Lecture 4 & 5-

Nutritional
Assessment

Introduction to Nutrition Therapy

Semester 4

Department of Food Science and Human Nutrition

Nutritional assessment

– Nutrition assessment provides the foundation for the nutrition care process.
– Nutrition assessment is defined as “a systematic method for obtaining, verifying,
and interpreting data needed to identify nutrition-related problems, their causes,
and significance.
– Nutritional assessment is the interpretation of anthropometric, biochemical
(laboratory), clinical and dietary data to determine whether a person or groups of
people are well nourished or malnourished (over-nourished or under-nourished).
Nutritional Status
Determination of nutritional status involves evaluating indices that reflect the
body’s nutrient stores.
Nutritional status is altered when stores of energy, protein, water, vitamins, or
minerals fluctuate as a result of
increased need,
increased or altered utilization, or
altered intake.
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
Nutritional Risk
– Determination of nutritional risk involves the attempt to predict potential nutritional problems based on
the client’s current health status.
– Specific factors increase or decrease a client’s nutritional risk; for example, a diagnosis of pancreatic
cancer places an individual at a higher nutritional risk than admission for a cholecystectomy.
– Many nutrition problems seen in the hospitalized population are the result of disease or its treatment.
– The patient will most likely have an increased requirement for certain nutrients, an inability to consume
enough nutrients, or an inability to metabolize the ones that can be digested and absorbed.
– Therefore, understanding the pathophysiology, treatment, and clinical course of a disease or diagnosis
allows one to identify nutrition problems for an individual and ultimately determine the nutrition
diagnosis.
Nutrition Assessment and Screening

– As a component of the nutrition care process, the nutrition assessment consists of

gathering data in the following areas or domains:
– “food and nutrition related history;
– Biochemical data,
– medical tests and procedures;
– anthropometric measurements;
– nutrition-focused physical findings; and
– Client history.”
– Assessment data from these areas may be both subjective and objective in nature.
– The assessment process then moves to analysis of data so that current and potential
nutritional problems can be identified.
– While it is not possible, or necessary, to complete a full nutritional assessment of every patient
admitted to a clinic or hospital, it is essential to have a system in place that can quickly identify those
patients who may have nutritional problems.
– The World Health Organization defines screening as “the use of simple tests across a healthy
population in order to identify the individuals who have disease, but do not yet have symptoms.”
– The Agency for Healthcare Research and Quality defines screening as “those preventive services in
which a test or standardized examination procedure is used to identify patients requiring special
intervention.”
– Charney points out that the Academy of Nutrition and Dietetics (AND) uses this as their basis for
defining nutrition screening as the “process of identifying patients, clients, or groups who may have
a nutrition diagnosis and benefit from nutrition assessment and intervention by a registered dietitian
(RD).
– Nutrition screening can be performed by dietetic technicians or other trained
personnel, which allows for a more efficient and cost-effective collection and
identification of at-risk patients.
– A dietitian can then perform a full nutrition assessment for those identified as
being at nutritional risk.
– The AND’s Standards of Practice (SOP) in Nutrition Care include nutrition
assessment as the first standard.
Subjective and Objective Data
– Types of data include both subjective and objective information.
– Subjective data
– Include information that is obtained directly from the patient, family members, and any other caregivers,
usually during interviews.
– It would include the client’s perception of his or her medical condition, dietary intake, lifestyle conditions,
current medications or supplement intake, and family medical history.
– The interviewer’s observations are also considered subjective data.
– Objective data
– include information obtained from a verifiable source such as the current medical record and previous medical
histories.
– These data could include anthropometric measurements, biochemical data, and medical tests and procedures.
– The organization and content of the medical record will vary from institution to institution.
Methods of Nutritional Assessment
Nutrition is assessed by two types of methods;
direct and
indirect.
The direct methods deal with the individual and measure objective criteria, while
indirect methods use community health indices that reflects nutritional
influences.
Parameters of Nutritional Assessment
Nutritional assessment can be done using the ABCD
methods. These refer to the following:
A. Anthropometry
B. Biochemical/biophysical methods
C. Clinical methods
D. Dietary methods.
A. Anthropometry
Anthropometric/Body Composition Measurements

– “Anthropometry is the measurement of body size, weight, and proportions.”

– Body composition refers to the distribution of body compartments (e.g., muscle mass and
body fat) as part of the total body weight.
– Evaluating both anthropometric and body composition data allows the clinician to fully
assess these compartments.
– It uses several different measurements including
– length,
– height,
– weight and
– head circumference.
 Nutrition Care Indicator:
Height/Stature

– Measurement of supine or standing height is necessary for monitoring growth of infants and
children and for interpretation of weight in adults.
– It is recorded to the nearest mm.
Instruments Used:
1. Length Board
– For children under the age of 2 years, length is measured recumbently using a length board.
– This device has a stationary headboard and a movable footboard.
– This measurement requires two clinicians, one of whom holds the child’s head against the
headboard while the other extends the leg and bottom of the heel to the footboard.
– Length is recorded to the nearest 0.1 cm.
2. Stadiometer
– Over the age of 2 years, standing height is measured using a tape measure or
stadiometer.
– The procedure for measuring height is to have the client stand barefoot and look
forward with shoulders, buttocks, and heels touching the vertical surface of either a
wall or the stadiometer with the Frankfort plane.
– This ensures the head is not tilted incorrectly.
– Sometimes a client cannot stand for the measurement of height—for example,
because he or she is disabled or confined to a wheelchair or bed.
– In these cases, any of several estimation methods may be used.
3. Arm span
– The client extends the arms from the body at a 90-degree angle and distance is measured
between the tips of the two middle fingers.
– The length of the dominant arm can be measured in the same fashion and multiplied by 2 to
estimate height.
– A limitation of this method is that it is an estimation of maximum adult height and not
actual, current height.
4. Knee height
– Method of height estimation.
– Measurement of knee height, using a knee-height caliper, can be taken when the client is
sitting or in a supine position.
– The client lies supine with right knee and ankle flexed to 90 degrees.
– The clinician should place the fixed portion of the caliper under the heel and position the
other blade over the anterior portion of the thigh above the knee.
– The shaft of the caliper is parallel to the tibia.
– The measurement (repeated two to three times) is recorded to the nearest 0.1 cm.
– Height is then estimated using the following equations
Errors
– Height or length has been noted to be one of the most inaccurate measures.
– Inaccuracies are introduced when
– Shoes are not removed,
– A verbal report is taken instead of a measurement, or
– the head, shoulders, or heels are not in the correct position.
– In clinical settings, it is often either estimated or recorded from the patient’s memory.
– Nonetheless, accurate measurement is crucial because height is used to interpret
weight, measure growth for children, calculate energy and protein requirements,
and calculate creatinine-height index
 Nutrition Care Indicator:
Weight
– Weight is an important indicator for growth, development and health.
– Ideally, the client should be weighed with minimal clothing and without shoes, at the same time daily,
and after urination.
Instruments Used:
1. A weighing sling (spring balance), also called the ‘Salter Scale’ is used for measuring the weight of
children under two years old, to the nearest 0.1 kg.
2. In adults and children over two years a beam balance is used and the measurement is also to the
nearest 0.1 kg.
3. In both cases a digital electronic scale can be used if you have one available. Do not forget to re-
adjust the scale to zero before each weighing. You also need to check whether your scale is
measuring correctly by weighing an object of known weight.
4. Bathroom scales and those that are moved frequently are not recommended due to problems with
calibration.
5. Wheelchair and bed scales are available for nonambulatory patients.
6. For those patients with an amputation, weight has historically been adjusted using the
following factors:
– Hand: 0.8%
– Forearm and hand: 3.1%
– Entire arm: 6.5%
– Foot: 1.8%
– Lower leg (below knee) and foot: 7.1%
– Entire leg: 18.6%
– Weight would be adjusted by using the following equation:
Adjusted body weight =
actual measured weight /100 - % amputation. The whole equation then is multiplied by 100.
For example, for an individual who has had an entire leg amputated and currently weighs 165 lbs,
The head circumference (HC)
– Measurement of the head along the supra orbital
ridge (forehead) anteriorly and occipital prominence
(the prominent area on the back part of the head)
posteriorly.
– measured using flexible, non-stretchable measuring
tape around 0.6cm wide.
– HC is useful in assessing chronic nutritional
problems in children under two years old as the
brain grows faster during the first two years of life.
– But after two years the growth of the brain is more
sluggish and HC is not useful.
Evaluation and Interpretation of Height and
Weight in Infants and Children
Growth Charts

– Weight and height for infants and children are evaluated using growth charts developed by the
Centers for Disease Control and Prevention (CDC) and the National Center for Health Statistics.
– Determination of height for age and weight for age allows comparison of an infant or child to a
reference population.
– When infants and children are either ≤ 3rd percentile or ≥97th percentile, further assessment should
be made to confirm any health problems.
– There are specific clinical diagnoses, such as genetic and endocrine disorders, that negate use of
these standard growth charts.
– Alternative growth charts have been developed for children with specific health care needs.
– Weight-for-age is an index used in growth monitoring for assessing children who may be
underweight. You assess weight-for-age of all children under two years old when you
carry out your community-based nutrition (CBN) activities every month
– Height-for age is an index used for assessing stunting (chronic malnutrition in children).
Stunted children have poor physical and intellectual performance and lower work output
leading to lower productivity at individual level and poor socioeconomic development at
the community level
– Weight for height and percentile weight for height can also be evaluated using
CDC growth charts.
– These measurements allow evaluation to be independent of age and can be used
to monitor
– acute malnutrition (<5th percentile) or
– The incidence of obesity (>95th percentile).
Body Mass Index
– Revision of the CDC growth charts in 2000 added the
measurement of body mass index (BMI).
– BMI is weight (kg)/[height(m2)]
– Calculation and interpretation of BMI in children and adolescents
has increased in recent years.
– Assessment is not based on adult standards, however; instead,
– overweight is defined as 85th to <95th percentile of BMI-forage,
– obese is defined as > 95th percentile of BMI-for-age, and
– underweight is defined as < 5th percentile.
Evaluation and Interpretation of Height and
Weight in Adults
Usual Body Weight
– In the clinical setting, variations from usual body weight have been strongly
linked to nutritional risk and health complications.
– Such variation may be more clinically useful than comparison to ideal body
weight standards.
– In general, an adult is considered at nutritional risk if there is a > 5%
unexplained
weight change in less than 1 month or > 10% in a 6-month period.
Percent Usual Body Weight and Percent Weight Change

– Percent usual body weight is calculated as:

– Percent weight change is calculated as:

Reference Weights - IBW
– Calculation of body mass index is considered to be the only validated method for estimating
desirable or ideal body weight.
– Nonetheless, in many clinical settings, reference body weight is calculated using
the Hamwi equation even though it does not adjust for differences in age, race, or frame size.

– %IBW =
(Actual Weight / Desirable Body Weight) x 100
 Weight as an Indicator of Nutrition Status
% IBW % UBW Nutritional Status
>120 - Obese
110-120 - Overweight
90-109 - Adequate
80-89 85-95 Mildly underweight
70-79 75-84 Moderately underweight
<70 <75 Severely underweight
Body Mass Index (BMI)
– BMI or Quetelet’s Index, as stated previously, is calculated as:

– The use of BMI has been correlated with overall mortality and nutritional risk.
– It still does not estimate body composition, but it is better at indicating obesity
than mere height and weight alone.
– Table shows interpretation of BMI in adults and children, respectively.
Waist Circumference
– Waist circumference of
– > 40 inches (102 cm) for men or
– > 35 inches (88 cm) for women
– is considered to be predictive of obesity and chronic disease risk in Caucasian, African-American,
Hispanic, and NativeAmerican populations.
– Within Asian populations, risk is defined at
– > 90 cm in men and
– > 80 cm in women.
– Fat accumulation, primarily in the abdominal region, has been linked to an increased risk of type 2
diabetes mellitus and other obesity-related diseases.
– The current recommendations from the Endocrine Society Practice Guideline (2008) and the National
Heart, Lung, and Blood Institute/American Heart Association are that waist circumference should be
used as a part of routine physical examination.
Frame Size
– Body frame size is determined by a person's wrist
circumference or elbow circumference in relation
to his height.
– Formula used:
r = Height(cm) / wrist circumference
Or
r = Elbow breath(mm) / Stature (cm) x 100
– For example, a man whose height is over 5' 5" and
wrist is 6" would fall into the small-boned category.
Waist Hip Ratio
– It assesses the distribution of fat or adipose tissue.
– Formula:
Circumference of weight (inches) / Circumference of hip (inches)
Obesity Adjustment
– Commonly, an "adjustment" for obesity will be calculated in patients who are
greater than 20-30% of their ideal body weight.
– Adjusted body weight is used by some dietitians for obese patients when
calculating energy requirements. Adipose tissue is not as metabolically active
as lean tissue, so using actual body weight in equations to predict BEE for obese
persons may result in an overestimation
– Formula:
(ABW – IBW) X 0.25 +IBW