NUTRITIONAL ASSESSMENT and

SURVEILLANCE
Mekelle University
college of health sciences

Department of public health

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• Nutritional assessment is the first step in the treatment of
malnutrition.
• An optimal scheme of nutritional assessment enables
the health worker to quickly detect the presence of
malnutrition and provides guidelines for nutritional
therapy.

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• Nutritional assessment is an interpretation of
anthropometric, biochemical (laboratory), clinical and
dietary survey data to tell whether a person/group of
people is/are well nourished or malnourished
• The ABCDs of assessing nutritional status include
collection nutritional data using the following methods
• A=Anthropometry,B=Biochemical/biophysical, C=Clinical,
D=Dietary

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© 2008 Thomson - Wadsworth
1.Antropometric measurements
– Involve measurement of the physical dimensions and
gross composition of the body
– Vary with age (and sometimes with sex and race) and
degree of nutrition
– Particularly useful in circumstances where chronic
imbalances of protein and energy are likely to have
occurred
– In some cases, they can detect moderate and severe
degrees of malnutrition but the methods cannot be
used to identify specific nutrient deficiency states

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– Provide information on past nutritional history which
cannot be obtained with equal confidence using other
assessment techniques
– Performed relatively quickly, easily and reliably using
portable equipment provided standardized methods and
calibrated equipment are used
– Raw measurements are generally expressed as an
index such as height-for-age
– Can be used both in clinical and field set ups

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A. Anthropometric measurements of growth
• Head circumference (HC)
– Supra orbital ridge anteriorly and occipital
prominence posteriorly.
– Measuring tape round 0.6cm wide

– Uses chronic nutritional/problems in under two

children.
– > 2 years (Brain growth sluggish)

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• Recumbent length
– A widen measuring board (also called sliding board) is
used for measuring length
– It is measured in recumbent position in children < 2
years old to the nearest 1 mm
– It is always greater than height by 1 – 2 cm

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• Height
– Measured in 2 years or more old children and adults in
standing position
– Head should be in Frankfurt position during
measurement and occipit shoulders and the buttock
should touch the vertical stand
– Can be measured using stadiometer , portable
anthropometer or acustat stadiometer (plastic
instrument)
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• Weight
• Weighing sling (spring balance) also called salter scale is used
for measuring weight to the nearest 10g in under two children
• In adults and > 2 yrs old children, beam balance is used and
the measurement is performed to the nearest 0.1 kg
• Lower leg length (in infants)
• Arm span
• Elbow breadth

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• Anthropometric growth indices
– Index is a combination of two measurements
– Indices are continuous variables and their biological
significance vary with age

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• Head circumference-for-age
• Weight-for-age
• Height-for-age
• Weight-for-height ratios

– Weight-for-height (Benn’s index)

– Body mass index (Quetelet’s index) [BMI= wt in
kg /(ht in m)2]
– Ponderal index [PI= wt in kg /(ht in m)3]
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 Indices derived from growth measurements

Weight-for-age = Weight of the child x 100

Weight of the reference child of the same age

Weight-for-height = Weight of the child x 100

Weight of the reference child of the same height

Height-for-age = Height of the child x 100

Height of the reference child of the same age
• Expressing anthropometric measurements
– Z score

Z score = (Observed value) – (Median reference value)

Standard deviation of reference population

– Percentile (percent of the median)

% ile = Observed value__________ x 100
Median value of the reference population
– Expressed according to the value of the subject in
reference to the NCHS’s 3rd, 5th, 10th and 90th centiles
– Usually the 3rd centile is taken as a cut off point for
labeling malnourished subject
– Expressing nutritional status in terms of standard
deviation is more advisable as it can clearly indicate
how the child is below the cut off point (-2Z or -2 SD)

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 Calculate W/H, H/A and W/A of the following children

Child Sex Age Weight Height Median Median wt SD

(kg) (cm) ht
1 Male 6 yr 5 mo 13.3 107.5 118.5 W/A = 21.6 H/A = 4.9
W/H = 17.9 W/A = 3.2
W/H = 1.6
2 Female 26 mo 12.4 86
3 Male 9 mo 7 71
4 Female 24 mo 11.9 90

Child 1:
H/A Z score = [(observed height – median reference height)/std dev]
= (107.5 – 118.5)/4.9 = -2.25 Z (Stunted)
W/A Z score = [(observed weight – median reference weight)/std dev]
= (13.3 – 21.6)/3.2 = -2.59 Z (Under weight)
W/H Z score = [(observed weight – median reference weight)/std dev]
= (13.3 – 17.9)/1.6 = -2.86 Z (Wasted)
• Anthropometric indicators
– Are indices used in conjunction with predetermined cut off points
to estimate the prevalence of different degrees of malnutrition
• Stunting (low height-for-age) < -2z scores

• Under weight (low weight-for-age) < -2z scores

• Wasting (low weight-for-height) < -2z scores

– Note that
• -2z corresponds roughly to the 3rd percentile

• Weight-for-height is index sensitive to acute changes to nutritional

status
• Height-for-age of children indicates chronic changes in nutritional
status
B. Anthropometric assessment of body composition

• In assessing body composition, we consider the body to

be made up two compartments
– Fat mass
– Fat free mass
• Different methods are used to assess these
compartments
– Assessment of body fat
• Skin fold thickness measurements
» Performed using precision SFT calipers
– Can be done in five different sites

– Triceps skin fold

» Measured at the mid point of the back of the
upper arm

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• Biceps skin fold

– Measured as the thickness of a vertical fold on the

front side of the upper arm, directly above the
center of the cubital fossa, at the same level as
the triceps skin fold
• Subscapular skin fold

– Measured below and laterally to the angle of the

shoulder blade with the shoulder and arm relaxed
• Suprailiac skinfold
– Measured in the midaxillary line immediately
superior to the iliac crest
• Mid axillary
– On the maxillary line at the level of xyphoid
process

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• Waist circumference
• Waist hip circumference ratio
– Circumference of the waist measured midway
between the lowest rib cage and anterior superior
illiac spine divided by the circumference of the hip
measured at the level of the greater trocanter of the
fumer
• High risk of coronary heart disease
– Ratio > 1 in men
– Ratio > 0.87 in women
• Assessment of the fat free mass
– Mid upper arm muscle circumference
– Mid upper arm muscle area
– MUAC
• A decrease in arm circumference reflects a loss of fat
stores and lean tissue mass
• A small circumference is postulated to reflect first the
fat tissue decrease and later the lean tissue mass
 Pros and cons of Anthropometric
measurements
Advantages Disadvantages
Quick Difficulty of selecting appropriate cut off
Cheap Limited diagnosis relevance (only for PEM)
Give gradable results Considerable potential for inaccuracy
More accepted by the community Need for reasonably precise age in
children and age is difficult to know in
agrarian society
Not invasive
Objective
2. Biochemical (Laboratory) Methods

• Measure nutrients in biological fluids and tissues

– Blood
– Breast milk
– Adipose tissue
– Liver and bone
– Hair
– Finger nails and toe nails
– Buccal mucosal cells
– Urinary excretion rate of nutrients or their
metabolites
Many micronutrient deficiencies do not produce signs or
symptoms until they are quite severe.

As a result, mild micronutrient deficiencies can only be

diagnosed using biochemical indicators

Biochemical indicator Micronutrient deficiency

Hemoglobin estimation Iron deficiency anemia

Serum retinol level Vitamin A deficiency

Urinary iodine level Iodine deficiency

• Assessment of protein status
– Total serum protein
– Serum albumin
– Serum transferrin
– Serum RBP
• Assessment of iron status
– Hemoglobin
– Hematocrit
– Serum iron
– Serum ferritin
– Serum transferrin receptor
• Assessment of vitamin A status
– Serum retinol
– Serum RBP
– Serum carotenoids
– Breast milk retinol
– Subjective assessment of night blindness
– Total body stores of VA
• Assessment of iodine
– Thyroid volume by ultrasonography
– Urinary iodine excretion
– Thyroid stimulating hormone
– Serum thyroglobulin
– T3 and T4
Pros and cons of Biochemical Methods
Advantages
• Detectsubclinical malnutrition
•Give gradable nutritional
information
•Are more objective
Disadvantages
• For many nutrients ideal biological
material is not accessible for routine use
• Many quality control problems during
sample taking, carrying out the test,
analysis, etc
•Some times low values may not have any
health Implication (May not reflect
presence of pathological lesions)
•There is no ideal biological sample for
some nutrients and some nutrients may
have multiple storage sites
•They are invasive (involve traumatizing
procedures)
•They are expensive
•Need sophisticated equipments
•Need highly skilled staff
3. Clinical Methods

– Medical history and physical examination are the clinical

methods used to detect signs (observations made by a
qualified examiner) and symptoms (manifestations
reported by the patient) associated with malnutrition
– These signs and symptoms are often non specific and only
develop during the advanced stages of nutritional
depletion
 • For this reason, diagnosis of a nutritional deficiency
should not rely exclusively on clinical methods
– It is obviously desirable to detect marginal nutrient
deficiencies before a clinical syndrome develops and as a
result, laboratory methods should also be included as an
addition to clinical assessment

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• Changes in the superficial tissues or in organs near
the surface of the body, which are readily seen or felt
upon examination. These include changes in:
– Eyes
– Skin
– Hair
– Thyroid gland
• Example
– Assessment of IDA
• Signs and symptoms of anemia
– Assessment of vitamin A deficiency
• Signs and symptoms of night blindness, xerophthalmia,
Bitot’s spot, etc
– Assessment of iodine
• Thyroid size by neck palpation
• Thyroid volume by ultrasonography
Clinical indicator Micronutrient deficiency

Pallor of palms or inside of eyelids or mouth Iron deficiency anemia

Night blindness (inability to see in low light) Vitamin A deficiency

Bitot's spots (spots on whites of eyes) Vitamin A deficiency

Goitre (enlargement of thyroid gland) Iodine deficiency

Edema PEM, particularly Kwashiorkor

4. Dietary Methods
• The first stage of any nutritional deficiency is
identified by dietary assessment methods
• During this stage, the dietary intake of one or
more nutrients is inadequate either because of
– Primary deficiency
• Low levels in the diet
– Secondary deficiency
• Dietary intakes may appear to meet nutritional needs
• But conditioning factors (such as certain drugs, dietary
components, or disease states) interfere with the
ingestion, absorption, transport, utilization or excretion
of the nutrients
• Dietary data could be gathered at
– National
• Food balance sheet
– Household
• Nutrition situation of household could be
roughly estimated by gathering data on the
amount of food available for consumption and
the amount of income spent for purchasing
food
– Individual levels
• The different methods commonly used for measuring
the food consumption of individuals
– Past intake
• 24 hour recall method
• Dietary history
• Food frequency questionnaire
– Current intake
• Weighed food records (gold standard)
• 24 hr recall
– Subjects and their parents or caretakers are asked by the
interviewer to recall the subject’s exact intake during the
previous 24 hr period or preceding day
– Assesses the actual intake of individuals
– However, a single 24 hr recall is not sufficient to describe an
individual’s nutrient intake of food and nutrients
– Multiple 24 hr recalls on the same individual over several
days are required
– The success of the 24 hr recall depends on the subject’s
memory, the ability of the subject to convey accurate
estimates of portion sizes consumed, the degree of
motivation of the respondent and the persistence of the
interviewer
• Repeated 24 hr recall
– 24 hr recalls can be repeated during different seasons of
the year to estimate the average food intake of individuals
over longer period of time period (i.e. usual food intake).
– The number of 24 hrs recalls required to estimate the
usual nutrient intake of individuals depends on the day to
day variation in food intake within one individual (i.e.
within subject variation)
Nutritional Assessment Systems

• Nutritional assessment systems can take any one of

four forms
– Surveys
– Screening
– Surveillance
– Intervention
Nutritional Surveillance
• Surveillance: from French “surveiller”, to watch over with great attention…
• The concept of nutrition surveillance was first introduced in
Thailand in 1977
• Definition
– Surveillance
• Is the ongoing systematic collection, analysis, and interpretation of
health data, essential to the planning, implementation, and
evaluation of public health practice, closely integrated with the
timely dissemination of these data to those who need to know so
that action can be taken
– Nutritional surveillance
• Is a system organized to monitor the food and nutrition situation
of a country or region within a country on a continuous and
regular basis
• NS information must be
– Community (population) based
– Decision and action oriented
– Sensitive
– Accurate
– Relevant
– Timely
– Readily accessible
– communicated effectively
• Three methods of acquiring data in nutritional surveillance
– Passive surveillance
• Often gathers disease data from all potential reporting health
personnel
• Data are obtained from the ongoing programs and it does
not incur too much in terms of cost, time and personnel
• Data generated is not as reliable and as relevant to the
program as compared to the former
– Active surveillance
• Requires substantially more time and resources and is
therefore less commonly used in emergencies
• Information obtained is more reliable and relevant to the
needs of the program
– Sentinel surveillance
• Refers to the application of epidemiological surveillance
to limited populations or sites to detect trends in health
events, or events that mandate a specific response (e.g.
polio outbreaks)
• Limited in scope, less costly, less complex, but not
representative
• Community-based Surveillance (CBS)
 Comparison of NS with other data collection
methods
Rapid assessment
Often collects qualitative or
semi-quantitative data
Collects wide variety of
data
Collects data on
convenience sample of
people and facilities
Collects data at a single
point in time
Collects only data for
numerator of prevalence
and incidence rates;
Denominator must come
from separate source
Surveillance
Collects quantitative data
Collects limited data
Often tries to collect data
on every case of illness
Collects data over ongoing,
prospective time period
Collects only data for
numerator of incidence
and prevalence rates;
Denominator must come
from separate source.
Survey
Collects quantitative data
Can collect wide variety of
data
Usually collects data on
sample of population
Collects data at single point
in time
Collects data for numerator
and denominator, allowing
calculation of prevalence
or incidence rates
 ???
END!

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 Quiz
• Write at least 4 methods of nutritional
assessment and their pros(for each at least 2)
and cons(for each at least 2) (8%).

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