Nutritional Assessment

1. CH-3
Assessments of community nutritional status
HORN INTERNATIONAL UNIVERSITY COLLAGE
Department Of Human Nutrition
Course: Community Nutrition (HN 3105)

2. What is Nutritional Assessment?
• What is nutritional assessment and how can it be completed?
Nutritional assessment is an extremely useful tool for the
application of nutritional therapy.
It is related to the individual’s
Food and nutrient intake (diet history) Lifestyle Social and
medical history and
Anthropometric, body composition and biochemical
measurements

3. Nutritionl Assessment
What happens when a person doesn’t consume enough or consumes too much of a specific
nutrient or energy?
If the deficiency or excess is significant over time, the person experiences symptoms of
malnutrition.
With a deficiency of energy, the person may display the symptoms of undernutrition by becoming
extremely thin, losing muscle tissue, and becoming prone to infection and disease.
With a deficiency of a nutrient, the person may experience skin rashes, depression, hair loss,
bleeding gums, muscle spasms, night blindness, or other symptoms.

4. M & E
M & E M & E
The ‘TRIPLE A’ Cycle

5.  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
 To develop 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

6. Why Nutrition Assessment ?
 A thorough assessment of the Situation and Root Causes of Under-Nutrition is
necessary:
1. To Design Proper and Targeting Interventions
2. To Provide Baseline Information on which to assess Progress and Improvements.
 In the field of nutrition, a major challenge is how to identify individuals and/or
populations who have nutritional problems?
 Appropriate and Rapid nutritional assessment can provide the answer.(must directly
related to the questions)

7. Nutrition Assessment of Populations
To assess a population’s nutrition status, researchers conduct
surveys using techniques similar to those used on individuals.
The data collected are then used by various agencies for
numerous purposes, including the development of national
health goals.

8.  Direct Methods of Nutritional Assessment
These are:
• Anthropometric methods
• Dietary evaluation methods
• Clinical methods
• Biochemical, laboratory methods
 Indirect Methods of Nutritional Assessment
These include three categories:
Ecological variables including crop production
Economic factors e.g. per capita income, population density & social habits
Vital health statistics particularly infant & under 5 mortality & fertility index

9.  Anthropometry (Anthropos = human, Metric = measure) is:
The study and technique of human body measurement
Measurement of variations of:
 Physical dimensions (Ht & Wt) &
 Gross composition of human body (body fat & fat free mass) at
different levels & degrees of nutrition (Jelliffe, 1966)

10. Con…
 Identification of individuals or populations at risk indicators must reflect :
 past or present risk, or predict future risk Evaluation of the effects of changing in :
 nutritional, health, or socioeconomic influences, including
• interventions indicators need to reflect response to past and present interventions
Selection of individuals or populations for an intervention— indicators need to predict the benefit to
be derived from the intervention.
 Excluding individuals from high-risk treatments/employment/certain benefits indicators predict a lack
of risk.(WHO Expert Committee, 1995)
•Refer : Appropriate use of Anthropometric indices and indicators note

11. Growth measurements . .
Recumbent length
 Height is measured as recumbent length in children:
 For the first two years of life (Younger than 24 months)
 Fewer than 87cm long if age is not known $ who are too ill to stand
 Correct measurement of length requires that:
 Child is relaxed with no shoes on
 Child lies parallel to the long axis of the board
 Crown of the head is against the fixed board
 Movable board is brought up against the heels

12. Growth measurements . . . .

13. A. Stunting (low height-for-age)
 Under-nutrition for a long time retards the growth of a child by height. The child is
shorter than for its age. This is called “Stunting”. For this, both height and age are to be
known.
 It reflects a process of failure to reach linear growth potential due to sub-optimal food
and/or health conditions in early childhood (<2 year). The condition needs remedy in
early childhood, otherwise the process is irreversible.
 The child is said to be of normal height, if its height-for-age is within 2 standard
deviations (-2SD) of the median height-for-age of a reference population.

14. Growth measurements . . .
Standing height:
 Measured in children:
 Over 24 months of age
 More than 87cm long if age is not known
 To measure height, the:
 Child stands barefoot wearing little clothing
 Child faces forward with legs straight and his or her feet should be close together.
 Head, Shoulder blades ,Buttocks and Heels contact the vertical board
 Movable headboard is gently lowered
 Height is recorded to the nearest 0.1cm

15. Height-for-age (HFA)
HFA is a measure of long-term/chronic nutritional status in children.
Children who suffer from chronic under-nutrition:
Grow poorly and have low height for their age i.e. they are short.
Children who are short for their age relative to a reference standard are classified as
“stunted.”.
Chronic consumption of diets of poor nutritional quality
Repeated infectious disease
Deficiencies in specific nutrients such as zinc and calcium.

16. con...
Stunting is also a visible manifestation of poverty (All causes of MN)
Stunting is associated with many negative outcomes:
Increased mortality
Susceptibility to infections in childhood
Decreased work productivity and lower incomes.
Low school performance (Less IQ, Class repetition, dropout)

17. Con…
Application HFA
Application 1.
This index is used primarily with children under five years of age
Low H/A commonly not appearing before 3 months of age.
The prevalence of stunting among children generally increases with age up to 24–
36 months
Then remains relatively constant thereafter (Window of opportunity closed)

18. STUNTING (inadequate height-for-age)
103 cm 7 years
old
125 cm
7 yeas
old
100 cm 4
years old

19. Con…
• Application 3: Stunting is cumulative and Cannot be compensated by fatness
 Thus At the population level the prevalence of stunting is useful:
For long-term planning and policy development
For targeting a range of interventions to a community
For monitoring malnutrition at the community/regional/ national level
As a reflection of socioeconomic status and equity
For poverty analyses

20. No. severity Stunting HFA Underweight WFA Wasting WFH
1 low *20 *10 *5
2 medium 20-29 10-19 5-9
3 high 30-39 20-29 10-14
4 Very high ≥40 ≥30 ≥15

21. B. Wasting (low weight–for-height)
 Wasting is a measure of underweight relative to height and
indicates a weight deficit associated with acute starvation
and/or severe disease.
 Acute, short-term malnutrition does not affect the height, but
the body weight.
 This is seen as “Wasting” of the body, i.e. loss of body mass
compared to the body size.
 Weight-for-height is therefore a useful indicator for assessing
body wasting.
 For this, age does not need to be known.

22. Weight for height (WFH)
A child with a low weight-for-height is thin
Extreme thinness is called wasting and is generally the result of:
 Acute (or short) periods of insufficient dietary intake
 Repeated episodes of illness such as diarrhoea
 Failure to gain weight or actual weight loss

23. Con...
• Advantage of WFH
An advantage of WFH over other indices of anthropometric status is
that there is no need to collection information on the age of the
child.
This is particularly useful in situations where dates of birth are not
registered.
The two extreme forms of severe wasting, kwashiorkor and
marasmus, occur in situations of extreme undernutrition.

24. Thin, flaccid skin
hanging in folds (baggy
pants)
Normal hair
Source: NutritionWorks
marasmus
Oedema (symmetrical oedema
involving at least the feet)
Moon face No appetite
Severe wasting prominent
ribs, spine, scapulae ,
Old man face
Alert and irritable

25. Application of WFH
1. Weight in individual children and population groups may
exhibit marked seasonal patterns associated with changes in
food availability or disease prevalence.
Attention: In non-emergency situations, the highest prevalence
of wasting generally occurs in young children 12–24 months
of age.

26. Con…
2. Among individual children, W/H is a useful index
 For assessing nutrition status under famine conditions and
 For identifying short-term nutrition problems in non-emergency
situations.
 Wasting is the usual indicator of choice for targeting treatment of
diarrheal and other diseases.
 High W/H (> +2 Z-scores) is used to screen children at risk for
developing obesity & future related morbidity such as heart disease.

27. Con…
Weight is influenced both by height and thinness.
Low W/A (underweight) is a combination indicator of H/A and W/H.
W/A is the most commonly reported anthropometric index & used frequently :
Monitoring growth &Identifying children at risk of growth failure & malnourished
Index of acute malnutrition (current nutritional status ) in children 6 months to
seven years of age when the measurement of length is difficult
Guide preventive measures such as nutrition counseling and entry into short-term
food supplementation programs.
Assessing the impact of intervention actions in growth Monitoring programs.

28. Skin fold thickness
 Measured by Skinfold callipers to measure the thickness of .
 The double thickness of the skin
 Subcutaneous fat
 The three most common sites for measurement are:
 Over the triceps skinfold sites
 In the sub-scapular skinfold sites
 Suprailiac skinfold sites
 The measurement is of considerable value in assessing the amount of fat & therefore the reserve
of energy in the body.
Using constant pressure
applied over a known area.

30. Triceps skinfold measurement

31. Sub-scapular skinfold measurement

32. • D. Mid-upper arm circumference (MUAC)
 MUAC is a better indicator of mortality risk associated with malnutrition
than Weight-for-Height. It is therefore a better measure to identify children
most in need of treatment.
 MUAC is simple, cheap, more sensitive and less prone to mistakes.
 Appropriate cut-off points of MUAC for children between 6 to 59 months
are given below:
Children
>13.5 cm
12.5 to13.5 cm
Normal
At risk of acute malnutrition
11.5 to 12.5 cm
<11.5 cm
Moderate acute malnutrition
Severe acute malnutrition

33. • C. Mid-upper arm circumference (MUAC) for Adults
• As with children, MUAC can be used to grade the degree
of body wasting in adults.
• Appropriate cut-off points of MUAC for adults are given
below:
Male
≥23 cm
<23 cm
Normal
Malnourished
Female
≥22 cm
<22 cm
Normal
Malnourished

34. Mid-upper Arm Circumference(MUAC)
MUAC is a proxy indicator of nutrient reserves and Wasting
Measurement is not time consuming, and is an effective predictor of risk of U5(under five)
death
MUAC has been endorsed as an independent admission criterion for nutrition programmes
addressing SAM.(seveier acute malnutrition)
The cut-off was recently modified from less than 11cm to less than 11.5 cm for classification
of SAM

35. How to measure MUAC
 The MUAC is always taken on the left arm.
 Measure the length of the child’s left upper arm, between the bone at the top of the shoulder and the elbow bone
(the child’s arm should be bent)
 Mark the middle of the child’s upper arm with a pen.
 The child’s arm should then be relaxed, falling alongside his/her body.
 Wrap the MUAC tape around the child’s arm, such that all of it is in contact with the child’s skin (It should be neither too tight,
nor too loose)
 The measurement is read from the middle window where the arrows point inward.
 Read the MUAC in millimetres (mm) (MUAC varies little at any given age)
 MUAC can be recorded with a precision of 1 mm

37.  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)/
Height (m²)
Evidence shows that high BMI (obesity level) is associated with
type 2 diabetes & high risk of cardiovascular morbidity & mortality

38. • Measurements for adults Height:
The subject stands erect & bare footed on a stadiometer with a movable head
piece.
The head piece is leveled with skull vault & height is recorded to the
nearest 0.5 cm.
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 100 gm (0.1kg)

39. Body Mass Index (BMI)
• BMI range Diagnosis
<16 Underweight (grade 3 thinness)
16–16.99 Underweight (grade 2 thinness)
17–18.49 Underweight (grade 1 thinness)
18.5–24.99 Normal range
25.0–29.99 Overweight (pre-obese)
>30 Obese

40. BMI (WHO - Classification)
BMI < 18.5 = Under Weight
BMI 18.5-24.5 = Healthy weight range
BMI 25-30 = Overweight (grade 1 obesity)
BMI 30-40 = Obese (grade 2 obesity)
BMI >40 =Very obese (morbid or grade 3 obesity)
• Weight in kilos divided by the square of height in meters
• Used to define thinness & overweight in adults

42.  Advantages of Anthropometry
– Objective with high specificity & sensitivity
– Measures many variables of nutritional significance (Ht, Wt, MAC, skin fold thickness, waist & hip ratio &
BMI).
– Readings are numerical & gradable on standard growth charts
– Non-expensive & need minimal training
 Limitations of Anthropometry
 Inter-observers errors in measurement
 Limited nutritional diagnosis
 Problems with reference standards, i.e. local versus international standards.
 Arbitrary statistical cut-off levels for what considered as abnormal values.

43. Biochemical / Laboratory methods
 Most objective and quantitative method of nutritional assessment
 Used primarily to detect sub-clinical deficiency states or to
confirm a clinical diagnosis
 Involves measurement of:
Total amount of the nutrient in the body, or
Concentration in a particular storage site (organ) in the body
or in the body fluids.

44. Con…
Laboratory Tests, A fourth way to detect a developing deficiency,
imbalance, or toxicity is to take samples of blood or urine, analyze them in
the laboratory, and compare the results with normal values for a similar
population.
• Laboratory tests are most useful in uncovering early signs of malnutrition
before symptoms appear.
• In addition, they can confirm suspicions raised by other assessment
methods.

45. Purpose of Biochemical tests
1. To recognize acute malnutrition for which the clinical
signs are non-specific, e.g. potassium deficiency.
2. To confirm the clinical diagnosis of a deficiency disease,
e.g. xerophthalmia, scurvy, beri-beri , rickets, kwashiorkor
3. For monitoring nutritional management in intensive
care

46. Con…
4. In community nutrition surveys, to detect Subclinical micro nutrient deficiency, e.g.
iodine deficiency, iron deficiency.
5. To demonstrate objectively the response to a nutrition education program
E.g. Reduction of plasma cholesterol or of urinary Sodium.
6. To diagnose nutritional supplement overdosing
E.g. with vitamin A
RCMDD(recommend)

47.  Advantages of Biochemical Method
It is useful in detecting early changes in body metabolism & 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.
 Limitations of Biochemical Method
Time consuming
Expensive
They cannot be applied on large scale
Needs trained personnel & facilities

48. • Physical Examinations,
A type of nutrition assessment technique is a physical examination looking for clues to
poor nutrition status.
Visual inspection of the hair, eyes, skin, posture, tongue, and fingernails can provide
such clues.
The examination requires skill because many physical signs and symptoms reflect more
than one nutrient deficiency or toxicity—or even non-nutrition conditions.
Like the other assessment techniques, a physical examination alone does not yield firm
conclusions.

49. It is an essential features of all nutritional surveys
It is the simplest & most practical method of ascertaining the nutritional status of a group of individuals
It utilizes a number of physical signs, (specific & non specific), that are known to be associated with
malnutrition and deficiency of vitamins & micronutrients.
Good nutritional history should be obtained
General clinical examination, with special attention to organs like hair, angles of the mouth, gums,
nails, skin, eyes, tongue, muscles, bones, & thyroid gland.
Detection of relevant signs helps in establishing the nutritional diagnosis

50. physcal methods
Used to:
Detect deviations from the normal state of nutrition
By observing and interpreting clinical signs and symptoms of
deficiency or excess.
Medical History and Physical Examination
Useful during advanced nutritional depletion; when obvious disease is present

51. Classification of physical signs
WHO classifies physical signs into three:
Signs indicating a probable deficiency of one or more of the
nutrients
Signs indicating probable long- term malnutrition in
combination with other factors
Signs not related to nutritional status

52. physical methods . . . .

53. 2. Dietary Assessment
• Nutritional intake of humans is assessed by five different methods.
– 24 hours dietary recall
– Food frequency questionnaire
– Dietary history since early life
– Food dairy technique
• 24 Hours Dietary Recall
A trained interviewer asks the subject to recall all food & drink taken in the
previous 24 hours.
It is quick, easy, & depends on short-term memory, but may not be truly
representative of the person’s usual intake

54.  Food Frequency Questionnaire
In this method the subject is given a list of around 100 food items to indicate his or her
intake (frequency & quantity) per day, per week & per month.
 Advantages
inexpensive, more representative & easy to use.
 Limitations:
 long Questionnaire
 Errors with estimating serving size.
 Needs updating with new commercial food products to keep pace with changing dietary
habits.

55.  Dietary History
It is an accurate method for assessing the nutritional status.
The information should be collected by a trained interviewer.
Details about usual intake, types, amount, frequency & timing needs to be obtained.
Cross-checking to verify data is important.
 Food Dairy
Food intake (types & amounts) should be recorded by the subject at the time of consumption.
The length of the collection period range between 1-7 days.
Reliable but difficult to maintain.

56. Dietary Assessment
 Encompasses food consumption at the :
National level (e.g., food supply and production),
Household level
Individual level.
Employed to assess
The first stage of a nutritional deficiency
During which time the dietary intake of one or more nutrients is
inadequate because of primary or secondary deficiency.

57. Steps in the assessment of food and nutrient intakes
1. Measuring food intake
 Factors affecting selection of dietary method
 Control of measurement errors
2. Converting foods to nutrients
 Converting portion sizes to weight equivalents
 Compiling or augmenting a local food composition database
3. Estimating intakes of available nutrients
4. Evaluating dietary adequacy
Note: This process assesses ‘risk’ of nutrient inadequacy and not nutritional
status

58. Measuring food consumption at individual/group level
1. Methods used to assess current intake(Q1)
 Dietary/Weighted record method (Quantitative)
(Weighed/Observed Record method)
2. Methods used to assess past intake(Q2)
 Twenty-four-hour recall method (Quantitative)
 Dietary history (Qualitative)
 Food frequency questionnaire (Qualitative)

59. A) Dietary/Weighted record method
 Most precise method for assessing food intakes of individuals
 Respondent or research assistant weighing and recording
 All foods consumed including drinks and occasional food consumed away from home during a specified time
period
 Both portion sizes consumed and left over
 Using a scale or house-hold measures (e.g., cups or tablespoons)
 Estimated, using models, pictures
 Details of methods of food preparation are also recorded

60. B) 24 Hours Dietary Recall
 Subjects/care takers are asked to recall the exact food intake
during the previous 24hrs/preceding day
 Including all beverages, snacks, supplements ...
 Portion sizes are estimated by different methods

61. Considerations when conducting 24-hr recalls
 Recall interviews can be conducted on adults and older children
 Youngaer children (e.g., 4 - 8 years ) interviewed along with their primary
caretaker(s): i.e., consensus recall
 Preferable to conduct interviews in subject’s home
Encourages participation
Improves accuracy of recall
Facilitates calibration of local household utensils

62. Multiple - pass 24-hr recall: 4 steps
Step 1:
List all foods and drinks consumed sequentially during the preceding
24-hrs starting at the time of waking
Step 2:
Describe in detail each food listed by using list of specific food probes
and prompts
Probe/Recall information on ingredients of mixed dishes

63. Con....
Step 3:
 Estimate portion size of each food item consumed
 Cooked /raw, cooking method, edible/non-edible portion, served/consumed )
Step 4:
 Review recall to check all items are recorded correctly
 Check foods listed against picture chart; check recipes
 Check whether recall was a “usual” day

64. Advantages and limitations of recalls/records
Advantages 24-h recall Limitations 24-hr recall
Quick, cheap (4-6 interviews/d)
Large coverage;
 Low respondent burden
High response rate; non-threatening
Used for illiterate subjects
Surprise so less likely to alter diet
Relies on memory and motivation
Inaccuracies in portion size estimates
Inaccuracies when eating from
common pot and for mixed dishes
Relies on skill of interviewer
May omit foods consumed
infrequently; Under-reporting occurs
Advantages of weighed record Limitations of weighed record
Does not rely on memory
Easier method ; less training
Accurate data on portion sizes and mixed dishes
One can obtain accurate data on hygiene,
sanitation
Invasive; respondent burden may be
high; labor intensive; expensive
Recording may change eating pattern
Under-reporting may occur
Only literate subjects can complete
record
Advantages & limitations of recalls/records

65. Modified Dietary History
 Three-day estimated record
Usual portion sizes of most commonly consumed foods on
3 days weighed: 1- weekday; Saturday; Sunday
Weighted daily average intake calculated:
((5 x weekday) + Saturday + Sunday) / 7

66. Con...
Advantages
- Give the dietary habits over a longer periods of time
- Can target questions to specific dietary habits or intake of specific nutrients of interest (e.g. Alcohol intake, fat intake)
- Used for counselling patients
- Less respondent burden
Disadvantages
- Over emphasizes the regularity of the dietary pattern
- Very difficult to validate(no standardized method)
- Needs a very highly trained interviewer
- Gives just a relative if not an absolute information
- Time consuming : up to 2 hours

67. Historical information
Historical Information, One step in evaluating nutrition status is
to obtain information about a person’s history with respect to
health status, socioeconomic status, drug use and diet.
The health history reflects a person’s medical record and may
reveal a disease that interferes with the person’s ability to eat or
the body’s use of nutrients

68. con...
The person’s family history of major diseases is also noteworthy,
especially for conditions such as heart disease that have a genetic
tendency to run in families Economic circumstances may show a
financial inability to buy foods or inadequate kitchen facilities in
which to prepare them.
Social factors such as marital status, ethnic background, and
educational level also influence food choices and nutrition status.

69. con...
A drug history, including all prescribed and over-the-counter
medications, may highlight possible interactions that lead to nutrient
deficiencies.
A diet history that examines a person’s intake of foods, beverages,
and dietary supplements may reveal either a surplus or inadequacy of
nutrients or energy.
Anthropometric Measurements, A second technique that may help

70. Food Allergy - a condition in which the body’s immune system reacts to
substances in some foods. Here communities are prone for allerges
• Allergies to peanuts, tree nuts, eggs, wheat, soy, fish, and shellfish.
• These reactions may include rash, hives, or itchiness of the skin;
vomiting, diarrhea or abdominal pain; or itchy eyes and sneezing.

71. • Foodborne Illness – A term that means a person has food poisoning.
 To prevent foodborne illness you should clean, separate, cook and chill food when
handling it.
 A foodborne illness can result from eating foods contaminated with pathogens or
poisonous chemicals.
 The symptoms from the most common types of food poisoning generally start within 2
to 6 hours of eating the food responsible.
 The possible symptoms include: nausea/vomiting, abdominal cramps, diarrhea,
weakness, fever and headache.

72. Food Intolerance - a negative reaction to a food or part of a food
caused by a metabolic problem.
• The inability to digest parts of certain foods or food
components.
• May be associated with certain foods such as milk or wheat,
or even with some food additives.
• Common symptoms include nausea, vomiting, diarrhea, and
fever.

73. THE END