Nutrition

Assessment

1
General Objectives
Assess the nutritional status of
individuals across the life span
using basic measurement tools.

2
 Specific Objectives
• Define the terms: nutrition screening, nutrition assessment, nutritional
status.
• Describe the four methods used in nutrition assessment – (A, B, C, D), their
appropriate uses, advantages and limitations.
• Perform common anthropometry measurements using appropriate
equipment and following standard procedures:
• Estimate body fat composition using BIA.
• Explain the principles behind the anthropometry measurements and BIA.
• Differentiate between these terms: body fat composition and distribution,
overweight and obesity, subcutaneous and visceral fat,
• android/upper body/abdominal and gynoid/lower body obesity, fat-free and
lean body mass
• Interpret data from the anthropometry measurements and BIA by comparing
against age, gender and population-specific references.
• Describe sophisticated techniques for assessing body composition
3
 Specific Objectives
• Interpret common biochemical indicators of nutritional status.
• Describe common clinical signs associated with poor nutritional status.
• Collect food intake data using common methods, the appropriate forms and
following standard procedures
• Analyze food intake data using food composition tables and nutrient
databases.
• Evaluate dietary intakes by comparing against appropriate references.
• Recommend the most appropriate methods of collecting nutrition
assessment data in a given scenario.
• Communicate intention and describe procedures clearly when obtaining
informed consent before performing nutrition assessment.
• Respect gender and cultural differences when performing data collection.
• Maintain confidentiality and safeguard data collected.

4
Nutrition/Health Status

Optimal Clinical/

?
health deficiency
disease

Good nutrition is critical for the well-being of an

individual.
The variety, quality, quantity, cost & accessibility
of food & the patterns of food consumption
profoundly affects health.
How do we measure one’s nutrition status?
5
 Optimal Nutrition Status

Nutrition status: the degree to which physiologic

nutrient needs are met for an individual.
6
 Nutrition Screening

?
Clinical/
Optimal
deficiency
health
disease

Nutrition screening: the initial process of identifying

individuals at risk so they can go for further/more
extensive nutrition assessment to determine need for
prevention/treatment.
To be cost-effective the process should be completed quickly
using simple assessment techniques to identify characteristics
known to be associated with nutrition problems.
7
MUST
The Malnutrition Universal
Screening Tool - a 5-step
screening tool to identify adults
who are malnourished, at risk of
malnutrition (undernutrition) or
obese.
A validated tool. For use in
hospitals, community or other
care settings; can be used by all
care workers.
Developed by the Malnutrition Advisory
Group of the British Association for
Parenteral & Enteral Nutrition (BAPEN).
Most commonly used screening tool in the
UK, also used in many other countries
worldwide. 8
http://www.bapen.org.uk. Feb14
 Nutrition Assessment
A more detailed evaluation & interpretation of
multiple indicators of dietary & nutrition-related health
status of individuals or populations who are / at risk of
MALNUTRITION
Purpose :
To determine nutritional status
To identify current and potential nutritional nutrition-related
medical complications
To monitor changes in nutritional status during certain policy
changes, fortification programs, nutrition intervention, or the
course of a chronic or acute illness

Malnutrition
• undernutrition - underweight, poor protein status, vitamin deficiency

• overnutrition - obesity, vitamin toxicity, hyperlipidemia

9
 Why Assess Nutrition Status?
For the individual:
to establish the nature & cause of the problem
 to provide appropriate treatment & prevent recurrence

For the community:

to establish the extent & distribution of the problem in the
community
to identify associated environmental factors
 to develop appropriate community-based intervention
programs (nutrition/health education, food
enrichment/fortification, supplementary feeding, etc)
10
 Nutrition Assessment Methods
4 different methods are used to collect data to assess an
individual’s nutrition status. Remember the mnemonic
‘ABCD’:
A nthropometric methods
B iochemical methods
C linical methods
D ietary methods
Can be used alone, but more effective when used in combination to provide a more
accurate picture of an individual’s nutrition status.
A group or series of measurements & observations preferred over a single11
determination.
 Assessment Methods for
Different Stages of Deficiency
STAGES OF DEFICIENCY ASSESSMENT METHOD

INADEQUATE FOOD INTAKE DIETARY

IMPAIRED ABSORPTION, UTILIZATION OR

TRANSPORTATION. INCREASED REQUIREMENT,
DESTRUCTION OR EXCRETION.

BIOCHEMICAL &
DECREASED TISSUE LEVELS ANTHROPOMETRY

ALTERED PHYSIOLOGICAL / BIOCHEMICAL

BIOCHEMICAL FUNCTIONS

SIGNS & SYMPTOMS OF DEFICIENCY CLINICAL

Sequence of events in prolonged nutrition inadequacy & appropriate assessment methods
12
 A-B-C-D Methods
Anthropometry = the measurement of the physical
dimensions & gross composition of the body e.g.
height/length, weight, head circumference & the use of
skinfold thickness, MRI, BIA to estimate % of fat & lean
tissue in the body. The results are then compared with
standard values / data obtained from measurements of
large numbers of subjects.

Biochemical = the measurement of a nutrient or

its metabolite in blood, feces or urine or measuring
a variety of other components in blood & other
tissues that have a relationship to nutritional status
e.g. serum hemoglobin, 24-hr urinary sodium
excretion.
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 A-B-C-D Methods
Clinical = a qualified examiner reviews the subject’s
personal/family history, medical & health history &
conducts a physical examination to detect signs &
symptoms of malnutrition e.g. enlargement of the
salivary glands, loss of tooth enamel & calloused
knuckles are commonly seen in patients with eating
disorders who make themselves vomit.

Dietary = collecting data to measure the quantity of

food & beverages consumed during the course of one
to several days, or assessing the pattern of food use
during the previous several months e.g. 24-hr recall,
food record. Numerous software programs allow
analysis of the nutrient composition of dietary intake.
14
A-B-C-D Topic Focus
In this topic, we will be looking at A-B-C-D
measurements for adults.
A-B-C-D measurements & issues specific to a particular
stage of the life span will be discussed in the relevant
topics. However fundamental principles are covered here.

15
Anthropometry Assessment

16
 Common Anthropometric
Measurements For Adults
Physical dimensions
Stature/Standing height
Weight
Body composition
Measurements of fat mass
skinfold thickness
Bioelectrical Impedance Analysis BIA
Measurements of fat-free mass (FFM)/muscle mass status
mid-arm muscle area MAMA
Assessing fat distribution
Waist circumference

17
 Uses of Anthropometric
Measurements in Adults
The measurement of weight & stature allows the tracking of
weight changes & the calculation of the Body Mass Index (BMI) to
evaluate one’s nutritional status:
obesity due to overnutrition
emaciation due to undernutrition
Measurement of body fat mass/ fat-free mass allows us to
assess the health implications of depleted/excessive fat & protein
reserves.
Determining body fat distribution helps us to
assess risk for chronic health conditions related to excess abdominal
fat.
These measurements also allow us to monitor the effects of
nutritional intervention.
18
 Weight Status & Standards
John lost 10 kg over the pastThese figures
3 months. Is his current alone don’t
weight status acceptable? make much
sense.
Jim gained 1 kg over the past How do we
2 months & is now 58 kg. Is assess one’s
his weight status acceptable? weight status
more
Standards & references are used as a basis objectively?
for comparison:
these should be validated for the
population
may be age, gender & population
specific
e.g. not correct to compare Jim’s weight
with Sally’s (female) or little Sue’s (child)
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 Overweight & Obese
Overweight
Body weight greater than some reference point of acceptable weight
in relation to height.
It is possible for very muscular people to be overweight because
of high muscle mass.
But in most cases people are overweight because their body has
excess amount of fat.
Obesity
Excess amount of body fat in relation to lean body mass
To determine the relative amounts of fat & lean tissue (body
composition analysis) requires certain difficult techniques. It
cannot be done by simply measuring weight & height to calculate
BMI.
But because it is easier to calculate BMI, we use/define BMI > 25 as
overweight & BMI > 30 as obese. 20
The Body Mass Index
Weight (in kg)
BMI =
Height2 (in m2)
For adults >18 yrs
but NOT for pregnant/lactating ♀
Has a high correlation with estimates of body fatness .
a convenient & reliable indicator of obesity
measurements are quick, noninvasive & precise
Does not distinguish between weight associated with muscle
or body fat  elevated BMI may result from excessive
adiposity, muscularity or edema.
Does not give an indication about the distribution of body fat
 abdominal fat is a risk factor for disease.
Besides BMI, include other measures of adiposity like skinfold thickness or
waist circumference as a surrogate estimate of abdominal fat.
21
 BMI & Disease Risk
BMI has been used to
assess disease risk among
RISK INCREASES AS BMI

EXTREMELY
adults.

HIGH RISK
It has a U-curve relationship

VERY HIGH RISK

with all cause mortality
DECLINES

Leanest & obese individuals

have increased death risk.
MODERATE RISK

HIGH RISK

It has a J-curve relationship

MINIMAL RISK
LOW RISK
LOW RISK

with cardiovascular
disease risk
MORTALITY

Increasing BMI is
associated with increased
risk of cardiovascular
BODY MASS complications, including
15 20 25 30 35 40 INDEX
hypertension, type 2
diabetes, stroke. 22
 BMI & Disease Risk
Classification BMI (WHO cut-off values, BMI (Asian cut Disease risk
international classification) off values)
Underweight <18.5 <18.5

Normal 18.5 – 24.9 18.5 – 22.9

Overweight 25 – 29.9 23 – 27.4 Increased

Obesity class I 30 – 34.9 27.5 – 32.4 High

Obesity class II 35 – 39.9 32.5 – 37.4 Very high

Obesity class III >40 >37.5 Extremely high

At the same BMI, ♀ tend to have > body fat than ♂.

At the same BMI, older people tend to have > body fat
than younger adults.
At the same BMI, Asians tend to have > abdominal fat &
increased risk of diabetes & cardiovascular disease.
The Asian values are identified public health action
points to manage the increased risk for our population.23
 Cadaveric Studies

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 BODY COMPOSITION
• To measure the amount and distribution of fat and lean body mass

Cadaveric Studies

The GOLD standard for body composition analysis.

Only by analysing cadavers can direct measurement of human
body composition be made.
The most comprehensive was the Brussels Cadaver Analysis
Study involving more than 30 cadavers (1979-1983).
The skin & subcutaneous tissue were cut open & carefully measured so that skinfold
measurements could be directly compared with measurements of skin & subcutaneous
adipose tissue thickness.
The skin, adipose tissue, skeletal muscle, bone & viscera were dissected out & weighed in air
& under water to determine density of the organs & tissues.
A major assumption was that anthropometric measures & body
composition in cadavers are similar to those of living subjects.

25
Body Composition - Models
Two-compartment model
The body consists of two chemically distinct Fat mass
compartments:
Adipose tissue
fat mass
fat-free mass (muscle, water, bone & other Fat-free mass
tissues devoid of fat) Skeletal muscle
+
Body composition is defined as the ratio of fat
Non-skeletal
to fat-free mass. muscle
Assumes constant lean mass characteristics +
for a given age & gender (problematic in Soft lean tissue
individuals with deranged body composition +
or hydration). Skeleton
These measurements – skinfold thickness, +
limb (i.e mid arm circumference) Water
circumferences, underwater weighing are
based on this model.
26
Body Composition - Models
2 compartment 3 compartment 4 compartment
Fat mass Fat mass Fat mass
Adipose tissue Adipose tissue Adipose tissue

Total body water Total body water

Fat-free mass
Water
Skeletal muscle Water
+
Non-skeletal Bone mineral mass
muscle
Fat-free dry mass
Skeleton
+ Skeletal muscle
Soft lean tissue +
+ Non-skeletal Residual mass
Skeleton muscle Skeletal muscle
+ + +
Water Soft lean tissue Non-skeletal
+ muscle
Skeleton +
Soft lean tissue27
 Body Composition - Models
Four-compartment model
Multi-compartment models are considered
sufficiently accurate to act as reference, against
which other methods should be evaluated.

Measurements by
Bioelectrical impedance analysis BIA
Computed tomography CT
Dual energy X–ray absorptiometry DEXA
Magnetic resonance imaging MRI
are based on this model.

There are also BIA

equations based on two
compartment models 28
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 Measurements Of Fat Mass
Skinfold thickness
Measures compressed
double fold of fat & skin
Uses skinfold calipers
Indirectly estimates the
size of subcutaneous fat
storage
& indirectly estimates
total body fat as:
1/3 Total Body Fat =
Subcutaneous Fat

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http://www.harpenden-skinfold.com Mar14
 Skinfold Measurements
Thickness of subcutaneous adipose
tissue varies at different sites – thus,
it is best to measure at multiple
sites.
Several prediction equations have
been developed to calculate % body
fat using sum of skinfold
measurements.
Durnin & Womersley Equations
Mitchell. (2003). Nutrition across the life span
use the sum of four skinfold sites –
biceps, triceps, subscapular &
suprailiac
The % body fat is then compared
30
with normal body fat ranges.
 Body Fat Ranges
Classification Males (> 18 yr) Females (> 18 yr)
Unhealthy range – too low < 5% < 8%

Acceptable range – lower end 6 – 15% 9 – 23%

Acceptable range – upper end 16 – 24% 24 – 31%

Unhealthy range – too high > 25% > 32%

Nieman DC. (2003)

Note:
Limitations: The triceps is the most
Poor accuracy & precision commonly measured
site because of its easy
especially in obese individuals & accessibility.
when used by untrained But single site
personnel. measurements cannot
be used to estimate %
Although there are generalized body fat &
equations, population-specific must be interpreted
with caution.
equations are lacking.
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 Hydrodensitometry (Underwater
Weighing)
Based on Archimedes’ principle :
volume of object submerged in
water = volume of water the object
displaces.
If mass & volume are known, a
formula allows calculation of % body
fat.
Not practical for testing large number
of subjects, infirm subjects
Whitney & Rolfes. (2005). Understanding Nutrition. Need specialized bulky equipment,
trained personnel
Subject must be willing &
cooperative
Assumes constant density of fat &
32
fat-free mass
 Air Displacement
Plethysmography

BOD POD

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http://ybefit.byu.edu, https://en.Wikipedia.org May16
 Air Displacement
Plethysmography
Same principle as underwater
weighing: when subject enters a
chamber with a known volume,
the subject’s body volume = the
reduction in chamber volume.
Calculations of % body fat & fat-
free mass.
Fairly quick & easy, even suitable
for elderly & infirm
Need specialized equipment,
trained personnel
Assumes constant density of fat
BOD POD commercialized by Life
Measurement Inc ~$37,000. & fat-free mass
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http://calorielab.com Mar14
 Bioelectrical Impedance
Analysis (BIA)
When an electrical current is passed through the body,
electrolytes dissolved in water (largely found in fat-free
tissues) conduct electricity
fat tissues oppose the current  impedance
The body’s resistance to the current is measured by the
instrument .
Analysis yields values for total body water (TBW)
Fat-free mass & % body fat estimated from the value of TBW
using regression equations – recent equations are more
accurate.
Assumes subject is normally hydrated – dehydration will result in
overestimation of fat mass.
Safe, convenient, portable, rapid & noninvasive; cost of
instrument varies. 35
 Body Fat in Reference ♂ & ♀
Fat location Reference Male (kg) Reference Female (kg) Body fat
Essential fat (bone marrow, 2.1 4.9 content is the
CNS, mammary glands, etc) most variable
Storage fat 8.2 10.4 component of
• Subcutaneous • 3.1 • 5.1 the body.
• Intermuscular • 3.3 • 3.5 Sensitive to
• Intramuscular • 0.8 • 0.6
acute
malnutrition,
• Fat of thoracic & abdominal
cavity
• 1.0 • 1.2 can be used as
indirect
Total fat 10.5 15.3
estimate of
Body weight 70.0 56.8 energy
% fat 14.7 26.9 balance.
There is a tendency for increased fat deposition & a reduction in
muscle mass with aging. Such changes in body composition
are not evident in weight measurements alone but can be
assessed by determining body fat or fat-free mass. 36
 Subcutaneous vs
Visceral Fat
Subcutaneous fat cells
main function is energy
storage
Visceral fat cells
are metabolically active
impact fasting glucose, serum
triglyceride & cholesterol
levels
are dangerous because they
contribute to inflammation,
atherosclerosis, dyslipidemia
& hypertension
is considered a pathogenic fat
depot
37
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 Assessment Of Fat Distribution
The site of fat storage (fat distribution) is a more
important risk factor for morbidity & mortality than is
obesity per se.
Especially excessive fat in the abdominal
area
Made up of subcutaneous & visceral fats
Total abdominal fat can be accurately
measured using MRI/CT scan but these are
expensive & not readily available.
2 simple measurements are waist-to-hip ratio
(WHR) & waist circumference (WC).

38
http://www.mohrresults.com Mar14
http://www.medicaldude.com Mar14

WHR
Waist -to-hip ratio (WHR)
= waist circumference
hip circumference
In ♀ WHR > 0.8 or in ♂ WHR >
1.0 indicates
upper body/abdominal/
android/central obesity
‘apple shape’
increased risk of type 2
diabetes, CVD

With weight loss, & fat loss from both waist & hip
regions, WHR is not a good index for tracking beneficial
39
reductions in abdominal fat.
 WC
Waist circumference is the recommended
measurement to assess abdominal obesity.

Easy & practical to use

Positively correlated with amount of fat in the abdomen, a
good indicator of abdominal visceral obesity.
Valuable to assess the health risks of persons with
normal weight /overweight in terms of BMI
In Asians WC may be a better predictor of disease risk than BMI, In
older person, WC is more valuable in estimating obesity-related
disease risks
Compared to ethnic & gender specific cut-off values
WC Cut-off Values (South Male Female
Asians) For Abdominal
Obesity > 90 cm > 80 cm 40
http://www.myvmc.com Mar14
 Body Composition – Muscle
Mass
Body Composition Analysis for Janet Terminology:
Weight : 63.3 kg Body weight =
Fat-free Mass Fat Mass fat mass + fat-free
53.1 kg 10.2 kg
mass
Soft Lean Mass Minerals
49.1 kg 4.0 kg Lean body mass =
Body water Protein fat-free mass +
38.2 kg 10.9 kg
essential fats
ICW ECW
23.4 kg 14.8 kg

Fat-free mass is made up of water, minerals & proteins,

with most of the protein being stored in the muscle.
Assessment of muscle mass provides an index of the
protein reserve in the body.
Mid arm circumference (MAC) & mid arm muscle area
(MAMA) correlate with measures of total muscle mass.
41
 MAC & MAMA
MAC = circumference of the upper arm at the
triceps skinfold site
Indicator of muscle & subcutaneous adipose
tissue
MAMA is estimated from MAC by:
MAMA = {MAC – (π x TSF)}2
4π
Size of arm muscle changes with growth &
Assumptions: nutritional status.
Limbs are cylindrical
the changes in MAMA is greater than MAC
Fat is evenly
distributed about its thus MAMA is the preferred index of total
circumference body muscle mass as these changes may not
Skinfold compressibility be so easily detected by MAC
is a constant

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 MAMA – Percentile Charts, ♂
Age Mean n Mean SD Percentiles
Group Age
5th 10th 15th 25th 50th 75th 85th 90th 95th
20.0 – 24.96 1564 64.5 13.4 45.2 48.8 51.4 55.4 63.8 73.4 79.1 83.2 89.6
29.9
30.0 – 34.72 1405 66.6 13.5 48.7 52.4 55.2 59.4 68.1 78.1 84.0 88.3 95.0
39.9
40.0 – 44.35 1158 69.9 12.8 49.8 53.5 56.2 60.5 69.1 79.0 84.8 89.0 95.6
49.9
50.0 – 54.89 815 67.4 12.6 49.7 53.3 55.8 59.7 67.8 76.9 82.3 86.1 92.1
59.9
60.0 – 64.83 1122 64.8 12.4 45.8 50.2 52.7 56.5 64.4 73.3 78.6 82.4 88.3
69.9
Frisancho, A.R. (2008)

Percentiles
The set of data is divided into 100 equal parts & arranged in
rank order from lowest to highest
There is no zero percentile rank – the lowest score is
at the first percentile
There is no 100th percentile – the highest score is at
the 99th percentile
Used to determine the relative standing/position of an 43
individual in a population
 Evaluating Anthropometry Data & Indices
Reference population

Reference sample group

Determine reference values,

reference distribution

Calculate reference limits,

define reference intervals
H0 sampling H1 sampling
distribution distribution

β α

Do Not Reject Ho 44
Reject Ho critical value
 Evaluating Anthropometry Data & Indices

Cut-off points
are decided based on the relationship
between nutritional assessment indices & low
body stores, functional impairment or clinical
signs of deficiency.
may vary depending on conditions e.g. for
pregnancy or elderly
sometimes more than 1 cut-off point is
available e.g. different cut-offs for BMI

45
 Sophisticated Methodologies
Computed Tomography (CT Scan)
Due to differing density, there are differences in the transmission
of an X-Ray beam through body tissues
A computer reconstructs a subject’s cross-sectional anatomy
based on mathematical equations
Provides a highly detailed cross-sectional images of the body
can differentiate between different types of lean tissue –
skeletal muscle, visceral mass, organ mass
can differentiate subcutaneous & visceral fat
Limitations
Problems of radiation exposure – repeat scans, pregnant ♀
High cost
Limited availability
Use limited to research applications
46
 Sophisticated Methodologies
Magnetic Resonance Imaging
The subject is placed in a strong magnetic field
Some of the nuclei in the body attempt to align themselves relative to
the applied field
When the field is turned off, the nuclei return to their original state,
emitting a signal which can be picked up by the system
The data are then processed by a computer to generate an image
Can give accurate & precise measurements of muscle & adipose
tissue – differentiate between visceral & subcutaneous fat
MRI is the method of choice for calibration of field methods
designed to measure body fat & skeletal muscle in vivo
Advantages - non invasive, uses no ionizing radiation, produces high
quality images, allows amount & distribution of body fat to be studied,
can be used to study the metabolic activity of tissues or organs
Drawback - restricted availability & high cost 47
 Sophisticated Methodologies
Dual-energy X-Ray Absorptiometry (DEXA)
Originally developed to assess bone mineral density
Can be used to assess body composition
Dual-energy X-Ray source passes X-rays through the body
relative absorption of the two energies is measured
the data are then processed by a computer to generate an
image
New breakthroughs allow measurement of visceral fat
Advantages - fast,
safe, low dose
radiation exposure
Drawback -
restricted
availability & high
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 Common Anthropometry Measurements:
Advantages
Referring to simple field methods, not sophisticated ones
Procedure
Simple & quick to do, data easily obtained
Safe, non-invasive
Low respondent burden
Suitable for large sample sizes
Equipment – portable, inexpensive, easily obtainable
Minimal training for personnel
Data can be precise & accurate if trained personnel & standardized
techniques are used
Can identify mild to moderate states of malnutrition (as well as
severe)
Can evaluate changes in nutritional status over time – retrospective
information is generated on past long term nutritional history 49
 Common Anthropometry Measurements:
Limitations
Referring to simple field methods, not sophisticated ones
 Poor accuracy & precision – measurement errors, did not adhere
to proper techniques, no proper calibration of equipment,
between-examiner differences
 Based on many assumptions – may not always hold true, source
of error
 Insensitive – cannot detect small changes/over short periods of
time
 Unable to distinguish between specific nutrient deficiencies,
specific body composition components
 Lack of appropriate standards/population references to compare
results – error magnified by use of prediction equations not
derived from comparable population

50
Biochemical Assessment

51
 Biochemical Assessment
Laboratory measurements
Done on body tissues, usually blood or urine, cells, breast milk,
saliva, sweat, hair, amniotic fluid.
Clinical laboratories use automated analyzers capable of
performing thousands of tests/hr, print out the test results
including reference ranges & flag abnormal results.
Measures
Level of nutrients or their metabolites
Substances that contain the nutrient (e.g. Hb for iron)
Enzymes that require the nutrient
Substances that result from abnormal metabolism from a
deficiency of the nutrient
52
 Biochemical Assessment: Advantages
 Provide the objective & quantitative data on nutritional
status.
 Can detect sub-clinical deficiency (early signs of
malnutrition) before anthropometric measures are changed
or clinical signs/symptoms of a deficiency disease appear.
 Sufficiently accurate to be use as a validation method in
dietary surveys – to determine if respondents are
over/underreporting what they eat e.g. compare reported
protein intake with 24hr urinary nitrogen excretion; compare
reported sodium intake with 24hr urinary sodium excretion.

53
 Biochemical Assessment: Limitations

 No single test or group of tests is by itself sufficient to

monitor nutritional status
 Data must be interpreted correctly – influenced by
non-nutritional factors like disease, inflammation,
trauma, medication use, hormonal status, hydration
status. See example on serum calcium, Hb
 Subject to sampling error e.g. contamination,
hemolysis, recent dietary intakes, diurnal variations –
thus need to collect & handle under standardized conditions e.g.
fasting state.
 Need trained personnel & accredited facilities

54
 Biochemical Assessment: Limitations -
Explanation
Acute Phase Response = systemic & metabolic changes due to
release of acute phase proteins e.g. C-reactive protein (CRP) in
response to inflammation
CRP albumin  (production by the liver drops, in part to allow
synthesis of acute phase proteins)

Albumin transports Ca, Mg, Zn, Se, lipids, FFA

The level of these are severely affected by acute or
chronic inflammation
Check CRP values
During acute phase response, malnutrition might
be better diagnosed by anthropometry/body
composition methods
55
 Biochemical Assessment – Calcium Status

Serum Ca DOES NOT reflect overall nutrient status of the

individual or whether the body as a whole is in a state of
nutrient excess or depletion. Because of homeostatic
control, it remains constant under most conditions.

Activation of vitamin
D
Kidneys reabsorb
Ca
Parathyroid hormone

Bones, where 99% of

Increased Ca
Ca is stored, release
absorption from the
Ca
GI

SERUM CALCIUM
Ca level rises Ca level falls
8.5 – 10.2 mg/dL 56
 Biochemical Assessment – Iron Status
Stage 1 Stage 2 Stage 3
Iron depletion Iron deficiency Iron deficiency anemia
Iron stores

Erythrocyte
protoporphyrin
Hb level

Serum ferritin
(main storage form of iron)

Transferrin
(iron transport protein)

Hb, often used in screening, is not a good indicator at Stage 1,

unlike ferritin. At Stage 2, when adverse physiological
consequences begin to occur, serum transferrin, transferrin
saturation (% transferrin saturated with iron) & erythrocyte
protoporphyrin (precursor of heme) are better indicators.
57
 Biochemical Assessment – Protein Status
SOMATIC PROTEIN Creatine content of muscle is assumed to
mainly in the skeletal be constant. Catabolised to creatinine &
muscles excreted via urine. Urinary creatinine
clearance is used as an index of muscle
BODY
mass but affected by renal function,
PROTEIN
physical activity, trauma, infections.
VISCERAL PROTEIN within
organs (liver, kidney,
pancreas, heart, etc) blood Serum albumin has a large pool
cells, serum protein size & long half life of 14-20 days. It is
NOT sensitive to short term changes in
protein status. During malnutrition,
levels may remain due to reduction in
Prealbumin, a transport protein, has a albumin catabolism & movement of
small pool size & short half life of 2-3 extravascular albumin to the blood.
days. More sensitive indicator of recent More useful for monitoring long term
dietary intakes, responds rapidly to changes. Affected by infection, liver
changes in protein status. Affected by function, etc
infection, liver function, etc 58
Biochemical Assessment – Typical Lab
Report

There are different

types of blood glucose
tests:
Fasting blood sugar
(FBS)
2-hour postprandial
blood sugar (2HPP)
Random blood sugar
(RBS)
Oral glucose tolerance
test (OGTT)
Glycated Hb A1c

59
Clinical Assessment

60
 Clinical Assesment
Consists of a routine medical history & a
nutrition-focused physical examination done
by a qualified medical examiner
 to detect signs & symptoms associated
with malnutrition.
Most useful during advanced stages of
nutritional depletion, usually when overt
signs already present.
Medical history can be obtained from medical
records or interview with patients/family
members/caregivers.

61
 Clinical Signs Associated With Malnutrition
- Examples
Body system/normal Clinical Finding Possible
appearance deficiency
Hair – shiny, firm in the Lack of natural shine, dull & dry, PEM
scalp sparse, loss of color, pluckable

Eyes – bright, clear, Membranes pale, night Iron, vit A,

shiny, no sores at blindness, Bitot’s spots, redness riboflavin,
corners, membranes & fissuring of eyelid corners, B6
pink & moist dryness of membranes, cornea
dull & soft

Tongue – deep reddish Swelling, scarlet & raw, purplish B6, niacin,
in appearance, surface color, smooth, swollen sores iron, B12,
papillae present folate,
riboflavin
62
 Clinical Assessment:
ADVANTAGES
 Quick to perform (i.e blood pressure taking)
 Relatively inexpensive, especially for large sample sizes
 Noninvasive

LIMITATIONS
 Non-specificity of the physical signs
 some may be produced by > 1 nutrient deficiency or by non-nutritional
factors (e.g. cheilosis from B2, B3, B6, iron; glossitis from B2, B3, B12,
folate)
 Multiple physical signs exhibited
 may exhibit multiple physical signs due to co-existing nutrient
deficiencies  confusing
 Examiner inconsistencies  adequate training
 Unable to detect deficiencies at early stages

63
 Subjective Global Assessment
A clinical technique of nutrition assessment based
exclusively on a carefully performed medical history &
physical examination.
Based on the features, physicians assign a rank
Well nourished
Moderate or suspected malnutrition
Severe malnutrition
Limitations:
Subjective, reproducibility depends on training &
experience of examiner.
Nevertheless, regarded as a reliable & efficient method to
assess nutritional status at the bedside.
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HISTORY
1. WEIGHT CHANGES
Maximum body weight _____ Weight 6 months ago _____ Current weight _____
Overall weight loss in past 6 months ______
% weight loss in past 6 months ______
Change in 2 past weeks: ___increase ___no change ___decrease
2. DIETARY HABITS (relative to normal)
___No change
___Change Duration ___weeks
Type ___increased intake ___suboptimal solid diet ___full liquid diet
___IV or hypocaloric liquids ___starvation
3. GASTROINTESTINAL SYMPTOMS (lasting > 2 weeks)
___None
___Nausea ___Vomiting ___Diarrhea ___Anorexia
4. FUNCTIONAL CAPACITY
___No dysfunction
___Dysfunction Duration ___weeks
Type ___works suboptimally ___ambulatory ___bedridden
PHYSICAL EXAMINATION (for each trait specify 0=normal, 1+=mild, 2+=moderate, 3+=severe)
___Loss of subcutaneous fat (shoulders, triceps, chest, hands)
___Muscle wasting (quadriceps, deltoids)
___Ankle edema
___Ascites
SUBJECTIVE GLOBAL ASSESSMENT RATING
___A = well-nourished
___B = moderately (or suspected of being) malnourished
___C = severely malnourished
65
Dietary Assessment

66
 Dietary Assessment - Reasons
Determining an individual or a population’s usual
dietary intake is important
to identify potential dietary inadequacies/excesses
to provide data on intake of nutrients or specific
classes of food
to investigate the relationship between diet &
diseases
to formulate policies for disease reduction & health
promotion

67
 Methods Of Dietary Assessment

24-hour recall
Food record or diary
Estimated food records
Weighed food records

Food Frequency
Questionnaire (FFQ)
Diet history

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24-hour Recall
Conducted in 4 steps using a standardised protocol.
1. Obtain list of of foods & drinks consumed in the previous
24 hr/preceding day.
2. Obtain detailed description of foods &
drinks consumed – cooking methods, brand names, details of
mixed dishes
3. Estimation of amounts of foods &
drinks consumed in household measures – food models,
calibrated utensils, photographs
4. Review of interview data
Nutrient intakes is then calculated using food
composition data.

69
24-hour Recall
A single 24hr recall may not be sufficient to describe
an individual’s food intake.
Multiple 24hr recalls can be obtained –
nonconsecutive days, include weekdays & weekends.
Nevertheless, single 24hr recalls on different
individuals is more feasible & can give a valid
measure of the intake of a large group or population.

70
 24-hour Recall
Success depends on:
respondent’s memory
ability of the respondent to
convey accurate estimates
of portion size consumed
degree of motivation of the
respondent
persistence of the
interviewer

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 24-hour Recall: Advantages
 Quick & easy to use
 Low respondent burden, high compliance
 Requires only short term memory
 Low cost to administer
 Its administration does not alter the usual diet
 Ideal for illiterate respondents
 Can provide detailed information on types of food consumed
 Can be used for large groups

72
 24-hour Recall: Limitations
 Reliance on memory  difficult for the elderly & young
children.
 Estimation errors of food portion sizes occur (can be reduced by
using graduated food models).
 One recall is seldom representative of a person’s usual intake.
 Over-report intakes at low levels, foods considered to be
healthful & under-report intakes at high levels, binge eating,
foods considered to be unhealthful. Drinks, sauces, dressings
often not reported.
 Withold/alter information because of embarrassment/want to
impress interviewer.

73
Food Record / Diary
The respondent records, at the time of consumption, the
identity & details of all foods & liquids consumed in
household measures.
Period of time usually 3 - 7 days, include weekdays &
weekends. Includes information on time, place & situation
of eating.
Respondent estimates/weighs the amount of food &
liquids consumed.
Nutrient intakes is then calculated using food composition
data.

74
 Food Record / Diary: Estimated
Estimating food portion sizes can be done via
standard household measuring cups, spoons, ruler
colour photographs
for some food items e.g. eggs, apples – simply
counted

Puts less burden on respondents compared to

weighed method, thus better compliance.
Researchers quantify these measures by volume
& weight for analysis.
75
 Food Record / Diary: Weighed
Respondents weigh the amount of food & liquids
consumed on a food scale, including leftovers.
Meals eaten out – researcher can buy duplicate portion to
obtain weight, or phone restaurant for information.
Considered more accurate than the estimated record, thus
the preferred method when correlation of dietary intakes
with lab parameters are involved. More reproducible.
Higher respondent burden, thus less compliance.

76
 Food Record / Diary:
Advantages
 Does not depend on memory
 Provides detailed intake data
 Provides data about eating
habits
 Multiple-day data is more
representative of usual
intake

77
 Food Record / Diary:
Limitations
 Requires a high degree of co-operation
 High respondent burden  low response
rates/compliance
 Subject must be literate
 Time-consuming to obtain data
 Analysis is labor-intensive & expensive
 Act of recording may alter diet – respondents
change their usual eating pattern to simplify the
process/impress interviewer.
78
FFQ
Assesses energy/nutrient intake by determining how
frequently a person consumes a limited number of foods that
are major sources of the nutrient in question.
Questionnaires consist of a list of ~ 150 individual foods or
food groups that are important contributors to the
population’s intake of energy & nutrients.
Respondents indicate how many times a
day/week/month/year they consume the foods.
May be non-quantitative, semi-quantitative or quantitative
A computer program converts portion sizes & frequency of
intakes of a particular food to derive energy/nutrient intake
values.

79
Food Items Average use during the past year
< 1x/month 1-3 x/month 1-4 x/week 5-7x/week 2-4x/day > 5x/day
Coffee
Dark bread
Ice cream

Food Items Average use during the past year

< 1x 1-3x 1x 2-4x 5-6x 1x 2-3x 4-5x > 6x
/month /month /week /week /week /day /day /day /day
Coffee (1 cup)
Dark bread (1 slice)
Ice cream (1/2 cup)

Food Items Medium Your serving size How often?

serving S M L Day Week Month Year Never

Coffee 1 cup

Dark bread 1 slice

½ cup 80
Ice cream
 Estimate the amount of food / drink taken
fro FFQ
Food item (Milk as a Portion
Drink)
How often do you Per day Per week Per month Rarely /
have the never
following
Full cream milk 250 ml 1
(fresh, UHT, powder) (1 glass)
Low fat milk (fresh, 250 ml 4
UHT, powder) (1 glass)
Skimmmed milk 250 ml X
(fresh, UHT, powder) (1 glass)

For e,g low fat milk: 250 ml x 4 = 1000ml / 7 days

on average daily 143 ml of low fat milk

81
 FFQ
FFQs known as screeners have been developed to
assess intake of calcium, dietary fiber, fruits &
vegetable & % energy from fat.
Useful in situations that do not require assessment of
the total diet or quantitative accuracy in dietary
estimates or when financial resources are limited.
Commonly used in epidemiologic research
investigating the relationship between diet &
conditions such as cancer or CVD.
NOT considered a substitute for more definitive
approaches to measure dietary intakes such as
multiple 24 hr recalls/weighed food records.

82
 FFQ: Advantages
 Can be self-administered
 Machine readable/optically scanned & directly downloaded into a
computer for analysis  saves time & money
 Modest demand on respondents
 Inexpensive for large sample sizes
 More representative of usual intake than a few days of diet records
 provides data on a respondent’s intake of foods,
including those infrequently consumed, over a longer period
of time, usually over the course of a year
Considered by some to be the method of choice for research on diet-
disease relationships, especially in large scale studies.

83
 FFQ: Limitations
May not represent usual foods or portion sizes chosen by
respondents
 Must include foods commonly consumed by a particular group e.g.
ethnic foods
 Need to update food list with new products entering the market
Does not provide good data about how much food or
beverage a person consumes
Intake data can be compromised when multiple foods are
grouped with single listings
Depends on ability of subject to describe diet
Short questionnaires easy to administer but lack
comprehensiveness; long questionnaires are tedious to
complete

84
Diet History
A detailed dietary assessment conducted by a trained
nutritionist.
Burke’s original method involved these steps:
24 hr recall - actual intake & general information on the
overall eating pattern over an extended period e.g. past
month or year. Collect related info about health habits –
smoking, exercise, appetite, use of supplements, food
dislikes, intolerances, weight history, etc
Cross check on data with specific questions about
preferences/habits with a FFQ
Respondent is required to complete a 3-day food record
(many omit this step)

85
 Diet History: Advantages
Can assess usual nutrient intake
Can detect seasonal changes
Data on all nutrients can be obtained
Correlates well with biochemical
measures
Can be used with subjects who are
not literate
Its administration does not alter the
usual diet

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 Diet History: Limitations
 Lengthy interview ~ 1-2 hr
 Requires trained interviewers
 Difficult & expensive to
analyse, not applicable in large
scale population studies
 Tends to over-estimate nutrient intake
 Requires respondent’s co-operation, with the ability
to recall usual diet (not suitable for those < 14 or >
80)
 This method is difficult for those who highly
variable food habits 87
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Plate wastage
• Commonly used in hospital caterings / childcare settings
• Can be used among groups that are illiterate / loss of hearing / elderly
where other means of diet assessment is less feasible
• Interviewer must know what food is served and how much
• Must be present before and after each meal consumed, for the whole
day
• Food is weighed before and after consumed
• Can be used to improvise menu
• Assess if portion served is enough / too much

88
Nutrient Analysis
To calculate nutrient intakes of individuals or population groups if
quantitative methods were used to collect data.
Use food composition tables or databases.
Issues:
food names & descriptions may not correspond to the actual food
being analysed, recipe variations
a food name is ambiguous or spelling hinders a food search e.g.
ketchup vs. catsup; donut vs. doughnut
fruits & vegetables have variable composition due to differences in
maturity, length & method of storage, variety, etc but typically only one
value is provided in a database
some databases have a limited range of food or do not have complete
data for a specified nutrient
Users must recognize limitations of the data & use judgment when
reporting estimated nutrient intakes.
89
Nutrient Analysis – Converting
Food to Nutrients

90
 Nutrient Analysis – Converting
Food to Nutrients
Meal /Item Amount Calories Prot, g CHO, g Fat, g Sat fat, Cholesterol, Sodium, Dietary
g mg mg fiber, g
Breakfast
Toast 2 pc 64 1.98 11.97 0.88 0.13 0 130 0.6
Butter 1 tsp 34 0.04 0 3.8 2.4 10 33 0
Jam 1 tsp
Coffee 1c
Sugar 1 tsp
Lunch
V linguine ½ plate
Fruits 1c
Coffee 1c
Sugar 1 tsp
Milk, fresh 1 tbsp
Dinner
Roll 1

TOTAL
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 Nutrient Analysis – Converting
Food to Nutrients
Meal /Item Calories Prot, g CHO, Fat, g Sat fat, Cholesterol, Sodium, Dietary Calcium,
g g mg mg fiber, g mg
TOTAL 1900 72 246 70 28 250 1955 12 768
Requirements, 2035 58 800
female 40 yr
% requirement 93.4 124.1 96.0

92
 Recommended Dietary Allowances (RDAs)

EAR for nutrient X RDA: The daily

intake value needed
to meet the
RDA for nutrient X
requirement of
Percent of population

nearly all (97-98%)

of the healthy
population in a life
stage & gender
group.
-2 SD +2 SD
EAR = estimated average requirement. The daily intake
value that is estimated to meet the requirement of half
of the healthy population in a life stage or gender group.
93
Singapore RDA
Recommendations of daily levels of nutrients considered
to be adequate to meet the known nutritional needs of
nearly all healthy individuals in a particular age & gender
group.
For the maintenance of good nutrition of all healthy
people in the population.
NNS indicator of adequacy : 70% RDA
Available:
RDA levels for protein, iron, calcium, vits A, D, B1, B2, B3, B6,
B12, C & folic acid
Average Requirements for Energy

94
 MY HEALTHY PLATE
Meal /Item Amount Wholegrain Fruits Vegetables Meat & others, of which
dairy or calcium rich foods

Breakfast
Wholemeal 2 pc 1
bread
Butter 1 tsp
Coffee 1c
Sugar 1 tsp
Lunch
Brown rice 1 bowl 2
Grilled fish 95 grams 1
Papaya 1 wedge 1
Wholegrain Fruits Vegetables
Meal /Item Meat & others, of which
dairy or calcium rich foods

TOTAL 3 1 0 1
RECOMMENDED 5-7 2 2 3
DAILY SERVINGS
DIFFERENCE (SVG) (4) (-1) (-2) (-2)
 Evaluating Dietary Intakes
Besides the RDAs, dietary intakes can be compared with dietary
guidelines & food guides:
Singapore Dietary Guidelines
Singapore My Healthy Plate

96
 Summary

Anthropometric, biochemical,
clinical & dietary investigations
together provide a better picture of
one’s health & nutritional status &
risks.

97
 Nutrition Ethics

Ethics = the principles of conduct governing an individual

or a group
= guiding philosophy = consciousness of moral
importance
Nutrition ethics shares many principles with other branches
of healthcare ethics, such as medical ethics & nursing
ethics

98
 Nutrition Ethics
Some common values that apply to healthcare ethics
are:
Beneficence - a practitioner should act in the best
interest of the patient.
Non-maleficence - "first, do no harm"
Autonomy - the patient has the right to refuse or
choose their treatment.
Dignity - the patient (& the person treating the
patient) have the right to dignity.
Truthfulness & honesty - the concept of informed
consent has increased in importance.
99
 Nutrition Ethics
Patient Confidentiality
Healthcare practitioners have a duty to keep their patients'
confidences.
This allows the patient to feel free to make a full & frank
disclosure of information to the practitioner to enable
proper diagnosis &treatment.
The practitioner should not reveal confidential
communications or information without the patient's
express consent unless required to disclose the
information by law (other exceptions to the rule: such as
where a patient threatens bodily harm to himself or to
another person).

100
NUTRITION RESEARCH IN TP

• http://www.xn--
48sx1dz2x13fyo0ceubx4l.edu.sg/schools/asc/industry/institutional-review-
board
• All studies to be approved by the TP Institution Review Board.
• TP IRB B is a constituted group that has been formally designated to review
and monitor biomedical research involving human subjects. In accordance
with FDA regulations, an IRB has the authority to approve, require
modifications in (to secure approval), or disapprove research. This group
review serves an important role in the protection of the rights and welfare of
human research subjects.

• The purpose of IRB review is to assure, both in advance and by periodic

review, that appropriate steps are taken to protect the rights and welfare of
humans participating as subjects in the research. To accomplish this purpose,
IRBs use a group process to review research protocols and related materials
(e.g., informed consent documents and investigator brochures) to ensure
protection of the rights and welfare of human subjects of research.

101