1. Assessing Nutritional status
Dr. Shivananda Nayak
Faculty of Medical Sciences
The University of The West Indies
The nutritional status of an individual is the result of many
interrelated factors
It is influenced by food intake, quality, quantity and physical
health
The spectrum of nutritional status spread from obesity to
malnutrition

2. Why Nutritional assessment required
It is required to:
Develop health care programs which meet the community needs which are defined by the assessment
Measure the effectiveness of the nutritional programs and intervention once initiated
Methods of nutritional assessment
It is assessed by direct and indirect methods

3. The direct method
Deal with the individual and measure objective criteria
Summarized as ABCD
Anthropometric methods
Biochemical and laboratory methods
Clinical methods
Dietary evaluation methods
Indirect methods of nutritional assessments
Uses community health indices that reflects nutritional influences
These include
Ecological variables including crop production
Economic factors e.g. per capita income, population density and social habits
Vital health statistics particularly infant under 5 mortality and fertility index

4. Clinical assessment method
It is an essential feature of all nutritional surveys
Simplest and most practical method of ascertaining the nutritional status of a group of individuals
It utilizes a number of physical signs that are known to be associated with malnutrition & deficiency of vitamins & micronutrients

5. General clinical examinations, with special attention to organs, like hair, nails, skin, gums, eyes, muscles, tongue, angles of mouth and thyroid gland
Detection of relevant signs helps in establishing the nutritional diagnosis
Advantages of Clinical assessment
Fast and easy to perform
Inexpensive
Non-invasive
Limitations
May not detect the early stages

6. Anthropometric measurements
Anthropometry is the measurement of body weight
and proportions
It is an essential part of clinical examination of
infants, children and pregnant woman
It is also used to evaluate both under and over
nutrition
The measured values reflect the current nutritional
status.

7. Other anthropometric measurements:
Mid-upper arm circumference
Head circumference
Skin fold thickness
Head/chest ratio
Hip/waist ratio
Anthropometry for children
Accurate measurement of height and weight is necessary to
evaluate the physical growth of the child
Ht/Age:
Height of index child compared with the expected weight of a healthy child of the same age
Measure of long term nutritional status or stunting
Wt/Ht:
Measure of wasting ie. Appropriate weight for given height

8. Mid Upper Arm Circumference:
Measured half-way between the acromion process of the scapula and the tip of the elbow (ulnar) with the arm hanging vertically and forearm supinated
Provides an estimate of Arm Muscle Area: reflect skeletal protein reserves lean body mass useful in monitoring vulnerable groups, especially children
Head Circumference:
Useful in children under the age of 3 and is an indicator of non-nutritional abnormalities. Under nutrition must be severe to affect head circumference

9. Anthropometry for adults
Height measurement
The subject stands erect and bare footed on a stadiometer with a movable head piece is leveled with skull vault and height is recorded to the nearest 0.5 cm
Weight measurement
Use of regularly calibrated electronic or balanced-beam scale is suggested to measure the weight.
During weight measurement wearing light clothes without shoes is suggested
Read to the nearest 100 gm.
Skin folds
Triceps, Biceps, Sub-scapular, Supra-iliac used in combination to obtain body fat

10. Nutritional Indices in adults
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) kg/m2
Height (m2)
< = Underweight
= Normal Weight
= Overweight
= Moderate Obese (Class 1)
= Severely Obese (Class 2)
40 = Extreme Obesity

11. BMI = Weight (lbs) x 703
Height (in2)
< = Underweight
= Normal Weight
= Overweight
= Moderate Obese (Class 1)
= Severely Obese (Class 2)
 = Extreme Obesity (Class 3)
High BMI (obesity level) is associated with type 2 diabetes and
high risk of cardiovascular morbidity and mortality
Waist/Hip ratio
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

12. Waist circumference
Waist circumference predicts mortality better than any other anthropometric measurement
It has been waist circumference alone can be used to assess obesity and two levels of risks have been identified
Males Females
Level 1 >94 cm >80 cm
Level 2 >102 cm >88 cm
Level 1 is the maximum acceptable waist circumference irrespective of the adult age and there should be no further weight gain
Level 2 detects the obesity and requires weight management to reduce the risk of type 2 diabetes and cardiovascular complications

13. Hip circumference
It is measured at the point of greatest circumference around hips and buttocks to the nearest 0.5 cm
The subject should be standing and the measurer should squat beside him
Both measurement should be taken with a flexible, non-stretchable tape in close contact with the skin, but without indenting the soft tissue
Interpretation of Waist/Hip Ratio (WHR)
High risk WHR = >0.80 for females and >0.95 for males i.e. waist measurement > 80% of hip measurement for women and 95% for men indicates central obesity and is considered high risk for diabetes and cardiovascular disorders

14. A WHR below these cut-off levels considered low risk
Advantages of Anthropometry
Simple, non-invasive.
Equipment is inexpensive, portable.
Relatively unskilled personnel can perform measurements.
Methods are reproducible.
Measures long term nutritional history.
Quickly identifies mild to moderate malnutrition.
Measures many variable of nutritional significance like height weight, skin fold thickness, head circumference waist and hip ratio and BMI

15. Disadvantages of Anthropometry
Relatively insensitive to short term nutritional status
Cannot identify specific nutrient deficiencies
Measurements: e.g.. Skin-folds difficult to carry out in obese people
Ethnic differences in fat deposition
Dietary assessment
Nutritional intake of humans is assessed by five different methods
24 hour dietary recall
Food frequency questionnaire
Dietary history from the beginning
Food dairy technique
Observed food consumption

16. 24 hour dietary recall
A trained interviewer asks the subject to recall all food and drink taken in the previous 24 hours
It is quick, easy, and depends on short term memory, but may not be truly representative of the person’s usual intake
Food frequency questionnaire
The subject is given a list of around 100 food items to indicate his or her intake (frequency and quantity) per day, per week and per month
It is inexpensive, more representative and easy to use

17. Dietary history
It is an accurate method for assessing the nutritional status
The information should be collected by a trained interviewer
Details about the usual intake, types, amount, frequency and timing needs to be obtained
Cross-checking to verify data is very important
Food dairy
Food intake should be recorded by the subject at the time of consumption
The length of the collection period range between 1-7 days
It is reliable but difficult to maintain

18. Observed food consumption
The most unused method in clinical practice (must for research)
The meal eaten by the individual is weighed and contents are to be calculated exactly
High degree of accuracy but expensive and needs more time and efforts
Interpretation of dietary data
1. Qualitative method
Using the food pyramid and the basic food groups method
Different nutrients are classified into 5 groups (fats and oils, bread and cereals, milk products, meat-fish-poultry, vegetables and fruits

19. Determine the number of serving from each group and
compare it with minimum requirement
2. Quantitative method
The amount of energy and specific nutrients in each food consumed can be calculated using food composition tables and then compare it with the recommended daily intake
Evaluation by this method is expensive and time consuming, unless computing facilities are available
Laboratory measurements
Blood: accessible, relatively non-invasive reflect recent dietary intakes but influenced by: diet; drugs; infection; stress

20. Haemoglobin is the most important test and useful index of the overall state of nutrition. Beside anaemia it also gives idea about protein and trace element nutrition
Stool examination: to detect the presence of ova and intestinal parasites
Urine examination for albumin, sugar and blood
RBC vs WBC: gives idea about long/short term nutrient status
Analysais of hair nails and skin for micronutrients (Cu, Se, Zn, Hg,etc)
Detection of abnormal amount of metabolites in the urine (creatinine/hydroxyproline ratio)
Functional tests done to study about the metabolic pathways

21. Reference: Essentials of Biochemistry by Dr S Nayak
Advantages of Biochemical Measurements
It is useful in detecting early changes in body metabolism and nutrition before the appearance of overt clinical signs
It is precise, accurate and reproducible
Useful to validate data obtained from dietary methods (e.g. comparing salt intake with 24- hour urinary excretion
Disadvantages of Biochemical Measurements
Expensive
Time consuming
Needs trained personal and facilities
Reference: Essentials of Biochemistry by
Dr S Nayak