CHAPTER FOUR

• Assessments of community
nutritional status
 Terminology you have to know

Terminology you have to know

Diet:
Selection of food which is normally eaten by person or population

Food:
Substance when eaten , digested, absorbed provide at least one nutrient

Balanced diet :
Diet that provide adequate amount of all nutrients
Malnutrition:
 Caused by incorrect amount of nutrient intake

Nutritional status:
 Health status that produced by balanced between requirements
and intake

Nutritional assessment:
 Measurement of nutritional status by anthropometrics ,
biochemical data, dietary history
 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
Medication intake
Social and medical history and
Anthropometric, body composition and biochemical
measurements.
 It includes both :
– the screening and assessment of the person’s nutritional status,
– the collection of data through the use of interviews,
questionnaires and specially designed forms and the scientific
analysis of the information obtained.
• These data are used in order to identify the nutritional status of
the individual, to design the appropriate nutritional therapy and
to investigate the need for greater nutritional support.
 The nutritional status of an individual is often the result of many inter-
related factors.

 It is influenced by food intake, quantity & quality, & physical health.

 The spectrum of nutritional status spread from obesity to severe

malnutrition
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
 Methods of Nutritional Assessment
Nutrition is assessed by two types of methods;
o direct and
o indirect.

The direct methods deal with the individual and measure

objective criteria
while indirect methods use community health indices that
reflects nutritional influences.
 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
1. 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 .
Other anthropometric Measurements
– Mid-arm circumference
– Skin fold thickness
– Head circumference Group
– Head/chest ratio
– Hip/waist ratio
assignment
– Z- score of reference population (15%)
– percentile in reference distribution
Cont’d
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
 Weight for age
 Malnutrition

 Height for age

 Stunting

 Weight for height

 Wasting
 Weight for age, Malnutrition

• Composite measure of H/A and W/H

• So, interpretation difficult.
• Confounds short- and long-term problems
• Low W/A=“lightness” extreme=“underweight”
• Used for monitoring growth and change in malnutrition over time
• Indicator used for MDG1(Target 2)
– W/A= W/W(N) x 100
– 90-110 = Normal
– 75-89 = 1st, Mild
– 60-74 = 2nd , Moderate
– <60 = 3rd, Severe
 Height for age, Stunting
• Reflect cumulative linear growth
• H/A deficits indicate past inadequate nutrition and/or chronic/frequent
illness
• Not measure of short-term changes
• Low H/A =“shortness”, extreme=“stunting”
• Mainly used as population indicator, not for individual monitoring
– H/A=H/H(N) x 100
– < -2 SD = Stunted, Wasted
– > 95 = Normal
– 87.5-95= Mild
– 80-87.5= Moderate
– < 80 = Severe
 Weight for height, Wasting
• Indicator of current nutritional status
• Used for screening kids at risk & to identify short-term changes in
nutritional status
• Low W/H = “thinness”, extreme =“wasting”
• Wasting can be due to starvation or severe disease (especially
diarrhea)
• At other extreme, identifies obesity
– W/H= W/W(at same H) x 100
– < -2 SD = Stunted, Wasted
– > 90 = Normal
– 80-90 = Mild
– 70-80 = Moderate
– < 70 = Severe
 Reference population

 Until 2006, WHO recommended use of US NCHS reference group

(US sample)

 Distribution of child height/weight mostly determined by nutrition &

disease, not ethnicity

 But controversy over the use of the US reference

 In 2006 WHO issued new growth standards for 0-5 years based on the
Multi-Centre Growth Reference Study

 New standards calculated from samples from diverse ethnicity all

adopting recommended practices e.g., breastfeeding, no smoking
Comparison with the reference population

xia  ma r
z  scoreia  r
sd a
xia
% of median  r 100
ma
 Example Computation of Anthropometric
Indices
• 12-month-old girl weighs 9.1 kg
• In reference sample, median weight for 12-month-old
girls is 9.5 and standard deviation is 1.0.

9.1  9.5
z  score (W/A)   0.4
1

 9.1 
% median (W/A)     95.8%
 9.5 
9.1 falls between the 30th and 40th percentile in
reference distribution
Growth Monitoring Chart
• 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)

 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
 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
 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

Advantages of Anthropometry
– Objective with high specificity & sensitivity
– Measures many variables of nutritional significance (Ht, Wt,
MUAC, skin fold thickness, waist & hip ratio & BMI).
– Readings are numerical & gradable on standard growth charts
– Readings are reproducible.
– 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.
2. Dietary Assessment
• Nutritional intake of humans is assessed by five different
methods. These are:

– 24 hours dietary recall

– Food frequency questionnaire
– Dietary history since early life
– Food dairy technique
– Observed food consumption
• 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
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.
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.
3. Clinical Assessment
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

4. Biochemical, laboratory methods
• Initial Laboratory Assessment
Hemoglobin estimation is the most important test, & useful index of
the overall state of nutrition. Beside anemia it also tells about protein
& trace element nutrition.

Stool examination for the presence of ova and/or intestinal parasites

• Urine dipstick & microscopy for albumin, sugar and blood

• Specific Lab Tests
Measurement of individual nutrient in body fluids (e.g. serum retinol,
serum iron, urinary iodine, vitamin D)

Detection of abnormal amount of metabolites in the urine (e.g. urinary

creatinine/hydroxyproline ratio)

Analysis of hair, nails & skin for micro-nutrients.

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

5. Socio-cultural and ethnic food consumption issues

Reading assignment
 6. Nutritional intervention
 Four categories of nutrition interventions:
1. Food and/or nutrient delivery

2. Nutrition education

3. Nutrition counseling

4. Coordination of nutrition care

1. Food and/or Nutrient Delivery
 Meals and snacks
 Enteral/parenteral nutrition
 Medical food supplements

 Vitamin and mineral supplement

 Bioactive substance supplement
 Feeding assistance

 Feeding environment
 Nutrition-related medication management
2. Nutrition Education
• Initial/brief nutrition education
– E.g. survival skills on discharge
• Comprehensive nutrition education
– Purpose
– Recommended modifications
– Result interpretation
– Other
3. Nutrition Counseling
1. Theory or approach
 The theories or models used to design and implement an
intervention; provide a research-based rationale for
designing and tailoring nutrition interventions

 Cognitive-behavioral therapy

 Health belief model

 Social learning theory

 Transtheoretical Model/Stages of Change

 Other
2. Strategies
Motivational interviewing

Goal setting

Self-monitoring

Problem solving

Social support

Stress management

Stimulus control

Cognitive restructuring

Relapse prevention

Rewards/contingency mgt

Other
4. Coordination of Care
• Coordination of other care during nutrition care
– Team meeting
– Collaboration with other providers
– Referral to community agencies/programs
• Discharge and transfer of nutrition care to new
setting/provider
– Collaboration
– Referral to community agencies/programs
Thank you