INTRODUCTION

In order to diagnose and treat nutrition-related problems, thorough nutritional assessments must be
conducted by trained professionals. There are 4 major components of nutritional assessment. It is
important to include all of these components in an assessment in order to have a good overall picture of
the individual’s nutritional status. One component on its own will not provide enough information to
determine the overall health of the person.  The four components  (The ABCDs of assessment)
are: Anthropometric Assessment, Biochemical Assessment, Clinical Assessment, Dietary Assessment.
OBJECTIVES

 Explain the purpose of conducting a nutritional assessment.

 Outline the principles of ABCD tools available for assessment for nutritional status.
 Discuss the relationship between clinical signs, biochemical levels and dietary intakes of
nutrients.
 Compare various methods of dietary assessment.

HOW TO PROCEED

 Familiarize yourself with the unit objectives.

 Complete the assigned readings as outlined in the schedule.
 Take notes as necessary and complete the review questions found within the text.
 Read the synopsis material presented here and complete the activities as directed

Aspects of conducting a nutritional assessment

ACTIVITY 1: IMPORTANT MISCONCEPTION- YOU ARE NOT WHAT YOU EAT!

While we get components of our bodies from food, there is no association between the amount of nutrient
consumed with the amount of nutrient present in our body. The amount of carbohydrate stored in our
body (1%) does not reflect the proportion of our diet that is carbohydrate (maybe 300-400 consumed by
an adult).
Table of body composition based on approximate values for the body weight of individuals cited from
information provided by Wells (1999) American Journal of Clinical Nutrition volume 69, issue 904.

  Boys Girls

Water 61% 57%

Proteins 16% 14%

Fats 18% 24%

Minerals 4% 4%

Carbohydrates            1% 1%

What determines your body composition is rather a result of the biological need and your bodies ability to
process incoming nutrients. Before we move any further in this unit it is important to understand some of
the units of measure we will be working within the rest of this unit and in all other units as well.
Kilocalories (kcal): Energy is measured using kilocalories. One kilocalorie is the amount of heat needed
to raise the temperature of 1 Kg of water at 1 atmospheric pressure by 1ºC.
Grams (g): Macronutrients are measured in grams. 1 g of Carbohydrate will provide you with 4kcal as
does one 1g of Protein. One gram of fat on the other hand provides you with 9kcal.
Milligrams, Micrograms and International units (mg, µg, IU): Micronutrients such as vitamins and
minerals are measured in these smaller units. The international unit is a measure of the biological activity
of a micronutrient, while milli- and micro- grams are measures of mass. For example, one IU of Vitamin C
is equivalent to 50 µg or 0.050 mg of the vitamin, while 1 IU of Vitamin A is equivalent to 0.30 µg or
0.0003 mg because they have different biological activities.
To convert micrograms (µg) to milligrams (mg), divide by 1,000–or move the decimal point 3 positions to
the left. 1000 mcg = 1.000 mg. Converting International Units (IU) isn’t straightforward because it’s a
different conversion for each nutrient based on its biological effect.
Determine:
The upper limit of safe consumption of Vitamin D is 4000 IU daily. I IU of Vitamin D is equal to 0.025
micrograms. How many milligrams can you take daily?
Answer: 0.1 mg
ACTIVITY 2: SECOND MISCONCEPTION-MALNUTRITION DOESN’T ALWAYS MEAN
STARVING!
When you hear the word malnutrition what is the first image to come to your mind? For many people,
malnutrition is characterized by images of starving children from war-torn or drought-ridden countries.
This is one form of malnutrition but not the only one.
Primary Malnutrition: is caused by inadequate or excessive dietary intake. If more/less of the nutrient
was supplied by the diet the deficiency could be alleviated.
Secondary Malnutrition: this is caused when the biochemical needs of a person are not being met in
spite of normally adequate intakes. Factors other than diet are creating the deficiency.
Net Intake = Total Intake – Amount Not Absorbed
Again we see, the level of nourishment depends on the balance between net intake and biochemical
need. Total intake and net intake are not the same. Total intake includes everything that you consume,
whereas net intake does not include components of food that are not absorbed. For example, fibre that
we consume is not digested by the body, therefore it is not included in net intake. There are some factors
that can affect net intake, such as diarrhea and vomiting. Both of these problems decrease how much
food is actually absorbed into the body, thereby decreasing net intake. Intake and needs change over
your life cycle and can be impacted by both external and internal factors. These can impact how much is
consumed and/or the nutrients needed.
External Factors: adequate time for eating/preparing food, food availability, peer pressure,
culture/religion, and the media.
Internal Factors: stages of physiological development, your state of health (disease, nausea,
medication/drug consumption, depression) and allergies.

ACTIVITY 3: CONDUCTING ASSESSMENTS: DIETARY

The big question then is how do you determine if your intake is meeting your needs? Nutritional
assessments are used to assess the nutritional status required for the growth, maintenance and repair of
a body. They are also used to determine nutritional deficiencies or toxicities. This allows clinicians to
identify people at risk of diet-related problems. Nutritional assessments also provide the information
needed to allow for nutritional support and to monitor the progress or efficacy of dietary interventions.
Although last in the ABCD list, the dietary assessment is one of the first assessments conducted because
it is one of the easiest at least expensive tests to carry out. There are different ways to conduct a dietary
assessment, and each one has its advantages and disadvantages.
24-hour recall: Subjects or their parents/caregivers are asked to recall all food intake during the previous
24 hours. This recall may not represent the usual intake, so multiple recalls may be necessary to obtain a
true picture. This might also include conducting recalls during different seasons to observe seasonal
variations in consumption. A specific form may be used, but this method is problematic because it relies
on the subjects' memory.
Food Frequency Questionnaire (FFQ): This method is often used when assessing the frequency of
foods consumed over a period of time. This method is also subjective and people tend to underestimate
their food intake.
Dietary History: This method combines the use of a 24-hour recall and FFQ with a lengthy interview in
order to gain more information about the usual intake and insights into subject habits. This is more
accurate than the previous two tests used alone.
Estimated Food Record: Subjects or their caregiver's record all foods and beverages eaten during a
specific period of time. This method is an improvement on the recall methods because it does not rely on
memory, however, subjects may find estimating portion size difficult and therefore reduce the accuracy
because of inaccurate estimates.
Weighed Food Record: This method asks that all food consumed over a specific period of time be
recorded and weighed before consumption, therefore eliminating the problem of estimation in the
previous method. Along with the weights, methods of food preparation, a description of the food ( and
brand names) should also be included. This is the most accurate measure but also the most inconvenient
as a subject must weigh all food items.

Once dietary data is collected it must be analyzed. This can be done using a variety of tools and
compared to specific standards.
The most commonly used tools are computerized databases that can calculate nutrient intake based on
estimates of nutrients found in particular foods. In some cases, the database may not contain all foods
eaten and so substitutions must be selected. With more and more of these tools available online free you
have to be sure to ask yourself:
Is this database complete?
Has the database used accurate nutrient equivalencies for foods?
before you invest a lot of time entering your data! The analysis is done by comparing the compiled list of
nutrients obtained from your data to set standards. Every country has their own set of standards for its
specific populations. Standards used in Canada come from four sources: nutrient recommendations for
Canadians, Canada’s guidelines for healthy eating, Canada’s food guide and Nutrient Reference values.
The amount needed is further qualified by terms such as:
Adequate Intake (AI): If more research is needed into the human requirements of a nutrient, an estimate
of the adequate intake is created based on the best available evidence.
Estimated Average Requirement (EAR): the average requirement of energy or nutrient intake for a
group of people.
Recommended Daily Allowances (RDA): the level of essential nutrient intake needed to meet the
functional needs of the average healthy person. Statistically, this intake would prevent deficiency
disorders in 97% of the population.
Upper Limit (UL): the highest amount of the nutrient intake unlikely to post a risk to health or adverse
health effects for almost all individuals in the general population.
Daily Reference Intakes (DRI): a collective name given to the nutrient-based reference values: EAR,
RDA, AI and UL
By comparing intake to the standards a dietary assessment can provide information of the estimate or risk
for an individual, however further measurements are needed to confirm actual deficiencies of toxicities.
ACTIVITY 3: BIOCHEMICAL ASSESSMENT

Before moving on to the next unit ponder upon:

Biochemical assessment involves the internal assessment of body tissues and fluids (blood or urine). The
tests that are performed will depend on what problems are suspected. The tests will look for specific
nutrients, enzymes (as many nutrients are part of enzymes or coenzymes) or metabolites (the end
product of a nutrient breakdown). For example, if a teenage girl is experiencing chronic fatigue and does
not appear to be consuming enough iron, blood haemoglobin and ferritin may be analyzed to determine
the status of body iron. A metabolite is an end product resulting from metabolic processes.
Biochemical assessments can be affected by many factors: disease, dehydration, drugs, diet or physical
activity. These factors may affect the accuracy of the biochemical measurements of nutrients in blood or
other tissues. For example, if the concentration of a nutrient is measured in serum samples under a state
of dehydration, the levels may falsely show higher concentrations of the nutrient due to dehydration (low
blood volume).
Common lab tests include:

 Blood lipids: standard test for heart disease factors

 Blood glucose: screen for diabetes, which includes conducting a fasting glucose concentration
measure and a glucose tolerance test
 Iron status: iron deficiency (anemia) is common and affects people at all stages of the life cycle.
ACTIVITY 4: CLINICAL ASSESSMENT
A clinical assessment is a visual exam done by a qualified professional (such as a physician) to identify
any signs of malnutrition. This assessment involves examining parts of the body that are easily observed
in a routine physical, hair, eyes, mouth, skin etc. Findings could include excessive body fat, bruises and
or pallor. If any of these symptoms are found, they would need to be investigated further to determine
what, if any, nutritional problem is present. This is the first non-invasive search for signs of nutrient
deficiency or toxicity.
ACTIVITY 5: ANTHROPOMETRIC ASSESSMENT
These measurements involve looking at the visible and easily measurable features of a person. This
includes measurements of the entire body (height and weight) and measurements of body parts
(circumference of head or fat fold). These measurements are used by comparing them to a population
standard or to previous measurements of the individual to determine if the person falls into the “normal”
range or has changed “significantly” since the last measurement. By normal, we are referring to the
statistical normal, where 50% of the people measured will have measurements that fall within one
standard deviation from the mean (midpoint). By significance, we are discussing how many standard
deviations away from the mean the recorded numbers fall. Luckily you do not need to determine the
mean/normal or standard deviation or any other statistical calculation when reviewing anthropometric
measurements as this has already been scientifically calculated and color-coded growth and development
charts are available for use. You only need to concern yourself with plotting your measurements
accurately on the graph and interpreting the trend.
Plot your own Growth Chart: Female, Male
Use the chart and to the best of your memory plot your BMI (the calculation of this is presented in the
growth chart) for at least five years of your life. Look at the trend. uSe the following table to evaluate your
BMI for age. (Normal BMI: 3rd  85%h percentile for ages 5-19. Average BMI: 50th percentile)

Source: Dieticians of Canada and Canadian Pedriatic Society, 2014

People above the age of 19 have generally stopped growing, and therefore rather than a chart, a simple
calculation of BMI is used and compared to a table of BMI norms using standard weight status categories
that are the same for all ages and for both men and women. This is a second difference from
measurements involving children and teens where the interpretation of BMI is both age- and sex-specific.
Before moving on to the next unit: