Nutritional Status Assessment

for Patient Management

Fiastuti Witjaksono
Department of Nutrition, Faculty of Medicine, Universitas Indonesia
Cipto Mangunkusumo Hospital

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Nutritional Status Assessment
• Nutritional assessment is an explanation derived from data
obtained by using various methods to assess patients who
are at risk of undernutrition or overnutrition or suffering
from undernutrition or overnutrition

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Nutritional Assessment Methods
Assessment of nutritional status based on subjective data
• Food intake
• Weight loss

Assessment of nutritional status based on objective data

• Anthropometry
• Physical examination
• Laboratory data
• Other diagnostic tests

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Food Intake
Malnutrition
Criteria
Mild Moderate Severe
Inadequate Less energy %TEE Time %TE Time
food intake intake than E
moderate Acute <75 7 days Acute ≤50 ≥5 days
malnutrition
criteria Chronic <75 ≥1 Chronic ≤50 ≥1
month month
Environmental/ <75 ≥3 Environmental/ ≤50 ≥1
Social months Social month

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Anthropometry
Anthropometric measurements used in assessment of nutritional status:
• Body weight
• Body height
• Body mass index
• Arm circumference
• Waist circumference

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 Body Weight Measurement
• Using non-electronic or electronic body scale
• Body scale is placed in a hard and flat surface
• Subject puts on light clothing and takes off footwear
• Subject stands in the middle of the body scale
• Subject stands without anyone’s help
• Measurement is carried out to the nearest 0.1 kg

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Body Height Measurement
• Using body height measuring instrument in standing position
• Tools needed are upright stadiometer, right angle headboard,
and inelastic measuring tape
• The measuring instrument is placed on a flat surface
• Subject is standing up right and head is on Frankfurt Plane
position
• The soles of the feet are closed and both knees are straight
• Heel, buttocks, and shoulder blade touch the vertical surface
of the measuring instrument
• The headboard is lowered and directed until it touches the
crown of the head
• The assessment is taken during maximal inspiration and the
examiner's eyes are at the same level as the headboard
• Results are recorded in the nearest millimeter
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Body Mass Index Calculation
Body Weight (kg)
BMI=
Body Height m x Body Height (m)

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Mid-upper Arm Circumference Measurement
• Using a non-elastic and flexible tape
• Subject stands upright
• Head is on Frankfurt Plane position
• Both arms hanging down
• Both legs are stretched
• Remove subject’s shirt or roll the sleeves up
• The arm should be at a 90-degree angle at the elbow
• Find the midpoint of the upper arm; between acromion process
and the tip of olecranon
• Put the arm straight down in a relaxed state after you find the
midpoint
• The measuring tape is looped past the midpoint
• Results are recorded in the nearest millimeter
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 Waist Circumference Measurement
• Using a non-elastic and flexible tape
• Subject stands upright with both
arms at the sides of the body
• Both legs are closed so that the
weight is evenly distributed
• The measuring tape is placed at the
point that passes halfway between
the lower rib and iliac crest
• Measurements are taken at the end
of expiration
• Results are recorded in the nearest
millimeter
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Physical examination
• Body fat examination
• Muscle examination
• Fluid accumulation examination

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 Specific Areas to Assess for Subcutaneous Fat Loss

White JA, Academy of Nutrition and Dietetics; 2013 12

Fischer M, Nutrition in Clinical Practice; 2015
 Specific Areas to Assess for Muscle Loss

White JA, Academy of Nutrition and Dietetics; 2013 13

Fischer M, Nutrition in Clinical Practice; 2015
 Specific Areas to Assess for Muscle Loss

White JA, Academy of Nutrition and Dietetics; 2013 14

Fischer M, Nutrition in Clinical Practice; 2015
 Fluid Accumulation Examination
Fluid Severe Mild-Moderate
Tips Well Nourished
accumulation Malnutrition Malnutrition

Deep to very deep Mild to moderate

pitting, depression pitting, slight
View and palpate
Rule out other lasts a short to swelling of the No sign of fluid
ankles and hands for
causes of edema moderate time (31-60 extremity, accumulation
evidence of edema
sec); extremity looks indentation subsides
swollen (3-4 +) quickly (0-30 sec)

White JA, Academy of Nutrition and Dietetics; 2013 15

Laboratory tests
• Hemoglobin
• Albumin
• C-reactive protein (CRP)

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Other tests
• Handgrip measurements
Using dynamometer – e. g. Jamar
• Body composition analysis, to determine fat mass, fat free mass,
muscle mass, total body water
Using body impedance analysis (BIA)

fat free mass (kg)

FFMI (fat free mass index) =
body height m x body height(m)

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Dynamometer
• Hand digital dynamometer is used
to measure hand grip strength
• Hand grip strength reflects the level
of muscle strength in the hand,
wrist and lower arm
• Measurement is taken using
subject’s dominant hand

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BIA (Body Impedance Analysis)
• Bioimpedance analysis (BIA) is an instrument to calculate
body composition
• BIA measures body resistance, hence the value of muscle
mass, fat free mass, fat mass, and total body water is
obtained
• Turn on BIA, then enter subject’s age, height, and gender
• Subject stands on the measurement tool
• Press start button and wait a while to see the results
• Compare measurement results with the cut-off values (as
recommended in the manual)
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Malnutrition Screening Tools (MST)
1 Have you lost weight recently without trying? Score
Unsure 2
No 0
If yes, how much weight (kg) have you lost in the last 3-6 months
1-5 kg 1
6-10 kg 2
11-15 kg 3
>15 kg 4
Unsure 2

2 Have you been eating poorly because of decreased appetite?

No 0
Yes 1
Total Score

If score ≥ 2: at risk of malnutrition 20

Overweight and obesity classification according to
BMI and waist circumference
Risk of co-morbidities

Classification BMI (kg/m2) Waist circumference

< 90 cm (men) ≥ 90 cm (men)

< 80 cm (women) ≥ 80 cm (women)

Underweight < 18.5 Low (but increase risk of Average

other clinical problems)

Normal range 18.5 – 22.9 Average Increase

Overweight ≥ 23.0

- At risk 23.0 – 24.9 Increased Moderate

- Obese I 25.0 – 29.9 Moderate Severe

- Obese II ≥ 30.0 Severe Very severe

The Asia Pacific criteria 21

Malnutrition (WHO 2004)
• According to BMI = body weight (kg)/body height2 (m2)

BMI (kg/m2) Classification

17.00-18.49 Mild malnutrition

16.00-16.99 Moderate malnutrition

<16.00 Severe malnutrition

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Malnutrition (ESPEN 2015)
• Criteria 1: BMI <18.5 kg/m2, or
• Criteria 2:
Unintentional weight loss (>10% over indefinite amount of time
or >5% over the last 3 months)
In addition to:
• BMI <20 kg/m2 if <70 years of age or BMI <22 kg/m2 if ≥70
years of age OR
• Fat free mass index (FFMI) <15 kg/m2 and <17 kg/m2 in men
and women, respectively

Cederholm T, Clin Nutr 2015;34:335-40.

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 Malnutrition (ASPEN 2012)
Diagnosed if there are at least 2 from total 6 criteria:
1. Inadequate energy intake
2. Weight loss
3. Muscle mass depletion
4. Loss of subcutaneous fat
5. Local or generalized fluid accumulation
6. Functional status (Grip strength)

White JV, et al. JPEN J Parenter Enteral Nutr 2012;36:275-83.

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 Malnutrition (ASPEN Criteria)

White JV, et al. JPEN J Parenter Enteral Nutr 2012;36:275-83.

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Thank You for
Your Attention
Stay Healthy
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