269 CHS (# 5) PART II

Evaluation of Nutritional Status (Nutritional Assessment)

2- Biochemical test
(Biomarkers of dietary intake)

2- Biochemical test
(Biomarkers of dietary intake)
All estimates of food intake are subjective.
Some subjects forget, Some did not notice what food they ate, Some do not report because they would be ashamed to admit having that food, drink or amount.

The search is on for biomarkers which are objective biochemical indices of dietary intake. For some food components there are useful biomarkers; for others there is nothing available. Example: protein intake is reflected by 24-hr urinary nitrogen.

Biochemical tests:
Biochemical tests are an integral part of modern medical diagnosis: -Take sample of: blood, urine, feces -Measure for levels of enzymes, nutrients OR metabolites Examples: -Serum albumin indicative of protein status -Blood hemoglobin indicative of iron status -Plasma sodium & potassium concentrations are essential for diagnosing & treating difficult electrolyte disorders -Plasma or red cell folate & plasma B12 should be measured before treating patient with megaloplastic anemia

With most other nutrients also, biochemical tests have been developed which can be used:
(a) To confirm diagnosis of a deficiency disease in

places where it is uncommonly seen or where the clinical picture is complicated, OR

(b) In community surveys and general practice to

find individuals deficiencies.

with

subclinical

nutrient

Biochemical indicators of nutritional status

Biochemical indicators can include assessment of blood and urine samples for levels of:
o A variety of nutrients, &/or

o Their by-products, or o For levels of nutrient-linked enzyme activities. Analysis may also be performed on samples of hair.

Blood samples
Blood can provide a great deal of information. Analysis can be used to determine:
Actual levels of a nutrient in relation to expected values Plasma vit C, red cell folate The activity of a nutrient-dependent enzyme Transketolase for thiamin The activity of a nutrient-related enzyme Alkaline phosphatase for vit D The rate of a nutrient-dependent reaction Clotting time for vit K The presence of a nutrient carrier or its saturation level Retinol-binding protein Transferrin (iron) Levels of nutrient-related products Lipoprotein levels

Urine and hair

Urine o For some nutrients such as sodium, iodine, phosphorus urinary excretion is the best way to establish status.. But complete urine collections are difficult to obtain. Hair o Levels of some trace elements o Scientific accuracy not proven

Data Interpretation
Caution for many nutrients there is inadequate information to establish guidelines. Guidelines for interpretation must take into account age, sex, pregnancy, lactation, inflammation, infection, trauma etc..

Cut-offs -often derived from healthy individuals

Limitations: The use of biomarkers is almost as complex as the assessment of diet. A wide variety of factors influence the accuracy and interpretation of these indicators of dietary exposure.
-Most of the currently available biomarkers reflect nutrient intakes over a relatively short period of time and few of them reflect truly long-term intakes over a period of years or decades. This is an important limitation, since long-term patterns of dietary intake are of great interest in studies of chronic diseases. -Some theoretically valuable biomarkers may be of little use because their collection is unacceptable to study subjects. The concentrations of nutrients in the liver are of great interest, for example, but they are rarely measured in healthy individuals because few people would be willing to have a sample of their liver taken solely for research purposes.

-Some indicators are influenced by factors other than dietary intake. For example, smoking reduces blood levels of vitamin C and carotenoids. In such instances, the biomarker may still be a good indicator of nutritional status, but it may not accurately reflect dietary intake. -Contamination of samples may occur even before the specimens are collected and may occur after specimen collection unless appropriate precautions are taken. For example, specially prepared tubes must be used in the collection of blood for zinc measurement because standard tubes may be contaminated with zinc. -Some biomarkers, such as vitamin C, are easily degraded during storage. So, it cannot be measured in blood samples that have been subjected to prolonged frozen storage. -Biochemical indicators of dietary intake are only as good as the laboratories that measure them (quality laboratories)

3-Clinical observations
(physical examination)

3- Clinical observations
(physical examination)
Hair, nails, skin, eyes, lips, mouth, bones, muscles, joints. RARELY provides information about specific nutrients Signs often nonspecific but can do further testing: Example: -Cracking at corners of mouth may indicate niacin, riboflavin, or B6 deficiency -Vitamin C deficiency (scurvy) indicated by bleeding gums, petechiae

Clinical Indicators of Deficiency

Includes information from medical history and physical examination by health professionals to identify signs and symptoms of deficiency. Examination of hair, skin, eyes, muscles, teeth, gums, nails, skeletal structure etc.

Limitations
Signs & symptoms often non specific They only become apparent when diet has been lacking for some time

Physical Assessment:
Signs of Nutritional Deficiencies
Most observable where cell replacement is rapid Hair, skin and digestive tract including mouth and tongue Signs of PEM, vitamin and mineral deficiencies

Limitations of Physical Assessment

Requires knowledge and skill Nonspecificreflect several deficiencies or none at all Needs further assessment support

Clinical Indicators - Example

Hair is an epidermal structure which sometimes reflects a state of nutritional deficiency Clinical signs - dispigmentation, easy pluckability, thin, sparse. Possible Deficiency - Kwashiorkor

4-Dietary Assessment

Food intake/consumption can be measured at the population, group or individual level to identify problems and observe intake. Different methods are suited to these different needs. At the population level (ecological studies), food disappearance data (national food consumption) are often used. For example food balance sheets are constructed by FAO (Food Agriculture Organization) from national accounts of the supply and use of foods. These data are crude. Their quality varies from country to country and they reflect waste and spoilage of food as well as actual consumption. Some surveys rely on household purchases as a proxy for food consumption, but this may not take into account food eaten outside the home OR food waste OR withinhousehold variation.

For individual-based studies, researchers must use more accurate methods of assessing dietary intake. The methods in current use include: Dietary history (interview)

24-hour dietary recall: memory-based Food diary or Record

-Record exact amounts of foods consumed -Diary over several days -Includes time of day eating -Symptoms associated with eating

Food Frequency Questionnaire

-Use daily food guide -Specific food list

Subjects are asked open-ended questions regarding their usual (present or past) dietary intake. The interviewer carefully inquires about food consumption meal by meal, seeking information about variations in intake and trying to establish the usual pattern of consumption. Interviews of this type are time-consuming, often lasting for more than 1 hour, but they can provide considerable detail about an individual's eating habits, including subtle aspects such as food preparation practices and seasonal variations in food choices. Dietary histories, unlike records or recalls, require subjects to make judgments about their usual food habits. Thus, the answers may reflect what the subjects think they eat (or what they would like the interviewer to think they eat), rather than what is actually eaten.

Subjects are asked to list the foods they consumed during a certain period of time, usually the preceding 24 hours. This method is relatively quick and simple and does not require the researcher to have prior knowledge of the subjects' food habits. Under reporting of food intake may be a problem. Increasing evidence indicates that many people systematically underreport their total food intakes and that this tendency is stronger in some segments of the population (especially overweight people) than in

Dietary recalls are best suited to obtaining information on present diet rather than diet in the distant past, when lapses of memory could be a problem. A single 24-hour recall is not adequate for measurement of an individual's usual intake; as only ONE 24-hour period would not be best way to assess an individuals nutritional health - too much variation on daily basis. So, multiple recalls must be used for one individual to get better picture. Repeated visits make this method more costly, so, it is possible to conduct the recalls by telephone where appropriate.
A single 24-hour recall from each individual can be used, however, to estimate the mean nutrient intakes of groups of people rather than of specific individuals.

Advantages of 24 hour recall method: -Subjects require no training and need only to spend minimal effort in providing the information requested by the interviewer. -Processing data from a 24 hour recall is cheaper and less time consuming than processing data from 3-7 day dietary records. -Useful for assessing average usual intakes of a large population, and are therefore often used for large dietary surveys Disadvantages of 24 hour recall method: -A single 24 hour recall cannot take account of day-to-day variation in an individuals food consumption, -Due to its retrospective nature, the 24 hr recall is less suitable for use with children and the elderly. -The effectiveness of dietary assessment by diet history is very dependent on the skill of the interviewer. -It is labour-intensive and time-consuming, and relies on the memory of the subject. -The unstructured nature of the enquiry renders it more useful in clinical settings than research

Subjects record their intake as they eat. They may be asked to estimate portion sizes, to weigh food before they consume it or even to provide a duplicate meal for later analysis. If records are obtained for a sufficient number of days and if subjects cooperate well, food records can provide a good picture of usual current dietary intake. In fact, scientists often consider the weighed food record to be the gold standard for measuring food intake.

However, this method imposes considerable burdens on the subject and can be used only with relatively educated, literate people. Also, subjects may not comply with the researchers instructions to maintain their customary eating habits during the study period and some subjects may underreport their intakes.

Food diary: record exact amounts of foods consumed

Like diet histories, food frequency questionnaires focus on usual intake. This method is far more structured as subjects complete an intervieweradministered or self-administered questionnaire that asks how frequently they consume a series of foods.

Food frequency questionnaires (FFQs)

-Usually self-administered and are therefore designed to be easy to complete by the study subjects. -Usually comprise a list of foods or food groups, and a corresponding frequency response section (e.g. never, once per week, twice per week etc). -Often rely on assumptions regarding portion size, and are limited by the amount of detail that it is feasible to include in the questionnaire. -Often designed to gain information about specific aspects of diet, such as dietary fats or particular vitamins or minerals, and other aspects may be less well characterized. -It is possible for the questionnaires to be semiquantitative where subjects are asked to estimate usual portion sizes. -Often filled in with reference to the previous year in order to ascertain usual food consumption patterns for that period.

Some types of food frequency questionnaires pose their questions in open-ended form, whereas others use closed-ended questions with predetermined response categories.
For example, in the open-ended type of questionnaire, subjects would be asked how often they eat apples. In the closed-ended type of questionnaire, they might be asked whether they eat apples daily, four to six times per week, one to three times per week, less than once per week but more than once per month, less than once per month or never.

To design a good questionnaire, epidemiologists need considerable advance knowledge of their study subjects. If the study population is to include e.g. immigrants, the researchers will need information about their countries of origin so that they can include appropriate ethnic dishes in the questionnaire. Researchers also need an accurate knowledge of the food sources of the nutrients that they wish to study so that they can include the appropriate foods in the questionnaire.
E.g. it has been reported that some questionnaires currently used in the United States to assess carotenoid intake may yield misleading results because they omit certain mixed dishes (e.g, vegetable soup) that contribute substantially to total carotenoid intake.

Food frequency questionnaire Main advantage -Relatively easy to complete, -Probably good compliance

Main disadvantage -Erratic consumption of foods may introduce error, -Can be difficult to convert data to daily averages without use of computer

Estimating food intake quantitatively is labour intensive (and so expensive). It depends on adequate memory and the honesty and interest of the subjects. Some peoples food habits are very irregular and most people eat differently in the weekends from during weekdays and on holidays. Methods that ask subjects to record or remember the food/drinks they really consume are better for national nutrition surveys of samples of the population. For large epidemiological surveys, food frequency questionnaires have enables tens of thousands to be included. What these lose in precision, they gain in numbers of subjects.

The choice of dietary assessment method in

research depends on the study objectives together with the time-scale and resources available for the project. None of the available methods is without limitations (no gold standard methods for food intake), and it is essential to take into account all considerations at the design stage. Bearing in mind the objectives of the study and the population under investigation, it is important to clarify the detailed format of the chosen dietary assessment method. In all cases, it is crucial to conduct a pilot study before a large scale study is undertaken.

Evaluation of food intake data:

How to evaluate data once collected? -Usually use a computer! -Get estimate of nutrient intakes -Compare to dietary standards, food guide pyramid

5- Economic, educational status and health history

5- Economic, educational status and health history

Economic status
-Personal, cultural, financial, environmental influences on food -Intake, nutrient needs, diet therapy options

Educational status
-Ability to comprehend information/instructions (written or oral)

Health history
-Current, previous health problems, family history that affect nutrient needs, nutrition status, or need for intervention to prevent problems

Drug/alcohol use
-Medicine, dietary supplements, alternative therapies that affect nutritional status