NUR412 Nutrition & Dietetics

Week 2: Dietary and nutritional assessment, planning,

intervention and evaluation
Learning Objectives
After completion of this session, you will be able to:
• Describe different forms of dietary and nutritional assessment
• Identify the ways in planning nutritional intervention
• Recognize the different forms of intervention methodologies
• State different ways of evaluating in intervention
Topics Covered
• Dietary and nutritional assessment
• Nutritional planning
• Implementation
• Evaluation
Introduction to Nutrition and Dietetics
What is nutrition?
Nutrition is the branch of science that studies the process by which
living organisms take in and use food for the maintenance of life,
growth, reproduction, the functioning of organs and tissues, and the
production of energy.
Public health nutrition
Usually described as the “the promotion of good health through
nutrition and the primary prevention of nutrition-related illness in the
population”. Emphasis is on maintaining the wellness of the population
through applying public health principles to influence food and
nutrition systems. There is no internationally agreed definition.
Nutrition in Health Care
Correcting nutrition problems, however, may improve both short- and
long-term outcomes of medical treatments and help to prevent
complications.
Malnutrition – especially with acute illness.
Poor nutrition status – weakens immune function & compromises a
person’s healing ability.
Complications of malnutrition – lengthen hospital stays and increase
the overall cost of patient care.
Ways in which illness can affect nutrition status

anorexia, nausea, pain

mouth ulcer, chewing &
Restrictive diets, surgical
problem of GI tract, side
Reduced
swallowing difficulty,
stress
effects of medications food intake
Ways in which illness can affect nutrition status

Inflammation of GI tract,
insufficient of secretion
Radiation therapy; GI Impaired
surgery; side effects of
of digestive enzymes or
medications on GI digestion and
bile salt; alter in GI
structure or function
structure or function absorption
Ways in which illness can affect nutrition status

elevated metabolic rate; Chemotherapy; use of

muscle wasting; changes diuretics (increased Altered nutrient
in hydration; nutrient urination and nutrient
losses due to excessive excretion); side effects of metabolism and
bleeding, diarrhea, or other medications (can excretion
frequent urination affect nutrient function)
Responsibility for Nutrition Care
Physician: prescribe diet orders & other instructions related to nutrition
care, including referrals for nutrition assessment & dietary counseling.
Nurses: interact closely with patients, screen patients for nutrition
problems and participate in nutrition and dietary assessments. As
members of nutrition support teams.
Dietitians: a food & nutrition expert who is qualified to provide medical
nutrition therapy, can conduct nutrition & dietary assessment; diagnose
nutrition problems; develop, implement & evaluate nutrition care plans,
order patient diets, plan & approve menus, and provide dietary
counseling and nutrition education services.
The Nutrition Care Process
• Dietitian : systematic
Nutrition
approach to medical assessment

nutrition therapy called the

nutrition care process
Nutrition
Nutrition
monitoring screening Nutrition
and diagnosis
evaluation or
referrals

Nutrition
intervention
Nutrition Assessment
• Community-Level Assessment
• Clinical/Physical Assessment
• Dietary Assessment
Community-Level Assessment

• A target community’s “state of nutritional health” can

generally be estimated using existing vital statistic data,
seeking the opinions of target group members and local
health experts, and making observations.
• Information gathered from community-level nutrition
assessment can be used to develop community-wide
programs addressing specific problem areas, such as
childhood obesity or iron-deficiency anemia.
• Nutrition programs should be integrated into community-
based health programs.
Individual-level Nutrition Assessment
• Clinical/physical assessment
• Dietary assessment
• Anthropometric assessment
• Biochemical assessment
Clinical/physical assessment
• Involves visual inspection of person by a trained registered
dietitian nutritionist (RDN) or other qualified professional
to note features that maybe related to malnutrition.
Nutrition Assessment
• Collection & analysis of

• Information

• Interview:
Nutrition Diagnosis
• PES statement: (P): specific problem, (E):etiology or cause,
(S): signs & symptoms that provide evidence of problem
• Like nursing diagnoses, a nutrition diagnosis can change
during the cause of an illness
Nutrition Intervention
• Include counseling or education about appri0prate dietary and
lifestyle practices, a change in medication or other treatment, or
adjustments in the meals or services offered to hospital patient.
• Need to set goal which is measurable.
Nutrition Monitoring and Evaluation
• Must be evaluated periodically and closely. Sometimes a
new situation alters nutritional needs.
• The nutrition care plan must be flexible enough to adapt to
the new situation.
• The care plan could be redesigned and take into account the
reasons why the plan was not successful.
Historical Information
Medical History Medication & Personal & social Food & nutrition
supplement history history history

Age Prescription drugs Cognitive abilities Food intake

Current complaint(s) Over-the-counter drugs Cultural/ethnic identity Food availability

Past medical problems Dietary & herbal Educational level Recent weight changes
supplements
Ongoing medical Employment status Dietary restrictons
treatments
Surgical history Home/family situation Food allergies or
intolerances
Family medical history Religious beliefs Nutrition and health
knowledge
Chronic disease risk Socioeconomic status

Mental/emotional health Use of tobacco, alcohol, Physical activity level and

status or illegal drugs exercise habits
Medical History
• History helps to identify health problems or medical
treatments that may interfere with food intake or require
dietary changes; e.g. AIDS, cancer DM, liver disease,
malabsorption.
• The medical history generally includes the family medical
history as well; this information may reveal genetic
susceptibilities for diseases that can potentially be
prevented with dietary and lifestyle changes.
Medication and supplement history
• A number medications can have detrimental effects on
nutrition status, and various components of foods and
dietary supplements can alter the absorption and
metabolism of drugs.
Personal & Social History
• These 2 factors can influence both food choices and the ability to
manage health and nutrition problems. E.g., cultural
background or religious beliefs can affect food preferences,
whereas financial concerns may restrict access to health care &
nutritious foods.
• Some individuals may depend on others to prepare or procure
food. A person who lives alone or is depressed may eat poorly or
be unable to follow complex dietary instructions.
• Patients use of alcohol, tobacco, or street drugs may alter food
intake or have disruptive effects on health and nutrition status.
Food and Nutrition History
• It includes information about food intake, lifestyle habits
and other factors that may affect food choices, such as food
allergies or beliefs about nutrition and health.
• Interview: 24-hour dietary recall, & a survey about usual
food choice (such as a food frequency questionnaire).
• In hospital: direct observation in the food intake
Dietary Assessment
• Obtaining accurate food intake data.

1. 24-hour dietary recall

2. Food frequency questionnaire
3. Food record/dietary history
4. Direct observation
5. The healthy eating index
24-hour dietary recall
Guided interview in which the foods and beverages consumed in a 24-hr
period are described in detail

Advantages Disadvantages
❖ Results are not dependent on literacy or ❖ Process relies on memory.
educational level of respondent. ❖ Underestimation & overestimation of
food intakes are common.
❖ Interview occurs after is consumed, so
method does not influence dietary ❖ Food items that cause
choices. embarrassment(alcohol, desserts) may be
omitted.
❖ Results are obtained quickly; method is ❖ Data from a single day cannot accurate
relatively easy to conduct. represent the respondent’s usual intake.
❖ Seasonal variations may not be
❖ Method does not require reading or addressed.
writing ability.
❖ Skill of interviewer affects outcome.
Food frequency questionnaire
Written survey of food consumption during a specific period of time, often a 1-
year period

Advantages Disadvantages
❖ Process examines long-term food ❖ Process relies on memory.
intake, so day-to-day & seasonal
❖ Food lists often include common foods
variability should not affect results. only.
❖ Questionnaire is completed after food ❖ Serving sizes are often difficult for
is consumed, so method does not respondents to evaluate without
influence food choices assistance.

❖ Method is inexpensive to administer. ❖ Calculated nutrient intakes may not be

accurate
❖ Food lists for the general population are
of limited value in special populations
❖ Method is not effective for monitoring
short-term changes in food intake.
Food record
written account of food consumed during a specified period, usually several
consecutive days. Accuracy is improved by including weights or measures of foods

Advantages Disadvantages
❖ Process does not rely on memory. ❖ Recording process itself influences
food intake.
❖ Recording foods as they are consumed
may improve accuracy of food intake ❖ Underreporting & portion size errors
data. are common.
❖ Process is time-consuming &
❖ Process is useful for controlling intake burdensome for respondent; requires a
because keeping records increases high degree of motivation.
awareness of food choices.
❖ Method requires literacy & the physical
ability to write.
❖ Seasonal changes in diet are not taken
into account
The weighed inventory (weighed dietary record)
• The weighed inventory: a record of all food eaten by the subject
during a period, usually 7 days, is weighed and record
• “good standard” of quantitative dietary assessment methods
• A prospective method
• Actual nutrient intakes are calculated using data from food
composition tables
– Foods that are recorded as much as possible:
• Water
• dietary supplements
• Alcohol
• Ingredients
• Eating occasions and other relevant information
How to use the weighed dietary record
1) a set of weighing scale and record sheet for food are provided to the
client
2) The client records the description of the food, its brand, the weight
served and leftovers
3) For composite food, e.g. fruit pie, the client provides recipe details
4) For recording foods eaten in restaurant, the client needs to record
the details as much as possible
Attributes of each dietary entry
1) Temporal factors: date, day of a week and time
2) Item: food name, food code and group and recipe; home-made or
purchased
3) Quantity: amount in gram; amount in volume
4) Setting: occasion (e.g. breakfast); location; with whom; watching TV
(yes/no); sitting table (yes/no)
Strengths of the weighed dietary record
• Avoid recall bias

• Can obtain a more accurate amount of food intake

• Can show the habitual intakes

Limitations of the weighed dietary record
• Imposes great respondent burden
• The respondent must be numerate and literate
• Difficult to weigh and record food that eaten away from
• Unable to capture the foods that eaten less than once or twice a week
• May introduce reactivity bias (the respondents may alter his/her diet
to make it easier to record, or to conceal poor eating habits)
• Dietary data input and translation into nutrient data is complex
Food diaries (estimated dietary record)
• Food diaries: a prospective technique that the food eaten is simply
recorded in a notebook, without being weighed, usually for 7 days
• Comprehensive instructions are provided to the subjected with
explanation
• information to be collected including:
– Cooking methods
– Brand names
– Recipe
• The respondent needs to provide an estimate of the portion size, e.g.
spoons, cups, units, slices or recording packet weights
• The users calculate the portions eaten
Direct observation
observation of meal trays or shelf inventories before and after eating;
possible only in residential facilities.

Advantages Disadvantages
❖ Process does not rely on memory. • Process is possible only in residential
situations.
❖ Method does not influence food intake.
• Method is labor intensive.
❖ Method can be used to evaluate the
acceptability of a prescribed diet.
The diet interview
• The diet interview: a technique used by dietitian to obtain a general
picture a person’s food intake
• It required a skilled person to obtain an accurate picture of a person’s
diet history
• Time frame: usually 7 days
• The interview may be more or less detailed, depending the diet
information required
• A checklist of food maybe used to remind the respondents about
foods that they ate
Sample questions in the diet interview
• Questions about daily eating pattern
– E.g. what do you usually have for breakfast, mid-morning, lunch etc.

• Questions to focus on the current or previous intake

– E.g. what did you have breakfast, mid-morning, lunch, etc. today or yesterday?
Limitations of the diet interview
• Required both a skilled interviewer and a subject with a reasonable
memory
• Time-consuming to complete interview and perform data analysis
• Not suitable for children and elderly with failing memory
• May introduce recall bias
Issues in dietary assessment methods
• Misreporting
• Measurement errors, bias and precision
• Validity
Misreporting
• Misreporting can occur through errors or memory lapses
• Intentional misreporting is common
– Example: obese people report eat less
thin people report eat more
The healthy eating index
• HEI: based on 10 dietary
components
• The components are
assigned scores based on
the extent to which diets
meet recommended
standards of intake
• A valid tool for assessing
dietary quality
Measurement errors, bias & precision
• Two types of errors occurring during dietary assessment:
– Random errors
• Occur by chance or by mistake
• Do not affect the accuracy of the assessment tool
• Contribute to decreasing the precision of an assessment tool
• Possible to overcome the lack of precision by taking more measurements
– Systematic errors
• A flaw in study design and execution which is consistent → introduction of bias
• Make the assessment tool less accurate
• Not possible to remedy bias in dietary assessment
Accuracy and precision
•Accuracy: the closeness of a
measured value to a standard
or known value
•Precision: the closeness of
two or more measurements to
each other
 Examples of random and systematic errors in
dietary assessment
Source Random errors Systematic errors
Measurement of quantity of Occasional occur in recording portion The instruments, e.g. kitchen
food by the subject size: scales, is not properly calibrated
•forgetting to calibrate the kitchen and consistently show the wrong
scale, or amount
•writing down incorrect weights
Reporting of intake by the A food is forgotten, by mistake, on a A group of food is never (or most
subject specific occasion often)reported
Burden associated with the A high burden triggers occasional A high burden means that
study mistakes subjects adapt their diet to make
the assessment exercise more
bearable
The researcher The research changes his or her The researcher asks questions in a
interview style on a given occasion, and way that primes the subject to
elicits a different answer compared to favor certain type of answer
the standard interviewing technique
 Examples of random and systematic errors in
dietary assessment (cont’d)
Source Random errors Systematic errors
The technique used Instructions to the subject are confusing or not The method used is not adequate to
clear, leading to potential misinterpretation of measure a specific nutrient or food group
what needs to be done and, as a result, does not provide a true
picture of intake
Data analysis Tying errors are made when entering food The database has significant gaps which
quantities or food codes in a spreadsheet or leads to the under-/over-estimation of
SPSS specific nutrients in the diet
Validity
• Validity: the extent to which an instrument measures what it intends
to measure
• It is important to validate an assessment tool before use, i.e. to
evaluate the performance of a specific dietary assessment tool
• A validated assessment tool can avoid introducing bias
How to validate an assessment tool
• Compare the new assessment tool to a “Good standard” tool
– Example: food frequency questionnaire vs weighed dietary record

• Compare the new assessment tool to Biomarkers

– Example: food diary vs urinary nitrogen
Biochemical Analyses
• Help in the evaluation of PEM (Protein-Energy Malnutrition), vitamin
and mineral status, fluid and electrolyte balances and organ function
• Most values are obtained: blood & urine samples
(which contain proteins, nutrients, and metabolites that reflect various aspects of health
and nutrition status)

❖ Interpreting laboratory values: fluid imbalances may alter test values

(fluid retention dilutes substances, rehydration increase in lab values. Serum protein levels :
fluid status, infections, inflammation, pregnancy, etc.)

• Serum levels of vitamins and minerals are often poor indicators of nutrient
deficiency
Serum proteins
• Can aid in the assessment of
protein-energy status
– Metabolic stress alters serum
proteins because the liver
responds to stress by increasing
its synthesis of some proteins
and reducing the synthesis of
others
– Influenced by hydration status,
pregnancy, kidney function,
zinc status, blood loss, and
some medications
Albumin
• Most abundant serum protein & easily measured
• Routinely monitored in hospital patients
Limitations
– Slow to reflect changes in nutrition status especially for the
chronic PEM
– Not a sensitive indicator of effective treatment
Transferrin
• An iron-transport protein
• Blood concentrations respond to iron status, PEM, and
various illnesses
• Transferrin levels rise as iron status worsens and fall as iron
status improves (not for iron deficiency)
• Degrades more rapidly than albumin, but its levels change
relatively slowly in response to nutrition therapy
Transthyretin & Retinol-Binding Protein
• Decrease rapidly during PEM and respond quickly to improved
protein intakes
• More sensitive than albumin to short-term changes in protein status
• More expensive so not routinely included during a nutrition
assessment
• Limited because they are affected by a number of different factors,
including metabolic stress, zinc deficiency, and various medical
conditions
C-Reactive Protein
• Rise rapidly in response to inflammation or infection
• Often elevated in individuals with critical illness, heart disease, and
certain cancers
• Help to identify individuals at risk for malnutrition
Blood
• Blood (plasma, cells or serum) can provide the following information:
– Actual levels of nutrient in relation to expected levels (e.g. vitamin B12, folate,
carotenes, vit. C, in white blood cells)
– The activity of a nutrient-dependent enzyme (e.g. transketolase for thiamine)
– The activity of nutrient-related enzyme (e.g. alkaline phosphatase for vit. D)
– The rate of a nutrient-dependent reaction (e.g. clotting time for Vit. K)
– The presence of nutrient carrier or its saturation level (e.g. retinol-binding
protein, transferrin ,<iron>)
– Levels of nutrient-related products (e.g. lipoprotein levels reflecting saturated
fatty acid intake)
Urine
• Monitor the baseline
excretion of a water-soluble
nutrient, or to follow
excretion after a loading dose
• Assess the level of metabolites
of nutrients appear in urine
(e.g. 24-hour urine sample:
creatinine which indicate
muscle turnover rates or
nitrogen content for protein
intake)
Physical Examination

• Clinical signs of malnutrition: e.g. kwashiorkor

• Hydration status: such as fluid retention in PEM; dehydration due to vomiting etc.
• Functional assessment:
– Nutrient deficiencies sometimes impair physiological functions, so clinician
may conduct tests or procedures to evaluate some aspects of mal-nutrition
– Example PEM and zinc deficiency can depress immunity which swelling when
immune function is adequate
– Muscle weakness due to wasting(loss of muscle tissue)
– Exercise tolerance: reduced in heart & lung disorders, may be evaluated using a
treadmill or cycle ergometer
Nutritional Planning
• Once the dietitian or nurse has collected and analyzed assessment
information, the next steps of nutrition care can be carried out
• Some interventions may fall within the scope of nursing practice
whereas others require the assistance of other health professionals
• Need diet order by physician or dietitian
• The care plan involve nutrition education or counseling
 Examples of Nutrition Interventions
Intervention Examples
Food &/or nutrient delivery • Providing appropriate meals, snacks, and dietary supplements
• Providing specialized nutrition support (tube feedings or parenteral nutrition)
• Determining the need for feeding assistance or adjustment in feeding
environment
• Managing nutrition-related medication problems
Nutrition education • Providing basic nutrition-related instruction
• Providing in-depth training to increase dietary knowledge or skills
• Providing information about a modified diet or change in formula
Nutrition counseling • Helping the individual set priorities and establish diet-related goals
• Motivating the individual to change behaviors to achieve goals
• Solving problems that interfere with the nutrition care plan
coordination of nutrition of care • Providing referrals or consulting other health professionals or agencies that can
assist with treatment
• Organizing treatments that involve other health professionals or health are
facilities
• Arranging transfer of nutrition care to another professional or location
Tasks in nutritional planning
• Set goals
• Define objectives for goals
• Create quantitative targets
Setting goals and objectives
• The goals and objectives should be clearly specified in the nutritional
planning
• Goal is a statement that:
– Describes in broad terms the desired direction or outcome the intervention will achieve
– Describes the general intent of the intervention
– Provides an indication of the value underpinning the intervention. E.g. “to reduce the
number premature deaths related to a high-fat diet”

• Development of goals should be based on

– Assessment findings about reasons for and factors causing the nutrition-related
problems
Setting goals and objective (cont’d)
• Objective is:
– A statement that describes the change that must occur for the goal to be
achieved
– More specific and precise than goals
– Stated in terms of actual results rather than general terms

• Objectives must be tangible, recognizable and achievable within the

available resources and capacity
Characteristics of good objectives
• Specific
• Measurable
• Achievable
• Relevant
• Time-bound
Intervention
• this stage of process is the decision on the methodology to be used
• The methodology should take account into the following:
– Information about previous uses of this methodology & their level of success
– Flexibility & adaptability to meet the target subjects
– Constrains must be take into account
e.g. written promotional material → ? Target group can, and want to read
computer-based images → ? More appealing to young and illiterate
evaluation
• Evaluation:
1. Assesses whether the intervention objectives have been met
2. Determines if the methods used were appropriate and well-
organized
3. Feeds the finding back into the planning process to improve the
intervention
Several levels of evaluation:
– Process evaluation
– Impact evaluation
– Outcome evaluation
Evaluation
• Process evaluation assesses whether the intervention was
delivered as planned
• Impact evaluation
– measures whether the intervention objectives have been met
– considers the changes that have occurred since the intervention began and how
participants or target group think the intervention will affect their future
behavior
– commonly involves three methods: post-test only, pretest/posttest or
pretest/posttest with control group
Outcome evaluation
• Outcome evaluation
– Measures whether the intervention goal has been achieved
– Assesses the longer-term effects of the intervention
– Measures the sustainability of changes over time after the
intervention
– Is more complex, more difficult and more costly than other forms
of evaluation
What we are: BODY COMPOSITION
Assessing body composition involves:
• Quantifying overall size
• Size of major organ or tissue compartments
• Assessing the structure and nutrient or chemical contents of
tissues
All are influenced by DIET &
all affect functions
Measuring body composition
• Anthropometry: measurement of man & involves
measurement of height, weight, skin-fold thicknesses,
circumference, and various lengths and breaths of the body.
(require relatively cheap equipment and are widely used in
clinical practice.
• Purpose of anthropometrics: to assessing growth and body
fat distribution.
Anthropometric measurements
1. Body mass index
2. Skinfold & skeletal measurements
3. Waist & hip circumference
4. Underwater weighing
5. Bioelectrical impedance
6. Dual-energy x-ray absorptiometry (DEXA)
1. Body mass index (BMI)
World Health Organization(WHO), Centre for Health Protection,
GLOBAL recommendation LOCAL recommendation (CPH, Hong
Kong)
BMI (kg/m2 ) Grade BMI (kg/m2 ) Grade
<18.5 Underweight <18.5 Underweight
18.5-24.99 Normal weight 18.5-<23.0 normal
25.0-29.99 Overweight 23.0-<25.0 overweight
30.0-34.99 Obese(grade 1 obesity) >25.0 obese
35-39.99 Obese(grade 2 obesity)
≥40.0 Obese(grade 3 obesity)
BMI: Advantages vs Disadvantage
Advantages Disadvantages
• Convenient to use • Cannot indicate the physical
development of children, e.g. growth of
brain and body etc.
• Can help to identify the risk of coronary • Not take into account of the components of
heart disease the body weight
e.g. BMI 25-29 doubled than those BMI < 21 e.g. A trained athletes with a
BMI 29.5 3.5 times greater than those BMI 35 is classified as “obese”
BMI <21 → in fact, they have high percentage of
• Can help identify the risk of diabetes lean tissue and little body fat.
e.g. BMI <24.5 tripled than those BMI<22
BMI >28.5 tripled than those BMI <24.4
Assessment of Body Fat Content
Methods of assessing body fat content
• Skinfold thickness measures
• Bioelectrical impedance analysis (BIA)
• Underwater weigh (uncommon used)
• Magnetic resonance imaging (MRI)
• Dual-energy X-ray absorptiometry (DEXA)
• whole-body air displacement (uncommon used)
Everybody Needs Some Body Fats
• Men: 3-5%
• Women: 10-12%
Fat is needed for survival:
• Essential roles in the manufacture of hormone
• Cell component
• Energy formation (no matter how low energy reserves become)
• Delayed physical maturation
Skinfold measurement
• Estimated by measuring the thickness of the fat folds that lie
underneath the skin.
• Inexpensive, painless, fairly good estimate of percent body fat.
• Skinfold measurement points:
➢ Mid-triceps
➢ Mid-biceps
➢ Subscapular
➢ Supra-iliac
Bioelectrical Impedance Analysis (BIA)
• Food is a poor conductor while water and muscles are good
conductors.
• Advantages: the equipment is portable, and the test is easy, painless.
The result is more accurate than skinfold measures. (who are not at
the extremes of weight for height)
Underwater weighing
• Underwater weighing: a method for measuring body fat
• Based on Archimedes’ principle:
– An object’s loss of weight in water = the weight of the volume of water displaces

• The density of the body can be calculated using the formula:

– Density of the body = weight in air – weight in water

• the percentage of body fat can be determined using the formula:

Body fat (%)= (495/body density) – 450
• More accurate value for percent body fat
• Expensive, people who don’t swim, sick, etc.
Magnetic Resonance Imaging (MRI)
• The fat & muscle mass can be photographed from cross-
sectional images obtained.
• Advantages: provides highly accurate assessment of fat &
muscle mass.
• Limitations: expensive and largely used for clinical &
research purposes.
Dual-energy x-ray absorptiometry (DEXA)
• dual-energy x-ray absorptiometry(DEXA): a measurement of bone density.
• The measurement is made by scanning the body with a small dose of X-rays & the
calculating body fat content based on the level of X-ray absorption.
Advantages: highly accurate, can used to assess bone mineral content and lean tissue
mass.
Limitations: expensive, the machine must be operated by a trained and certified
radiation technologist.
 Skeletal measurement: Demispan
• Demispan: a measurement of skeletal size
(an alternative to height measurement when the subject is difficult to maintain an upright
posture)
Measuring demispan:
1. Stretch out the arm at shoulder height to the side of the body
2. Measure the difference between the sternal notch and the roots of the middle and
third fingers
• Interpretation of demispan vales (Demiquet & Mindex)
BMI vs Demiquet vs Mindex
World Health Organization (WHO) recommendation for Asian
Grade BMI Demiquet Mindex
(kg/m2) (kg/m) (kg/m2)
Underweight <18.5 <75.60 <55.95
Normal weight 18.5-22.9 75.60-93.58 55.95-69.25
Overweight 23-24.9 93.98-101.75 69.55-75.30
Obese I 25-29.9 102.16-122.18 75.60-90.42
Obese II ≥30 ≥122.59 ≥90.72
Skeletal measurement: Knee height
• Knee height: proxy for measuring body height
• Measuring knee height:
✓In supine position, measure the right at 90 degree using
Cescorf caliper
✓Measure from the knee to the heel

Chinese-based knee height prediction equation (Li et al., 2000)

Women: 46.11 + (2.46 x knee height) –(0.12 x age)

Men:51.16 + (2.24 x knee height)

 Waist circumference & waist-hip ratio
• The size of visceral fat deposits can be closely estimated by
measuring waist circumference.
• A strong indicator of disease risk
Waist circumference & waist-hip
• Waist circumference and waist-hip ratio: relating measure of
central adiposity
• Measuring waist circumference:
– Midway between the uppermost border of the iliac crest and the lower border of
the costal margin
– Measure at the end of normal expiration

• Central obesity in Chinese:

– Men: >90 cm
– Women: >80 cm
Waist-hip ratio (WHR)
• Measuring hip circumference
– Measure at the largest circumference of the buttocks

• Calculation of WHR: waist(inch)/hip(inch)

• Standard WHR of normal Asian adult:

– Male <1.0
– Female < 0.8
References
Anuurad, E., Shiwaku, K., Nogi, A., Kitajma, K., Enkhmaa, B., Shimono, K., & Yamane, Y. (2003). The new BMI criteria for Asians by regional
office for the western pacific region of WHO are suitable for screening of overweight to prevent metabolic syndrome in elder Japanese workers.
Journal of Occupational Health, 45, 335-343.

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