Overview of Nutritional
assessment and surveillance
assessment systems, methods,
indices and ethical issues
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Introduction
Nutritional assessment
interpretation of information obtained from dietary,
biochemical, anthropometrics and clinical studies.
Information is used to determine the health status of
individuals or population groups as influenced by
their intake and utilisation of nutrients
• nutritional status is often a result of many inter-
related factors
• emphasis: simple, non-invasive approaches that can
measure risk of inadequacies and excesses
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Introduction
Nutritional surveillance
• is the ongoing systematic collection, analysis and
interpretation of outcome-specific data for use in
the planning, implementation and evaluation of
health and nutritional programmes
o closely monitoring of indicators that measure
nutritional status gives a better understanding of
the evolving situation of a vulnerable population
• surveillance data are used to inform appropriate
response strategies
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Introduction
• Nutritional assessment procedures were first used
in surveys designed to describe the nutritional
status of populations on a national basis
o methods were initially described after a conference held
in 1932 by Health Organization of the League of Nations
• Many countries now collect data on nutritional
status of the population
o In some countries, data are collected on an ongoing
basis using nutrition surveillance systems
o Assessment systems used to target high-risk population
(low-income mothers, children < 5yrs, pregnant women),
but now all groups are covered due to increased
awareness of role of nutrition in health
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Introduction
• Nutritional status is a well-recognised outcome
indicator of human welfare and economic
development
o commonly used by international organisations
World Bank WHO, FAO, UNICEF to evaluate the
economic and social progress of countries
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Nutritional assessment systems
Nutritional assessment systems (information systems)
• collect, analyse, interpret and report on information
about the nutritional status of populations and
most importantly are used to inform appropriate
response strategies
• utilise a variety of methods to characterise each
system in the development of a nutritional
deficiency state
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Nutritional assessment systems
Nutritional assessment systems take one of the
following forms:
• Surveys
• Surveillance
• Screening
• Interventions
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Nutritional assessment systems
Nutrition surveys
assessed by means of a cross-sectional survey, which
establish baseline nutritional data on the extent of
existing nutrition problems and/or ascertain overall
nutrition status of the population
• a necessary first step in an investigation of causes
• identify and describe subgroups ‘at risk’ of chronic
or acute malnutrition
• allocate resources to groups in need
• formulate policies to improve overall nutrition of
the population 8
Nutritional assessment systems
Nutrition surveillance
• a continuous monitoring of nutritional status of
selected population groups
• differ from surveys because data are collected,
analysed and utilised for an extended period of
time. Sometimes, only data for specific at-risk
subpopulation groups identified in earlier nutrition
surveys are collected
• identify possible causes of malnutrition, then
formulate and initiate intervention measures
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Nutritional assessment systems
Nutrition surveillance
• monitor effect of government policies and evaluate
efficacy/effectiveness of nutrition intervention
programmes
Other objectives of surveillance are:-
o Formulation of predictions on the basis of current trends
o Evaluation of effectiveness of nutrition projects,
research-oriented interventions
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Nutritional assessment systems
Nutrition screening
• identifies malnourished individuals requiring
intervention
• involves a comparison of individual’s measurements
with predetermined risk levels or “cut-off” points
• screening programmes are generally less
comprehensive than surveys or surveillance studies
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Nutritional assessment systems
Nutrition screening
• screening can be carried out on whole population,
targeted to specific individuals or sub-population
considered to be at risk
o commonly used in medical settings using validated
tools
o utilises medical diagnosis, medical record, physical
measurements, lab reports, diet history
o early indicators of a problem: unintentional weight
loss, appetite and diet changes, mental condition,
medical problems, etc
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Nutritional assessment systems
Nutrition interventions
often target subgroups identified as “at-risk” during
nutrition surveys or nutrition screening
Examples of nutrition interventions:
i. Supplementation (food, nutrients)
ii. Fortification/Bio-fortification
iii. Dietary/Food-based approaches
iv. Nutrition education
v. Health-related programmes (hygiene, sanitation)
………. home/school gardens, micro-credits, etc
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Methods used in nutritional assessment
Direct methods (deal with individuals, measure
objective criteria)
• Dietary
• Biochemical
• Anthropometry
• Clinical
Indirect methods (use community health & food
production indices related to nutrition)
• Vital health statistics (demography, morbidity, mortality)
• Ecological factors (crop production, food situations, etc)
• Other factors related to nutrition and health
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Evaluation of nutritional assessment indices
evaluated by comparing collected data with reference
values, reference distribution, reference limits drawn
from reference population
predetermined cut-off points can be used to relate
levels of indices to low body stores of the nutrient,
impaired function, and/or clinical signs of deficiency
Example BMI cut-off points (adults)
severe undernutrition (<16.0 kg/m2)
moderate undernutrition (16.0-16.99 kg/m2)
mild undernutrition (17-18.49 kg/m2)
normal (18.5-24.9 kg/m2 )
overweight (25-29.9 kg/m2 ), obese (≥ 30 kg/m2 )
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Evaluation of nutritional assessment indices
• uses of cut-off points is less frequent than
reference limits because information relating
indices and signs of deficiency is often not
available
o can be used to represent degree of depletion
(deficient, low/marginal,
acceptable/adequate)
o common in dietary assessment when
Recommended Nutrient Intakes (RNI) are used
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Evaluation of nutritional assessment indices
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Questions? Clarification?
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Ethical issues
…….. learning about standards of conduct of studies and
research involving human subjects
ethical considerations date back to the trials of war
criminals (Nazi doctors) in human experimentation after
the Second World War, resulted in Nuremberg Code 1947
Primary concern of investigators/researchers
• Respect for persons as autonomous agents
• Beneficence: an obligation to i) do no harm, ii)
maximize research benefits
• Justice: who is to receive benefits of research and bear
the burdens i.e. distributive justice
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Ethical issues
• investigator need to use all available information to
ensure safety of participants:
o identify potential risks, establish means of
minimising risks and continue to monitor the
ongoing research for adverse events experienced
by subjects
o investigator must be prepared to stop the study if
serious unanticipated risks occur
IRON supplementation to control iron deficiency
anaemia in malaria-endemic areas also increases risk of
malaria and other infections
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Ethical principles
1. Scientific merit of the study/research
designed and conducted such that results provide
answers to research questions being addressed;
achievement of objectives are linked to improved
health/nutrition
2. Equitable selection of participating subjects
benefits and burdens distributed equitably among
participating individuals/communities; no single
subgroup (disadvantaged, vulnerable, minority)
should bear a disproportionate share of risks
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Ethical principles
3. Informed consent (individual level)
• participant agrees to take part after being informed
about the study, had opportunity to carefully consider
risks, benefits and ask relevant/important questions
(i.e. makes informed choice)
o uses a form consisting of 2 parts: information sheet
about the study/research and the consent certificate
o participant signs (written informed consent) or
agrees verbally (verbal informed consent) to
participate
• each study group (e.g. healthcare workers, patients,
parents of children) should have a tailored consent 22
Ethical principles
Components of valid Informed consent
i. Disclosure: Informed consent document must be
open and make clear about:
nature and purpose of study/research
procedures to be used
expected benefits to participants and/or society
potential of reasonably foreseeable risks, stresses
and discomforts
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Ethical principles
ii. Understanding: participant must understand what
has been explained and must be given opportunity
to ask questions and have them answered by
someone fully conversant in the study particulars
iii.Voluntariness: participant's consent to participate
in the study/research must be voluntary, free of
any coercion or wrong promises of benefits;
participant may withdraw from the study and
discontinue participation at any time without
penalty 24
Ethical principles
iv.Competence: participant must be competent (i.e.
cognitive capacity) to give consent. If participant
is not competent due to mental status, disease or
emergency, a designated surrogate may provide
consent if it is in the participant's best interest to
participate
v. Consent: potential human subject must authorise
his/her participation in the research study,
preferably in writing, or verbal/oral
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Ethical principles
4. Communal consent involving leaders from
different levels (village, district, etc)
community leaders may take decisions about
individual participation in a study
communities are heterogeneous may have
different leaders and boundaries and factions with
own leaders whose co-operation must be sought;
consult all, public meetings conducted by
recognised leaders may be useful
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Ethical principles
5. Confidentiality of information collected
all information collected should remain confidential;
inform how confidentiality will be maintained
(assigning numbers to names, summarising data),
who within the study team will have access,
information only released to others with clear
consent of participants
6. Anonymity of communities being investigated
same rights of confidentiality should apply to
communities as to individuals; participants should
have access to reports before they are published; a
community may remain anonymous if sensitive
behaviours are discussed e.g. sexuality, crime, etc 27
Ethical principles
7. Coercion/Respect
• coercion (force, intimidation) and deception
(dishonesty, fraud), even if rationalised as “good,”
are unacceptable
• treat participants as autonomous individuals, obtain
their informed consent without coercion, their
welfare and rights must be respected
• treating participants as partners and collaborators
(not passive source of data) improve scientific
quality of study by adhering to study conditions
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Ethical principles
8. Potential benefit and risk of harm need to be
considered regardless of short-term benefits
minimise risks and maximise benefits in all
participating subgroups; possibility of long-term
harm (e.g. cancer) must be considered even if
there are some attractive short-term benefits
9. Incentives
avoid bribing/coercion; no absolute rules as to
what are acceptable but review each situation on
its merits in the local context e.g. positive
incentives: sugar, soap (associated with visits),
reimburse bus/taxi fares, etc
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Ethical principles
10. Feedback of results to participants/communities
inform participants/communities of the results,
ensure they understand implications of the findings;
give specific recommendations
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Ethical issues
Qualities of a good investigator
be Honesty in all communications (methods,
procedures, data reporting, publication); no data
fabrication or falsifying; no deception to colleagues,
granting agencies, the public if serious unanticipated
risks occur
maintain Integrity: keep promises, agreements; act
with sincerity; strive for consistency of thought, action
be Careful and Confidential: avoid careless errors,
negligence; keep good records of research activities;
protect confidential communications
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Ethical issues
Qualities of a good investigator
be Objective: avoid bias in all aspects of research
where objectivity is expected, required (design, data
analysis & interpretation, recruiting personnel, etc);
disclose personal or financial interests that may affect
research
be Open: share data, results, ideas, tools, resources;
be open to criticism and new ideas
follow Legal procedures: know and obey relevant laws
and institutional and governmental policies
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Ethical issues
Qualities of a good investigator
respect for Intellectual Property: honour patents,
copyrights and other forms of intellectual property;
do not use unpublished data, methods or results
without permission; give credit where credit is due;
acknowledge all contributions to research, never
plagiarise
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Ethical issues
• ethical considerations impose on many aspects of
the study design and conduct of research
• research involving human subjects must satisfy
formal ethical review committees (e.g. Institutional
Review Boards (IRB) e.g. Tanzania-National
Institute of Medical Research, MUHAS, COSTECH)
• committees will have to approve study plan or
research protocol and procedures
• submission should indicate clearly how ethical
implications of the study have been given full
consideration by the researcher(s)
o multiple applications (> 1 institute) may be required
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Ethical issues
• Each IRB has own submission requirements. In most
cases the submitted package should contain a covering
letter, study protocol/proposal, informed consent
forms, ethical clearance fee, curriculum vitae of
investigators, Material Transfer Agreements (if samples
will be moved outside host country), Data Transfer
Agreement (if data will be moved outside host
country), etc
• after permission to conduct research is given,
investigators need to submit progress reports
• after the study, participants are entitled to be informed
about the outcome and to share any benefits that
result from it
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Ethical issues
• critical to the conduct of a successful study is that
o the study population cooperates well during the study
and accepts conditions of the study
o respondents must feel a part of the study and perceive
it to be for their benefit
• to guarantee these aspects:
o careful planning before the study begins
o appropriate explanation and discussion with
community leaders and participants themselves
o obtain informed consent from each participant or
community leaders
o monitoring of the study 36
Ethical issues
Common ethical problems
i. Deception in gaining the cooperation of participants
ii. Invasion of privacy
iii. Violation of confidentiality
iv. Coercion/intimidation
v. Empty promises made to respondents
vi. Injury or harm to participants, whether physical,
psychological, economic, social or political
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Questions? Clarification?
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