ASSESSMENT OF NUTRITIONAL STATUS Presented by: Dr. Soha Rashed Professor of Community M Alexandria Faculty of Medicine Year 1, Semester 1 Module 2: Nutrition and MetabolismDefinition of nutritional status Nutritional status is the current body status, of a person or a population group, related to their state of nourishment (the consumption and utilization of nutrients). The nutritional status is determined by a complex interaction between internal/constitutional factors and external environmental factors: = Internal or constitutional factors like: age, sex, nutrition, behavior, physical activity and diseases. = External environmental factors like: food safety, cultural, social and economic circumstances.The complex interaction between internal or constitutional factors and external environmental factors sty tortor orion t chao Sine goo a Tay ot ocondens roms Seto aie Household food treme ameouion |g) tion ——= oer on ne ater —| one Houstold fod Son Mom sine theron enous anes | ee teen convo Coe -1 cuter ton tae fet Sentary, +) ‘itd caret — Grogth ane arvlooment Physoloncal by intl Activity ts ae Ghindidial™ Housshoia (vel ana ‘octustons) Genvral welh being oficial* An ideal nutritional status occurs when the supply of nutrients conforms to the nutritional requirements or needs. Nutrient intake Requirements* Diets are rated in quality according to the balance of nutrients they provide, and not solely on the type of food eaten or the amount of caloric intake. Fats, oils and sweets Milk, yogurt and cheese Meat, poultry, Food guide Mish, dry beans, pe flea pyramidPeople can have an optimal nutritional status or they can be under-, over- and/or malnourished. Morbid Obesity (Over-nourished) Severe underweight (Under-nourished) Healthy baby (Optimal nutritional status)The nutritional status of an individual has consequences: An optimal nutritional status is a powerful factor for health and well being. It is a major, modifiable and powerful element in promoting health, preventing and treating diseases and improving the quality of life. Malnutrition may increase risk of (susceptibility to) infection and chronic diseases: — undernutrition may lead to increased infections and decreases in physical and mental development, and — overnutrition may lead to obesity as well as to metabolic syndrome or type 2 diabetes.Purpose of nutritional assessment Identify individuals or population groups at risk of becoming malnourished Identify individuals or population groups who are malnourished To develop health care programs that meet the community needs which are defined by the assessment To measure the effectiveness of the nutritional programs & interventions once initiatedMethods of Nutritional Assessment * Nutrition is assessed by two methods; direct and indirect. * The direct methods deal with the individual and measure objective criteria, while indirect methods use community indices that reflect the community nutritional status/needs.Direct Methods of Nutritional Assessment These are summarized as ABCD ¢ Anthropometric methods * Clinical methods * Dietary evaluation methods * Biochemical, laboratory methodsIndirect Methods of Nutritional Assessment Ecological variables including agricultural crops production Economic factors e.g. household income, per capita income, population density, food availability and prices Cultural and social habits Vital health statistics: morbidity, mortality and other health indicators e.g., infant and under-fives mortality, Utilization of maternal and child health care services, fertility indices and sanitary conditionsDirect Methods of Nutritional Assessment 1, Anthropometric Methods Anthropometry is the measurement of body height, weight & proportions. It is an essential component of clinical examination of infants, children & pregnant women. These measurements are compared to the reference data (standards) of the same age and sex group, in order to evaluate the nutritional status.¢ Although they indicate the nutritional status in general, still they are not used to identify specific nutritional deficiencies. * They are used to evaluate both under & over nutrition. * The measured values reflect the current nutritional status & don’t differentiate between acute & chronic changes.Other anthropometric Measurements Mid-arm circumference Skin fold thickness © Head circumference Head/chest ratio Hiphwa ist ratioz:... fais Mast w=Measurements for adults Height measurement ¢ The subject stands erect & bare footed ona stadiometer with a movable head piece. The head piece is leveled with skull vault & the height is recorded to the nearest 0.5 cm.Measuring Recumbent length in infants & standing height in children Movable headpiece “o> of tar at foo aeWeight measurement Use a regularly calibrated electronic or balanced-beam scale. Spring scales are less reliable. Weigh in light clothes, no shoes. Read to the nearest 100 gm (0.1kg)Weighing infants and young children Spring Scale Electronic and Balance Beam Infant ScalesNutritional Indices in Adults * The international standard for assessing body size in adults is the body mass index (BMI). * BMI is computed using the following formula: BMI = Weight (kg)/ Height (m7) * Evidence shows that high BMI (obesity level) is associated with type 2 diabetes & high risk of cardiovascular morbidity & mortalityExample: Weight = 68 kg, Height = 165 cm (1.65 m) BMI= 68 = (1.65)? = 24.98 kg/m?Interpretation of BMI for adults For adults 20 years old and older, BMI is interpreted using standard weight status categories that are the same for all ages, and for both men and women. DMM een ee Below 18.5 Underweight 18,5- 24.9 Normal A ‘ ‘ 25.0-29.9 Overweight 30.0 and Above Obese 1Waist circumference ¢« Waist circumference _ is measured at the level of the umbilicus to the nearest 0.5 cm. ¢ The subject stands erect with relaxed abdominal muscles, arms at the side, and feet together. * The measurement should be taken at the end of a normal expiration.Waist circumference * Waist circumference predicts mortality better than any other anthropometric measurement. posses ects LEVEL 1 >94cm >80cm LEVEL 2 >102 cm >88cm Overweight obese eat Level 1 is the m um eptable )waist circumference irrespective of the t uld be no further weight gain. Level 2 denotes ir it manage Ateto reduce the risk of typ: abet CVS ications.Hip Circumference * Is measured at the point of greatest circumference around hips & buttocks to the nearest 0.5 cm. The subject should be standing. Both measurements (Waist and hip) should be taken with a flexible, non-stretchable tape in close contact with the skin, but without indenting the soft tissue.Interpretation of Waist / Hip ratio (WHR) High risk WHR= > 0.80 for females & > 0.95 for males Y 7 a i.e. waist measurement > 80% of hip measurement for women and > 95% | Tt > for men indicates central (upper body) obesity and is considered high risk for diabetes & CVS disorders. A WHR below these cut-off levels is considered low risk.Body Mass Index for Children and Teens The criteria used to interpret the meaning of the BMI number for children and teens are different from those used for adults. For children and teens, BMI age- and sex-specific percentiles are used for two reasons: * The amount of body fat changes with age. ¢ The amount of body fat differs between girls and boys.Body Mass Index for Children and Teens Less than 5" percentile Underweight 5" percentile to less than the 85" Healthy weight perbentile - eh 85'" percentile to less than the 95 Risk of overweight percentile sh 95'" percentile or greater OverweightLae Body mass index-for-age percentiles: o 2 ‘5th Percentile ‘5th Percentile i ‘sth Pescentie ‘0 ® ‘A 10-year-old boy with “ anor 13 would be in ‘10-year-old boy with {he underwoight category Ml of 18 would bon {iees than 5th percentie} the heatny weigh » ees arene | lew’ Doren ‘Age (years),Advantages of Anthropometry Objective with high specificity & sensitivity Measures many variables of nutritional significance (Ht, Wt, MAC, HC, skin fold thickness, waist & hip ratio & BMI). Readings are numerical & gradable on standard growth charts Readings are reproducible. Non-expensive & need minimal training Limitations of Anthropometry Inter-observers errors in measurement Limited nutritional diagnosis Problems with reference standards, i.e. local versus international standards. Arbitrary statistical cut-off levels for what considered as abnormal values.2. Clinical assessment It is an essential feature of all nutritional surveys. It is the simplest & most practical method of ascertaining the nutritional status of a group of individuals. It utilizes a number of physical signs, (specific & non specific), that are known to be associated with malnutrition and deficiency of vitamins & micronutrients.2. Clinical assessment * Good nutritional history should be obtained * General clinical examination, with special attention to organs like hair, angles of the mouth, gums, nails, skin, eyes, tongue, muscles, bones & thyroid gland. * Detection of relevant signs helps in establishing the nutritional diagnosisExamples of illnesses caused by improper nutrient consumption Too little Too much PEM (protein-energy malnutrition), ice = Stroke me jeart/arterial fonaateenent 17S disease » Some cancers Osteoporosis IN” l Obesity (calcium isaer/)\ 2, | Diabetes mellitus Goitre (iodine Gallstones sted Dental caries ccna // ah ) a: aut Scurvy (vitamin C deficiency) Rickets (vitamin D nce | (vitamin A” doticorcy) Lo i X - /GX Beri-beri (vitamin B ‘efidercy UUXerophthalmia Bitot’s spot Fig. 761 Bitot’s spot: T manifestation of vitamin A and essential fatty acid deficiencyVitamin A DeficiencyBeriberi Vitamin B1 (Thiamine) deficiencyVitamin B2 Deficiency (Ariboflavinosis)Pellagra Vitamin B3 (Niacin) Deficiency Clinical-4 D’s: Dermatitis, Diarrhea, Dementia, DeathScurvy (Vitamin C Deficiency)Rickets (Vitamin D deficiency) Z/itarmnirh A deficiency of vitamin D or an inability to utilize vitamin D may lead toa condition called rickets, ‘a. weakening and softening of the bones brought on by extreme calcium lossGoitre (Iodine deficiency disorder)Protein energy malnutrition Marasmus KwashiorkorProtein-energy malnutrition (PEM) Old Man's Face Thin Muscles/ Thin Fat Marasmus Kwashiorkor2. Clinical assessment ADVANTAGES * Fast & Easy to perform * Inexpensive * Non-invasive LIMITATIONS * Did not detect early cases3. Dietary assessment Nutritional intake of humans is assessed by five different methods. These are: e 24 hours dietary recall ¢ Food frequency questionnaire ¢ Dietary history since early life ¢ Food dairy technique © Observed food consumption Healthy dieta. 24 Hours Dietary Recall * A trained interviewer asks the subject to recall all food & drinks taken in the previous 24 hours. «It is quick, easy & depends on short-term memory, but may not be truly representative of the person’s usual intakeb. Food Frequency Questionnaire In this method the subject is given a list of around 100 food items to Figure 2. Example of Food Frequency Questionnaire indicate his or her intake s alt ' i 2 (frequency & quantity) per day, per Rs ls|_| 2/212 week & per month. It is 2 (8 [2/5 |a)8|8|8 inexpensive, more representative |iien"""" JojoQO|OjOj0 0) & easy to use. raeret lO lolclolololclo Limitations: Ee ire elereevererere) * Long questionnaire caros (Team) |O|O|O[O|O|O|O|O 4 reat A ge Hee lololojolo|ojolo * Errors with estimating serving size. reste (ios) |O|O C|O|O|O|O|O . Needs updating with new —— SR EIS commercial food products to keep sen er Telolclolalclolo pace with changing dietary habits.c. Diet history The diet history aims to discover the usual food intake pattern of individuals over a relatively long period of time. It is an interview method composed of two parts. recall: question: coupled with " the entire da household m r breakfast yesterday?" ast?", following through estimate portion sizes in poons and cups, foodc. Diet history 2. The second part is known as the "cross-check". This is a detailed list of foods that are checked with the subject. Questions concerning food preferences, purchasing and the use of each food serve to verify and clarify information given in the first part. Questions about purchasing can also provide a check on portion estimates.c. Diet history The diet history has advantages over other methods in that it estimates nutrient intakes over a long period of time. Its disadvantages are that it takes about one hour of careful questioning, and the interviewer must be a nutritionist or dietitian experienced in obtaining diet histories. The most common fault of an inexperienced interviewer is probably that of suggesting answers.d. Food Diary * Food intake (types & amounts) should be recorded by the subject at the time of consumption. ¢ The length of the collection period range between 1-7 days. * Reliable but difficult to maintain.e. Observed Food Consumption * The most unused method in clinical practice, but it is recommended for research purposes. * The meal eaten by the individual is weighed and contents are exactly calculated. * This method is characterized by having a high degree of accuracy but expensive & needs time & efforts.e Interpretation of Dietary Data . Qualitative Method Using the food pyramid & the basic food groups method. Different nutrients are classified into 5 groups (fat & oils, bread & cereals, milk products, meat- fish-poultry, vegetables & fruits) Determine the number of servings from each group & compare it with minimum requirements. . Quantitative Method The amount of energy & specific nutrients in each food consumed can be calculated using food composition tables & then compare it with the recommended daily intake. Milk4. Initial Laboratory Assessment * Laboratory tests based on blood and urine can be important indicators of nutritional status, but they are influenced by non- nutritional factors as well. * Lab results can be altered by medications, hydration status, and disease states or other metabolic processes, such as stress. * As with the other areas of nutrition assessment, biochemical data need to be viewed as a part of the whole.* Hemoglobin estimation is the most important test & useful index of the overall state of nutrition. Beside anemia it also tells about protein & trace element nutrition. * Stool examination for the presence of ova and/or intestinal parasites * Urine dipstick & microscopy for albumin, sugar and bloodSpecific Lab Tests * Measurement of individual nutrient in body fluids (e.g. serum retinol, serum iron, urinary iodine, vitamin D) * Detection of abnormal amount of metabolites in the urine (e.g. urinary creatinine/ hydroxyproline ratio) ¢ Analysis of hair, nails & skin for micro- nutrients.Biochemical Methods Advantages of Biochemical Methods It is useful in detecting early changes in body metabolism & nutrition before the appearance of overt clinical signs. It is precise, accurate and reproducible. Useful to validate data obtained from dietary methods e.g. comparing salt intake with 24-hour urinary excretion. Limitations of Biochemical Methods Time consuming Expensive They cannot be applied on large scale Needs trained personnel & facilities