Learning objectives

Introduction
to
Nutrition Assessment

151.232

To identify the need for nutritional

assessment
To know the different methods / techniques
for assessing the nutritional status
To identify uses / applications, strengths
and weaknesses of the main sources of
nutritional status information

A/Prof Rozanne Kruger - 2015

Famous Quote

INTRODUCTION

If we could give every individual the right

amount of nourishment and exercise, not too
little and not too much, we would have found
the safest way to health.

The nutritional status of an individual is often

the result of many inter-related factors.

Hippocrates c. 460-377 B.C.

It is influenced by food intake, quantity &

quality, & physical health.
The spectrum of nutritional status spread from
obesity to severe malnutrition

Good nutrition DIET

Well being

Most NB
modifiable
lifestyle
determinant

Poor nutrition

DIET
Heart disease

Disease

Ht, Stroke
Diabetes
Cancer

Society

Individuals

Adult death

Optimal Nutritional Status

Nutritional Assessment
Evaluation of nutritional status

State of health resulting from the

consumption, digestion, absorption,
transport and utilization of
nutrients.

Needs

Intake

May be influenced by pathological

factors.

Nutrition impacts on

Practical use
ASSESSMENT
of the nutritional
situation in target
population
ACTION
based on the
analysis &
available
resources

To define the nutritional problem of

the targeted population, it is
necessary to measure its nutritional
status.

ANALYSIS
of the causes
of the problem

Nutritional status assessments enable us to

determine whether the individual is wellnourished or undernourished.

Source: UNICEF, Triple-A Cycle

Two outcomes of NA

The purpose of nutrition assessment is to collect

and interpret relevant patient/client information
to identify nutrition-related problems and their
causes.

human growth & development

..requires accurate assessment of

A B C D (E)

standardized methods

Levels of Nutritional Assessment

Minimal

Screening

MidMidLevel

It is the first step in the Nutrition Care Process

Used in nutrition monitoring and evaluation

where similar or same data may be used to
determine changes in client behavior or nutrition
status and the efficacy of nutrition intervention

Comprehensive

Individual Clinical/
Community Setting

In-depth evaluation with multiple tools any setting

Explore the importance of

Nutritional Assessment in...

Public health

determination of dietary adequacy or risk for treatment / counseling

Data can be used to characterize patient populations

Community settings

Nutritional monitoring & surveillance of populations for dietary adequacy or

risk
Public policy decisions ~ e.g. food assistance programs
Fortification, safety & labeling,
Development of public health recommendations for dietary intake

Clinical or hospital settings

Nutrition Assessment Involves

Critical Thinking

Wellness/rehabilitation centers
Long-term care

Research activities

Epidemiological studies on dietary intake and disease risk / group

comparisons e.g. intervention vs. control group or randomized control trials

Stages in the Development

of a Nutrient Deficiency

Progression of Nutritional Deficiencies

TOOLS

Optimal
Marginal
(at risk)

Deficits

Inadequate intake, impaired

absorption or increased need
Depletion of tissue levels
and body stores (gradual)
Altered biologic, cellular and
physiologic functions (subclinical)
Clinical or overt signs
Morbidity

Mortality

Dietary

Anthropometric
Biochemical

Clinical &
Functional
Vital Stats

Assessment Measurements

Anthropometry

Measurements of changes in:

physical dimensions (growth & development) and

body composition

Include height, weight, body mass index, growth chart
percentile, growth rate, and rate of weight change.

Assessment Measurements (cont.)

Clinical/Physical
Ascertains clinical consequences of imbalances
nutrient intakes

Subjective evaluation of overt signs and
symptoms of malnutrition

Biochemistry (biomarkers)

Determine appropriate data to collect

Select valid and reliable tools
Distinguish relevant from irrelevant data
Select appropriate norms and standards for
comparing the data
Organize and categorize data in a meaningful
way that relates to nutrition problems

Measurements of nutrients and metabolites in body

fluids and tissues

Include oral health, general physical appearance,

muscle and subcutaneous fat wasting

Includes medical history.

Reflects either nutrient intake or impact of nutrient intake.

Nutr Ass : A = Anthropometry

Assessment Measurements (cont.)

Dietary

Anthropos = human; metron = measure

Purposes:

Estimate food and / or nutrient intakes

Measurements of food consumption (observed or
reported).

Functional

Measurements of physiologic performance and

activities.

Pleiotropism

Head circumference - brain growth

Abdominal girth measurement abdominal fluid retention in liver
disease or CVD risk

Nutr Ass : A = Anthropometry

Non-genetic

Nutritional status

Disease state

Nutrition X infection

Age or maturity

Psychological stress

Measurement error

Other environmental
factors (e.g. altitude,
pollution)

population standards specific for gender & age (to reveal level) or
with previous measures (to reveal changes)

Specific measures are used for specific situations:

Genetic

Paternal and maternal
genetic effects

Effects linked to X or Y
chromosome

Sex limited effect

dont differentiate between acute & chronic changes.

Detect malnutrition (over & under) (all ages)

Measure changes in body composition over time

Compare measurements taken on an individual with:

Variation in Anthropometry

Evaluate progress in growth (women, children, adolescents)

The measured values reflects the current nutritional status

Measures of growth and development

Length (recumbent length / crown-heel), stature (or height),

or knee height /armspan
Weight Hamwi (% IBW) / Devine equations
Head circumference
Chest circumference
Elbow breadth (frame size)

Analysis of measures (reference data)

Infants & children - attained size vs. growth

(growth charts), BMI standards (Cole)
Adults relative weight-for-height standards e.g. BMI

Weight Status as a Predictor of

Morbidity and Mortality

Nutr Ass : A = Anthropometry

In young to middle aged adults, morbidity/

mortality is highest in the highest quintile of
BMI
In the elderly, morbidity/mortality is highest in
the lowest quintile of BMI
In most populations, there is a J-shaped
relationship between mortality and BMI

Weight Status as a Predictor of

Morbidity and Mortality

Body Mass Index and Mortality Risk

Strong evidence from RCTs and epidemiological studies

demonstrating relationship between BMI classification
and risk for morbidity and mortality
Analysis from 57 prospective studies shown that with
every 5kg/m2 BMI increase above 22.5-25kg/m2 there is
an 30% increase in overall mortality

Inverse association with BMI<22.5-25kg/m2 & overall

mortality due to respiratory D & lung C
Excess mortality at BMI>40kg/m2 smoking

(Adapted from Bray GA. Gray DS, Obesity, part 1: Pathogenesis. West J Med 149:429, 1988; and Lew EA, Garfinkle L; Variations
in mortality by weight among 750,000 men and women. J Clin Epidemiol 32:563, 1979.)

Anthropometrics in Pediatrics

Rate of length or height gain reflects long-term

nutritional adequacy
Head circumference: used to evaluate growth in
children <3 years of age; usually detects nonnutritional abnormalities
A more sensitive measure of nutritional adequacy
than height, and reflects recent nutritional intake

Nutr Ass : A = Anthropometry

Measures of body fat and lean tissue

Skinfolds

Triceps, biceps, subscapular (below shoulder blade), suprailiac
(above hip bone), abdomen, upper thigh

Good estimation of total body fat

Fair assessment of the fats location

DM, Renal, Hepatic D 60-120% risk

Vascular D 40% risk
Respiratory D & all other D 20% risk

Nutr Ass : A = Anthropometry

Measures of body fat and lean tissue

Significant weight changes can reflect over/under
nutrition with respect to energy & protein

To estimate the degree to which fat stores or lean
tissues are affected by nutrition

Measures include:

Skinfolds
Waist circumference

Waist-to-hip ratio

Hydrodensitometry

Bioelectric impedance

Arm circumferences

Nutr Ass : A = Anthropometry

Waist circumference predicts mortality better

than any other anthropometric measurement.
It has been proposed that WC alone can be
used to assess obesity
LEVEL 1
LEVEL 2

MALE
> 94cm
> 102cm

FEMALE
> 80cm
> 88cm

L 1 = maximum acceptable WC irrespective of adult age;

there should be no further weight gain.
L 2 = obesity; requires weight management to reduce the
risk of type 2 diabetes & CVS complications.

Nutr Ass : A = Anthropometry

Nutr Ass : A = Anthropometry

Measures of body fat and lean tissue

Measures of body fat and lean tissue

Hydrodensitometry

Bioelectric impedance

Mid-Upper-Arm Circumference (MUAC)

Waist circumference

Smallest area below the ribcage and above the umbilicus

Indicator of fat distribution; abdominal visceral obesity

Weighed on land & submerged in water (body fat estimate)

Measure body fat using very-low-intensity electrical current

Correlated with total muscle mass - in combination with TSF

can determine arm muscle area (lean body mass).

A useful index of protein status.

Male (apple)

WHR

Higher health risk

Female (pear)
Lower health risk

Measure the waist (abdominal) circumference

and the hip (gluteal) circumference

Mid-Upper-Arm Muscle Circumference (MAMC)

MAMC corrects for the contribution of subcutaneous fat

MAMC=MUAC cm (TSF mm X 0.314)

Nutr Ass : A = Anthropometry

Other measures of body composition

Body density: under water weighing, BodPod
Isotope dilution (total body water)

DEXA - dual-energy x-ray absorptiometry; bone
mineral density and fat and boneless lean tissue

Total body electrical conductivity

Magnetic resonance imaging (MRI): size of skeleton
and internal organs; abdominal fat

ADVANTAGES OF ANTHROPOMETRY

LIMITATIONS OF
ANTHROPOMETRY

Objective with high specificity & sensitivity

Measures many variables of nutritional significance
(Ht, Wt, MAC, HC, skin fold thickness, waist & hip
ratio & BMI).
Readings are numerical & gradable on standard
growth charts
Readings are reproducible.
Non-expensive & need minimal training

Nutr Ass : B = Biochemical






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.

Determine what happens to the body internally

to:

detect sub clinical or marginal deficiencies

enhance or support other nutritional data

Typical tests include:

analysis of blood or urine for nutrients, enzymes and
metabolites that reflects nutritional status

other tests to help pinpoint disease-related problems
with nutrition related implications e.g. organ
function

biopsy of tissues

Nutritional Assessment

Nutr Ass : B = Biochemical

Interpretation of biochemical data requires skill

No single test can reveal nutrition status due to the
various factors influencing the results
Best approach to combine with other parameters /
assessment data e.g.
vitamin/mineral analyses + diet histories + physical
findings

Many nutrients interact

Diseases influence biochemical measures

Exceptionally useful in detecting subclinical malnutrition

BODY COMPARTMENTS
ADIPOSE TISSUE

SOMATIC PROTEINS 30%

VISCERAL PROTEINS 8%
PLASMA PROTEIN

3%

EXTRACELLULAR

20%

It is useful in detecting early changes in body

metabolism & nutrition before the appearance of
overt clinical signs.
It is precise, accurate and reproducible.

ASSESSED BY
Triceps Skinfold
Body Weight
Arm Muscle Circumference
Body Weight
Creatinine Height Index
Serum Albumin, Transferrin

Serum electrolyte levels

SKELETON

Advantages of Biochemical Methods

25%

10%

DEXA

Limitations of Biochemical Method

Time consuming
Expensive
They cannot be applied on large scale

Useful to validate data obtained from dietary

methods e.g. comparing salt intake with 24-hour

Needs trained personnel & facilities

urinary excretion.

Nutr Ass : C = Clinical

Detect signs and symptoms of malnutrition

deficiency or toxicity
Medical history: previous illness, duration
Physical assessment: hair, skin, nails, eyes, mouth (gums,

Physiological Tests: Immune competence, taste acuity, night

Clinical signs of nutritional deficiency

HAIR
Sparse & thin

Protein, zinc, biotin

deficiency

Easy to pull out

Protein deficiency

Corkscrew
Coiled hair

Vit C & Vit A

deficiency

teeth, tongue), glands, bones, muscle

blindness, muscle function, cognitive function

Requires trained observer inter observer variability

Deficiency usually severe before clinically evident
Symptoms may be caused by non-nutritional factors
Symptoms may relate to several nutrients

Clinical signs of nutritional deficiency

EYES

MOUTH
Glossitis
Bleeding & spongy gums

Clinical signs of nutritional deficiency

Riboflavin, niacin, folic acid,

B12 , pr.
Vit. C,A, K, folic acid & niacin

Angular stomatitis, cheilosis B 2,6,& niacin

& fissured tongue
leukoplakia

Vit.A,B12, B-complex, folic acid

& niacin

Sore mouth & tongue

Vit B12,6,c, niacin ,folic acid &

iron

Night blindness,
exophthalmia

Vitamin A deficiency

Photophobia-blurring,
conjunctival
inflammation

Vit B2 & vit A

deficiencies

Clinical signs of nutritional deficiency

NAILS

SKIN

Spooning

Transverse lines

Iron deficiency

Protein deficiency

CLINICAL ASSESSMENT

ADVANTAGES

Fast

& Easy to perform

Inexpensive

Non-invasive

LIMITATIONS

Did

Clinical signs of nutritional deficiency

not detect early cases

Pallor

Folic acid, iron, B12

Follicular
hyperkeratosis
Flaking dermatitis

Vitamin B & Vitamin C

Pigmentation,
desquamation
Bruising, purpura

PEM, Vit B2, Vitamin A,

Zinc & Niacin
Niacin & PEM
Vit K ,Vit C & folic acid

Nutr Ass : D = Dietary Assessment

Why do we need to know what people eat?

Link with health measures (eg. saturated fat intake and

blood cholesterol)
Population trends in food intake over time
Evaluation of public health campaigns
Evaluation of population risk
Identifying at-risk populations
Economic reasons

Nutr Ass : D = Dietary Assessment

Nutr Ass : D = Dietary Assessment

Methods of Obtaining Intake Data?

Measurement of Food Intake

Retrospective

Prospective

Qualitative

Quantitative

Nutr Ass : D = Dietary Assessment

24 Hour Recall

Nutr Ass : D = Dietary Assessment

Estimated Food Record

Subject recalls food intake past 24 hours

Quantities estimated with household measures
Food models may be used as memory aids or to help
quantify serving sizes
Intake calculated using food composition data

Nutr Ass : D = Dietary Assessment

Used to assess actual or usual intake of individuals

depending on days recorded
All food and plate waste is weighed
Food samples may be saved for analysis
Number of days depends on nutrients of interest
Intake calculated using food composition data
GOLD STANDARD

Record food & beverage in a food diary 1 to 7

days
3-4 day diaries usually include one week-end day
Number of days depends on nutrients of
interest
Quantities estimated in household measures
Intake calculated using food composition data

Nutr Ass : D = Dietary Assessment

Dietary History

Weighed Food Record

24 hr recall
Estimated food record
Weighed food record
Dietary history
Food frequency questionnaire
Apparent consumption

Retrospective, with extensive interview

24 hr recall of actual intake + usual intake followed
by food frequency questions to verify & clarify
Skilled interviewer (dietitian)
Collects dietary intake over past 1-3 mos (usually)
Info on intake patterns, beliefs and habits
Used in diet assessment in clinical practice
Intakes calculated using food composition data

Nutr Ass : D = Dietary Assessment

Nutr Ass : D = Dietary Assessment

Dietary History

Dietary History

Nutr Ass : D = Dietary Assessment

FFQ - example
1.On average, how many servings of breakfast cereal do you consume per
week? (Please mark one only)

Food Frequency Questionnaire

(A serving = 1 cup porridge or cornflakes or cup muesli or 2 weetbix).

Extensive questionnaire/list of specific food items

Records intake over given period (day, week,
month, year)
Asks about a wide range of foods
Self administered or interview
Can be designed for nutrient specific questions
Intakes calculated using food composition data

E.g. 1 cup of porridge 3 times per week + 2 weetbix 4 times a week = 7

servings per week
Per Week
None
< 4 servings
46 servings
79 servings
1012 servings
1315 servings
16 servings
1.How often do you usually consume these foods?

FFQ - example

Nutr Ass : D = Dietary Assessment

Breakfast Cereals

Please fill in one category for

each food

Never

Less
than
once a
month

1-3
times
per
month

Once
per
week

2-4
times
per
week

5-6
times
per
week

Once
per
day

2 or more
times per
day

Apparent Consumption /
qualitative assessment

Porridge, rolled oats, oat bran,

oat meal
Muesli (all varieties)

Weetbix (all varieties)
Cornflakes or rice bubbles

Bran based cereals (all varieties

e.g. All Bran, Sultana Bran)

Light and fruity cereals (e.g.

Special K, Light and Tasty)

Chocolate based cereals (e.g.

Milo cereal, Coco Pops)
Sweetened
cereals
(e.g.
Nutrigrain, Fruit Loops, Honey
Puffs, Frosties)
Breakfast drinks (e.g. Up & Go)

Obtained from supermarkets, industry turnover

Does not account for waste
Rough estimate only
Does not reveal who is eating what
Impossible to determine individuals at risk
In-depth descriptive content
Supplementary to other techniques

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