Methods of Nutritional Assessment

By:
Mohamed Arab (Nutritionist)

2024

1
 Outline

• Definitions

• Principles of assessing nutritional status

• Rationale of assessing nutritional status

• Methods of nutritional assessment

12 June 2023 2
 Malnutrition- Under nutrition and over nutrition

12 June 2023 3
 Introduction...Con’t.
• 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 (normal) or malnourished (Over
nourished/under nourished).
• In other words it is a process of gathering, analyzing and interpreting
information from anthropometric, biochemical, clinical, dietary, and
ecological studies.

• Nutritional status can be assessed at individual or group level

12 June 2023 4
 Nutritional assessment Methods

There are direct and indirect methods of assessing Nutritional status:

ABCDE
• Anthropometry
• Biochemical Direct
• Clinical
• Dietary

• Ecological Indirect

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 Direct methods
The direct methods involve the direct measurement of body dimensions and
proportions, determination of tissue or body fluid concentrations of nutrients,
dietary intake, appearance of the clinical symptoms and signs related to a specific
nutrient dependent functional impairment.

Abbreviated as the ABCDs:

 A=Anthropometry
 B= biochemical/Biophysical,
 C= Clinical,
 D= Dietary
12 June 2023 6
 Indirect methods
 Indirect methods include assessment of indicators of the food and
nutrition situations in the area/ region of interest by looking at
certain data that are closely related to malnutrition or which are
aggravated by malnutrition

 These include:
 Cause specific mortality rates
 Age specific mortality rates
 Health service statistics
 Rate of nutritionally relevant infections
 Meteorological data (rainfall data )
 Production and distribution patterns
 Income levels
 Market price of foods
 Predominance of cash crops

12 June 2023 7
 Indirect Methods 3. Vital health statistics

1. Ecological variables • Infant & under 5 mortality

⚫Crop production, meteorological data, • Cause specific mortality rates
production pattern and distribution
• Age specific mortality rates
pattern, predominance of cash crops,
• Health service statistics
etc

2. Economic factors • Rate of nutritionally relevant

⚫Per capita income, population density, infections, etc

social habits, income levels, market
price of foods, etc
 Stages of development of nutritional deficiency

STAGE DEPLETION STATUS ASSESSMENT METHOD

One Dietary inadequacy Dietary

Two Decreased level in the Biochemical

tissue reserves
Three Decreased level in the Biochemical
body fluids
Four Decreased functional level Biochemical
in the tissues
Five Decreased activity of nutrient Biochemical
dependent enzymes

Six Functional changes Clinical/Anthropometric

Seven Clinical symptoms Clinical

Eight Anatomical signs Clinical

 Rationale of assessing nutritional
status
 Nutritional assessment helps to:
Assess the prevalence and distribution of nutritional
problems
 Identify high-risk groups
Assess the role of different epidemiological factors in
nutritional deficiencies
 It also has a role in:
 Policy-making
 Nutritional recommendations
 Fund allocations for program managers
 Evaluating the effectiveness of interventions

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 Nutritional assessment systems
 Three forms
 Surveys: One time data collection
 establish baseline nutritional status
 formulate policies
 identify geographic areas &/or sub-groups “at risk”
 Surveillance: data collected over time on same groups
 can identify both acute and chronic malnutrition
 can identify seasonal differences
 possible causes of malnutrition for intervention programs
 monitoring policies; evaluating nutrition interventions
 Screening: data from whole population/only those “at risk”
 On apparently healthy population
 simple & cheap
 Can be used for large population

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 A. Anthropometric
Assessments
 Anthropometry comes from two Greek words:
 Anthropo = Human, and

 Metry/metron = measurement

 Anthropometry refers to measurement of variations of physical

dimension and gross composition of human body at different levels
and degrees of nutrition (Jelliff, 1966)

 Is anthropometry a measurement or assessment?

 Usually needs transformation of measurement to indicators
12
 Anthropometry…
Con’t
 Anthropometric measurements
• Growth
 Length/height
 Weight
 Head circumference
• Body fat
 Skin folds
 Hip circumference
 Waist circumference
• Fat-free mass
 Mid-upper arm circumference

13
 Anthropometry…
Con’t measurements could be used both in the clinical
 Anthropometric
and field set-ups

 In the clinical set-ups they are used to assess the nutritional

status of:
 post-operative patient
 post traumatic patient
 chronically sick medical patient
 patient preparing for operation
 severely malnourished patient

14
 Anthropometry…
Con’t
 In field set-ups we use to assess the nutritional status of:

Population (Prevalence, screening for risk, intervention,

monitoring and evaluation)

 In general, anthropometric measurements are performed

with
two
major purposes in mind:

1. IN CHILDREN: to assess physical growth

2. IN ADULTS: to assess changes in body composition or 15

 I. Anthropometric Measurement of Growth
Growth performance of children is an excellent reflection of
their underlying nutritional status
 Growth is most rapid in the first year of life

Children adapt to the chronic nutritional insult by either reducing their

rate of growth or by totally failing to grow

Measurement of Child Growth

 Optimal growth occurs only with:
• presence of adequate food
• absence of illness
• appropriate caring and
nurturing
• conducive social
environment 16
 Anthropometry…
Con’t
How to measure growth?
Weight

• Most accurate and sensitive method of measuring growth is

weight gain

• Weight gain can be measured by regularly weighing

• Sensitive to acute malnutrition

17
 Weight…
Con’t.
• Weighing sling (spring balance) also called salter scale is used for measurement
of weight in children < 2 years

• In children the measurement is performed to the nearest 10g

• In adults and children ≥2 years, beam balance is used and the measurement is
performed to the nearest 0.1 kg

• What if the older child irritable and cannot stand alone?

• For both digital (electronic) scales can be used and are very accurate.

18
 Weight…
Con’t.
Salter Scale

a. For infants b. For older children and

adults

19
Weight…
Con’t.

Not at center
20
Weight…
Con’t. Improvising Weight Measurement

21
 Heigh
t in children >2 yrs and adults in standing position to the nearest 0.1
• Is measured
cm.

• The head should be in the Frankfurt plane during measurement, knees should
be straight and the heels buttocks and the shoulders blades, should touch the
vertical surface of the stadiometer (anthropometer) or wall.

• Stadiometer or portable anthropometer can be used for measurement

• There is also a plastic instrument called acustat Stadiometer that is cheaper

than the conventional Stadiometer

22
 Height…
Con’t.

Stadiometer
23
Height…
Con’t.

24
 Lengt
h measuring board (also called sliding board) is used
• A wooden
for measuring length

• Itis measured in recumbent position in children ≤2 yrs

old (< 87 cm) to the nearest 1mm

• It is always > height by 1-2cm

• At least one assistant is needed in taking the measurement

• Measurement is read to the nearest mm

25
 Length…
Recumbent length board, Technique:
Con’t.  Toes are pointing upwards
 Heels against footboard
 Knees must be straight
 Use only left leg, if subject restless

wooden measuring
board/sliding
board/Length board

26
Length…
Con’t.

27
Head Circumference
(HC)
Measured using flexible measuring tape around 0.6cm wide
to the nearest 1mm

It is the circumference of the head along the supra orbital ridge
anteriorly and occipital prominence posteriorly

HC is useful in assessing chronic nutritional problems in under

two children

But after 2 years as the growth of the brain is sluggish it is not

useful

28
HC…
Con’t
Technique
 Subject stand with left side facing; arms relaxed
 Ensure tape at same level on each side of head
 Pull tightly to compress hair

Figur
e
29
 Indices and
 Anindicators...Con’t.
index is a combination of two measurements or a measurement plus
age
• Constructed from > 2 raw measurements

• Necessary for interpretation of measurements

 The following are few of them:
 Head circumference-for age
 Weight -for-age
 Height-for age
 Weight for height

 An indicator is an index + a
cut-off point
Examples:-W F A < 60% = is
indicator of severe malnutrition
-HFA < -3 z score
6/12/2023
indicator of severe
stunting 40
Indice
• Height-for-age (HFA)
s
• Is a measure of stunting, past malnutrition
• Is a reasonable predictor of long term mortality
• Is less useful measure of growth over time than weight-for-age

• Weight-for-height
• Is a measure of wasting
• Indicates recent or current malnutrition
• Is a good predictor of short term mortality
• Requires that two measurements are made

31
Weight for age
• Weight-for-age (WFA)
• Is a composite measure of under nutrition when low
• Fails to distinguish between wasting and stunting
• Is a good predictor of long term mortality

Head circumference for age

• An index of chronic malnutrition for under two children

32
Body mass index ( BMI)
• Described by weight in kg divided by height in meter square
• Gives no indication about the distribution of the body fat
• Misclassification is common
• Lean individuals
• Very short individuals ( <150cm) or very muscular
• Abnormal relationship between leg and trunk length

33
 Meanings of the indices derived from growth
measurements
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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51
 II. Anthropometric Measurements of
Body composition
Five levels of body composition assessment:

 Atomic level(C, H, N, P, Ca, O)

 Molecular level (fat, Water, protein, glycogen, mineral)

 Cellular level (body cell mass, intra/extra cellular water, intracellular

solids)

 Tissue level (adipose tissue, muscle, visceral organs, bone)

 Whole body level (Weight, height, skin folds) 35

 Assessment of Body
Composition
 Linear growth ceases at around the age of 25-30 years

 Therefore, the main purpose of nutritional assessment of adults using

Anthropometry is determination of the changes of body weight and body
composition

 Inassessing body composition we consider the body to made up of

two compartments:

 The fat mass and the fat free mass

 Total body mass= Fat mass + fat free Mass

 Therefore different measurements are used to assess these two compartments:

36
 Measurements used for assessing fat free mass
 Mid upper arm circumference
 Mid upper arm Muscle area
 Mid thigh circumference
 Mid thigh muscle area
 Mid calf circumference
 Mid calf muscle area

Measurements used for assessing fat mass

 Weight & Height(Body mass index )
 Waist to Hip circumference ratio
 Skin fold thickness
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86
 Mid upper arm circumference
 Is used (MUAC)
for screening purposes especially in emergency situations where there
is shortage of resources as it is less sensitive as compared to the other indices

 It is a sensitive indicator of risk of mortality

 Useful for the assessment of nutritional status of pregnant women

 It is measured half way between the olecranon process and acromion process
using non stretchable tap

 In children the cut-off points are:

 Normal > 12.5 cm
 Moderate malnutrition 11.5-12.5 cm
 Severe malnutrition < 11.5 cm
38
Child Mid-Upper Arm
Circumference Measurement

39
FAO MUAC for children and
adults

40
 Indices derived from height & weight
measurements
Body mass index (Quetelet’s index) = Wt/
(Height in meters)2
Weight/height ratio (Benn’s index)

Ponderal index = Wt/ (ht) 3

Body mass Index(BMI)

BMI is most frequently used for assessing adult

nutritional status
6/12/2023
90
  These cut-offs are based on the mortalities and
morbidities associated with extreme values

Mortality Chronic diseases

Malnutrition
And (hypertension,
related The
Morbidity diabetes, cancer,
infections and Safe zone
In % coronary heart
deficiency
disease
diseases

18.
1
6

2
5

3
0
4
0
5
Body mass index
KG/M2
 Relationship between BMI and relative
risk of mortality
As BMI increases, risk increases of:

 High blood pressure

 Type 2 diabetes mellitus

 Other CVD risk factors

 Mortality

WHO (2000)
 Classification of over weight ,obesity and CED in
adults ( WHO, 2000)
Body mass index Grade
<16 Grade III CED
16.0-16.9 Grade II CED
17.0-18.5 Underweight (grade I, CED )

18.5-24.9 Normal
25.00-29.99 Overweight ( pre-obese)
30-34.9 Class I obese
35-39.9 Class II obese
>40 Class III severe obesity
 Waist to Hip circumference
ratio
 It is the circumference of the waist measured mid-way between the lowest
rib cage at the mid-clavicular line and anterior superior iliac spine divided
by the circumference of the hip measured at the level of the greater
trochanter off the fumer (widest Area) [both are measured to the nearest
0.1cm]
Health risks of obesity depend on the regional fat distribution
as well as total body composition

Android Gynoid
obesity
obesity
 Central (android) obesity increases the risk of:

Diabetes Hyperlipidemia

CHD
Arthritis

CVD

Hypertension Some cancers

 Regional fat deposition: Visceral
fat
 Visceral body fat poses greater health risks because this fat is more

labile and has greater access to the circulation.

 The accumulation of visceral body fat is typical of the

android (male) fat pattern

• males: visceral accounts for 10-35% of total fat

• females: visceral accounts for 8-13% of total fat

Skinfold
Thickness
• Measures double thickness of skin and subcutaneous fat
 Skinfold …
Con’t.
Layers of subcutaneous
fat are measured at
different sites of body
to estimate total body
fat levels

Cross sectional view

 Quality control measures in anthropometric
surveys
 Calibration of the instrument after each measurement and after

moving the instrument from one room to another.

 Standardization of procedures.

 Making subjects wear a uniform gown before measuring weight

or measuring their weight nude if they are children.

 Verification of at least 10 % of the data by the main investigator.

 Advantages and limitations of anthropometry
Advantages Limitations
Simple, safe, non- invasive techniques Insensitive: cannot detect disturbances over
short- time
Inexpensive equipment: portable, durable Non- specific: cannot distinguish between Zn
and
PEM
Precise and accurate methods if well designed Specificity and sensitivity lowered by
non nutritional factors
Yield retrospective information on past Need reasonably precise age in children
nutritional history
Identifies mild, moderate, and severe Error is very likely
malnutrition
Can be used to screen persons at high risk Difficult in selecting appropriate cutoff point

More accepted by the community

 2. Biochemical Methods of Assessment

 Measures the total amount or concentration of nutrients

in the body fluids (blood, serum, urine) and storage
sites
 The test reflect recent nutritional status
 It also detects sub-clinical deficiencies
 The most commonly used test are: hemoglobin, vitamin
A, thiamin in urine, etc.
 It is an indicator of defect in intermediary metabolism
in other words they occur when there is a biochemical
lesion (Depletion).

36 June 19,
2022
A. Static biochemical tests

 This involves measurement of nutrient or its metabolites

in pre-selected biological material (blood, body fluids,
urine, hair, fingernails etc.).

Example of Biochemical Tests (laboratory)

o Serum ferritin level

o Serum HDL

o Erythrocyte Folate

o Tissue stores of Vit. A, Vit D,

B. Functional biochemical(Biophysical) tests
 These are diagnostic tests used to determine the

sufficiency of host nutrient to permit cells, tissues,

organs or the host to perform optimally the intended
nutrient dependent biological function.
 These functional biochemical tests are also useful for:

 Sub-clinical deficiency states

 Based on measurement of functional impairment

B. Functional biochemical….

 Have greater biological value and significance than

static tests, because they measure the extent of

functional consequence of a specific nutrient deficiency.
Advantages & Disadvantages of Biochemical Tests

Advantages
 Detect sub-
clinical malnutrition  Many quality control problems during

 Give gradable sample taking, carrying out the test,

nutritional Information analysis. Etc

 Are more objective  Some times low values may not have

Disadvantages any health Implication

 No ideal biomarker for each nutrient

 Need highly trained staff
 Need sophisticated instruments
 Involve invasive procedures
 3. Clinical methods of assessment
 It is theuse of signs and symptoms to assess
the nutritional status of children/adults.
 It is cheap, noninvasive and quick method
 Based on the examination of changes in the skin, Hair, buccal
mucosa etc.
Drawbacks
• Very subjective
• Less specific (other disease may have similar
features)
Clinical signs of nutrition that are used for nutrition ass’t
 PEM  Edema, easily pluckable and gray hair, flaky paint
dermatosis, muscle wasting etc
42
 VAD  Corneal
Anemia xerosis, bitotand
 pale conjunctivae spot, keratomalacia
palms June 19,
2022
 3. Clinical methods of ….
Sign/ symptom Nutritional abnormality
 Inability to see during the evening or dim Vitamin A deficiency:
light (Night blindness also called
 nyctalopia) Bitot’s spots
 Easy bruisingof skin Scurvy (vitamin C deficiency)
 Spongy bleeding gums
 Pale: palms, conjunctiva, tongue Anemia: Which may
herald,
 Easy fatigability, loss of appetite shortness
deficiency of: Iron, Vitamin
of breath
B12, Folic acid, copper,
protein (main causes of

59
nutritional anemia) June 19,
2022
 4. Dietary method of assessment

 This methods include assessment of past or current

intakes of nutrients from food by individuals or a group

in order to know their nutritional status.
 It assess through recording food intake and translating it

into nutrient consumed

 Dietary data can be collected at: National, Household,

and Individual level

 Dietary data can be estimated at individual level
60
 A. Methods used to assess current intake
I. Weighed record method: In this method the subject will be
asked to weigh whatever he/she consumes including drinks both
before cooking and after cooking and the portion sizes he
consumed and the left over.
 Advantages:
 It is more accurate
 There is no respondent memory loss
 Disadvantages
 High respondent burden and Costly
 Change of the dietary habit during the survey due fear of
burden
45  Needs literate and numerate respondents
A. Methods used to assess ….
II. Observed weighed method:
• The investigator him/herself records the amount and
type of food consumed by the study subjects over
specified period of time.
• This method is usually applied for disabled people,
infants and small children, mentally ill people or
institutionalized elderly people or patients admitted to a
hospital.
 Advantage VS disadvantages
• The same as the observed weighed
 A. Methods used to assess ….
III. Food Diary method
In this method the subject/s are asked to record what ever
they eat including beverages for specified period of time
with estimation of the portion sizes consumed.
 Advantage
May give relatively accurate estimate of the
nutrient intake if done properly
 Disadvantage
 High respondent burden
 Literacy and numeracy of subjects are needed
 High coding burden
B. Methods Used to assess past intake
a. 24 hours dietary recall
In this method, the subjects are requested to remember
whatever they consumed within the last 24 hours.
This involves all beverages, snacks, desserts, etc that
have been ingested from x time yesterday to x time
today.
The portion sizes consumed during this time should
also be determined by the respondents by assisting
them to use either photographs or the common food
being consumed at different sizes or by using a line
48 graph etc.
a. 24 hours dietary recall….
Advantages Disadvantages
 Relatively cheap and  A single day 24hrs recall

doesn’t quick indicate the usual intake of

individuals

 Less
 respondent
Respondents hasburdenno  Respondentdesirability
Social memory laps bias

chance to change (the flat-slop their syndrome)

dietary habit  Has less precision

 The usual intake  Accuracy depends on the respondent’s

of a group can be ability to estimate portion
determined
 a. 24 hours dietary recall….
 Reasons why a single day assessment doesn’t
give the true mean intake:
 Day of the week effect
 Seasonal effects
 Consecutive /non-consecutive days
 Random within person variance
 Holiday effects(feasts and fasts)

50
b. Dietary history

o This method is used to assess the nutrient intake of an

individual or a group from food over a longer period of

time, usually to see the association between diet and
disease.
Advantages and disadvantages of Dietary Hx

Advantages Disadvantages
 It gives the dietary habits of  It over emphasizes the
an individual or a group of regularity of the dietary
people over a longer periods pattern
of time.  It is very difficult to
 It is possible to target the validate
dietary questions to specific  It needs a very highly
dietary habits or intake of trained interviewer
specific nutrients of interest  It gives just a relative if
not an absolute
 Less respondent burden information
6/19/2022
c. Food Frequency Questionnaire (FFQ)
 This method is based on the preparation of a FFQ, which

is based on the local staple diet to determine the

frequency of consumption of a particular nutrient.
 This could be achieved through self or interviewer

administered questionnaire.
 Sometimes the quantities consumed could be included, in

such circumstances, the FFQ is called semi quantitative

FFQ.
Example of semi-quantitative FFQ for
vitamin A friendly foods

Frequency of consumption
Every Once Once Portion
Food list
Daily othe per per size
r wee mont consumed
day k h
Carrot
Cabbage
Papaya
Mango
Cod liver oil
Liver
6/19/2022
Advantages and Disadvantages of FFQ

Disadvantages
Advantages
 It is very difficult to develop
 It is usually used for areas where there
especially in multi-cultural
is a geographically widely scattered
society where different staple
study population.
foods are consumed.
 It is less costly especially if self
 It needs literate and numerate
administered.
subjects.
 Less respondent burden
24 Hours Dietary
Recall….

Different Portion Sizes

 Example of portion size aids:
Play- dough

• Use clay / play-dough

moulded into the correct
size & shape of food.
• Determine volume by
displacement, and hence
weight consumed
 Example of portion size
aids: Photographs - Bread
 Respondent points to
photograph that represents
the type of and size of
bread consumed.
 Interviewer records the
information and the
number of “slices” .
 The amount in grams
is
then recorded
 Example of portion size
aids: picture book/atlas
• Amount (in grams)
consumed, net of
waste, is recorded
 Example of portion size
aids
• Respondent points to spoon
that represents that used &
specifies amount
consumed: heaped; level
etc;
• Interviewer records spoon
number & level

1 2 3 4 5
 Example of portion size aid for volumes of fluids
using a computer display

• Respondent is requested
to slide the pointer up or
down to change the level
of the liquid until
it
matches
consumed. the
• The volume is
level
then displayed
Thank
You!