NUTRITIONAL ASSESSMENT 

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 Introduction
 Assessment
– A process of gathering, analyzing, and interpreting
information
 Nutritional Assessment
– Gathering, analyzing and interpreting information from
anthropometric, biochemical, clinical, dietary and
ecological studies
– Aimed at discovering facts to guide actions intended to
improve nutrition and health

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 Systems of nutritional assessment
 Surveillance: Regular and timely (ongoing)
collection, analysis and reporting of nutrition relevant
data
 Survey: a cross-sectional assessment of nutritional
status of a selected population group
 Screening: early identification of malnourished
individuals requiring intervention

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 Two methods of nutritional assessment
1. Direct methods
Direct measurement of body dimensions and
proportions (A)
Determination of nutrients concentrations in tissue
or body fluid (B)
Appearance of the clinical symptoms and signs
related to a specific nutrient dependent functional
impairment (C)
Dietary intake (D)

Can a single assessment detects the whole stages of

nutrient deficiency?
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 Con…
Each method detects a stage in development of a nutrient
deficiency
2. Indirect methods (Ecological methods) include:
 Ecological variables
 Economic factors
 Vital health statistics

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Nutritional Deficiency Development Stages

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 1. Dietary assessment
• Measures of food intake have a variety of purposes:
– To assess the adequacy of the diets of populations, groups
or individuals
– To relate dietary factors in populations or individuals to
disease incidence or risk factors
– To compare the diets of different countries, regions,
socioeconomic groups and different age and ethnic groups
– To monitor changes in the diets of populations, groups or
individuals over time
e.g. to monitor the effectiveness of nutrition education programs

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 Con…
• Steps in the assessment of food and nutrient
intakes
1. Measuring food intake
2. Converting foods to nutrients
3. Estimating intakes of available nutrients
4. Evaluating dietary adequacy
– Note: dietary assessment assesses ‘risk’ of nutrient
inadequacy and not nutritional status

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 At National Level
– Food balance sheet (National food disappearance
data or food going in to consumption)
• Are rough estimates of the amount of food available for
national consumption
• Estimation of food available for consumption per capita
for a year
• Don’t take the food that is produced by the subsistence
farmers in to consideration
• Can be used as one of the indicators for food self-
sufficiency but not for food security

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 Household Level
• The amount of food available for consumption at the
household level and the amount of income spent for
purchasing food, excluding that eaten away from
home

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 Individual Level
• Current Intake
– Weighed Food Records (Gold Standard)
• Most precise method for assessing food intakes
• Respondent or data collector weighs all foods and
drinks consumed during a specified time period
• Details
– Methods of food preparation
– Description of each food item including brand
names (if known) also recorded
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 Con….
• Advantages:
– More accurate
– No respondent memory loss
– Easier method for data collectors
– Requires less training
– Accurate data on hygiene, sanitation, infant motor skills can be obtain
• Disadvantages:
– Costly
– High respondent burden
– Change of the dietary habit during the survey due fear of burden
– Needs literate and numerate respondents

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Estimated Food Records
Subjects are taught to describe and either estimate the amount of food
immediately before eating and to record leftovers
Write and describe everything eaten and drunk for the next 3 (4 or 7)
day using household measures
Advantages
– Used to assess actual or usual intakes of individuals (Diet counseling)
Limitations
– Accuracy depends on carefulness of subject and ability to estimate
quantities
– Longer time frames
– Subjects must be literate

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Methods used to assess past intake
24 hour recall method
Respondents are requested to
 Remember whatever they consumed within the last 24 hrs

Steps in multiple pass 24 hr recall

Step 1: List all foods and drinks consumed sequentially
Step 2: Describe in detail each food listed
Step 3: Estimate portion size
Step 4: Review recall

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 Con…
• Advantages
– Quick, cheap (4-6 interviews/d)
– Large coverage
– Low respondent burden
– High response rate; non-threatening
– Used for illiterate subjects
– Less likely to alter diet

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 Con…
• Limitations
– Relies on memory & motivation
– Inaccuracies in portion size estimates
– Inaccuracies when eating from common pot and
for mixed dishes
– Relies on skill of interviewer
– Under-reporting, may omit foods consumed
infrequently

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 Con…
Calories Protein Fat Fiber ( Ca Iron
(gm) (gm) (gm) gm) (mg) (mg)

Tyef, nech', 145 3.00 0.6 1.00 56.0 7.0

injera
Nech sindye 222 6.8 .8 1.2 27 2.7
dabo
Egg 295.1 9.8 26.3 .5 63 3.4

Banana 87.8 .8 .6 .4 8 .5

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 Con…
USDA Conversion Factors
1 fruit 118g Bananas
1 slice 25g Bread
1 tbsp 14.2g Butter
1 cup 250g Buttermilk
1 piece 44g Chicken
1 cup 250g Coffee
1 cup 226g Cottage Cheese
1 cup 130g Kale
1 cup 250g Milk
1 tbsp 16g Peanut butter
1 cup 210g Potatoes, Irish
1 tbsp 8g Sugar
1 cup 250g Tea
1 tbsp 25ml
1 tsp 5ml
1cup 250ml

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 Con…
• Preferable place and interviewer to conduct
interviews?
• What should we do if they eat from common pot?

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 Food Frequency Questionnaire (FFQ)
• A questionnaire in which the respondent is presented with a
list of foods and is required to say how often each is eaten in
broad terms such as x times per day/per week/per month, etc
• Foods lists are usually chosen for the specific purposes of a
study and may not assess total diet

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 Advantages and limitations of a semi-
quantitative FFQs
• Advantages
– Quick, large coverage, FFQ is standardized
– Provides data on usual intakes over longer time frame
• Limitations
– Relies on memory
– Need source of valid data for portion sizes
– Respondents may have difficulty with concept of “usual”
frequency and “usual” portion sizes
– Single SQ-FFQ rarely valid for multiple micronutrients

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 Past intake con…
 Dietary History
• Attempts to estimate the usual food intake and meal pattern of
individuals over a relatively long period of time – often a month
– Includes determining the respondent’s eating habits
• Timing and frequency of meals, tastes and allergies
• Ability to access food physically and economically
• How food is prepared and distributed at household level

• Includes
– Interview about usual overall eating patterns
– FFQ on consumption of specific food items
– Three day estimated record

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 Dietary History…
– Three-day estimated record
• 1- week day; Saturday; Sunday
• Usual portion sizes of most commonly consumed foods
on 3 days weighed
• Weighted daily average intake calculated:
– ((5 x week day) + Saturday + Sunday) / 7

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 Dietary History…
• Advantages
– Used for counseling patients
– Provides data on usual intakes at the individual level that
may be more representative
• Limitations
– Time consuming
– Relies on household measures for portion size estimates
– Respondents must be numerate
– Respondents might have difficulty with concept of usual
intake and usual portion sizes
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 Interpretation of Dietary Data

• Dietary data are interpreted using

1. Qualitative methods
• Example: DDS
• Individual dietary diversity score (IDDS)
– Is used as a proxy measure of the nutritional quality of
an individual’s diet
• HDDS
– Is used as a proxy measure of the socio-economic
level of the household
2. Quantitative methods
– Example: FCTs

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 The 9 food groups for adult
Food group (new variable on IDDS need to be created and frequency table generated accordingly)
1. Starchy staples (cereals such as maize, rice, wheat, barley, sorghum, millet, teff or any other grains or foods
made from these (eg bread, injera, roasted cereals, porridge, spaghetti, macaroni, etc) and white roots and
tubers such as white potatoes, white cassavas or other foods made from roots)

2. Dark green leafy vegetables (amaranth, cassava leaves, kale, spinach)

3. Other vitamin A rich fruits and vegetables (vitamin A rich vegetables and tubers such as pumpkin, carrot,
squash, orange flesh sweet potato, etc; vitamin A rich fruits such as mango, papaya, peach, etc; and red palm
oil)

4. Other fruits and vegetables (vegetables such as tomato, onion, egg plant, etc and other fruits)

5. Organ meat (liver, kidney, heart, blood based foods, etc)

6. Meat and fish (flesh meats such as beef, pork, lamb, goat, sheep, chicken and fish and sea food)

7. Eggs

8. Legume, nuts and seeds (beans, peas, lentils, nuts, peanut butter, etc)

9. Milk and milk products (milk, cheese, yoghurt)

DDS
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 Con…
• The 7 foods groups for children are:
– Grains, roots and tubers
– Legumes and nuts
– Dairy products (milk, yogurt, cheese)
– Flesh foods (meat, fish, poultry and liver/organ meats)
– Eggs
– Vitamin-A rich fruits and vegetables
– Other fruits and vegetables
• Interpretation of food group consumption:
• Adult <4 -poor DDS
4-6 - fair
>=7 - good
• A child should eat a minimum of 4 DDS per day
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2. Biochemical/laboratory Methods
• Used primarily to detect subclinical deficiency states or
to confirm a clinical diagnosis
• It provides an objective and quantitative means of
assessing nutritional status
• Measures either:
– the actual level of nutrient (nutrient in biological fluids or
tissues or the urinary excretion rate of a nutrient or its
metabolites) or
– the extent of functional consequence of a specific nutrient
deficiency
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2. Biochemical/laboratory Methods…

• Eg
• Hemoglobin: iron deficiency anemia
• Plasma ferritin: level of iron store
• Plasma transferrin receptor : tissue iron
• Plasma retinol binding protein: vit A
• Plasma transthyretin: iodine
• Urine specimens: Cr, I, Se, Protein, water soluble vitamins
• Breast milk: Vitamin A, B6, B12, Thaimin, Iodine,
Selenium
• Hair: zinc, Selenium

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 Biochemical Tests…
• Advantages
– Detect sub-clinical Malnutrition
– Give gradable nutritional Information
– More objective

• Disadvantages
– Involve invasive procedures
– Need sophisticated instruments and highly trained staff
– Many quality control problems
– No ideal biomarker for each nutrient
– No ideal specimen or storage site

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 3. Clinical Methods
• Involve checking of Signs (physical examination) and
symptoms (medical history) of deficiencies from the
patient
• Clinical signs of nutrient deficiency include
• Pallor, Bitot's spots on the eyes, pitting edema,
goiter and severe visible wasting

• These sign and symptoms are often non-specific and

only develop during the advanced stages of nutritional
depletion
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 4. Anthropometric Assessments 
– Anthropo = Human, and Metry = measurement
– Provides information on past nutritional history
– Widely used as a tool to;
• Monitor the growth and health of individuals
• Estimate the nutritional status of populations
– Major purposes of anthropometric measurements
• Physical growth (Children)
• Changes in body composition or weight (Adults)

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 Anthropometric Assessments 

 Anthropometric measurements of growth

E.g. Head circumference, Length, Height,
Weight
 Anthropometric measurements of body
composition
E.g. MUAC, Skin fold thickness, WC, WHR,
WHtR, BMI

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 Con…
• Head circumference (HC)
– The circumference of the head along the supra
orbital ridge anteriorly and occipital prominence
posteriorly
– Measured using flexible, non-stretchable measuring
tape around 0.6cm wide to the nearest 1mm
– Useful in assessing chronic nutritional problems in
under 2 children

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 Measuring HC
Head circumference should be measured
using a narrow non- stretchable plastic or
disposable lasso tape. Clean tape with
antiseptic wipes [or soapy water] between
child use

Measurement should be taken at the

maximum occipito-frontal
circumference taking the largest of 3
consecutive measurements

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 Con…
• Knee height (KH)
– Highly correlated with stature
– Used to estimate the height of a person who has spinal curvature
(kyphosis, scoliosis) or cannot stand up
– Measured using a caliper consisting of an adjustable measuring stick with
an angel attached to it at 90 
– Males: Height in cm = {84.88 - (0.24 x age)} + (1.83 x knee height)
– Females: Height in cm = {64.19 - (0.04 x age)} + (2.02 x knee height)
• Length
– Measured by a widen measuring board (sliding board)
– Measured in recumbent position in children <2 years old to the nearest
1mm

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 Con…
• Arm span
– ‘The distance from tip of the middle finger of the
left arm to the tip of the middle finger of the right
arm with the arms stretched out’
– Arm span can be a useful proxy for height,
especially for older people whose ability to stand
straight is affected by spinal disease

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Measurement of knee height

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Length measurement

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Correct positions for length measurement

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 Con…
– Height
• Children 2 years and in adults
• Measured in standing position using stadiometer
or portable anthropometer
• During measurement
– The head should be in the Frankfurt position
– The occiput, shoulders, buttocks and heels should touch the
vertical stand

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Position of head

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– Weight
• Salter scale for children < 2 years (nearest 10g)
• Beam balance for adults and children >2 years
(nearest 0.1 kg)

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© 2007 Thomson - Wadsworth
 Conventional cut-off for diagnosing moderate
malnutrition

Standard Height for Weight Weight

age for height for age
Z score -2 -2 -2
Standard deviation -2 -2 -2

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 Calculating z score
Example Calculate the weight for age z score for a 19-month-
old boy who weighs 9.8 kg compared to the reference standards.
 9.8 kg - 11.7 kg / 1.2sd = -1.58 SD units
 Con…
Weight for Age = Weight of the child x 100
Weight the normal child of
the same age

Weigh for height = Weight of the child x 100

Weight of the normal child of
the same height

Height for age = Height of the child . X 100

Height of the normal child of
the same age

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 Median

Low weight
for age

Very low
weight for
age

06/03/2023 FM 48
Prevalence of malnutrition and interpretation levels

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 MUAC
The arm contains
– Subcutaneous fat and muscle
– A decrease in mid upper-arm circumference may
therefore reflect either a
• Reduction in
– Muscle mass
– Subcutaneous tissue or both
• MUAC is the only anthropometric measurement to assess nutritional
status of pregnant women
• It is used as a screening tool for community based nutrition
programs such as: Outpatient therapeutic programs (OTP),
Community-based interventions
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 Con…
Advantages
– Easy to perform
– Does not require age (relatively age independent?)
– “Best" predictor of mortality in children
Disadvantages
– Measurement error
– Age dependency
– Multiple cut-off values
– Have poor correlation with stunting
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• New WHO standards recommend MUAC < 11.5cm as
criteria for severe malnutrition among children of age 6
months and above
• MUAC ≥ 13.5 cm: satisfactory nutritional status
• A special tape is used for measuring the MUAC of a
child which has three colors
 The red indicating severe acute malnutrition
 The yellow indicating moderate acute malnutrition
 The green indicating normal nutritional status
06/03/2023 FM 52
 Body mass Index (BMI)
• Best method for assessing adult nutritional
status
• BMI is indicative of body adiposity
• BMI = weight (kg) / [height (m)] 2
– BMI <18.5 kg/m2 – underweight
• 18.5 to 24.9 kg/m2 – healthy/low risk
• >25 kg/m2 - overweight
• >30 kg/m2 – obese

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 Body Composition
• Fat mass and fat free mass
Waist to hip circumference
Waist circumference
Waist to height ratio
Skin fold thickness

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 Pros and Cons of anthrop…
Pros Cons

Quick Difficulty of selecting appropriate cut off

point

Cheap Limited diagnosis relevance (only for

protein-energy

Give gradable results Considerable potential for inaccuracy

Not invasive Need for reasonably precise age in

children
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 Quality Control
• Calibration of the instrument
• Standardization of procedures
• Making subjects wear a uniform gown before
measuring weight
• Verification of at least 10 % of the data by the main
investigator
• Training of the data collectors and limiting the
coefficient of variation to be less than 3%. CV =
standard deviation/ mean X 100

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 Indirect Methods
Ecological methods
Ecological Variables
Crop production, meteorological data (rainfall data), production
pattern and distribution pattern, predominance of cash crops, etc.
Economic Factors
Per capita income, population density, social habits, income
levels, market price of foods, etc.
Vital Health Statistics

– Infant & U5 mortality, fertility, cause specific mortality

rates, age specific mortality rates, health service
statistics, rate of nutritionally relevant infections, etc.

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