Methods of Assessing Nutritional Status

Christine Serrano - Tinio, MD

Dept. of Family & Community Medicine

At the end of the lecture the students should be able:

To describe the methods used in assessing nutritional status To discuss the basic anthropometric techniques To discuss the use of the international reference standards as a method of assessing nutritional status

What is nutritional status?

Refers to the state of health of an individual as it is affected by the intake and utilization of nutrients.

Methods of Assessing Nutritional Status

Direct methods deal with the actual measurement of the individual Indirect methods use community health indices that reflects nutritional influences.

Indirect Methods of Nutritional Assessment

These include three categories:
Ecological variables including crop production Economic factors e.g. per capita income, population density & social habits Vital health statistics particularly infant & under 5 mortality & fertility index

Direct Methods of Nutritional Assessment

Clinical methods Dietary evaluation methods Biochemical, laboratory methods Anthropometric methods

CLINICAL ASSESSMENT
It is an essential feature of all nutritional surveys It is the simplest & most practical method of ascertaining the nutritional status of a group of individuals It utilizes a number of physical signs, (specific & non specific), that are known to be associated with malnutrition and deficiency of vitamins & micronutrients.

CLINICAL ASSESSMENT
Good nutritional history should be obtained General clinical examination, with special attention to organs like hair, angles of the mouth, gums, nails, skin, eyes, tongue, muscles, bones, & thyroid gland. Detection of relevant signs helps in establishing the nutritional diagnosis

CLINICAL ASSESSMENT
ADVANTAGES
Fast & Easy to perform Inexpensive Non-invasive

LIMITATIONS
Does not detect early cases

Clinical signs of nutritional deficiency

HAIR
Spare & thin Easy to pull out Corkscrew Coiled hair Protein, zinc, biotin deficiency Protein deficiency Vit C & Vit A deficiency

Clinical signs of nutritional deficiency

MOUTH
Glossitis Bleeding & spongy gums Angular stomatitis, cheilosis & fissured tongue leukoplakia Sore mouth & tongue Riboflavin, niacin, folic acid, B12 , pr. Vit. C,A, K, folic acid & niacin B 2,6,& niacin

Vit.A,B12, B-complex, folic acid & niacin Vit B12,6,c, niacin ,folic acid & iron

Clinical signs of nutritional deficiency EYES

Night blindness, xerophthalmia Photophobiablurring, conjunctival inflammation Vitamin A deficiency Vit B2 & vit A deficiencies

Clinical signs of nutritional deficiency NAILS

Spooning
Transverse lines

Iron deficiency
Protein deficiency

Clinical signs of nutritional deficiency SKIN

Pallor Folic acid, iron, B12

Follicular hyperkeratosis Flaking dermatitis

Pigmentation, desquamation Bruising, purpura

Vitamin B & Vitamin C

PEM, Vit B2, Vitamin A, Zinc & Niacin Niacin & PEM

Vit K ,Vit C & folic acid

Clinical signs of nutritional deficiency Thyroid gland

in mountainous areas and far from sea places Goiter is a reliable sign of iodine deficiency.

Clinical signs of nutritional deficiency Joins & bones

Help detect signs of vitamin D deficiency (Rickets) & vitamin C deficiency (Scurvy)

DIETARY ASSESSMENT
Nutritional intake of humans is assessed by five different methods. These are:
24 hours dietary recall Food frequency questionnaire Dietary history since early life Food dairy technique Observed food consumption

Initial Laboratory Assessment

Hemoglobin - most important test, & useful index of the overall state of nutrition. Ex. anemia indicates lack of protein & trace element Stool examination - presence of ova and/or intestinal parasites Urine dipstick & microscopy for albumin, sugar and blood

Specific Lab Tests

Measurement of individual nutrient in body fluids (e.g. serum retinol, serum iron, urinary iodine, vitamin D) Detection of abnormal amount of metabolites in the urine (e.g. urinary creatinine/hydroxyproline ratio) Analysis of hair, nails & skin for micro-nutrients.

Advantages of Biochemical Method

It is useful in detecting early changes in body metabolism & nutrition before the appearance of overt clinical signs. It is precise, accurate and reproducible. Useful to validate data obtained from dietary methods e.g. comparing salt intake with 24-hour urinary excretion.

Limitations of Biochemical Method

Time consuming Expensive Needs trained personnel & facilities

Anthropometry
measurement of body height, weight & proportions. used to evaluate both under & over nutrition.

ADVANTAGES OF ANTHROPOMETRY
Objective with high specificity & sensitivity Readings are numerical & gradable on standard growth charts Readings are reproducible. Non-expensive & need minimal training

Limitations of Anthropometry
Inter-observers errors in measurement Limited nutritional diagnosis

Problems with reference standards, i.e. local versus international standards.

Arbitrary statistical cut-off levels for what considered as abnormal values.

Anthropometric Methods
Height Weight BMI Mid-arm circumference Skin fold thickness Head circumference Head/chest ratio Waist/hip ratio

Waist/Hip Ratio
Waist circumference is measured at the level of the umbilicus to the nearest 0.5 cm. The subject stands erect with relaxed abdominal muscles, arms at the side, and feet together. The measurement should be taken at the end of a normal expiration.

Hip Circumference
Is measured at the point of greatest circumference around hips & buttocks to the nearest 0.5 cm. Both measurements should be taken with a flexible, nonstretchable tape in close contact with the skin, but without indenting the soft tissue.

Mid-arm Circumference
can be used as a measurement of growth, an index of energy and protein stores and can provide information on fat patterning. The measurement is taken at the midpoint of the upper arm, located halfway between the lateral tip of the acromion and the olecranon when the arm is flexed at a 90 angle (measured and marked).

Head circumference
Head circumference is a measurement of a childs head around its largest area -- it measures the distance from above the eyebrows and ears and around the back of the head.

The International Reference Standards

Weight and height measurements

Most common indicators for measuring growth or body size Practical anthropometric measurements:
Objective measurements Can be taken by non-technical staff Relatively inexpensive in terms of time and facilities Useful in growth monitoring, screening and surveillance

Recommended measuring equipment

For Weight: beam balance scale, Salter scale

Recommended measuring equipment

For Length: Infantometer

Recommended measuring equipment

For Height: Microtoise steel tape and triangular rulers

Nutrition Indices
Weight-for-age Height-for-age Weight-for-height (length)

Age in months
Compute the age of the child to the nearest month as of his/her last birth date: Age= (#or yrs/mos./days from date when measurement was taken)(birthdate) birth date: Nov. 10, 2011 Date of measurement: Nov. 29, 2011 Example: 2011 11 29 2011 11 10 0 0 19 Convert age in yrs. to mos. By multiplying by 12. Add the age in mos. To the product and the total gives the age in mos. Disregard the number of days.

Age in months
Example:
birth date: October 1, 2005 Date of measurement: Aug. 31, 2010
2010 2005
4

08 10 10

31 01 30

Therefore: age is 4 years 10 mos. 30 days; (4x12)=48 + 10 = 58 mos. **Disregard no. of days

Weight-for-age
Basic and simplest among the indicators Assesses body mass Indicator of current nutritional status Weigh to the nearest 0.1 kg

Weight-for-age
If the weight is within:
+ 2SD values, the child is within the normal limits < -2SD values, the child is below normal or low for his/her age > +2SD values, the child is above normal or high for his/her age

Height-for-age good indication of stunting; will estimate past & chronic malnutrition
less sensitive indicator of current nutritional status than weight-for-age because height does not decrease but simply slows down in the presence of malnutrition needs to be supplemented by another indicator like weight-for-age or weight-forheight

Height-for-age good indication of stunting; will estimate past & chronic malnutrition

If the height is within:

+ 2SD values, the child is within the normal limits < -2SD values, the child is below normal or short for his/her age > +2SD values, the child is above normal or tall for his/her age

Weight-for-length
Can distinguish current malnutrition (acute) from past malnutrition (chronic) Can identify wasted or thin child from a child who may be light in weight because he/she is short but currently healthy Can assess level of fatness of the child who may be heavy in weight but currently short in length or height Useful for the assessment of the nutritional status when exact age of the child is not known

Types of Growth charts

Weight-for-age charts Height-for-age charts

Growth Charts
Means of monitoring and interpreting changes in weight and height measurement over time. Accomplished by plotting the wt and ht at regular time intervals to get the path or direction of the childs measurement, ideally from birth up to 5 or 6 y/o. The pattern/direction of the curve represents the pattern of growth of the child and an excellent indicator of his/her nutrition and health status