Assessment of nutritional status

• Gibson 2005: determination of nutritional status of individuals or population groups as influenced by the intake and utilization of nutrients

• Simko et. al., 1995: the first step in developing nutrition goals/recommendations for a population, a community, county, city or an individual

• the interpretation of information from:

  • anthropometric

  • biochemical

  • clinical

  • dietary

Purpose of Nutritional Assessment

1. to assess the severity and geographical distribution of malnutrition

2. to identify the 5 W’s

   • what type of malnutrition

   • who are at risk of becoming malnourished, and how many are they?

   • where are the malnourished

   • when do people become malnourished?

   • why are they malnourished?

3. to develop appropriate interventions in improving the nutritional status of the population based on the assessment

4. to evaluate the effectiveness of nutrition programs and interventions in reducing under nutrition

Methods of Nutritional Assessment

1. anthropometric: 3rd stage: degrees of malnutrition

2. biochemical: second stage: changes in the levels of nutrients in the body

3. clinical: 4th stage: clinical signs associated with malnutrition

4. dietary assessment: first stage: dietary inadequacy

Forms of nutritional assessment

1. nutrition survey

   • assess the nutritional status of a selected population at one point in time

   • usually conducted face-to-face, by self-completed questionnaires, by telephone, or by postal service.

   • able to identify geographic areas or populations

   • ex: ENNS or NNS

2. nutrition surveillance (monitoring)

   • continuous, systematic collection, analysis, interpretation, and feedback of nutrition and other related data needed for planning, implementation, and evaluation of public health and nutrition programs

   • able to monitor the effects of nutrition and health policies and evaluate existing nutrition interventions in terms of effectiveness and efficacy.

   • ex: OPT plus (0-71 months)

3. nutrition screening

   • used to identify malnourished individuals

   • can be carried out on the whole population, on specific populations at risk or on selected individuals

4. nutrition interventions

   • carried out on population groups at risk that are identified during nutrition surveys or screening

Uses of Nutritional Assessment

1. Clinical setting:

   • determination of a person’s dietary adequacy or risk and for purposes of treatment or counseling

2. Public health setting

   • nutrition monitoring and surveillance of populations for dietary adequacy risk

3. research

   • for epidemiological studies on dietary intake and disease risk and for comparison of groups

Make sure that the estimates derived from any methods of Nut ass are VALID AND RELIABLE

• Validity

  validity differs when:

  • 2 diff methods are used to asses the same phenomenon

  • the same method is used to asses two diff physical activity

  • the same method is applied in different contexts or populations

  examples:

  • using un-calibrated weighing scales which could produce inaccurate measurements

  • taking blood samples when the child has fever, which could result to lower Hb level as compared to the true Hb when the child has no fever

• Reliability

  

  ---

  reliability relates to consistency,

  while validity relates to accuracy

  

Anthropometric Assessment

• most frequently used method to assess nutritional status

• direct measurement methods, which uses standardized techniques of measurements

• suitable for large sample sizes, e.g., national nutrition survey

• Two types of anthropometric measures

  1. body size: height, weight, length

     • Weight in combination with age, sex, or heigh

       -weight for height: wasting

       -weight for age: underweight

       -BMI: underweight or overweight

     • Recumbent lenght (<2 yo), and height (>2 yo)

       -basic measurement of linear or skeletal growth

       -recumbent length is measured among children <2 yo in lying position

       -height measured in standing position (>2 yo); height-for-age- index for stunting

     • reference standards

       

       • <5 yo: WHO child growth standards, using Z-scores

       • cut-off points are criteria set based on the relationship between indices an functional impairment, deficiency or clinical signs

     • growth indices

       

     • cut-off points

       

       

       

     • BMI in Adults

       

       

     • BMI in Children >10 yo

       BMI-for-Age is used in children 10-19 in assessing thinness, overweight and obesity

       

  2. body composition: measures body fat and fat-free mass

     1. MUAC: may reflect reduction or changes in muscle and fat mass

        

     2. WHR: used to assess body fat distribution

        • identify two types of body fat distribution: upper body (android or apple) and lower body (pear-typed)

        • Male: WHR>0.90

        • Female: WHR>0.85

     3. Waist Circumference

        • Male: >94cm

        • Female: >80cm

• Advantages and limitations of anthropometric measurements

  

• How are Anthropometric data evaluated?

  

• Key Results of NNS (2013) and ENNS (2018–2021, excluding 2020)

  • Trends

    

    

    

    

    

    

    

    

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  • Summary

    

Dietary Assessment

• Gibson, 2005: The First Stage of malnutrition

  • assess the first sign of any nutritional deficiency or inadequacy

• Major reasons for assessing diet

  1. assess and monitor food and nutrient intake

     • ensure the adequacy of food supply

     • estimates the adequacy of an individual's or population's food intake

     • Monitor trends in food and nutrient consumption.

     • estimate exposure of food additives and contaminants

  2. formulate and evaluate government health and agricultural policies

     • planning food production and distribution

     • establish programs for nutrition education and disease risk reduction

     • evaluate cost-effectiveness of nutrition education and feeding programs, among others

  3. assess the relationship between diet and health (as outcome) and identify groups at risk of developing diseases because of their diet and nutrient intake (epidemiological studies)

• Dietary assessment methods

  

• Level of dietary data

  

• Level of food consumption data

  • household: assess food, energy and nutrient intake at the household level

    • provide information on quantity and quality of food consumed at the household level with the use of the food weighing technique to generate per capita food consumption

      1. food inventory: recording of all food available at the household for one day, including non-perishables

      2. food record: information on the actual amount of food consumes by the household for one-day through food weighing technique

  • Individual:

    

    

• Evaluating Dietary intake

  • Using PDRI

    • EAR: estimate adequacy of protein and all micronutrient intakes

    • REI: level of intake of energy

• Indicators and metrics derived from dietary data

  

• Relevant information that can be derived from food consumption data:

  • food consumption data can describe key metrics of particular foods of interest for policy discussions:

    • % consuming age groups

    • amount/quantity consumed

    • percent distribution of food items or groups to energy and/or nutrient intake by age or population groups

  • insights are often descriptive in nature, but often these information are most relevant to national policy discussions

• Food consumption survey: per capita intake

  

  • fruits and vegetables intake of Filipinos

    • despite the consumption of vegetables and fruits, NNS found out that it is not adequate and does not meet the recommended half-plate of fruits and vegetables per meal, or at least 5 servings daily

    • WHO recommends consuming at least 400g combined fruits and veg a day, or at ;east ‘five-a-day’ serving of 80g for a healthy, balanced diet

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    • top 3 food sources of Micronutrients

      

Biochemical Assessment

• determines the levels of inadequacies or deficiencies of some important nutrients in the body before sub-clinical levels or clinical signs of deficiency becomes evident

• biochemical tests are done thru lab tests, thus, offers more objective indicator of NS

• biochemical survey

  • Anemia (hemoglobin) in PH, ENNS

    

    • hemoglobin concentrations

      

    • Trends in anemia prevalence

      

  • Vitamin A deficiency (serum retinol)

    

    • guidelines and prevalence cutoffs

      

    • trends in Vitamin A deficiency Prevalence

      

  • iodine deficiency (Urinary iodine concentration)

    

    • criteria and cutoff points

      

    • trends in iodine deficiency prevalence

Clinical Assessment

• clinical assessment is those changes believed to be related to inadequate nutrition that can be seen or felt in superficial epithelial tissues, especially the skin, eyes, hair and organs near the surface of the body

• direct method which detects different symptoms and signs occurring during nutritional disturbances

• cheap, fast, and does not need high-tech equipment

• limitations:

  • Subjective factor play a role: differences between two observers in diagnosing one single symptom, depending on the level of experience in the field

  • does not specifically detect one single nutrient deficiency but rather a multiple micronutrient deficiency

  • interpretation is not always easy: judgement to decide, whether the clinical sign is due to nutritional deficiency, will have to consider variations of physical signs recognized to be influenced by age, genetics, physical activity, environment, dietary habits, and others

• clinical assessment is based on 3 indicators:

  1. symptoms: any change in the body’s health experienced or felt by an individual.

     • The most recognized symptom that is used to diagnose nutrient deficiency is night blindness.

  2. physical signs: any detectable change in individual’s health, either by the person himself or exasminer

     • e.g., angular stomatitis due to Vit B12 deficiency

  3. functional test: test based on the consequences of body’s function or performance due to the nutritional status

     • e.g., muscular strength, cognitive performance, immune function, mobility

• types of Protein-Energy malnutrition or Acute Malnutrition

  1. Marasmus, means wasting, now known as severe acute malnutrition

     • a manifestation of severe dietary malnutrition and as a result of total caloric deficiency

     • usually occurs when a child from low socio-economic level reaches 6–18 months of age or during the first 1000 days

     • associated with relatively high mortality (9x more likely to die than well-nourished children)

     • Treatment of SAM: therapeutic feeding in health facility-based settings

     • Physical signs: old man face, skin-bone appearance, dermatosis / depigmentation of skin

       

  2. Kwashiorkor, a severe acuate malnutrition (SAM)

     • associated with poor quality diet high in carbohydrates but low in protein such that the child may have a sufficient total energy intake

     • severe protein insufficiency leads to bilateral pedal edema and ascites

     • Physical signs: moon face, muscle wasting, loss of subcutaneous fat, dermatosis/flaky pavement.

       • depigmentation, paleness due to anemia, easily pluck-able hair, flag sign of hair or blonde discoloration of hair, non-lustrous hair, usually accompanied by signs of vitamin A deficiency and other nutrient deficiencies

     • Management Guidelines: PH integrated management of Acute Malnutrition (PIMAM)

       

• Assessment of Vitamin deficiency

  1. Vitamin A deficiency (VAD)

     • appears after depletion of liver reserve

     • source of Vit A may be sufficient, coming from fruits and vegetables, but lack of fat for absorption and lack of good bio-available sources of vitamin A from animal sources in the diet result to low vitamin A intake and consequently low Vitamin A levels.

     • symptoms: loss of appetite, growth failure, diarrhea

     • physical signs: skin and ocular dryness

       different stages of ocular signs are as foolows:

       • night blindness

       • conjunctival xerosis

       • bitot’s spot

       • corneal xerosis

       • keratomalacia

       • corneal scar

       • xerophthalmia

         early signs of VAD in the skin include dry rough skin / small bumps surrounding hair follicle due to keratinization

     

  2. Vitamin D deficiency

     • occurs in children who were kept bundled or when someone is not exposed to sunlight

     • A person on a low-fat diet or a strict vegetarian may also suffer from VIT D deficiency. the clinical manifestation is different between children and adults.

     • Symptoms: bone deformity, bone tenderness, recurrent fracture, weakness

     • Physical signs

       Children: Rickets - rachitic rosary, epiphyseal enlargement, bow legs, knock knee

       

       Adults: fracture, osteoporosis

       

  3. Vitamin C deficiency

     

  4. Thiamin deficiency

     

  5. folate deficiency

     

  6. vitamin B12 deficiency

     

• Assessment of Mineral deficiency

  1. iron deficiency

     

  2. Zinc deficiency

     

  3. iodine deficiency