NUTRITIONAL ASSESSMENT of patients in community

ASSESSMENT OF
NUTRITIONAL STATUS
Dr. Piyush
Parmar

WHAT IS NUTRITIONAL STATUS?
The nutritional status of an individual
 is a balance between the intake of the nutrients
and the expenditure of these in processes of
growth, reproduction and health maintenance.
 is influenced by food intake , quantity , quality
and physical health.
The spectrum of nutritional status spreads from
obesity to severe malnutrition.

Nutritional Assessment Why?
 To obtain precise information on prevalence and
geographic distribution of nutritional problems
of given community.
 To identify individuals or populations
~who are at risk of becoming malnourished &
~who are already malnourished
 To develop health-care programs.
 To measure the effectiveness of nutritional
programs and interventions once initiated.

METHODS of Nutritional
Assessment
 Direct – deal with the individuals and
measure the objective criteria
 Indirect – use community health indices
that reflect nutritional influences

1. Direct methods of nutritional
Assessment
These can be summarized as ABCD
 Anthropometric methods
 Biochemical, laboratory methods
 Clinical methods
 Dietary evaluation methods

2. Indirect methods of Nutritional
Assessment
These include three categories
 Ecological variables
 Economic factors
 Vital health statistics

Direct methods
A. Anthropometric methods
Anthropometry is the measurement of
 Height
 Weight & other measurements like
 Mid Upper-arm circumference
 Skin fold thickness
 Head and chest circumference
 Hip/waist ratio

1. Height measurement
 The subject stand erect on
stadiometer
 The movable head piece is
leveled with head vault
 Height is recorded to
nearest 0.5 cm.
 For infants
infantometer is
used.

 growth monitoring of a child by comparing with
international / national standards using growth
charts over a period of time.

2. Weight measurement
 Can be used to assess infants, children, pregnant women
and adults.
 Uses a regularly calibrated electronic or balanced-beam
scale.
 Measured in light clothes nearest to 100g.

A. Anthropometric Methods
3. Mid Upper-arm Circumference
 Circumference left upper arm
at mid point between acromion
process and olecranon
process
 Fiber-glass tape which does
not stretch

4. Skin-fold thickness
 skin fold calipers are used
(Harpenden and Lange)
 measures the thickness of the
skin and subcutaneous fat using
constant pressure applied over a
known area
 Common sites: triceps and in the
sub-scapular region
 It has value in assessing the
amount of fat and therefore the
reserve of energy in the body

5. Head and chest circumference

6. Waist/hip ratio
 Waist measurement
 Measured at the level of umbilicus
nearest to 0.5cm
 Subject stands erect with relaxed
abdominal muscles, arms at the
side and feet together
 Measurement taken at the normal
expiration

 Hip measurement
 Measured at the point of greatest circumference
around hips to nearest 0.5cm
 Close contact with the skin without indenting the
soft-tissues
 Subject should be standing and measurer beside
him.
 Interpretation of WHR
 High-risk WHR=>0.8 in females and =>0.95 in
males indicates central obesity and
considered high-risk for diabetes and cvs
disorders.

Advantages
 Objectives with high specificity and sensitivity.
 Measures many variables of nutritional
Significance. (ht, wt, MUAC, WHR , BMI)
 Readings are numerical and gradable on
standard growth charts.
 Readings are reproducible.
 Non-expensive and needs minimal
training.

Limitations of Anthropometry
 Inter-observers error in measurement.
 Limited nutritional diagnosis.
 Problems with reference standards i.e. local
versus international.

Direct methods
B. Biochemical & laboratory methods
I. INITIAL LABORATORY ASSESSMENT
 Haemoglobin estimation
 most important test when accurately measured,
tells about overall state of nutrition (anemia,
and also protein and trace element nutrition)
 Blood is collected from a finger, ear lobe or heel
prick
 Haemoglobinometres which are simple, cheap
and reasonably accurate are used

2. Haematocrit or packed cell volume (PCV)
 percentage of the blood volume composed of red
cells.
 important in the diagnosis of anemia.
3. Red cell counts and blood films
 the size and uniformity of the red blood cells can
be seen.
 Use of such slides may facilitate the diagnosis of
malaria and the haemoglobinopathies.
 Parasites if present can be seen.

4. Stool examination
 For presence of ova and/ or intestinal parasites
 When assessed quantitatively parasite load can
be known
5. Urine examination
 Dipstick and microscopy for albumin, sugar and
blood

II. SPECIFIC LAB TESTS

6. Measurement of nutrients in body fluids
e.g. serum retinol, serum iron

7. Measurement of abnormal metabolites
e.g. urinary iodide, urinary creatinine/
hydroxyapatite ratio

Advantages
 Useful in detecting early changes in body
metabolism and nutrition
 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 & laboratory methods
 Time consuming and expensive
 Cannot be applied on large scale
 Reveal only current nutritional status

Direct methods
C. Clinical methods
 Essential feature of all nutritional surveys
 Simplest and most practical method
 Utilizes a number of physical signs (specific and
non-specific) that are known to be associated
with malnutrition and deficiency of vitamins and
other micro-nutrients.

C. Clinical methods
 General Clinical examination with special
attention to organs like hair, angles of mouth,
gums, nails, skin, eyes, tongue, muscles, bones
& thyroid gland.
 Detection of relevant signs helps in establishing
the nutritional diagnosis.

C. Clinical methods
Clinical signs of nutritional deficiencies.
1. Hair
Spare and thin Protein, Zinc, Biotin,
deficiency
Easy to pull out Protein deficiency
Cock-screw
coiled
Vit A and Vit C deficiency
Depigmentation Protein deficiency

C. Clinical methods
2. Mouth
Bleeding and
spongy gums
Deficiency of
Vit C, A, K,
Folic acid,
Niacin
Glossitis ,
Cheililitis
Deficiency of
Riboflavin,
Niacin, Folic
acid, B12 and
proteins.

C. Clinical methods
2. Mouth
Angular
stomatitis,
cheilosis and
fissured tongue
B2, 6 & Niacin
deficiency
Leukoplakia Vit A, B12, B-
complex, Folic
acid and Niacin
deficiency

C. Clinical methods
3. Eyes
Xerosis of
conjunctiva or
Xerophthalmia
First clinical
sign Vit A
deficiency
Bitots spots Moderate
deficiency of Vit
A deficiency

C. Clinical methods
3. Eyes
Corneal
ulceration and
keratomalacia
Severe Vit a
deficiency –
medical
emergency
Night blindness,
photophobia,
blurring of
vision
Vit A and Vit
B2 deficiency

C. Clinical methods
4. Nails
Spooning of
nails
Iron deficiency
Transverse
lines
Protein
deficiency

C. Clinical methods
6. Glands
Goiter Iodine deficiency

C. Clinical methods
7. Skeletal system
Beading of ribs
(rickety rosary),
bow legs
Vit D deficiency
Epiphyseal
enlargement,
skeletal
deformities, bone
tenderness
Vit D deficiency

C. Clinical methods
8.
Muscles
Wasting of muscles PEM, severe
protein deficiency

Functional Indicators
Also-’physiologica
l indicators’
These reflect the
functional
consequence of
a deficiency
particularly useful
for detecting
early
perturbations in
nutritional status

System nutrients
1. Structural integrity
RBC fragility
capillary
fragility
tensile strength
Vit E, Se
Vit C
Cu
2. Host defense
WBC chemotaxis
WBC phagocytic capacity
WBC bactericidal
capacity T cell
blastogenensis
P/E, Zn
P/E , Fe
P/E , Fe, Se
P/E , Zn
P/E , Zn
Functional Indicators

3. Hemostasis - prothrombin time Vit K
4. Reproduction- sperm count Energy, Zn
5. Nerve function- nerve
conduction dark
adaptation
Vit B1, B12
Vit A, Zn
6. Work capacity
heart rate
vasopressor
response
P/E, Fe
Vit C

Immune function: malnutrition leads to a decline
in immune function
These immune changes predispose children to
severe and chronic infections, infectious
diarrhea, which further compromises nutrition

Studies of malnourished children showed
changes in the developing brain, including,
 a slowed rate of growth of the brain,
 lower brain weight,
 thinner cerebral cortex,
 decreased number of neurons,
 insufficient myelinization, and changes in
the dendritic spines.

Assessment of dietary intake
 This is actually an assessment of
food consumption through dietary
surveys.
 It provides information about dietary
intake patterns, specific foods
consumed and estimated nutrient
intakes.
 Reviewing dietary data may suggest
risk factors for chronic diseases and
help to prevent them.
 Diet surveys may be carried out by
the following methods:
1. weighment of raw foods
2. weighment of cooked foods
3. Oral questionnaire method

Other methods include
•Food records or diaries (including weighed
intakes)
•Food frequency questionnaires (FFQ's)
•Dietary histories
•Observed intakes

Weighment of raw foods:
 It is the most widely used method in
India.
 The survey team visits the household
and weighs all the food that is going to be
cooked and eaten as well as that which is
wasted or discarded.
Duration of survey: varies between 1
and 21 days. Most commonly for 7 days
which is called the dietary cycle.

•Weighment of cooked foods:
Foods are analyzed in the state
in which they are consumed.
•This method is not
easily acceptable.

Food Frequency Questionnaires (FFQ) –
FFQ's are standardized forms inquiring about the frequency of
intake
of different foods or food groups.
 not as accurate as other measures but useful in large
population studies

Oral questionnaire method:
Inquiries are made about the nature and quantity of foods
eaten during the previous 24-48 hours. It may also
include dietary habits and practices
If taken correctly, it can give reliable results.

NUTRITIONAL ASSESSMENT of patients in community

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