NUTRITIONAL STATUS ASSESSMENT

NUTRITIONAL STATUS ASSESSMENT:

NUTRITIONAL STATUS ASSESSMENT Dr.N.Bayapa Reddy ASST.PROFESSOR COMMUNITY MEDICINE CHENNI MEDICAL COLLEGE HOSPITAL & RESEARCH CENTER

LEARNING OBJECTIVES:

LEARNING OBJECTIVES To know the different methods of assessing nutritional status To understand the basic anthropometric techniques, applications.

INTRODUCTION:

INTRODUCTION The nutritional status of an individual is often the result of many inter-related factors. It is influenced by food intake, quantity & quality, & physical health. The spectrum of nutritional status spread from obesity to severe malnutrition

The purpose of Nutritional Assessment:

The purpose of Nutritional Assessment To Identify the malnourished and high risk groups to become malnourished To improve the nutrition at house hold level especially for vulnerable groups To Identify dietary trends . To develop national health programs that meet the community needs based on evidence To know the preferred and not preferred food items

Methods of Nutritional Assessment:

Methods of Nutritional Assessment Nutritional status is assessed by two methods The direct methods Individual assessment and lab measures. Indirect method community health indices.

Direct Methods of Nutritional Assessment :

Direct Methods of Nutritional Assessment These are summarized as ABCDF Anthropometric methods Biochemical, laboratory methods Clinical methods Dietary intake assessment Functional assessment

Indirect Methods of Nutritional Assessment:

Indirect Methods of Nutritional Assessment These include three categories: Vital statistics particularly infant & under 5 mortality, population density & fertility index Ecological studies Economic factors e.g. per capita income, social habits

CLINICAL ASSESSMENT:

CLINICAL ASSESSMENT It is an essential features of all nutritional surveys Assess the level of health of individual in relation to the food they consumed. In a group of individuals It is the simplest & most practical method. It utilizes a number of physical signs, (specific & non specific), that are known to be associated with malnutrition and deficiency of vitamins & micronutrients.

WHO expert committee classification of nutritional survey:

WHO expert committee classification of nutritional survey Not related to nutrition Alopecia, pyorrhoea, pterygium That need further investigation Malar pigmentation, corneal vascularisation, geographic tongue Known to be value Angular stomatitis, Bitot’s spots, Calf tenderness, absence of knee or ankle jerks( beri-beri ), enlargement of thyroid gland. etc

Clinical signs of nutritional deficiency:

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

Clinical signs of nutritional deficiency:

Clinical signs of nutritional deficiency MOUTH Riboflavin, niacin, folic acid, B12 , pr. Glossitis Vit. C,A, K, folic acid & niacin Bleeding & spongy gums B 2,6,& niacin Angular stomatitis, cheilosis & fissured tongue Vit.A,B12, B-complex, folic acid & niacin leukoplakia Vit B12,6,c, niacin ,folic acid & iron Sore mouth & tongue

Clinical signs of nutritional deficiency:

Clinical signs of nutritional deficiency EYES Vitamin A deficiency Night blindness, exophthalmia Vit B2 & vit A deficiencies Photophobia-blurring, conjunctival inflammation

Clinical signs of nutritional deficiency:

Clinical signs of nutritional deficiency NAILS Iron deficiency Spooning Protein deficiency Transverse lines

Clinical signs of nutritional deficiency:

Clinical signs of nutritional deficiency SKIN Folic acid, iron, B12 Pallor Vitamin B & Vitamin C Follicular hyperkeratosis PEM, Vit B2, Vitamin A, Zinc & Niacin Flaking dermatitis Niacin & PEM Pigmentation, desquamation Vit K ,Vit C & folic acid Bruising, purpura

Clinical signs of nutritional deficiency:

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:

Clinical signs of nutritional deficiency Joins & bones Help detect signs of vitamin D deficiency (Rickets) & vitamin C deficiency (Scurvy)

CLINICAL ASSESSMENT/3:

CLINICAL ASSESSMENT/3 ADVANTAGES Fast & Easy to perform Inexpensive Non-invasive DISADVANTAGES Malnutrition cannot be quantified Many deficiencies are unaccompanied Lack of specificity and subjective nature LIMITATIONS Did not detect early cases

CLINICAL ASSESSMENT:

CLINICAL ASSESSMENT Good nutritional history should be obtained by standard survey proforma General clinical examination should cover all areas of the body. special attention on organs like hair, angles of the mouth, gums, nails, skin, eyes, tongue, muscles, bones, & thyroid gland.

Anthropometric Methods:

Anthropometric Methods It is an essential component of clinical examination of infants, children & pregnant women Anthropometry is the measurement of body height, weight, Skin fold thickness & MAC etc. It is used to evaluate both under & over nutrition . If it is recorded over a period of time it will reflect pattern of growth and development. It shows deviation from the average at various ages Eg:- Body Size, Build and Nutritional status .

Other anthropometric Measurements:

Other anthropometric Measurements Mid-arm circumference Skin fold thickness Head circumference Head/chest ratio waist/Hip ratio

Anthropometry for children:

Anthropometry for children Accurate measurement of height and weight is essential. The results can then be used to evaluate the physical growth of the child. For growth monitoring the data are plotted on growth charts over a period of time that is enough to calculate growth velocity, which can then be compared to international standards

Growth Monitoring Chart :

Growth Monitoring Chart Percentile chart

Measurements for adults:

Measurements for adults Height: The subject stands erect & bare footed on a stadiometer with a movable head piece. The head piece is leveled with skull vault & height is recorded to the nearest 0.5 cm.

WEIGHT MEASUREMENT:

WEIGHT MEASUREMENT Use a regularly calibrated electronic or balanced-beam scale. Spring scales are less reliable. Weigh in light clothes, no shoes Read to the nearest 100 gm (0.1kg)

Nutritional Indices in Adults:

Nutritional Indices in Adults The international standard for assessing body size in adults is the body mass index (BMI). BMI is computed using the following formula: BMI = Weight (kg)/ Height (m ² ) Evidence shows that high BMI (obesity level) is associated with type 2 diabetes & high risk of cardiovascular morbidity & mortality

BMI:

BMI Western population BMI < 18.5= Under Weight BMI 18.5-24.5= normal BMI 25-30 = Overweight BMI >30-40 = Obesity BMI >40 =Very obese Asian Population BMI < 18.5 = Under Weight BMI 18.5-22.9= normal BMI 23-24.9 = Overweight BMI >25 = Obesity BMI >35 = need bariatric surgery like fat reduction

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 .

Waist circumference:

Waist circumference Waist circumference predicts mortality better than any other anthropometric measurement. It has been proposed that waist measurement alone can be used to assess obesity, and two levels of risk have been identified MALES FEMALE Asians > 90cm > 80cm Westerns > 102cm > 88cm More risk for type 2 diabetes & CVS complications.

Hip Circumference :

Hip Circumference Is measured at the point of greatest circumference around hips & buttocks to the nearest 0.5 cm. The subject should be standing and the measurer should squat beside him. Both measurement should taken with a flexible, non-stretchable tape in close contact with the skin, but without indenting the soft tissue.

Interpretation of WHR:

Interpretation of WHR High risk WHR= >0.80 for females & >0.9 for males i.e. >80% for women and >90% for men indicates central (upper body) obesity. high risk for diabetes & CVS disorders. A WHR below these cut-off levels is considered low risk.

ADVANTAGES OF ANTHROPOMETRY:

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:

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. The measured values reflects the current nutritional status & don’t differentiate between acute & chronic changes .

Dietary Survey:

Dietary Survey 1. Qualitative Method using the food pyramid & the basic food groups method. Different nutrients are classified into 5 groups (fat & oils, bread & cereals, milk products, meat-fish-poultry, vegetables & fruits) determine the number of serving from each group & compare it with minimum requirement. Mostly using to asses the nutritional status of Pregnant woman, Infants and Under five children

Dietary survey:

Dietary survey 2. Quantitative Method The amount of energy & specific nutrients in each food consumed can be calculated using food composition tables & then compare it with the recommended daily intake. Evaluation by this method is expensive & time consuming, unless computing facilities are available.

DIETARY ASSESSMENT:

DIETARY ASSESSMENT Nutritional intake of humans is assessed 24 hours oral recall method. Food Frequency Weighment method Inventory method Duplication method Dietary history since early life Food dairy technique Expenditure method Observed food consumption

24 Hours Dietary Recall :

24 Hours Dietary Recall A trained interviewer asks the subject to recall all food & drink taken in the previous 24 hours. It is quick, easy, & depends on short-term memory, but may not be truly representative of the person ’ s usual intake

Food Frequency Questionnaire:

Food Frequency Questionnaire In this method the subject is given a list of around 100 food items to indicate his or her intake (frequency & quantity) per day, per week & per month . inexpensive, more representative & easy to use.

DIETARY HISTORY:

DIETARY HISTORY It is an accurate method for assessing the nutritional status. The information should be collected by a trained interviewer. Details about usual intake, types, amount, frequency & timing needs to be obtained. Cross-checking to verify data is important.

FOOD DAIRY:

FOOD DAIRY Food intake (types & amounts) should be recorded by the subject at the time of consumption. The length of the collection period range between 1-7 days. Reliable but difficult to maintain.

Observed Food Consumption:

Observed Food Consumption The most unused method in clinical practice, but it is recommended for research purposes. The meal eaten by the individual is weighed and contents are exactly calculated. The method is characterized by having a high degree of accuracy but expensive & needs time & efforts.

Biochemical Laboratory Assessment:

Biochemical Laboratory Assessment Hemoglobin estimation the most important test & useful index of the overall state of nutrition. Beside anemia it also tells about protein & trace element nutrition. Stool examination the presence of ova and/or intestinal parasites Urine dipstick & microscopy albumin, sugar and blood

Specific Lab Tests:

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:

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:

Limitations of Biochemical Method Time consuming Expensive They cannot be applied on large scale Needs trained personnel & facilities

Functional indicators:

Functional indicators Structural integrity : Erythrocyte -Vit E, Se. Capillary fragility -Vit C, tensile strength -Cu Host Defence : Leucocyte chemotaxis- Zn, Leucocyte phagocytic capacity -Fe, T cell Blastogenesis- Zn Hemostasis : Prothrombin time - Vit K Reproduction : Sperm Count - Energy, Zn Nerve function : nerve conduction -Vit B1, B12 Dark adoptation -Vit A, Zn, Work Capacity : Heart rate Fe, Vasopressor response Vit C

Vital statistics:

Vital statistics Mortality and morbidity data

Assessment of Ecological factors:

Assessment of Ecological factors Food balance sheet Socio economic factors Health and Educational services Conditioning Influence