing).
• Its advantages are that less technical expertise is
required, it’s more comfortable, and it’s time efficient.
• Air-displacement plethysmography offers
several advantages over established reference
methods, including a quick,
• Comfortable
• Automated
• Noninvasive and safe measurement process, and accommodates
various subject types (e.g., children, obese, elderly, and disabled
persons)
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84. 3.Bioelectrical impedance (BIA)
• Bioelectrical impedance (BIA) is a second method in which
a weak electrical impulse is passed through the body.
• The difference in electrical conductivity of fat-free mass (lean
muscle mass and organs) and fat mass is used to calculate
the % of each in the body.
• One advantage of this method is that four body
compartments can be measured, including body cell mass
(BCM), fat mass (FM), extracellular tissue (ECT), and
fat-free mass (FFM).
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85. Cont …
• The analyzer is inexpensive, portable and convenient
for use in a clinical setting.
• This method may be useful in the elderly who usually
lose lean body mass and in patients with HIV/AIDS.
• Results may be affected by a patient’s hydration status,
so it is important that the patient is well hydrated,
fasted for > 4 hr, and has had no exercise in
previous 12 hours. (Clinical and research uses)
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87. 4. Dual-energy x-ray absorptiometry
(DEXA)
• Dual-energy x-ray absorptiometry (DEXA) is a more recent
method based on the different densities of fat mass, lean mass
and bone.
• It is more exact than BIA and can determine % bone, lean and
fat mass plus its regional distribution.
• It has the advantage of being safe (low radiation dose) and
being relatively fast (20-35 minutes) but is used mainly in
research or to diagnose osteoporosis.
• It is more expensive than the other methods.
• It is limited by the patient’s size (must fit length and width into
the scanning field) (Clinical and research uses)
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90. 5. Total Body Water
• Total Body Water: Water is normally the largest
component of the human body.
• It composes approximately 50%-60% of the weight
of the adult body.
• As much as 80%-90% of the weight of neonates is
water.
• Because all the water in the body is in the fat free
mass, a measure of the total body water (TBW)
should allow calculation of total body fat using some
derived equations. (Used in research)
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93. WHO Online calculator of
body composition
• http://olaf.czd.pl/index.php?option=
com_content&view=article&id=103:c
alculator
• Calculator
• The calculator below calculates:
• >> percentiles: blood pressure, height, weight, body mass
index (BMI) in the age range of 6.5-18.5 years (based on
the OLAF project)
• >> categories of body mass index (BMI) for ages 2 to 18 (
according to the International Obestity Task Force )
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94. Cont …
• In the examined groups, the occurrence of nonfatal body
mass was determined on the basis of the BMI for age
percentile, determined using a calculator developed as
part of the OLAF project
([1], http://olaf.czd.pl/index.php?option=com_content&vie
w=article&id=103:calculator). The WHO classification
was applied, taking into account the age and sex of the
respondent, distinguishing(i)underweight: BMI <5
percentile,(ii)normative body weight: 5 percentile <BMI
<85 percentile,(iii)overweight: BMI> 85 percentile.
• 1.Z. Kułaga, A. Różdżyńska, and I. Palczewska, “OLAF Percentile charts for growth and nutritional
status assessment in Polish children and adolescents from birth to 18 year of age,” Standardy
Medyczne, vol. 7, pp. 690–700, 2010.
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95. • In the children that were examined, segmental body composition
was determined by means of using the Tanita (Japan) eight-
electrode body composition analyzer BC-418MA. The total and
segmental values of adipose tissue in percent (FatP, [%]), fat
mass (FatM, [kg]), and fat-free (FFM, [kg]) were estimated
including right lower limbs (leg) (RL), left limbs (leg) (LL), upper
right limbs (arm) (RA), left limbs (arm) (LA), and trunk (TR). With
the use of fat and nonfat component, the FFF (fat–fat-free) index
was calculated using the formula
• N is the index order according to the body segment,
• FatM (N) is the segmental fat mass [kg],
• FFM (N) is the segmental fat-free mass [kg], FFF is the fat–fat-free index:
FFF1 fat–fat-free index for the right leg, FFF2 fat–fat-free index for the left
leg, FFF3 fat–fat-free index for the right arm, FFF4 fat–fat-free index for the
left arm, and FFF5 fat–fat-free index for the trunk [7, 8] (Rutkowski et al.,
2017).
• 7.A. Chwałczyńska, Fat-Fat Free age-related index as a new tool for body mass assessment Studia i
Monografie Akademii Wychowania Fizycznego we Wrocławiu, Wrocław, 2017.
• 8. A.Chwalczynska, G. Jedrzejewski, and K. A. Sobiech, “The Influence of a Therapeutic Programme on the
Segmentary Body Composition in over - and Underweight Children at the Early-School Age: Pilot Studies,”
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96. 6. Total Body Potassium
• Total Body Potassium: More than 90% of all the body’s
potassium is located within fat free tissues (as an intracellular
cation) and 0.012% of all potassium is the naturally occurring
potassium-40 isotope, which emits a very small yet detectable
amount of high energy gamma radiation.
• Using a very sensitive detector, the level of gamma radiation
emitted from subject can be determined.
• The process takes approximately 30 minutes and requires
expensive equipment.
• Computers aid in providing rapid data processing. (Used in
research)
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97. ASSESSMENT BODY COMPOSITION
Using Anthropometry
Whole body level assessment is used
In assessing body composition we consider
the body to made up of two compartments:
The fat mass and the fat free mass. Total
body mass= Fat mass + fat free Mass.
Therefore different measurements are used
to assess these two compartments:
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98. Measurements used for assessing fat free
mass:
Mid upper arm circumference***
Mid upper arm Muscle area
Mid thigh circumference
Mid thigh muscle area
Mid calf circumference
Mid calf muscle area
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99. Mid upper arm circumference
(MUAC)
Is used for screening purposes especially in
emergency situations where there shortage of
human resource, time and other resources as it is less
sensitive as compared to the other indices.
It is measured half way between the olecranon
process and acromion process using non stretchable
tap
In children the cut-off points are:
Normal > 13.5 cm
Mild to moderate malnutrition 12.5-13.5 cm
Severe malnutrition < 12.5 cm
***These cut-offs could be arbitrarily
modified based on available
resources
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100. The following cut-offs are used In community
Based Nutrition (CBN) programs of Ethiopia
Target
Groups
MUAC
Malnutrition
Under five
years old
children
11-11.9 cm
Moderate acute
malnutrition (MAM)
<11 cm
Severe acute
malnutrition (SAM)
Pregnant
women/
Adults
17 to <21cm
Moderate
malnutrition
18 to < 21 cm with recent
weight loss
< 17 cm
Severe malnutrition
<18 cm with recent weight
loss
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101. MUAC…
It is a sensitive indicator of risk
of mortality
Useful for screening of children for
community based nutrition
interventions
Useful for the assessment of
nutritional status of pregnant
women
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105. Softwares used for analyzing
Anthropometric data
• WHO Anthro, is a software which was
published in 2006 together with the first set of
the WHO Child Growth Standards (i.e. weight-
for-age, height-for-age, weight-for-height, BMI-
for-age and windows of achievement for six
gross motor milestones).
• In 2008 WHO Anthro was updated to
include the second set of attained growth
indicators:
– Head-circumference-for-age,
– Arm-circumference-for-age,
– Triceps and Subscapular skinfold-for-age, and to allow
users to choose a French or Spanish language version.
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106. •WHO AnthroPlus was developed to
facilitate the application of the WHO
Reference 2007 for 5-19 years to
monitor the growth of school-age
children and adolescents.
• Thus AnthroPlus facilitates the detection
of thinness, underweight, overweight
and obesity in individuals and
populations from 0-19 years.
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107. Cont …
• WHO Anthro and to continue monitoring children's
weight, body mass index and height as they grow
older (Individual assessment module) and to analyze
survey data including preschool, school age children
and adolescents (Nutritional survey module).
• Thus AnthroPlus facilitates the detection of
thinness, underweight, overweight and obesity
in individuals and populations from 0-19 years.
• WHO AnthroPlus consists of three modules:
Anthropometric calculator (AC)
Individual assessment (IA)
Nutritional survey (NS)
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108. Indexes to be used for the
different age groups
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109. Measurements used to assess fat
mass :
Body mass index
Waist to Hip circumference ratio
Skin fold thickness
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110. Indices derived from the
measurements
Different indices could be derived by
measuring the weight and height of
an adult
Body mass index (Quetelet’s
index) = Wt/(Height in meters)2
Weight/height ratio (Benn’s
index)P
Ponderal index = Wt/ (ht) 3
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111. Body mass Index(BMI)
Body mass index the best method for
assessing adult nutritional status as the
index is not affected by the height of
the person
Therefore, it is most frequently
used for assessing adult nutritional
status
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112. Slide 11-112
Weight (kg)
or Weight (lbs)
Waist circumference
Height (m)2
Height (in)2 x 705
Hip circumference
Body mass index =
Waist-to-hip ratio =
Objective Data—Physical Exam
(cont.)
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113. Body Mass Index (BMI) or
Quetelet’s Index
BMI = weight (kg)
height (m2)
This ratio was first suggested as a measure
of fatness by Quetelet in 1869
Example: If x weighs 58 kg and he is 165 cm
(1.65 m) tall, what is his BMI?
BMI = 58 = 58 = 21.3 kg/m2
1.652 2.7225
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116. Childhood BMI is gender
& age specific
CHILDREN BMI – body mass index
Underweight BMI-for-age < 5th percentile
Overweight / at risk
for obesity
BMI-for-age 85th to 94th
percentile
Obese BMI-for-age ≥ 95th percentile
Normal BMI-for-age - 5th percentile - <
85th percentile
(CDC, 2009)
http://www.cdc.gov/nccdphp/dnpa/obesity/childhood/defining.htm
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117. Cut-off points for BMI
> 40 kg/m2 = very obese
30-40 kg/m2 = obese
26-30 kg/m2 = overweight
18.5-25kg/m2 = Normal
17-17.9 kg/m2 = mild chronic energy
deficiency
16-16.9kg/m2 = Moderate chronic energy
deficiency
< 16 kg/m2 = severe chronic energy
deficiency
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118. • What BMI cut‐offs are used in
children and adolescents?
• WHO suggest a set of thresholds based
on single standard deviation spacing.
• Thinness: <‐2SD
• Overweight: between +1SD and
<+2SD
• Obese: >+2SD
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119. This classification is based on the
mortalities and morbidities associated
with either extremities
The
Safe zone
Chronic diseases
(hypertension,
diabetes, cancer,
coronary heart
disease
Malnutrition
related
infections and
deficiency
diseases
Mortality
And
Morbidity
In %
16
18.5
25
30
40
Body mass index KG/M2
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120. BMI for Situations where Height
measurements is Impossible
When it is not possible to measure height
as in the case of :
Elderly people
Kiphosis / Scoliosis
People unable to assume erect position
Height can be estimated from arm span or
demi-span
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122. Arm span and Demi-span and
Knee height # 3
Using a regression equation it is possible
to estimate the height from the
measurements of arm span, demi-span
or knee height.
Y= a + Bx
Height = a + b(arm span) or
Height = a + b(Demi - span) or
Height = a + b(knee height)
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123. Height(men)= 64.19-(0.4Xage) + (2.02 X knee height)
Height(women)=84.88-(0.24Xage) +(1.83 x knee height)
Estimating height from
knee height
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124. SKIN FOLD THICKNESSES #1
Skin fold thickness is done at the following
anatomical sights:
Biceps skin fold
Triceps skin fold
Subscapular skin fold
Suprailliac skin fold
Mid axillary skin fold
Thigh skin fold
Calf skin fold
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127. SKIN FOLD THICKNESSES # 2
• The measurement should be performed using
precision SFT calipers, which have a constant
and defined pressure of 10g/sq.mm through
out the range of measured skin folds.
• Other ordinary SFT calipers result in
underestimation of the subcutaneous fat as a
result of compression.
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128. SKIN FOLD THICKNESSES # 3
Skin fold should be read to the
nearest 0.5 mm after 2-3 seconds of
caliper application
Measurements are made in triplicate
until readings agree within ± 1.0 mm
All the measurements should be made
on the left side
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130. 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
• 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.
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131. WAIST TO HIP
CIRCUMFERENCE RATIO
It is the circumference of the waist measured
mid-way between the lowest rib cage and
anterior superior iliac spine divided by the
circumference of the hip measured at the
level of the greater trochantor off the fumer(
both are measured to the nearest 0.5 cm)
If the ratio is > 1 in male, and > 0.87 in
female there is high risk of coronary
heart disease.
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133. WOMEN
MEN
High Risk
Moderate Risk
Low Risk
> 1.0 > .85
.90 -1.0 .80-.85
HEALTH RISK
< .90 < .80
Waist to Hip Ratio (WHR)
• Waist to Hip Ratio is an effective way to
examine regional fat distribution. 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.
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136. QUALITY CONTROL MEASURES IN
ANTHROPOMETRIC SURVEYS #1
The following issues need to be considered in carrying
out anthropometric surveys to ensure the quality of
data:
Calibration of the instrument after each
measurement and after moving the instrument from
one room to another.
Standardization of procedures.
Making subjects wear a uniform gown before
measuring weight or measuring their weight nude
if they are children.
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137. QUALITY CONTROL MEASURES IN
ANTHROPOMETRIC SURVEYS #2
Verification of at least 10 % of the data by
the main investigator.
Training of the data collectors and limiting the
coefficient of variation to be less than
3%
(CV = standard / mean X 100).
Train observers by skilled professionals
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138. Advantages and disadvantages of
Anthropometric measurements
Advantages Disadvantages
Quick Difficulty Of Selecting
Appropriate Cut-Off Points
Cheap Have Limited Diagnostic
Relevance (Only For Diagnosing
PEM)
Objective Need Reasonably Precise
Age In Children
Gives Gradable
Results
More Accepted By
The Community
Non Invasive
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139. Indicator What it measures/What it is used for
Low weight-for-height
WASTING
(acute malnutrition).
Low height-for-age or
Low length-for-age
STUNTING
(chronic malnutrition).
Low weight-for-age
UNDERWEIGHT
(acute or chronic malnutrition, or both).
Nutritional status indicators
There are three primary anthropometric indices for children
under five years of age: Wasting; Stunting, and Underweight.
140. Index/indicator What it measures/What it is used for
Body Mass Index
(BMI)
•It measures thinness in adolescents, adults and the
elderly.
•It is calculated as weight divided by height squared.
Low Birth Weight
(LBW)
•It measures newborn weight.
•It is associated with poor nutrition in mothers
(although other factors can also contribute to low
birth weight).
Mid-Upper Arm
Circumference
(MUAC)
•It is an index of body mass.
•It is usually measured using a MUAC tape that is
placed around the middle of the upper arm.
•It is particularly good for identifying children with a
high risk of mortality.
Additional anthropometric indicators:
Nutritional status indicators
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141. Contexts in which these indicators are particularly useful:
Nutritional status indicators
Indicator What it measures Context
Low weight-for-height
(Wasting)
acute malnutrition EMERGENCIES
Low Mid-Upper Arm
Circumference (MUAC)
acute malnutrition EMERGENCIES
Low height-for-age
(Stunting)
chronic malnutrition
STABLE SITUATIONS
Low weight-for-age
(Underweight)
acute or chronic
malnutrition or both STABLE SITUATIONS
Low Body Mass Index adolescent/adult/elderly
nutritional status
EMERGENCIES and
STABLE SITUATIONS
Low Birth Weight
newborn underweight
(proxy for maternal
malnutrition)
STABLE SITUATIONS
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143. B. BIOCHEMICAL/ BIOPHYSICAL
(LABORATORY) METHODS
• This involves measurement of either total amount of
the nutrient in the body, or its concentration in a
particular storage site (organ) in the body or in
the body fluids.
• This group includes those that are indicative of defect
in intermediary metabolism in other words they
occur when there is a biochemical lesion (Depletion).
The depletion could be detected
• by biochemical tests and/or by tests that measure
physiological or behavioral functions dependent on
specific nutrient.
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144. Biophysical Methods
These methods include measurement of
alterations cell, Organ or tissues structures that
are dependent on specific nutrient
• Bone X-ray = calcium deficiency
• Corneal impression cytology= Vit. A
• Buccal smear cytology = Vit.A
• Hair root morphology =Vitamin A.
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147. 1) Static biochemical tests:-
This involves measurement a nutrient or its
metabolites in pre-Selected biological
material (blood, body fluids, urine, hair,
fingernails etc.)
Example, E.g. Biochemical Tests
(laboratory)
1. Serum ferritin level
2. Serum HDL
3. Erythrocyte Folate
4. Tissue stores of Vit. A, Vit D,
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148. Factors affecting the validity of
static biochemical tests
• Physiological factors(pregnancy, diurnal
variation, homeostatic regulation, physical
exercise, age, sex, recent dietary intake)
• Pathological(inflammatory stress,
infection, weight loss)
• Analytical(sample collection, sensitivity &
specificity of the test, hemolysis, sample
contamination, acuracy and precision of
the method)
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149. Scurvy
A positive tourniquet test on the right side of a patient with
scurvy. Note the increased number of petechial.
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154. 2. Growth or developmental
responses
• Both physical growth and mental
development are adversely affected
by the deficiency of many nutrients.
• This is manifested by either failing to
thrive or poor school performances,
lagging milestones of development
etc.
• E.g.Cognitive function = IRON
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155. ADVANTAGES AND DISADVANTAGES OF
BIOCHEMICAL TESTS
Advantages
• Detect sub-clinical
Malnutrition
• Give gradable
nutritional
Information
• Are more objective
Disadvantages
• No ideal specimen or storage
site
• Many quality control problems
during sample taking, carrying
out the test, analysis. Etc
• Some times low values may not
have any health Implication
• No ideal biomarker for each
nutrient
• Need sophisticated instruments
• Need highly trained staff
• Involve invasive procedures
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160. C.CLINICAL METHODS #1
• Clinical Examination
It is the simplest and most essential part of all nutritional surveys.
There are a number of physical signs, both specific and non-specific
known to be associated with the state of malnutrition.
• The subject is examined from head to foot in good illumination for
the presence or absence of these signs.
• To minimize subjective and objective errors in clinical examination,
standard survey forms or schedules have been devised covering all
areas of the body.
• This are detection of deviations from the normal state of nutrition
just by observing and interpreting clinical
– Signs and
– Symptoms of deficiency or under intake, for instance, see the
following
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178. KERATOMALACIA
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Keratomalacia is
an eye disorder that
results from vitamin
A deficiency.
Vitamin A is
required to
maintain specialized
epithelia (such as in
the cornea and
conjunctiva).
The precise
mechanism is still
not known, but
vitamin A is
necessary for the
maintenance of
the specialized
epithelial
surfaces of the
body. Melese.S
182. PELLAGRA
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A deficiency disease
caused by a lack of
nicotinic acid or its
precursor
tryptophan in
the diet. It is
characterized by
dermatitis, diarrhoea,
and mental
disturbance, and is
often linked to over-
dependence on
maize as a
staple food.
A deficiency niacin
(vitamin B3)
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191. PHRYNODERMA
Hypovitaminosis A (also known as Follicular Hyperkeratosis and
"Phrynoderma" which means Toad Skin) is common in children in the
developing world
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Phrynoder
ma is a rare
form of
follicular
hyperkerato
sis
associated
with
deficiencie
s in
vitamins A
or C or
essential
fatty acids.
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194. 194
Koilonychia
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Koilonychia (from the Greek: koilos-, hollow,
onikh-, nail), also known as spoon nails, is a
nail disease that can be a sign of hypochromic
anemia, especially iron-deficiency anemia.
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196. Deficiency: rare
• Lethargy, depression, hallucinations, muscle pain, parathesia,
anorexia, nausea, alopecia, dermatitis
• May occur during pregnancy
• May occur with excessive consumption of alcohol
• Is known as a teratogen in mammals
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198. Table 9.5 (continued) Clinical Findings Associated with Poor Nutritional Health
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199. Can we do nutrition surveys using
Clinical signs and symptoms?
• Palmar pallor
• Bitot’s Spots
• Night Blindness
• Endemicity of goiter among School age
children
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200. WHO’s Recommendation of using pallor for
low Diagnostic Facility Areas
• No palmar pallor = No problem
• Moderate palmar pallor = treat with Iron
tablet
• Severe Pallor = Refer
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201. Goiter
• Endemic goiter is defined as thyroid enlargement that
occurs in more than 10% of a population,
• Percentage of school-age children 6-11 years (or
other non-standard age) with goiter (grade 1 and grade
2 combined). Epidemiologic criteria for assessing the
severity of Iodine Deficiency Disorders (IDD) based
on the prevalence of goitre in school-age children
(WHO):
– prevalence < 5.0% : no public health problem
– prevalence 5.0 - 19.9% : mild public health
problem
– prevalence 20.0 - 29.9% : moderate public
health problem
– prevalence ≥30% : severe public health
problem
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202. WHO Indicators for Recognizing
Vitamin A deficiency as a public health
problem
Sign Prevalence < 5 year
• Night Blindness > 1%
• Bitot spot >0.5%
• Corneal xerosis / ulceration >0.01%
• Corneal scarring >0.05%
Source: A field guide to detection vitamin A
deficiency, WHO 1993
Cont…
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206. D. Dietary Examination
• The value of nutritional assessment is greatly enhanced when it is
supplemented by a diet survey.
• A diet survey provides information about the amount and type of
food consumed by the people and bring out dietary inadequacies as
judged by the available standards.
• Diet surveys constitute an essential part of nutritional status of
individual or group and provides essential information on nutrient
intake levels, sources of nutrients, food habits and attitudes.
• Even when frank signs of malnutrition do not exist, a survey of
intake of nutrients may give an indication of adequacy of diet for
promoting nutrition of individuals or groups.
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207. Cont …
• Diet surveys of communities yield data regarding the extent of
dietary deficiencies and the quantity and type of foods required for
overcoming them.
• These surveys also yield information regarding the economic and
social factors influencing food production and consumption.
• The factors to be taken into consideration in
conducting diet surveys are:
i) Trained personnel
ii) Population sampling
iii) Methods available for conducting diet surveys
iv) Calculation of the nutritive value of diets in terms
of adult consumption unit and interpretation of
results.
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208. D. DIETARY METHODS
• These methods include assessment of past or current
intakes of nutrients from food by individuals or a
group in order to know their nutritional status.
• At national level:-
• Food balance Sheet
– also called National food disappearance data or
– food going in to consumption
• Market data bases( for fortified foods by FDA)
At a household level
Household food inventory method
Food account method
List recall method
Household food record method
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209. Five Main Methods to Collect Data
on Dietary Intake:
1. Nutritional History
2. 1-7 Day Food Record
3. 24-Hour Recall
4. “Usual” Daily Intake
5. Food Frequency Questionnaire
(FFQ)
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210. Methods used to assess current intake
(at a group or individual level)
I. Weighed record method: In this method the
subject will be asked to weigh whatever he/she
consumes including drinks both before cooking and
after cooking and the portion sizes he consumed
and the left over.
Advantages:
It is more accurate
There is no respondent memory loss
Disadvantages
High respondent burden
Change of the dietary habit during the survey due
fear of burden
Needs literate and numerate respondents
Costly
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211. ii. Observed weighed method
In this method the investigator him/herself
records the amount and type of food consumed
by the study subjects over specified period of
time.
This method is usually applied for disabled
people, infants and small children,
mentally ill people or institutionalized
elderly people or patients admitted to a
hospital.
Advantage VS disadvantages
The same as the observed weighed
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212. Food Diary method
• In this method the subject/s are asked to
record what ever they eat including
beverages for specified period of time with
estimation of the portion sizes consumed.
• Advantage
– May give relatively accurate estimate o the
nutrient intake if done properly
• Disadvantage
– High respondent burden
– Literacy and numeracy of subjects needed
– High coding burden
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213. II. Methods Used to assess past
intake
24 hours dietary recall
• In this method, the subjects are requested to
remember whatever they consumed within the last 24
hours.
• This involves all beverages, snacks deserts etc.
That have been ingested from x time yesterday
to x time today.
• The portion sizes consumed during this time should
also be determined by the respondents by assessing
them to use either photographs or the common food
being consumed at different sizes or by using a line
graph etc.
• Currently- Multipass 24 hours is used to improve
the quality
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216. Repeated 24 hour dietary
recall #1
The number of days the recall has to be repeated is
determined by Nelson’s formula
D = r2 x Sw2
1-r2 Sb2
Where,
D = # of days of dietary data collection required
Sw = is within person variances of dietary intake
Sb = Between person variation of dietary intakes
r = correlation between the observed and true
mean intake of individuals
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217. Repeated 24 hour dietary
recall #2
For example, for poly unsaturated fatty acids the
Sw2/sb2 = 3.5, If we want to get correlation of
between measured intake and true intake of 0.9,
how many days of data collection are needed?
D = r2 x Sw2
1-r2 Sb2
D= (0.9 x 0.9) X 3.5 = 14.9 =15 days
1-(0.9 x 0.9)
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218. Reasons why a single day assessment
does not give the true mean intake
• Day of the week effect
• Seasonal effects
• Consecutive /nonconsecutive days
• Random within person variance
• Holiday effects(feasts and fasts)
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219. Advantages and disadvantages
of 24 hrs dietary recall method
Advantages
Relatively cheap
Quick
Less respondent burden
No chance for the
respondents to change their
dietary habit
The usual intake of a group
can be determined from a
single 24 hrs recall
Disadvantages
• A single day 24 hrs recall
does not indicate the usual
intake of individuals
• Respondent memory laps
• Social desirability bias (the
flat slop syndrome)
• Has less precision
• Accuracy depends on the
respondent’s ability to
estimate portion sizes
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220. Dietary history
This method is used to assess the
nutrient intake of an individual or a
group from food over a longer period
of time, usually to see the association
between diet and disease.
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221. Advantages and disadvantages of
Dietary history
Advantages
It gives the dietary
habits of an individual or
a group of people over a
longer periods of time
It is possible to target
the dietary questions to
specific dietary habits or
intake of specific
nutrients of interest
Less respondent burden
Disadvantages
It over emphasizes the
regularity of the
dietary pattern
It is very difficult to
validate
It needs a very highly
trained interviewer
It gives just a relative
if not an absolute
information
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222. Food frequency
questionnaire
• This method is based on the preparation of a food
frequency questionnaire, which is based on the local
staple diet to determine the frequency of consumption
of a particular nutrient.
• This could be achieved through self or interviewer
administration of the questionnaire.
• Sometimes the quantities consumed could be
included, in such circumstances, the FFQ is
called semi quantitative FFQ.
• The following table indicates the frame of a food
frequency questionnaire.
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225. Example of semi quantitative FFQ
for Vitamin A friendly foods
Frequency of consumption
Food list
Daily
Every
other
day
Once
per
week
Once
per
month
Portion size
consumed
Carrot
Cabbage
Papaya
Mango
Cod liver oil
Liver
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226. Advantages and
Disadvantages of FFQ
Advantages
• It is usually used for
areas where there is a
geographically widely
scattered study
population
• It is less costly
especially if self
administered
• Less respondent burden
Disadvantages
It is very difficult to
develop especially in
multi-cultural society
where different
staple foods are
consumed
It needs literate and
numerate subjects
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227. Errors in dietary surveys result
from
• Interviewer bias
• Food tables
• Coding and computation errors
• Reporting errors
• Wrong weight of foods
• Wrong frequency of consumption
• Response bias( the flat slop syndrome or
memory laps)
• Sampling bias
• Change in dietary habit
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228. Stages of development of nutritional
deficiency
STAGE DEPLETION STATUS METHOD OF
ASSESSMENT
One: Dietary inadequacy Dietary
Two: Decreased level in the
tissue reserves
Biochemical
Three: Decreased level in the
body fluids
Biochemical
Four: Decreased functional
level in the tissues
Biochemical
Five: Decreased activity of
nutrient dependent
enzymes
Biochemical/Biophysical
Six: Functional changes Clinical/biophysical/
Anthropometric
Seven: Clinical symptoms Clinical
Eight Anatomical signs Clinical
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229. Selection of assessment method
depends on:
• Objective of the study
• Technical Feasibility
• Cost
• Acceptability
• Performance(validity, reliability ,
predictive value
• Availability of reference data and or cut-
off points
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230. E. Exercise – Energy Balance
• OR Environmental or Other Factors
Smoking, Abuse or Substance Abuse , Foster Care
• Nutrition and exercise closely linked – metabolic and
physical fitness
• Functional capacity and Nutritional status
– Correlation between muscle mass and physical strength,
nutritional status and physical function
• Energy Balance to attain optimal weight and body
composition
• Bed Rest / Inactivity
– Negative effects on muscles, bone and CV system, eg. 8 g
protein loss / day of bed rest
– Exercise – affects on appetite, bowel function
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234. Assessment of Ecological Factors
• In any nutritional survey, it is necessary to collect certain
background information of the given community, in order to make
the assessment complete. A study of ecological factors related to
malnutrition comprise the following :
(i) Conditioning influences : Bacterial, viral and parasitic agents.
(ii) Cultural influence : Food habits, attitude to food, infant
feeding practices, child rearing practices, cooking practices,
beliefs and taboos.
(iii) Food production : Customs relating to method of cultivation
animal husbandry, food storage and distribution.
(iv) Socio-economic factors : Family size, occupation, income,
education, prices of food.
(v) Health & Educational : Number of hospitals and health centres,
health services personnel, preventive, promotive and
curative services, media of communication.
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236. Purpose of nutritional Surveillance
• Nutrition data is a vital indicator for the overall
health and welfare of populations especially where
regular demographic and health surveys are
lacking.
• Surveillance data is critical for making decisions
that will assist in improved nutrition outcomes
of a population e.g. when to start or phase out a
nutrition intervention such as supplementary
feeding program.
• Nutrition data can be used in crisis mitigation
especially as an early warning indicator to
respond to threats such as droughts or disease
outbreaks.
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237. • Data collected assists in providing baseline
information on nutrition, socio-economic factors,
demographic characteristics, food security and cultural
aspects of a population
• Information is important for decision making on
program planning, management, monitoring and
evaluation
PURPOSES OF PUBLIC HEALTH SURVEILLANCE
• Describing trends and the natural (secular) history of health
problems
• Detecting epidemics
• Providing details about patterns of disease
• Monitoring changes in disease agents through laboratory testing
• Planning and setting health program priorities
• Evaluating the effects of prevention and control measures
• Detecting critical changes in health practices
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238. NUTRITIONAL SURVEILLANCE
• It is system organized to monitor the food and nutrition
situation of a country or a region within a country on a
continuous and regular basis.
• It usually involves the regular and timely collection, analysis and
repotting of nutrition-relevant data for timely decision making.
• Health Surveillance -- the collection, analysis and
interpretation of data on individuals or groups to detect the
occurrence of certain events and their putative causes for (1)
the purpose of prevention or control of certain diseases and
other health conditions, (2) formulation of interventions, and (3)
evaluation of the impact of programs
• Generally, surveillance requires three functions in this sequence:
(1) data collection, (2) analysis and interpretations, and (3)
decision making
• Biologic Characteristics such as population growth, blood pressures, and nutritional
status may also be the subject of surveillance -- e.g., growth of school children made once
a year and supplemented by additional information from students and parents on nutritional
status, respiratory functions, etc. Allows comparison of such indicators as height and
weight of equivalent age groups in successive calendar years as well as the comparison of
annual growth rates of various age cohorts
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239. METHODS OF ACQUIRING DATA IN
NUTRITIONAL SURVEILLANCE
• Active surveillance: - the data are
collected actively by the group /individuals
running the program and hence it takes time
and other resources. Give more reliable
data.
• Passive surveillance: - in this type
of surveillance, data are obtained from the on
going programs and it does not incur too
much in terms of cost, time, personnel
as compared to the active surveillance,
but the data generated is not as reliable and
as relevant to the program as compared to
the former.
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240. TYPES OF SURVEILLANCE
• Four general categories of public health surveillance
• Passive Surveillance
– The most commonly practiced disease surveillance at state
and local health departments -- generally used standardized
reporting cards or forms that are distributed in batches to
hospitals, clinics, laboratories and other health care settings
– Passive surveillance usually targets physicians, laboratories,
and infection control officers
– Referred to as passive because no action is taken unless
completed reports are received by the public health agency
and further public health action is deemed desirable
– Completeness of reporting is usually lowest for passive
systems, but they tend to be the least expensive to
maintain
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241. TYPES OF SURVEILLANCE (cont’d.)
• Active Surveillance
– Active surveillance involves an ongoing search for cases
– This may involve regular contacts with key reporting
sources, such as telephone calls to physicians or
laboratories, or a frequent review of data that may include
cases of a specific condition, such as a review of laboratory
logs for certain bacterial isolates or a review of admissions
to burn units to identify severely burned individual
– Active surveillance systems may have high levels of
completeness but are usually much more expensive to
maintain; some question the cost-effectiveness of active
surveillance
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242. TYPES OF SURVEILLANCE (cont’d.)
• Sentinel Surveillance
– Sentinel surveillance involves the use of a sample of
providers -- most generally, a sample of physicians or
emergency rooms -- to identify trends in diseases that occur
at relatively high frequencies
– E.g., sentinel surveillance systems, such as those for
influenza, provide timely information about trends in
influenza-like illness activitiy, and are useful for obtaining
information about strains that may be circulating in a
community -- assuming that there is a laboratory-based
component to the surveillance
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243. TYPES OF SURVEILLANCE (cont’d.)
• Special Surveillance System
– Special surveillance systems have been found useful for
certain types of surveillance activities
– The Behavior Risk Factor Surveillance System
(BRFSS) involves administering a questionnaire to a
random sample of individuals on a ongoing basis to identify
trends in behavior that affect health risk -- e.g., monitoring
the impact of such activities as breast cancer screening
with mammography, cervical cancer with pap
smears, use of smoke alarms in houses, as well as other
health-related behaviors and practices
– Mocrobiologic surveys have been useful in determining
the antibioltic resistance among persons with invasive
pneumococcal infections
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244. Key issues in site based surveillance
• Importance of carrying out surveillance
• Anthropometric data- quality of
data/integrity of equipment and staff quality
• Recording and interpreting measurements
• Clinical diagnosis: obvious micronutrient
deficiency- VAD, anaemia, IDD
• Causes of malnutrition
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245. Objectives of Nutritional Surveillance
Type of nutritional
surveillance
Objective
i. Timely warning and
intervention
To prevent short term critical reductions in
food consumption
ii. Policy and programme
planning
To enhance nutritional effects of development
policies as expressed through program, to
assess policies and programs
iii. Management and
evaluation
To rationalize and maximize effectiveness of
health and nutrition program
iv. Advocacy To assess and or monitor indicators related to
nutritional status as a basis for directing funds
towards particular nutritional problems
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246. In emergency settings, the objectives
focus more specifically on:
• Advocacy: as a means to highlight an evolving
crisis. Nutrition information is a very powerful tool to
highlight a deteriorating situation and to sensitize
politicians and decision makers about the needs.
• Identification of appropriate response
strategies: the default response to large scale
emergencies where high rates of acute malnutrition
are reported is generally in the form of large relief
distribution of free food.
• Nutrition surveillance systems have the ability
to explore the underlying causes of the
deterioration in the nutrition situation, and
therefore can inform a more appropriate and
relevant response
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247. Cont …
• Triggering a response:
– Although the World Health Organization (WHO) has
set a range of thresholds for classifying the
nutrition situation these thresholds can have a
different meaning in depending on context.
– In many countries in Africa, high rates of acute
malnutrition (above 15 per cent weight for
height) can reflect a chronic problem whereas
in other countries such levels would be an indicator
of a significant deterioration in the nutrition
situation.
.
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248. Cont …
• Targeting: Anthropometric information
can help target which areas are more at
risk or in greater need of assistance.
• Identification of malnourished
children: Depending on the method applied in the
surveillance system e.g. routine measurement of
children through a clinic, or though sentinel site, the
children identified as acutely malnourished can be
referred to the appropriate selective feeding
programme (supplementary feeding or
therapeutic care) for management
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249. BASIC STEPS IN NUTRITIONAL SURVEILLANCE
Scope Assessment Implementation
1. Impact 1. Problem
identification including
desired impact of
action taken
1. Actual impact
2. Intervention 2. Proposed policies
and intervention
strategies
2. Intervention enacted
based on decision
3. Decision 3. Potential decisions
regarding policies
and interventions
3. Decision (s) made
based on information
4. Information 4. Information needed
to aid in decision
making
4. Data analysis: the
Transformation into
information
5. Data 5. Data needed to
generate information
5. Data collection action
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250. Nutrition Surveillance Systems
There are many approaches to establishing a nutrition
surveillance system. Deciding which approach to
adopt will depend on the objectives, resources,
environment and capacities available. The following
are the main methods used for surveillance:
• Large scale national surveys (DHS, MICS)
• Repeated small scale surveys
• Clinic based monitoring
• Sentinel site surveillance
• School census data
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251. Cont …
In an emergency setting additional
sources are also used:
• Rapid nutrition assessments
• Rapid screening based on mid upper arm
circumference (MUAC) measurement
either exhaustive community screening or
screening groups of children to provide an
indication of a problem
• Selective feeding programme or services
statistics monitoring (monitoring the use of
services such as health facilities)
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252. Steps in planning a rapid assessment
• Define objectives (who to assess-children,
women, why),
• Determine target site/area/population
• Develop appropriate method of data
collection: representative
• Staff identification and training (involve
the existing authority)
• Materials and equipment
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253. Type of information
• MUAC measurements: adults (women),
<5yr
• Food availability and accessibility
• Water sources
• Common diseases- how are recent trends
• Access to health services/ other
interventions
• Livestock and population movement-
destinations/ origin of emigrants
• Type of food consumed/freq. of feeding
• Security situation
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254. What indicators should be monitored?
The Early Warning (EW) system of the Disaster Risk
Management and Food security Sector(DRMFSS) in Ethiopia
is designed to provide assessments of food prospects within
the country and to detect (as early as possible) the likelihood
of deterioration in food security or, in worse case scenarios,
impending disaster. This includes data on :
– Crop assessments
– Epidemic outbreaks
– Nutritional status of vulnerable groups
– livestock conditions
– Impact of precipitation on crops and livestock
– Market situation
– Magnitude of food shortages and measures taken
for mitigation.
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255. EWS...
• Vulnerability mapping-A vulnerability map
gives the precise location of sites where people, the
natural environment or property are at risk due to a
potentially catastrophic event that could result in
death, injury, pollution or other destruction
• Hunger gap
• Surveillance (data analogue years
matching)
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268. Indicators of Early warning signs(EWS)
Food crises
Food stocks (food balance sheets)
Production patterns
Market prices
Fall In body weights
Rainfall pattern
Household food security
Employment levels
Market prices
Changes in real income and
purchasing power
Dietary energy supply
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269. Indicators of EWS…
Prevalence of malnutrition
Wt/age, wt/ht( Child growth)
BMI
Infectious disease rates
Food intake relative to need
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271. Indicators of EWS…
Micronutrient deficiencies
Iron deficiency(rates of anemia
Vitamin A Deficiency (Night blindness)
in children
IDD(goiter, cretinism)
Malnutrition-infection complex
Incidence of diarrhea
EPI coverage
availability of clean water
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272. The impact of an emergency on
nutrition
TRIGGERS
IMPACT ON POPULATION
IMPACT ON HOUSEHOLDS
IMPACT ON INDIVIDUALS
Advances in nutrition in emergencies
War
Natural disaster
(flood, drought, earthquake)
Political/economic
shock
Loss of earnings
and access to
health services
Large-scale
migration
Destruction of
infrastructure
(roads, markets
etc.)
Loss of property
and business
(houses, land,
animals, stock
etc.)
Breakdown of
essential services
(health, water,
sanitation etc.)
Reduced
access to food
Malnutrition Disease
DEATH
Residence in
overcrowded
settlements
Lack of
water,
hygiene,
sanitation
Social
disruption
Families
split
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273. Source of SURVEILLANCE
data
Source of
information
Nature of information
obtained
Nutritional implications
1. Agricultural
data food
balance sheets
Gross estimates of
agricultural production,
agricultural methods, soil
fertility, predominance of
cash crops, over
production of staples,
food imports and exports
Approximate-availability
of food supplies to a
population
2. Socio-economic
data
(information on
marketing,
distribution,
and storage)
Purchasing power,
distribution and storage of
food staffs
Unequal distribution of
available foods among the
socio-economic groups in
the community and within
the family
3. Food
consumption
patterns (cultural
and
Anthropological
data)
Lack of knowledge,
erroneous beliefs,
prejudices, indifferences
4. Dietary surveys Food consumption Low, excessive or
unbalanced nutrient intake
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274. Source…
Source of
information
Nature of
information
obtained
Nutritional
implications
5. Special studies on
foods
Biological values of diets,
presence of interfering
factors (e.g. goitrogens),
effects of food processing
Special problems related
to nutrient utilization
6. Vital and health
statistics
Morbidity and mortality
data
Extent of risk to the
community, identification
of high risk groups
7. Anthropometric studies Physical development Effect of nutrition on
physical development
8. Clinical Nutritional
surveys
Physical signs Deviation from health due
to malnutrition
9. Biochemical studies Levels of nutrients,
metabolites, and other
components of body
tissues and fluids
Nutrient supplies in the
body, impairment of
biochemical function
10. Additional medical Prevalent disease
patterns; including
infections and infestations
Interrelationships of state
of nutrition and disease
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275. Factors Affecting the Take-up of
Early Warning Information
• Ownership of Early Warning
Information
• A Clear and Consistent Early
Warning Message
• Interpreting Early Warning
Information
**The challenge is how to translate early
warning data into food aid requirements
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277. Decisions for intervention…
• GAM: percentage of child population (6-59
months) with WFH z score < -2 and/or
manifesting bilateral oedema.
• SAM: percentage of child population (6-59
months) with WFH z score < -3 and/or
manifesting bilateral oedema
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278. Growth Monitoring and promotion
Growth monitoring – Is a type of growth surveillance involving regular assessment of
growth in individuals to apply appropriate interventions.
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279. Challenges of nutrition surveillance
systems
Sustainability
• One of the biggest challenges facing nutrition
surveillance systems is the issue of sustainability
and continued effectiveness of the system.
• There are many examples of information systems
that have ‘withered’ away as donor interest has
waned (either because the area served by the
information system has not experienced crisis for a
number of years or because internal donor funding
priorities have changed).
• Continuation of adequate financial resourcing is
therefore crucial.
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280. Challenges of ….
• Institutional issues- Issues, such as where
the system should be housed and how it links with
existing early warning systems or health information
systems, also need to be considered, in terms of who
ultimately makes the decision in terms of the analysis
of the information and determines the appropriate
response.
• The challenge for many information systems is
that they rely on a range of information sources
that cut across several government ministries
including health, agriculture and education.
• This means that no one ministry takes responsibility
for the management of the system. Over time it may
be abandoned.
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281. Cont …
Linking information to action
• Data collected which is not linked to action is pointless and
unethical. Nutrition surveillance systems should be designed in
such a way as to maximize the likelihood that information will
elicit an appropriate response if one is needed. There are two
main reasons many surveillance systems fail to produce the
desired response:
• Firstly, there can be a lack of confidence in the data. This
is very common when data is based on trends and not on
prevalence data. Sometimes, data indicating a deteriorating
nutritional trend from the surveillance systems is only accepted
if it is confirmed by providing prevalence estimates from
representative surveys.
• Lack of international agreement on standards for
sentinel site surveillance or rapid assessments is
problematic.
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282. Summary of Types of emergency nutrition
assessment
Type of
assessment
Objectives Data collection methods
Rapid
assessment
To verify the existence
or threat of an
nutritional emergency
To estimate the number
of people affected
To establish immediate
needs
To identify local
resources available
To identify the external
resources needed
Direct observations of
population and environment
Interviews with key
informants
Focus group discussions
Review of records from
available feeding centres
and/or health facilities
Rapid surveys
Surveys To establish the
prevalence of
malnutrition (including
micronutrient
deficiencies)
To identify likely
causes of malnutrition
Cluster sample surveys of
under-fives (sometimes
women or older children)
Nutrition
surveillance
To identify trends in
nutritional status.
Repeated surveys
Growth monitoring
Sentinel site surveillance
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283. Timing of assessment
Type of assessment Purpose Methods Timing
Rapid health
assessment
To identify immediate
risks to health and
critical needs
To identify information
gaps for further
assessments.
Checklists
Key informant
interviews
Observations.
(e.g. Initial rapid
assessment tool)
A few days, in first
week of an emergency.
In-depth,
comprehensive
assessment
To gather more details
on health status, health
facilities, resources
available and needs.
Ideally multi-sectoral
collecting both
qualitative and
quantitative data data
(e.g. Health cluster is
developing a pocket book
with guidance on
assessments).
At least several days,
depending on access
and size of the
location.
Surveys To collect detailed data
on morbidity, mortality
and nutrition.
Random sampling
techniques
Interviews
Measurements.
Retrospective mortality
surveys.
(e.g. SMART).
Several weeks.
Surveillance To continuously monitor
health and nutrition
status.
(e.g. health information
systems).
On-going.
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284. Aggravating Factors:
• Poor household food availability and accessibility,
general food ration below mean energy requirement
• Crude mortality rate >1 per 10,000 per day
• Epidemic of measles, whooping cough (pertussis),
cholera, shigella and other important communicable
diseases
• High prevalence of respiratory or diarrheal diseases
• High prevalence of HIV/AIDS
• Outbreaks of diseases (malaria, etc.)
• Low levels of measles vaccination and vitamin A
supplementation
• Inadequate safe water supplies and sanitation
• Inadequate shelter
• War and conflict, civil strife, migration and displacement
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285. The ‘TRIPLE A’
Cycle
• Surveillance should be followed by intervention
action in a cyclic manner
Assessment
of the nutrition
Situation of
A country or
A region
Action based
on analysis
and available
resources
Analysis of the
cause of nutritional
Problems
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