Nutritional Assessment

Mirjana Gurinovic, Milica Zekovic, Jelena Milesevic, Marina Nikolic, and Maria Glibetic, Centre of Research Excellence in
Nutrition and Metabolism, Institute for Medical Research, University of Belgrade, Belgrade, Serbia
Ó 2017 Elsevier Inc. All rights reserved.

Introduction 1
Dietary Intake Assessment 2
Indirect Dietary Assessment Methods 2
Food Balance Sheets 2
Household Budget Survey 2
Direct Dietary Assessment Methods 3
Direct Dietary Intake AssessmentdObjective Methods 3
Direct Dietary Intake AssessmentdSubjective Methods 3
Evaluation of Nutrient Intake and Diets 7
Food Composition Databases 8
Dietary Assessment ToolsdNutritional Tools Software 8
Biochemical Indicators of Diet 9
Anthropometric Measurement and Body CompositiondNutritional Status Assessment 10
Global Nutritional Status and International Developments 10
Conclusion 11
References 11
Relevant Websites 13

Introduction

“Nutritional assessment can be defined as the interpretation from dietary, laboratory, anthropometric, and clinical studies. It is used
to determine the nutritional status of individual or population groups as influenced by the intake and utilization of nutrients”
(Gibson, 2005). Nutritional status represents meeting of human body needs for nutritive and protective substances and the reflec-
tion of these in physical, physiological, and biochemical characteristics, functional capability, and health status. Information about
nutritional status, i.e., nutritional assessments, is essential for identification of potential critical nutrients (at population groups at
risk of deficiency); formulation of recommendations for nutrient intake; development of effective public health nutrition (PHN)
program for nutrition-related diseases prevention; and monitoring the efficiency of such interventions (Elmadfa and Meyer,
2014). In current nutrition epidemiology (NE) and PHN research, data collection and comparison against each other, and recom-
mendations, and further development and application of a harmonized and standardized nutritional assessment methodology is
a necessity (Gurinovic, 2016). Beside these major instruments, to correctly interpret the results of nutritional assessment methods,
other factors (socioeconomic status, cultural practices, and health and vital statistics–ecological factors) should also be considered.
This article elaborates dietary, biochemical, and anthropometric measurements as nutritional assessment methods that can be
applied in four forms of nutritional assessment system: surveys, surveillance, screening, or interventions.
Nutrition Surveys are usually national cross-sectional studies that are performed to assess the nutritional status of a selected pop-
ulation, identify the group at risk of chronic malnutrition, evaluate existing nutritional problems, and inform evidence-based nutri-
tion policies. Another application of nutrition surveys is to evaluate the efficacy of an intervention using data from baseline and final
assessments (Gibson, 2005).
Nutritional surveillancedPublic health surveillance is the continuous, systematic collection, analysis and interpretation of health-related data
needed for the planning, implementation, and evaluation of public health practice (WHO, 2017). Data in nutritional surveillance studies
are collected, analyzed, and evaluated in a standardized manner during a longer period of time. They can be used for the identifi-
cation of possible nutritive risk factors of malnutrition of a whole population or specific vulnerable group. Formulation, evaluation,
and monitoring of the nutrition intervention programs and policies are main objectives of nutrition surveillance (Gibson, 2005).
Nutrition screening is used to identify malnourished individuals. It can be carried out on the whole population, on specific
subpopulations at risk or on selected individuals (Gibson, 2005). During nutritional screening, simple, cheap, and rapid measure-
ment methods are used.
Nutrition interventions are carried out on population subgroups at risk, which are identified during nutrition surveys or screening.
Supplementation and fortification are some examples of nutrition interventions. Providers require efficient monitoring and evalu-
ation to prove the efficiency and soundness of these interventions. There are three types of evaluation designs. In the simplest one,
the whole targeted group is exposed to the intervention, and the outcome is measured against previously defined goalsd“adequacy
evaluation.” The secondd“plausibility evaluation” requires quasiexperimental conditions, where one group receives an

Reference Module in Food Sciences [Link] 1

2 Nutritional Assessment

intervention while the othercontrol group does not, or receives a “placebo.” In this design, the subjects are not randomized, and
multivariate analysis is used to remove external factors and biases. This approach is more expensive than the previous one. The third
type of evaluating design is a randomized, controlled, double-blind experimental trial, where subjects are randomly assigned to an
intervention or control group. Evaluation of an intervention with this design, especially when it is well-planned and conducted,
gives the highest level of confidence that the outcome is the result of the interventiond“probability evaluation” (Gibson, 2005).

Dietary Intake Assessment

Measurement of dietary intake is an important part of overall nutritional status assessment. Accurate and reliable dietary intake
assessments and eating behavior analyses make a considerable challenge for all researchers in the field of NE. The complexity of
human diet and the multivariate relationships between dietary factors and health should be acknowledged in the analyses and inter-
pretation of dietary intake data.
Approaches to food consumption assessment are numerous and the selection of the most appropriate method depends on
research objectives, study hypothesis, needed level of accuracy and precision, characteristics of the defined study population, the
desired type of data, as well as on available personnel and financial resources (Willet, 2013).
Dietary assessment tools differ in observational perspective, time frame, method of administration, estimation of amount of
food eaten, and conversion into food components (Van Staveren et al., 2012). In general, methods of measuring food consumption
could be directed at individual, household, national, and other levels (Gibson, 2005), and it is important to clearly define the goals
of dietary assessment before choosing the most appropriate strategy. All dietary intake assessment methods have certain strengths
and limitations and knowing their nature enables better scientific interpretation of the results.

Indirect Dietary Assessment Methods

Food Balance Sheets
In terms of methodological approach, both direct and indirect food consumption surveys are used. Indirect measurement of food
consumption at the national level are Food balance sheets, FBS (also called “food disappearance data”), which provide a compre-
hensive compilation of data on the food supply within a country over a defined period (FAO, 2001; Patterson and Pietinen, 2004).
Gross national food supply is calculated by summing the domestic production of certain food and its import and subtracting the
export and food added to stocks. Next, food not diverted for human use and estimated for waste are subtracted from the gross food
supply to calculate the net amount of certain food items available for human consumption (Gibson, 2005). The resulting value is
then converted to a daily per capita estimate according to country-specific population data. Regular tabulation of annual FBS depicts
the trends of the overall national food supply, reveals shortages, surpluses, and changes in dietary pattern and provides data on the
country’s food supply adequacy in terms of meeting nutritional requirements (FAO, 2001). The dietary energy supply derived from
the FBS, is also used for estimation of prevalence of undernourishment at national, regional, and global levels. The FAO Statistics
Division analyzes food security indicators and evaluates different aspects of food insecurity in the world using FBS as harmonized
instrument (FAO et al., 2015).
The principal strengths of this dietary assessment method are objective approach, well-established standardized methodology,
low cost, and quantifiable measurement of overall food availability on the national level. FBS can be used to measure national food
supplies in routine monitoring, policy planning, and agricultural development, as well as to facilitate data-based trade. They also
serve for calculating national self-sufficiency and import-dependency ratios and projecting future demands regarding production
and supply. Furthermore, FBS are indispensable instruments for defining production and trade objectives, creating national
food and nutrition policies, performing intertemporal and international comparisons, and ensuring food security (FAO, 2001;
Jacobs and Sumner, 2002; Kelly et al., 1991; Njeru, 2011).
A major limitation of this dietary assessment method is that it provides an indirect estimation, rather than accurate measurement
of the food actually consumed by individuals. Due to remarkably high food waste in developed countries, energy and nutrient
intake estimates according to FBS usually exceed estimates of direct dietary assessment methods (Patterson and Pietinen, 2004).
In addition, FBS cannot be used for comparison and interpretation of food consumption data in relation to regional, socioeco-
nomic, demographic, and seasonal parameters within a country (Gibson, 2005).

Household Budget Survey

Another indirect approach for measuring food consumption, focusing on a household level, is the household budget survey (HBS).
HBSs are systematically carried out in many countries on a representative random sample of households with an objective to
explore in detail the pattern of household expenditure on food consumption. These data predominantly serve for the consumer
price index calculation and analyses of social and economic interest (Serra-Majem, 2001). For example, standardized and harmo-
nized HBSs have been used during the DAFNE project to describe dietary patterns and their sociodemographic determinants in 10
EU countries. This instrument has been proven reliable in ecological studies, formulation of dietary guidelines and public health
initiatives for specific population groups (Naska et al., 2006; Trichopoulou et al., 2003). Overall, sample representativeness must be
assured based on, at least structure, geographical distribution, degree of urbanization, socioeconomic, and employment status (Van
Staveren et al., 1991). Even though HBSs are not primarily conceived as nutrition surveys, they provide useful data on food
 Nutritional Assessment 3

availability and sociodemographic and economic factors affecting dietary choice (Gibson, 2005). Weights of foods and nutrients
per household member are derived from household structure and food expenditure data (Patterson and Pietinen, 2004). These
data are used as a general guide for evaluating the adequacy of food supply to household members, but are not considered appro-
priate for diet quality assessment in relation to sex- and age-specific nutrient recommendations.
The major limitation of this method is that, in most cases, it does not consider the edible food waste and food expenditure
outside the home. This omission often leads to a distorted estimation of true energy and nutrient intake (Gibson, 2005; Patterson
and Pietinen, 2004; Sichieri et al., 2008). Furthermore, HBS data are collected at a household level, ignoring intrahouse dietary
intake variation and not providing information on food consumption by specific members of the household. In some cases, age
and gender profiles of household members are not considered in the estimation of individuals’ intake. Alternatively, estimation
can include modeling and weighting based on specific requirements by age, sex, or anthropometric characteristics, assuming
that the total available food quantity is allocated to household members according to these requirements (Trichopoulou and Naska,
2003). For years, Eurostat in cooperation with the National Statistic Offices of EU member states compiles has been monitoring and
harmonizing the quality of data in HBS (Eurostat, 2015).
HBS also presents one of the instruments for harmonized monitoring of food security at the national and global level (FAO,
2008). For that matter, the FAO statistics division has developed a standard methodology for analyzing food consumption data
collected through national household surveys. FAO, in collaboration with World Bank and under the EU’s “Improved Global
Governance for Hunger Reduction Programme,” developed user-friendly softwaredthe ADePT–food security module, as a successor
of the food security statistics module, which derives food security statistics from survey data (Moltedo et al., 2014).

Direct Dietary Assessment Methods

Direct food consumption measurement could be performed by objective observation (duplicate diet approach and food consump-
tion record by a trained research staff) and by subjective report [24-h dietary recall, estimated and weighed dietary record, dietary
history, food frequency questionnaire (FFQ)] (Shim et al., 2014).

Direct Dietary Intake AssessmentdObjective Methods

Duplicate Diet Studies
In duplicate diet studies participants are asked to collect duplicate portions of all food products as prepared, served, and consumed,
in a suitable container provided by researchers. Food items are collected over a defined time, usually 24h, and sometimes for several
consecutive days. Prior to further analyses, provided duplicate portions are weighed and nonedible parts are removed. Samples are
then homogenized and later chemically analyzed. It is noteworthy that the intake estimation is derived directly from duplicate
portions without using composition data from other sources. This approach is considered valuable in assessing food chemical expo-
sure (particularly for potentially toxic chemicals such as pesticide residues and contaminants) (Kroes et al., 2002). Duplicate diet
studies are not suitable for large-scale food consumption studies due to time, resources, and the cost involved. This method is useful
for institutional groups (residential homes, schools, kindergartens, etc.), small surveys, and particular population subgroups sus-
pected to be at risk of exposure to high levels of dietary contaminants (Gibson, 2005; WHO, 1985). Considerable commitment
is required from the participants and one of the limitations of this approach is the risk that participants may alter their dietary
patterns during the observation.

Food Consumption Record Performed by Trained Professionals

A food consumption record reported by trained field workers represents an account of all the foods and beverages prepared and
consumed by individuals over a specific period based on the direct observation of skilled professionals. Observation may take place
within a research setting or the subject’s usual environment. This approach is appropriate for subjects with low literacy level and for
those who consume most of their meals at a place that is easily accessible for researchers. To assure adequate precision and detailed
recording process, special training for field workers and quality control techniques should be performed. Even though it provides
objective data on individuals’ dietary intake and food-related behavior, this method is laborious and time-consuming and imposes
a significant burden on investigators. Furthermore, participants may consider this process invasive and change their food consump-
tion behavior due to observation (Shim et al., 2014).

Direct Dietary Intake AssessmentdSubjective Methods

Direct dietary assessment methods based on subjective reports could be divided into two basic categories: prospective methods
(recording data at the time of food consumption) and retrospective methods (collection of data on diet eaten in the past). Prospec-
tive methods are weighted and estimated food records and they can be carried out for varying lengths of time according to the
research objectives and the level of accuracy needed. Retrospective methods may refer to recent consumption (24-h dietary recalls)
or could capture data regarding habitual diets (dietary history and FFQs).

Prospective Methods
Food Records
Food records (also called dietary records or dietary diaries) collect data on dietary intake by subjects’ self-record over a specified
period. This dietary assessment approach does not rely on individual’s memory since respondents are asked to record foods and
4 Nutritional Assessment

beverages as they are consumed throughout the reporting day (a “real-time” accounting). Duration of the survey depends on the
study aim and the desired level of precision in estimating food consumption or nutrient intake. To assure accurate and detailed
data, respondents must be trained to record adequately the food items consumed, including the name of the food, amount
consumed, preparation methods, brand names of commercially available products, recipes of composite dishes, as well as other
particularities of interest (Van Staveren et al., 2012). Additional data regarding the time and location of consumption, parallel
activity, and the presence of other people could be useful for the interpretation of an individual’s eating pattern and social context
of diet. Traditionally, food records capture information in an open-ended manner and accommodate any food consumed by the
participant with an unlimited level of specificity and detail in the dietary intake description (Willet, 2013). This highly flexible
method for dietary intake assessment could be applied in diverse groups with various lifestyle and eating habits.
Comprehensive written instructions should be given to respondents, ideally combined with face-to-face explanation, assistance,
and advice. It has been shown that debriefing sessions with a nutritionist improves the quality of the obtained data (Cantwell et al.,
2006). Therefore, at the end of the recording period, trained professional should review the record with the participant to clarify
potential omissions and ambiguities, probe for additional information or make necessary changes (Thompson and Byers, 1994).
There are two types of food records based on the way quantification of food items is performeddestimated and weighted. An
individual undertaking an estimated food diary records portion sizes and the amount of food consumed using standard household
measurements, natural unit sizes, weight/volume from the packaging and labels, or according to provided portion sizes. In
a weighted record, a subject weights foods and beverages prior to consumption, as well as any leftovers, and records detailed descrip-
tion of all the items and their weights in the recording sheet. Weighted food records provide precise food amount quantification, but
are more expensive and demanding for the participant. Both methods require participants to be literate, skilled in numeration,
trained before recording, and highly motivated. These requirements may cause a response bias due to overrepresentation of diet-
and health-aware individuals. A common concern is that the usual eating patterns may be changed or influenced by the recording
process and self-monitoring. Alteration of dietary behavior while keeping the food record (called reactivity) may occur unintention-
ally (through self-reflection) or intentionally (when respondents try to camouflage poor eating habits or avoid the recording
burden) (Margetts and Nelson, 1997; Willet, 2013). If multiple days of intake per individual are needed to satisfy research ques-
tions, adherence to recording protocol and the reporting accuracy may be even more compromised, due to fatigue and decreased
motivation. Furthermore, there is the risk that respondents develop the practice of filling out the record retrospectively rather than at
the time of intake (Shim et al., 2014; Thompson and Subar, 2013).

Retrospective Methods
24-h Dietary Recalls
This retrospective dietary assessment method involves an extensive interview where the individual recalls complete food and
beverage consumption from the previous day or the preceding 24 h. The interview is often structured, with standardized and pre-
tested protocol involving probing questions that help the respondent remember all the items consumed and relevant food descrip-
tion. Information on food type, preparation methods, recipes, brand names of commercial products, and estimated portion size are
usually required. Accompanying contextual data (location and timing of consumption, meal origin, company, and parallel activity)
are sometimes used for a more comprehensive interpretation in nutritional assessment. When the respondent fails to provide
adequate information, the interviewer should probe further to assure the necessary level of detail. It is important that the probing
questions used to encourage the recall are asked in a neutral, nondirective and nonjudgmental manner (Fowler and Mangione,
1990; Sanjur, 1982; Willet, 2013).
Potential errors in 24-h dietary recalls could arise from the interviewer, respondent, or the method itself. Interactions in this
triangular system define the quality of 24-h dietary recall measurement (Slimani et al., 2000). Intensive training of the inter-
viewers and a well-developed quality control system are critical in obtaining reasonably accurate and complete reports with suffi-
cient information for analysis. Furthermore, interviewers should be familiar with the study design and research objectives, dietary
components of interest, and food composition database (FCDB) to be used subsequently to process and analyze the obtained
consumption data.
Major issues in collecting food consumption data using 24-h recall are limited memory and the participants’ ability to describe
type and amount of food consumed, as well as social desirability bias. Memory problems may cause under- and overestimation of
dietary intake depending on the type of error. The error of omission is introduced when respondents fail to report foods that were
actually consumed, and error of commission when they report items that were not consumed during the recall day (Dwyer et al.,
1987). Factors associated with the ability of retrieving information and recall accuracy are gender, age, education level, intelligence,
mood, interview setting, eating pattern consistency, ethnic background and current nutritional status (Klesges et al., 1995; Krall
et al., 1988). Skilled interviewers, list of frequently forgotten foods, unhurried pace of interview, and related activities from the recall
day with food consumption, may reduce errors caused by memory limitations (Willet, 2013). To facilitate accurate recall, multiple-
pass technique is used increasingly in dietary surveys and research studies. This approach, based on cognitive principles and prac-
tical experience, employs sequential passes in the interview according to a predefined pattern. Even though specific protocols may
vary in number of stages and their scope, basic elements of the multiple-pass method are the same. First, the respondent provides an
uninterrupted recall of the foods consumed the previous day, not necessarily in chronological order. This pass is followed by asking
for any forgotten or omitted food items, and probing questions for more details about the intake (including time and occasion of
consumption and quantities consumed). In the final step, the interviewer reviews the list of reported foods with the addition of food
items, eating occasions, or relevant details if appropriate (Blanton et al., 2006; Rutishauser, 2005).
 Nutritional Assessment 5

Quantification of portion sizes should be concerned within the 24-h recall method. The ability of a respondent to quantify an
amount consumed with reasonable precision depends on a complex cognitive process. Various portion size estimation aids (PSEA)
may help respondents recall the portion size of food consumed. These may be either two-dimensional (photographs, rulers, grids,
drawings, and illustrations) or three-dimensional (food models, standard measuring cups, common sizes of mugs, glasses, and
bowls) (Souverein et al., 2011).
Due to high level of day-to-day variation in diet among free-living individuals, single 24-h dietary recall is not considered to be
a valid indicator of usual consumption. Therefore, to capture habitual intake, multiple recalls per subject are required (Willet,
2013). The number of recalls necessary to reliably assess diet depends on the research question, study sample, nature of diet,
and intake variability for foods or nutrients of interest.

Food Frequency Questionnaires

FFQs, widely used instruments for dietary intake assessment in epidemiologic studies, are designed to measure habitual consump-
tion over an extended period. They vary in listed food items, time frame of interest, response intervals specifying frequency of
consumption, portion size reporting, and manner of administration (Molag et al., 2007).
Two basic elements of FFQs are predefined limited food list and an accompanying “frequency of consumption” section. The
food list should be clear, concise, systematically structured, and carefully compiled according to the research objectives. The list
may be extensive to enable comprehensive evaluation of diet or focused on specific nutrients, food items and food groups, or dietary
exposures related to certain diseases (Cade et al., 2004; Shim et al., 2014). The listed items should reflect common dietary habits of
the studied population and be frequently consumed by a considerable number of individuals. Furthermore, selected foods should
represent a major source of nutrient(s) of interest and should significantly contribute to interindividual variability in intake (i.e., be
discriminative) (Willet, 2013).
Several strategies could be employed to assemble the most informative, culturally appropriate list. The selection of potentially
relevant items may be based on previously conducted surveys, expert consultation, or derived from FCDBs and consumption data
obtained in a pilot study using open-ended instruments (24-h recalls or food records). Usually, the list is initially constructed based
on abovementioned criteria, and further methodically reduced. Even though a longer food list enables a more detailed examination
of nutrient intake, too long questionnaire causes exhaustion and boredom of the participants that can negatively affect their accu-
racy, motivation, and willingness to complete the form (Willet, 2013).
The frequency of consumption section is usually based on a multiple-choice response format, with the number of options
ranging from 5–10. An alternate, open-ended format is less-frequently used approach.
Based on inclusion of portion size estimation, FFQs can be qualitative, semiquantitative, and quantitative. Qualitative FFQs
(also called food propensity questionnairesdFPQs) lack additional information on portion sizes and provide only descriptive
data on food-consumption patterns. In semiquantitative FFQs, reference portion size is presented as a part of question on frequency
of consumption. This option is particularly appropriate for foods that come in natural or standard units (e.g., an apple, an egg, a cup
of coffee, a slice of bread etc.). A disadvantage of this method is that the average portion size for the listed items could not be spec-
ified. For example, in case respondents usually consume portion that is twice the amount indicated in the questionnaire, they are
expected to double the reported frequency of consumption.
The third type, quantitative FFQs, include supplementary question for each item about the usual portion size. Researchers
may define medium portions and ask subjects to describe amounts they consume on average, using the categorization of small,
medium, and large. Alternatively, illustrations or photographs of various portions could be provided in the questionnaire in
a multiple-choice format. Finally, description of the usual serving size could be left for respondents to describe in an open-ended
manner. This allows more flexibility and could improve precision, but is more extensive for subsequent data processing (Cade
et al., 2004; Willet, 2013).
FFQs can be both interviewer administered (in person or over the telephone) and self-administered using the traditional paper-
based or electronic form. Paper questionnaires are frequently designed to be close-ended and viable for optical scanning and auto-
mated processing to facilitate data entry and minimize the risk for error. Although interviewer-administered approach increases the
cost significantly, it is necessary in certain situations, such as low literate and numeracy skilled participants. In contrast to 24-h
recalls, interviewer training is less demanding and a standardized food list reduces the between-interviewer variation.
FFQs are convenient for large groups and provide an evaluation of long-term dietary exposure with modest participant burden
compared to other dietary assessment methods, relatively low cost, and absence of reactivity. A major drawback of the FFQ method
is the inherent substantial measurement error. Inaccuracies are introduced with incomplete food listings, memory reliance, self-
reporting bias, and cognitively complex procedures involved in retrospective estimation of portion sizes and frequencies of
consumption (Pérez Rodrigo et al., 2015).

Validation/Calibration of Quantitative Food Frequency Questionnaire

For the evaluation of nutrient intake, quantitative FFQs must be validated. The purpose of validation studies is to prove that the FFQ
measures an intake of certain nutrients appropriately, or to assess the degree to which FFQ complies with a biomarker or other
referent method of measuring nutrient intake. Most validated FFQs (75%) are verified against another referent dietary intake assess-
ment method, while only 19% of them are validated against a biomarker (Cade et al., 2002). Trilateral comparison between data
from FFQ, reference dietary method, and biomarker measurement can be used to obtain a quantitative estimate of the FFQs (val-
idity coefficient). This method of validation is called “method of triads” (Ocké and Kaaks, 1997; Pérez Rodrigo et al., 2015).
6 Nutritional Assessment

Diet History
This retrospective method, attributed to Burke (1947), is used when detailed individual’s dietary intake and usual meal pattern over
a relatively long period is required. The original technique consisted of three parts: structured interview to estimate the respondent’s
usual daily eating pattern with amounts expressed using standard household measures; FFQ with detailed list of foods to assess
overall consumption and cross-check data obtained in the first part; and a 3-day food record (Juan Morán Fagúndez et al.,
2015). This model has been adapted over time and is currently applied in various versions and research settings without unani-
mously accepted standard protocol (Tapsell et al., 1999). Due to the complexity of this method, comprehensive training of skilled
and experienced interviewers with nutritional background is crucial for ensuring adequate data quality and reducing the systematic
error. In addition to good communication skills, interviewers should be familiar with the protocol, study objective, local dietary
practices, and food availability. The assessment produces plenty of data and analysis is usually challenging and requires nutritional
expertise. This method is expensive, time-consuming, and demanding for both researchers and respondents. Furthermore, since the
structure is not standardized, the comparison of data across studies is limited. This approach is not applicable for large-scale pop-
ulation studies and individuals with highly variable and irregular dietary habits.

Nutritional Assessment in Specific Population Groups

Disabilities affecting sight, hearing, speech, memory, or the ability to write present a challenge in the collection of dietary intake data
from affected individuals. When respondents are unable to give answers/fill questionnaires, surrogate responders may be engaged,
or interviewers could collect data by observation (Van Staveren et al., 2012).
Low income individuals and immigrantsdPeople from low-income households typically have less-nutritionally adequate diets,
especially those who live for long periods on limited resources. There is growing evidence suggesting poor nutritional status is
a specific cause of higher disease rates in low-income households. Therefore, it is of great importance in NE to study diet in this
group. The preferred methods are 24-h recalls and FFQs, as they were shown as the most appropriate method. On the contrary,
methods such as weighed inventory could yield higher estimates of energy and nutrient intakes compared to multiple-pass 24-h
recalls (Vucic et al., 2009).
Immigrants comprise a noteworthy segment of the European population that is constantly increasing. Research on the dietary
habits of immigrants is critical for NE, adequate provision of diet counseling and implementation of effective nutritional interven-
tions. Interview-administered FFQs and repeated 24-h recalls are the most frequently applied instruments. Inclusion of ethnic foods
and quantification of specific portion sizes of traditional foods and dishes in assessment tools, as well as FCDBs, are commonly
identified problems (Ngo et al., 2009b; Nikolic et al., 2014).
Infants and toddlers are population subgroups with the highest priority within risk assessment for nutrient inadequacy. Yet, chil-
dren up to the age of seven have insufficient ability to cooperate in dietary assessment procedures. Therefore, parents or other care-
givers act as surrogate respondents (Van Staveren et al., 2012). European Food Safety Authority (EFSA) recommends that the dietary
record method including two nonconsecutive days is applied to infants, toddlers, and other children (from 36 months to 10 years
old) (EFSA, 2009). Comparing different validation methods in infants, reviewed studies indicate FFQ as the most commonly
method used to assess micronutrient intake in infants (Ortiz-Andrellucchi et al., 2009).
As the world population is aging, nutrition presents a common problem that affects functional and physical status of elderly
people. Estimation of micronutrient intake in this population is often a challenging task as short-term memory fades with age,
and thus surveying the elderly requires particular care. Adaptations of recording methods and diet histories have resulted in valid
reports for older adults. Therefore, testing the method of data collection is particularly important in this age group to ensure valid
results. It may also be helpful to use a combination of different techniques, for example, a food record combined with dietary recall
(Ortiz-Andrellucchi et al., 2009; Van Staveren et al., 2012).
Athlete nutrition requires specific dietary assessment approaches because there is a practice that sport dietitians monitor
athletes’ dietary habits daily, and this should be efficient and effective. Yet, classical dietary assessment methods lack an adequate
level of validity and reliability and may cause significant errors. To perform efficient dietary assessments in sports, aims of the
assessments, employment of different approaches, and tools should be considered. There are two ways how a diet of athletes
can be assessed. The first one is to measure what athletes consume during the time when they make their own choices, i.e.,
without influencing the process. Here two methods are employed: retrospective (what the athlete consumed in the past) where
24-h recall, FFQ and diet history are used, and prospective (what an athlete planned to consume in the future) where written food
diary (diet record) is used. Both have merits and drawbacks. The second one is diet tracking or self-monitoring, where an athlete
changes his/her diet during the monitoring process, which allows them to have real-time feedback and direction about the prog-
ress they are having, which underpin their motivation to improve and maintain new nutritional habits and increase physical
performance (Burke, 2015).

Importance of Accurate Estimation of Portion Sizes by Using a Food Picture Book

Dietary intake methods based on subjective reports such as 24-h dietary recall, dietary records, dietary history, and FFQs have certain
limitations. The quality of these methods depends on the respondent’s memory and interviewer’s skills to minimize bias (Shim
et al., 2014). Monitoring of dietary intake assessment requires methods that are accurate, comprehensive, and suitable for the target
population (Foster et al., 2006). One of the limitations is a high level of bias that comes from portion size estimation (Nelson et al.,
2016). Accuracy of food and nutrient intake assessment linearly depends on the accuracy of measure or estimate of the portion size
of each consumed food item. Since weighing is not an option for retrospective methods such as 24-h recalls and FFQ, dietary intake
 Nutritional Assessment 7

relies on a subject’s estimation of portion sizes (Foster et al., 2006). Minimizing measurement error is the most important element
for pursuing valid dietary intake assessment, especially for examination of diet–disease relationships (Nelson et al., 2016).
Several tools have been developed to aid the subject in estimating portion sizes, as accurately as possible. These tools are photo
series of foods in different sizes, food replicas, and food models (Nelson et al., 2016). Food picture books with photo series of
different portion sizes are commonly used tools, convenient for the subjects’ estimation of size/weight/volume of consumed foods.
Subjects are asked to select a photo from the food picture book that most precisely depicts the portion size of a food they have
consumed.
Advantages of using food picture books to accurately estimate consumed portion sizes are reported in several studies (Faggiano
et al., 1992; Hankin et al., 1991; Tjønneland et al., 1991). Since the most errors in dietary intake assessment occur during the esti-
mation of food portion sizes, detailed methodology on development and validation of food picture books is set by Nelson and
Haraldsddottir (Nelson and Haraldsdottir, 1998). It is highly recommended that food picture books are developed on the national
level, depicting the most commonly consumed food items, as well as traditional recipes of the country where they will be used. The
list of foods, as well as portion sizes, should be derived through a previously conducted national food consumption survey (Nelson
and Haraldsdottir, 1998). Besides food items and recipes, food picture books should contain household measures like spoons,
bowls, as well as different types of liquid containersdcans, bottles, glasses, mugs etc. for the accurate assessment of liquids intake.
Correspondingly, food picture books should be age specific. Food picture books specifically developed for children are more
accurate in estimating a child’s portion size than books developed for adults (Foster et al., 2006). Moreover, Timon and colleagues
found that older adults may be less able to estimate portion size of certain food categories than younger adults by using the same
food picture book (Timon et al., 2011).
To avoid any optical illusions, all photos within the same series should be taken with the same digital camera mounted on
a tripod, under the same technical conditionsdlight, angle, and distance, which helps in framing all the photos in the same way.
To enable a quick identification, each food and each portion should be marked individually. For instance, every food item set
could be labeled with numbers, while portions within the set could be labeled by alphabetical letters in increasing order that follow
increase of portion sizes. Such codes are important since subject should see only the photo series, but not the actual amounts of
portion sizes, because it could be suggestive and bias the answer.
Several national food picture books were developed around the world (Abu Dhabi Food Control Authority, 2014; Instituto
Nazionale di Ricerca per gli Alimenti e la Nutrizione, 2010; Nelson et al., 1997; Tervise arengu instituut). Modern versions of
food picture books are integrated in software for dietary intake assessment, which is more convenient for computer assisted
personal/telephone interview (CAPI/CATI) methods systems.

Evaluation of Nutrient Intake and Diets

Diet and dietary intake can be studied at the levels of dietary patterns, food groups, foods, and nutrients. The evaluation of diet can
be quantitative or qualitative, conducted on individual or population levels.
The qualitative approach is usually based on dietary patterns and food-based evaluation of diet according to the Food Based
Dietary Guidelines (FBDG), which are country specific and reflect national public health dietary issues. WHO, FAO, and EFSA devel-
oped guidelines to support countries in creating their national FBDGs (EFSA, 2010; Montagnese et al., 2015). Several indices are
used for the evaluation of diet: Healthy Eating index (HEI), Healthy Diet Indicator (HDI), and Diet Quality Index (DQI) (Gibson,
2005). Recently, MDD-W Minimum Dietary Diversity for women of reproductive age has been recognized as a new indicator
adequate for global diet assessment (FAO and FHI 360, 2016).
Furthermore, evaluation of dietary patterns can provide valuable data on disease prediction and interactions between food
consumption and healthy habits or diet exposure–disease relationships. Overall, dietary pattern analysis is useful in the monitoring
of populations’ dietary trends and compliance with food-based dietary recommendations (Dhonukshe-Rutten et al., 2013).
In the quantitative approach, energy and nutrient intake per day are compared with the Dietary Reference Values (DRVs) and
Dietary Reference Intake (DRI) (according to age, sex, and life stage) to assess adequate nutrient intake of individuals and groups.
There are different reference values developed and accepted by WHO/FAO/EFSA (EFSA, 2010; FAO/WHO, 2004) and other inter-
national bodies, at regional (D-A-CH, 2015; Nordic Council of Ministers, 2012) or national levels (British Nutrition Foundation,
2015; Food and Nutriton Board and IOM, 2011). Plenty of terms, definitions and approaches are used to evaluate the intakes of
groups versus the intakes of individuals and interpret nutrient adequacy. The types of DRVs/DRIs are Estimated Average Require-
ments (EARs); Reference Nutrient Intakes (RNIs); Lower Reference Nutrient Intakes (LRNIs); Adequate Intake (AI), Tolerable Upper
Intake Level (UL), and Recommended Dietary Allowance (RDA) (Doets et al., 2008; Murphy and Poos, 2002; Pavlovic et al., 2007).
To calculate accurately nutrient intake from food consumption information, up to date and computerized database and software
(nutritional tool) are required assets (Gurinovic et al., 2016b). Besides, assessment of supplement use and their composition is also
necessary in NE studies.
Assessment of dietary intake is used to estimate the proportion of the population that is at risk of nutrient inadequacy, i.e.,
nutrient intake below the reference cut-off values. Within the EURRECA (EURopean micronutrient RECommendations Aligned)
Network (2007–12), the dietary assessment instruments to evaluate adequacy of intake at the population level were proposed.
Both methods, the probability approach and the cut-off point method, require estimation of population average intake
(Dhonukshe-Rutten et al., 2013; Roman-Vinas et al., 2009).
8 Nutritional Assessment

Food Composition Databases

FCDBs present important research infrastructure (RI) for PHN research. FCDBs are used to estimate food and nutrient intakes, both
at the individual and population level (regional, national, or international), for epidemiological research, monitoring of public
health, personified dietary advice, food labeling, and nutritional claims (Finglas et al., 2014).
The European Food Information Resource (EuroFIR) Network of Excellence and Nexus projects (2005–13) set the foundation of
harmonization in the field of FCDBs through standardized protocols for data collection and documentation, food description
system i.e., LanguaLÔ. Nowadays, The EuroFIRdAssociation Internationale Sans But Lucratif (AISBL) manages and provides
a comprehensive European online resource for food composition data compilers and users, which presents major RI in food
and health research in Europe. Its virtual platform currently hosts 30 national FCDBs (from Europe, Australia, Canada, Japan,
and the United States), comprising more than 40, 000 foods, all of which are available at the FoodEXplorer online tool (Finglas
et al., 2014). EuroFIR and EuroFIR Nexus projects identified FCDBs and adjacent infrastructure for harmonized data collection
and management as scarce, particularly in the Central Eastern Europe/Balkan (CEE/B) region. To support development of RI in
CEE/B, Food Composition Data Management (FCDM) software was created according to EuroFIRÔ standards (Glibetic et al.,
2010). This software was used to create the first online Serbian FCDB (Gurinovic et al., 2016a), as well as Balkan Food Platform
and Regional FCDB (Gurinovic et al., 2016c). Besides this, FoodBasket, an online application for recipe calculation (EuroFIR,
2011) and FoodEXplorer (EuroFIR AISBL, 2013), a browsing engine for foods on EuroFIR food Platform, were created with an
aim to provide access to harmonized food composition data worldwide. FCDBs and contemporary food composition tools have
wide application in dietary assessments and present essential RI for capacity development in nutrition research (Gurinovic et al.,
2016c).
The International Network of Food Data Systems (INFOODS) supported by FAO, contributes to improvements of the quality,
availability, reliability, and use of food composition data on the global level (FAO, 2017). USDA National Nutrient Database for
Standard Reference contains data on 8789 food items and up to 150 food components (US Department of Agriculture, Agricultural
Research Service, 2016).
To harmonize the process of food classification, EFSA established a Food Ex2 coding system. This hierarchical classification
system categorizes foods in different categories that can be applied in dietary intake and exposure assessment studies (EFSA,
2014a). Many national food composition data sets in Europe are adjusted to EFSA Food Ex2 system.

Dietary Assessment ToolsdNutritional Tools Software

The collection and assessment of food consumption data and evaluation of food and nutrient intakes in NE requires harmonized
and standardized data collection, following standardized methods and protocols and the application of nutritional assessment
tools, which will reinforce the comparability of results (EFSA, 2009, 2014b). On the other side, nowadays, there is an expanding
spectrum of computer-, Internet-, telecommunication-based, and imaging solutions that use technological advances with the
capacity to overcome limitations of the conservative written format of dietary data collection. Innovative technology has great
potential to improve accuracy and feasibility, reduces the participants’ and researchers’ burden and cost, and enables consistent
and standardized data collection. However, there is still growing pressure on dietary intake assessment, especially in high tech-
nology tools, to improve the accuracy, reduce the cost of data collection and processing (Thompson et al., 2010), and provide
acceptable subjects and validation before they can replace the traditional methods for research purpose.
A recent review of innovative technologies for measuring diet for NE identified six main groups of innovative technologies
“personal digital assistant based,” “mobile phone based,” “interactive computer based,” “Web based’, “camera and tape recorder
based,” and “scan and sensor based.” The review evaluated their potential to improve, complement or replace food frequency and
other dietary questionnaires, food records, and 24-h dietary recalls (Cade, 2016). Compared with conventional food records,
Personal Digital Assistant and mobile phone devices seem to improve recording through the possibility for “real-time” recording
at eating events and opportunity to measure food and nutrient intake from large populations at low cost. Still, their validity to
estimate individual dietary intakes is considered low to moderate because of challenges in portion size estimation (Illner et al.,
2012).
To validate software-based dietary assessment tools, the EFSA projectdDietary Monitoring Tools for Risk Assessment identified and
evaluated data collection protocols and tools for capturing food consumption information, suitable for harmonized data collection
with two main methods: 24-h recalls and food records. Within the project, EFSA team conducted a thorough literature review of
available nutritional tools and their outputs, followed with a ring trial of 6–11 software from Europe. Interviewers/food record
keepers passed extensive training for application and assessment of the tools. After the ring trial, tool procedures and integrated
databases were analyzed, with similarities on a European level and country-specific particularities being identified. Harmonization
and automatization of tools were proposed to improve the comparability of the data collected in different national European
studies (Gavrieli et al., 2014). One of the major advantages of software applications in dietary assessment is that they automatically
calculate dietary intake reports from raw data. The quality of reports directly depends on the quality of FCDB used for the analysis.
Moreover, if they are derived from the software, their quality also depends on the quality of software application used in the survey.
Basic reports usually contain data on food group and nutrient intake stratified by gender and age groups as set in the software. More
sophisticated applications can provide reports on nutritional inadequacy or other specific issues.
 Nutritional Assessment 9

Even though automatic/software-derived outputs provide harmonized reporting, in certain occasions additional calculation and
data preprocessing is essential for high quality analysis.
Statistical analysis is of great importance for investigating the relationship between dietary habits, health, and lifestyle. All
methods based on interviews or questionnaires are inclined to errors and biases. There is no perfect measurement method of
real long-term dietary intake. Nevertheless, to minimize errors related to self-reporting substantial investment in software and hard-
ware development is required to satisfy study requirements, and the users have to be well-trained to use new technology before the
study (Illner et al., 2012; Ngo et al., 2009a).
In assessment of dietary habits and nutrient intake in certain population groups, two types of measurement errors appear:
random or systematic. A random within-person error can be, for example, the result of using only one or two 24-h recalls per subject.
Problem of over- and underestimation of dietary intake is usually depicted by existence of random between-person errors. The standard
deviation for such sample is usually inflated. Systematic within-person errors are errors that are randomly distributed among subjects
in the group. Systematic between-person errors and random between-person errors are more common in combination. For example, if
FCDB used for the evaluation of nutrient intake contains incorrect values for certain frequently consumed foods, all participants
will be affected in the same direction, but the degree of affection will depend on the individual consumed amount of that food.
Correction of the effects of measurement errors are described in details by Willett (2013).
Besides correction for measurement errors, other improvements of collected data could be performed to provide more accurate
nutritional assessment. One of the most important is adjusting for confounders. A confounder is defined as a variable that correlates
with outcome, which means that changes in the confounder affect the outcome variable. For example, education, occupation, or age
can affect dietary habits, etc. The most common strategy for adjustment of confounders is by using different regression models
(Hartel, 2013).
For analysis related to certain nutrient intake– and diet-related disease, the most important confounder is caloric intake, partic-
ularly when caloric intake is associated with disease. In that case, it is advisable to adjust nutrient intake for energy, i.e., to assess
nutrient intake independent of caloric intake. There are two ways to do it: (1) to calculate nutrient density, i.e., calculate nutrient
intake per 1000 kcal for each subject or (2) to adjust the nutrient intake by regression analysis using residuals as explained by Willet
(Willett and Stampfer, 1986).
More objective data reflecting intake of certain nutrients can be aggregated from analyses of biological markers. Biological
markers play an important role in nutritional research and can provide data that are less inclined to subjective errors and biases
than data from dietary questionnaires. For example, blood profile of carotenoids has been used to assess vegetable intake (Hartel,
2013).

Biochemical Indicators of Diet

A dietary biomarker can be loosely defined as a biochemical indicator of dietary intake/nutritional status (recent or long term), or it
may be an index of nutrient metabolism, or a marker of the biological consequences of dietary intake (Potischman and Freuden-
heim, 2003). Here the focus is on biomarkers as biochemical indicators representing the dietary intake of nutrients and foods
related to epidemiological studies and not as the measure of nutrient status to predict diseases. The nutrient concentration in blood
or tissues is determined by nutrient intake, absorption, transport and distribution, bioavailability, genetic determinants, metabo-
lism, and nutrient excretion. Nondietary determinants such as lifestyle and environment may also influence biomarkers concentra-
tion. Dietary biomarkers have different uses: as a surrogate for actual dietary intake indicators of consumption of foods and food
groups in studies of disease occurrence; as a measure of nutrient status and as biochemical markers to validate other forms of dietary
assessment (Jenab et al., 2009; Willet, 2013).
There are different classifications of biomarkers in nutritional studies: biomarkers of dietary exposure, nutritional status, and
health/disease. Another classification of biomarkers distinguishes between recovery, concentration, replacement, and predictive
(Corella and Ordovás, 2015; Jenab et al., 2009). Biomarkers of dietary exposure should be valid, reproducible, able to detect
changes in intake over time, and suitable for the general population (Hedrick et al., 2012). A variety of dietary biomarkers identified
through the analysis of correlations with dietary intake have been measured in epidemiologic studies. These biomarkers have been
measured in plasma or serum (e.g., carotenoids, fatty acids, vitamins, polyphenols, food contaminants, and enzymes), red blood
cells (e.g., fatty acids, carotenoids, and hemoglobin adducts), and to a lesser extent in urine (e.g., polyphenols, vitamins, inorganic
compounds, and amino acids), hair (EPA, DHA, animal protein), adipose tissue (fatty acids), nail, and skin (Hedrick et al., 2012;
Jenab et al., 2009). Most dietary biomarkers have been identified, based on our knowledge of food compositions, by using
hypothesis-driven approaches. The main application of dietary biomarkers is as a reference measurement to assess the validity
and accuracy of dietary assessment methods (Bingham, 2002).
Recent development of highly sensitive modern analytical instruments for metabolomics, the availability of metabolite data-
bases, and progress in bioinformatics have made major progress in identification of novel biomarkers of intake of fruits, vege-
tables, beverages, meats, or complex diets (Hooper et al., 2009; Scalbert et al., 2014). Careful selection of specific nutritional
biomarkers and application of adequate reference cut-off points for the target population is necessary. Nutritional bio-
markersdbiochemical, functional, or clinical indices of nutrient intake, status, or functional effect are important and necessary
to support evidence-based clinical guidance and effective health programs and policies related to health, nutrition, and food
(Combs et al., 2013).
10 Nutritional Assessment

Anthropometric Measurement and Body CompositiondNutritional Status Assessment

Anthropometry is a widely used, inexpensive, and noninvasive measure of the general nutritional status assessment at the individual
and/or population level. One group of anthropometric measurements assesses body size and the other determines body compo-
sition (WHO, 1995). A combination of raw measurements is used to derive the anthropometric indices [weight-for age, body
mass index (BMI), waist–hip circumference ratio etc.] which are used for the interpretation of nutritional status. Anthropometry
can be used for various purposes, depending on the anthropometric indicators selected.
Selection of the best anthropometric indicators depends on sensitivity and specificity, and it will vary according to the age of the
population, cut-off points used, the severity and the prevalence of the nutritional problems. It should be taken into account which
nutritional assessment system is used for screening, surveillance or intervention, and the objectives of the study (Gibson, 2005;
WHO, 1995).
To interpret and evaluate anthropometric data and identify individuals at risk of malnutrition it is recommended to use the local
or international reference data. For instance, child growth is internationally recognized as an important indicator of nutritional
status and health in populations. For children under 5 years, it is recommended to use the WHO Child Growth Standards
(length/height for age, weight for age, weight for length, weight for height and BMI for age, head circumference for age, mid
upper-arm circumference for age, subscapular skinfold for age, triceps skinfold for age) as the toolkit. Worldwide implementation
of these standards is still ongoing (De Onis et al., 2012).
The WHO growth reference data for 5- to 19-year-old children and adolescents are BMI for 5-to 19-year-old, height-for-age for 5-
to 19-year-old, and weight-for-age for 5- to 10-year-old children. They are proposed to be used and readily available tools that facil-
itate analysis of nutritional status.
BMI is a simple index of weight-for-height which is commonly used to classify underweight, overweight, and obese adults, at an
individual level and in epidemiological studies. It is defined as the weight in kilograms divided by the square of the height in meters
(kg m
2). Classification of the BMI and Global database is available online ([Link]
html; WHO, 1995, 2000).
Beside anthropometry to determine body composition, nowadays, several advanced and bioelectrical impedance analysis (BIA)
methods, hydro-densitometry (HD), air displacement plethysmography (ADP), dual-energy X-ray absorptiometry (DXA), magnetic
resonance imaging (MRI), and quantitative magnetic resonance (QMR) are used. However, these methods cannot replace tradi-
tional anthropometric measures in large epidemiologic studies. Even more, these anthropometric measurement and indices are
used in surveillance and monitoring at a national and international level to track global nutrition targets for 2025 (WHO, 2014).

Global Nutritional Status and International Developments

The Global Nutrition Report is the only independent and comprehensive annual review of the world’s nutrition state (IFPRI, 2016).
The Global Nutrition Report brings together global data with more than 80 indicators on nutritional status assessment, progress,
and intervention coverage on a national, regional, and global level. Nutrition profiles of 193 countries, 28 regions and subregions,
and the world are available as individual two-page documents and as raw data from [Link]. Included data
are consistent across countries, and standardized and harmonized methodology is used for indicator comparisons to estimate prog-
ress toward global nutrition targets (IFPRI, 2016; WHO, 2014).
Malnutrition is the most complex nutritional problem, as it manifests in many ways and forms from stunting, wasting, defi-
ciencies of essential vitamins and minerals, and insufficient calorie intake to child and adult overweight and obesity, noncommu-
nicable diseases (NCDs) (diabetes, heart diseases, and some cancers) caused by high consumption of high energy diet, harmful fats,
sugar, and salt. It affects one in three people worldwide, i.e., approximately three billion people in the world have low-quality diets,
and lack vital micronutrients (e.g., iron, zinc, vitamin A, folic acid, iodine) which affect their health and life expectancy. The prev-
alence rates of diet-related NCDs are increasing in every part of the world, but most rapidly in low- and middle-income countries.
The major changes in dietary patterns across the world, population growth, urbanization, and globalization are long-term
drivers for world “nutrition crisis.” It is on policy makers and governments to prioritize actions to reshape the global food system,
promote and provide high-quality diets for all.
Effective evidence-based policy making should be supported by appropriate RI-analytical tools, global dietary database of indi-
vidual food consumption data, nutritional status assessment, and indicators for monitoring and evaluating progress on a national,
regional, and global level. All these elements are required to understand the links between food systems and actual nutritional
outcomes, i.e., effects that specific interventions and policy actions have on diet quality and to determine how they could be
improved (Global Panel on Agriculture and Food Systems for Nutrition, 2016).
At the international level, all countries have agreed on targets for nutrition which are to reverse world’s nutrition trend and erad-
icate all forms of malnutrition by 2030 (IFPRI, 2016). The United Nations General Assembly in April 2016 proclaimed the UN
Decade of Action on Nutrition (2016–25). The resolution calls upon FAO and WHO to lead the implementation of the Decade
of Action on Nutrition in collaboration with the World Food Programme (WFP), the International Fund for Agricultural Develop-
ment (IFAD), and the United Nations Children’s Fund (UNICEF), involving coordination mechanisms such as the United Nations
System Standing Committee on Nutrition (UNSCN) and multistakeholder platforms, i.e., Committee on World Food Security
(CFS) (FAO, 2016). The UN Decade of Action on Nutrition is a commitment of Member States to undertake 10 years of sustained
 Nutritional Assessment 11

and coherent implementation of policies and programmes, following the Rome Declaration of Nutrition recommendations and
commitments of the ICN2 Framework for Action (FAO and WHO, 2015) and the 2030 Agenda for Sustainable Development
(UN, 2016). The decade will increase visibility of nutrition action at the highest level and ensure coordination, strengthen multi-
sectoral collaboration, create synergies, and measure progress toward sustainable food systems and food and nutrition security for
all. Specifically, it seeks to support and harmonize nutrition actions and investments by helping countries attain SMART commit-
ments by 2025 (FAO, 2016). The Global Nutrition Report, an independent accountability mechanism for progress and action on
nutrition, invites all actors to make SMART Commitments to Nutrition Actiondthat is, commitments that are S-specific, M-
measurable, A-achievable, R-relevant, and T-time bound. They are to facilitate tracking progress at the national and global level
and link global initiatives, Sustainable Development Goal (SDGs) and Global targets, to define priorities and connect country-
level activities to the 2030 agenda, aligning commitments with the ICN2 Framework for Action (Fanzo et al., 2016).
Post-2015 SDG targets (UNSCN, 2015) proposed, in addition to Global Targets, two new priority indicators for the SDG frame-
work. They are, abovementioned, minimum dietary diversity for women (FAO and FHI 360, 2016) and the policy on “percentage of
national budget allocated to nutrition.” The latter indicator measures the overall national government’s spending on direct nutrition
actions, as well as on nutrition-sensitive actions in related sectors.

Conclusion

This article summarizes the achievements in nutrition assessment methodologies and research to date, but also points out the limi-
tations and where there is still room for improvement in research tools, methodologies, multisectorial engagements, etc. The avail-
ability of internationally comparable data on nutrition outcomes is still limited and unharmonized, which hinders assessments and
comparisons of nutritional indicators across cultures, countries/regions, and time. Therefore, it is essential to invest more in food
and nutrition RI, i.e., harmonized methodologies for nutritional assessment at the global, regional, and country levels. In relation to
that, capacity developments in nutrition research, particularly human resource development, and organizational, institutional, and
legal framework development, are necessary to enable attaining proposed targets.

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Relevant Websites

[Link] – Dietary Reference Intakes, Institute of Medicine; Food and Nutrition Board.
[Link] – European Food Information Resource (EuroFIR).
[Link] – Eurostat.
14 Nutritional Assessment

[Link] – FAO Hunger Map.

[Link] – FAO STAT.
[Link] – Food Balance Sheets.
[Link] – Food Based Dietary Guidelines in the World.
[Link] – Food Security Indicators.
[Link] – Food Security Statistics.
[Link] – Global Nutrition Report.
[Link] – International Network of Food Data Systems (INFOODS). Databases and Tables.
[Link] – International Nutrient Databank Directory.
[Link] [Link] USDA National Nutrient Database for Standard Reference.
[Link] – WHO Body Mass Index (BMI) Classification.
[Link] – WHO Child Growth Standards for Children 5–18.
[Link] – WHO Child Growth Standards for Children Under 5.