nutritional status assessment using Anthropometry, Biochemical, Clinical and Dietary methods
- 1. Nutritional Status Assessement ABCD Methods Dr. Vaishali Soni PhD. (Food and Nutrition)
- 2. •Nutritional status of an Individual is result of many inter-related factors -food intake, physical activity , genetic factors etc •Spectrum of nutritional status vary from severe malnutrition to obesity
- 3. OUTLINE OF PRESENTATION Introduction Nutritional Assessment Anthropometric Measurement Biochemical Assessment Clinical Assessment Dietary Assessment Functional Assessment Radiological Assessement Summary
- 4. INTRODUCTION The nutritional status of an individual is often the result of many inter- related factors. It is influenced by food intake, quantity & quality, and physical health. The spectrum of nutritional status spreads from severe malnutrition to obesity.
- 5. People can have an optimal nutritional status or they can be under , over and/or malnourished . Severe underweight (Under-nourished) Healthy baby (Optimal nutritional status) Morbid Obesity (Over-nourished)
- 6. INTRODUCTION The nutritional status of an individual is often the result of many inter-related factors. The spectrum of nutritional malnutrition(FAO- 460 million which contributes about 15% of world population excluding china) Of which 300million falls under south asia Identify individuals or population groups at risk of becoming malnourished Todevelop health care programs that meet the community needs which are defined by the assessment T o measure the effectiveness of the nutritional programs & intervention once initiated
- 7. Undernourished people in the world: 859,118,114 India Undernourished people - 194,400,000 Percent - 14.37% Population,2018 - 1,352,642,280 Ref. -https://www.worldometers.info/undernourishment/
- 8. Indicators to assess and analyse nutrition In the Triple-A Cycle model: ASSESSMENT of the nutritional situation in target population ACTION based on the analysis & available resources ANALYSIS of the causes of the problem The ASSESSMENT stage aims to define the nutritional problem in terms of magnitude and distribution. The ANALYSIS stage aims to analyse the causes of malnutrition
- 9. Relationship of nutrition with other elements
- 10. What is nutrition assessment? Nutrition assessment includes taking anthropometric measurements and collecting information about a person’s medical history, clinical and biochemical characteristics, dietary practices, current treatment, and food security situation.
- 11. Nutritional Assessment - Why? The purpose of nutritional assessment is to: Identify individuals or population groups at risk of becoming malnourished. Identify individuals or population groups who are malnourished. To develop nutrition and health care programs that meet the community needs which are defined by the assessment. To measure the effectiveness of the nutritional programs & intervention once initiated.
- 12. METHODS of Nutritional Assessment Direct – deal with the individuals and measure the objective criteria Indirect – use community health indices that reflect nutritional influences
- 13. DIRECT METHODS OF NUTRITIONAL ASSESSMENT Anthropometric methods Biochemical, laboratory methods Clinical methods Functional assessment Radiological examination
- 14. INDIRECT METHODS OF NUTRITIONAL ASSESSMENT Dietary assessment Ecological variables including crop production Economic factors e.g. per capita income, population density & social habits Vital health statistics ,infant & under 5 mortality & fertility index
- 15. Assessing Nutritional Status Nutritional status can be assessed through: Body (anthropometric) measurements, used to measure growth in children and body weight changes in adults. Clinical examination, biochemical testing and dietary Assessment used to diagnose deficiencies of micronutrients (e.g. iodine, vitamin A and iron).
- 16. Anthropometry Anthropometry is the most frequently used method to assess nutritional status. It is precise and accurate; relatively quick, simple, and cheap means of nutritional assessment. It uses standardized technique; It is suitable for large sample sizes, such as representative population samples; It does not require expensive equipment, and skills can be learnt quickly. Anthropometry is a study of the measurement of the dimensions of bone, muscle and adipose tissue of the human body.
- 17. ANTHROPOMETRIC METHODS It is an essential features of all nutritional surveys It is the simplest & most practical method It utilizes a number of physical signs, (specific & non specific), associated with malnutrition and deficiency of vitamins & micronutrients
- 18. Anthropometric measurements • Length/Heigh Weight • Weight • Mid-arm circumference • Skin fold thickness • Head circumference • Head/chest ratio • Hip/waist ratio
- 19. Other anthropometric Measurements • Mid-arm circumference • Skin fold thickness • Head circumference • Head/Chest ratio • Hip /Waist ratio
- 20. ANTHROPOMETRY FOR CHILDREN Accurate measurement of height and weight is essential. The results can then be used to evaluate the physical growth of the child. For growth monitoring the data are plotted on growth charts over a period of time that is enough to calculate growth velocity, which can then be compared to international standards
- 21. Height measurement The subject stand erect on stadiometer. The movable head piece is leveled with head vault Height is recorded to nearest 0.5 cm. For infants infantometer is used. Growth monitoring of a child by comparing with international/ national standards using growth charts over a period of time.
- 24. Correct Head Position Incorrect Position
- 26. WEIGHT MEASUREMENT UNDER YEARS
- 27. Weight For Individual child , if repeated it helps in identifying growth faltering & early identification of malnutrition Classified as normal, underweight, moderately underweight , severely underweight , overweight , obese
- 28. WEIGHT WEIGHING IS MOST COMMONLY USED ANTHROPOMETRIC MESUREMENT USED FOR ASSESSING NUTRITIONAL STATUS
- 29. Children who must be held by an adult while on the scale Press the “START” key with no load on the scale and wait until the display “0.00” appears. Ask the adult wearing light clothing and no shoes to step onto the center of the scale without the child and stand quietly with legs slightly apart. Wait until the numbers (weight of the adult) on the display no longer change and stay fixed in the display. Press the 2 in 1 key to activate the function. The scale stores the weight of the adult and the display returns to zero. “0.00” and “NET” appear in the display.
- 30. Children who must be held by an adult while on the scale Give the child wearing light clothing and no shoes to the adult. The scale determines the weight of the child. Once the value is stable for about 3 seconds, the display is retained. This avoids the display jumping about as a result of the child’s movements. “HOLD” and “NET” appear in the display. Record the weight of the child to 0.01 kg (i.e., 10 g) on the questionnaire.
- 33. Mid-upper arm circumference(MUAC) Mid-upper arm circumference (MUAC) measures the muscle mass of the upper arm. Measured on the left arm. A flexible measuring tape is wrapped around the mid-upper arm (between the shoulder and elbow) to measure its circumference. MUAC should be measured to the nearest 0.1cm. MUAC is a rapid and effective predictor of risk of death in children aged 6 to 59 months and is increasingly being used to assess adult nutritional status.
- 34. MEASURING MID ARM CIRCUMFERENCE
- 35. Steps of Taking Measurements 1. Position the Subject: The right arm bent 90⁰at the elbow, and the right palm facing up. 1. Mark the measurement site 2. Take the measurement to the nearest 0.1 cm 3. Mark the midpoint horizontally 4. Record the result
- 37. Common Errors
- 38. Skin-fold thickness Skin fold calipers are used (Harpenden and Lange) Measures the thickness of the Skin and subcutaneous fat using constant pressure applied over a known area Common sites: triceps and in the sub-scapular region It has value in assessing the amount of fat and therefore the reserve of energy in the body
- 39. Waist/hip ratio Waist measurement Measured at the level of umbilicus nearest to 0.5cm Subject stands erect with relaxed abdominal muscles, arms at the side and feet together Measurement taken at the normal expiration Hip measurement Measured at the point of greatest circumference around hips to nearest 0.5cm Close contact with the skin without indenting the soft-tissues Subject should be standing and measurer beside him. Interpretation of WHR High-risk WHR=>0.8 in females and =>0.95 in males indicates central obesity and considered high- risk for diabetes and cvs disorders.
- 40. Equipment Care and Maintenance Proper care for the scale and length/height boards is important to ensure that measurements are as accurate as possible. The accuracy of equipment should be checked at the time of purchase. Clean the white area of the infantometer with bleach disinfectant spray. Clean the digital measurement device of the height board and infantometer with a dry cloth. Check that the head/foot piece of the height board and infantometer slides smoothly along the measurement column.
- 41. 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 reproducable numerical & gradable on standard growth charts 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.
- 42. Four main data collection methodologies that provide anthropometric information are : Repeated Surveys Growth Monitoring Sentinel Site Surveillance School Census Data Anthropometry Two major sources of anthropometric information are: Demographic and Health Surveys (DHS) Multiple Indicator Cluster Survey (MICS)
- 43. 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 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 formicro-nutrients BIO- CHEMICAL &LABORATORY ASSESSMENT
- 44. INITIAL LABORATORY ASSESSMENT 1. Haemoglobin estimation most important test when accurately measured, tells about overall state of nutrition (anemia, and also protein and trace element nutrition) Blood is collected from a finger, ear lobe or heel prick Haemoglobinometres which are simple, cheap and reasonably accurate are used
- 45. INITIAL LABORATORY ASSESSMENT 2. Haematocrit or packed cell volume (PCV) percentage of the blood volume composed of red cells. important in the diagnosis of anemia. 3. Red cell counts and blood films the size and uniformity of the red blood cells canbe seen. Use of such slides may facilitate the diagnosis of malaria and the haemoglobinopathies. Parasites if present can be seen.
- 46. INITIAL LABORATORY ASSESSMENT 4. Stool examination For presence of ova and/ or intestinal parasites When assessed quantitatively parasite load can be known 5. Urine examination Dipstick and microscopy for albumin, sugar and blood
- 47. SPECIFIC LAB TESTS 6. Measurement of nutrients in body fluids e.g. serum retinol, serum iron 7. Measurement of abnormal metabolites e.g. urinary iodide, urinary creatinine/ hydroxyapatite ratio
- 48. Advantages Useful in detecting early changes in body metabolism and nutrition precise , accurate and reproducible. Useful to validate data obtained from dietary methods e.g. comparing salt intake with 24-hour urinary excretion.
- 49. Limitations of biochemical & laboratory methods Time consuming and expensive Cannot be applied on large scale Reveal only current nutritional status
- 50. What is clinical assessment of nutrition? Clinical assessment – estimation of nutritional status on the basis of recording a medical history and conducting a physical examination to detect signs (observations made by a qualified observer) and symptoms (manifestations reported by the patient) associated with malnutrition. Clinical Assessment
- 51. Clinical methods Essential feature of all nutritional surveys Simplest and most practical method Utilizes a number of physical signs (specific and non-specific) that are known to be associated with malnutrition and deficiency of vitamins and other micro-nutrients. General Clinical examination with special attention to organs like hair, angles of mouth, gums, nails, skin, eyes, tongue, muscles, bones & thyroid gland. Detection of relevant signs helps in establishing the nutritional diagnosis.
- 52. Clinical Signs Nutritional abnormality 1.Hair Spare and thin Protein, Zinc, Biotin, deficiency Easy to pull out Protein deficiency Cock-screw coiled Vit A and Vit C deficiency Depigmentation Protein deficiency 2. Mouth Bleeding and spongy gums Deficiency of Vit C, A, K, Folic acid, Niacin Glossitis , Cheililitis Deficiency of Riboflavin, Niacin, Folic acid, B12 and proteins. 2. Mouth Angular stomatitis, cheilosis and fissured tongue B2, 6 & Niacin deficiency Clinical signs of nutritional deficiencies
- 53. Clinical Signs Nutritional abnormality Leukoplakia Vit A, B12, Bcomplex, Folic acid and Niacin deficiency 3. Eyes Xerosis of conjunctiva or Xerophthalmia First clinical sign Vit A deficiency Bitots spots Moderate deficiency of Vit A deficiency Corneal ulceration and keratomalacia Severe Vit a deficiency – medical emergency Night blindness, photophobia, blurring of vision Vit A and Vit B2 deficiency 4. Nails Spooning of nails Iron deficiency Transverse lines Protein deficiency 5. Glands Goiter Iodine deficiency 6. Skeletal system Beading of ribs (rickety rosary), bow legs Vit D deficiency
- 54. Clinical Assessment Advantages • 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. Disadvantages • Time consuming • Expensive • They cannot be applied on large scale • Needs trained personnel & facilities
- 56. WHAT IS DIETARY ASSESSMENTS Dietary assessments are comprehensive evaluation to assess food consumption at national level, household level and a person’s food intake level. It is one of the tool for nutritional status assessment. It includes : Food supply Production at national level Food purchase at the household level Food consumption at individual level
- 57. Methods of Dietary Assessment
- 58. DIETARY ASSESSMENT Nutritional intake of humans is assessed by five different methods. These are: 24 hours dietary recall Food frequency questionnaire Dietary history since early life Food dairy technique Observed food consumption
- 59. FOOD BALANCE SHEET METHOD Used when information regarding availability and consumption of food is required at a macro level like at the global, national, region or state levels. Maintained by each country. indicates the total food available in the country along with buffer stocks. FAO monitors at international level since 1949
- 60. FOOD BALANCE SHEET METHOD Gives the estimate of available food in the country per person per year or per day. The total food supplies available and used up at a given level are taken into account in this method. Effectively the difference between receipt ( of food ) and expenditure over a given period of time gives the food consumed by population.
- 61. FOOD BALANCE SHEET METHOD Per person per day of food availability Beginning of the year stock + total food - produced + imports Stock at the end of the year+ exports + seeds+ cattle/poultry feeds + wastage Total mid year population * 365 days =
- 62. FOOD BALANCE SHEET METHOD ADVANTAGES : Inexpensive source of indirect nutrition data, standardized, accessible by all, relatively simple to analyze Include nearly all countries worldwide Monitor global nutrition patterns and dietary habits, including trends and changes in overall national food availability Helps national planners to take appropriate decision to avert “food crisis”.
- 63. FOOD BALANCE SHEET METHOD DISADVANTAGES Cannot provide disaggregated information across different population characteristics, e.g. socio-economic, demographic etc. Do not provide data on seasonal variations in the food supply Do not provide individual-based dietary estimates Food waste (domestic and retail), processed foods, home grown food production and food from non-retail sources are not accounted for
- 64. INVENTORY METHOD
- 65. INVENTORY METHOD Carried out at an institutional level, on a homogenous group as present in a hostel, jails, mess, army barrack, orphanage etc. It is essentially done from books. Log book method / food list method Actual amount of food stuff issued by the in-charge of institute are taken into account for consumption. Purchased / discarded food is taken into account. METHOD : two visits by investigators. one at the beginning – checklist of food stocks is prepared and handed over to in-charge. Second at the end of a week
- 66. FOOD BALANCE SHEET METHOD Average intake of food/person/day = Stock at Beginning of Week - - Stock at the end of Week Total inmates participating in mealx no. of days of survey
- 67. Advantage and Disadvantage Advantage Covers large area in short time. It is fast, much easier,less cumbersome and faster than the weighment methods. It is also fairly accurate. It may not indicate an accurate individual food consumption but fairly satisfactory for the purpose of planning. Disadvantage Gives the estimate of food available rather than food consumed. It doesn’t acount for wastage. It gives only the mean individual consumption but actual individual consumption is not reflected.
- 68. WEIGHT METHOD
- 69. WEIGHT METHOD In this method the foods are actually weighed using a grocer’s balance. Both raw and cooked food are weighed. In community Survey (at a family level), the raw food is weighed rather than the cooked food, since weighing coo food is not acceptable to the families. In an institution however, the cooked food can also be weighed, since cooking is carried out at a central kitchen.
- 70. While using weighment method at a family level the following points are important: 1. Convince the house wife of the need of the survey for the benefit of the family. 2. Avoid holidays/ fares/ festivals as the dietary practice of these does not reflect the actual dietary practie. 3. It should be carried out for 3 to 7 days consecutively. 4. At least two visits a day for lunch and dinner have to be made. 5. Two investingators should be available- one talks and weighs and the other records observations. 6. Any pets, breast fed children, guests etc. should be considered.
- 71. Advantages More accurthan 24 hr recall. Good to estimate caloric intake. It accounts for the non edible part of food as well. The wastage is also taken into account. Disadvantages Time consuming Uncooperating from family Applicability to other nutrients like Proteins, Vitamins is limited. Can be adopted in institution/hospitals.
- 73. 24 HOURS DIETARY RECALL A trained interviewer asks the subject to recall all food & drink taken in the previous 24 hours. It is quick, easy, & depends on short-term memory, but may not be truly representative of the person’s usual intake
- 74. Contd... Enlist all the family members who partook the meals yesterday. The completed age(in years for adults, in months for infants and young children). Their physiological status( pregnancy, lactation) Occupation- Sedentary, Moderate, Heavy. Economic status. This helps to arrive adult consumption units.
- 75. Contd... Housewife's/ individual is asked which food and what amounts were consumed on previous day or yesterday Avoid 3 F 1. Festival 2. Fast 3. Feast days
- 76. 24 HOUR RECALL METHOD An account of raw ingredients used for each of the preparations is obtained with the help of grocer’s balance Information on total cooked amount of each preparation is noted in terms of standardized cups.
- 77. Example
- 80. Example of 24 hr recall method Diet of a 28 years old sedentary female weighing 56 kgs
- 81. ITEMS (Amount) TOTAL CALORIES (kcal) PROTEIN (g) CALCIUM (mg) Morning BF (10.30 am) 2 chapati with ghee+1 cup tea 2*30=60gm wheat + 5ml ghee, 75 ml buffalo milk + 1 tsf =5g sugar =210+45+87+20 =362 =7.2+3.4 =7.6 17.4+157.5 =174.9 Lunch (1:00 pm) 3 chapati with ghee+ 1 bowl (200ml) Aloo sabzi with 1 tsf ghee 3*30=90gm wheat + 7.5ml ghee +150g potato+ 5ml oil+5ml ghee =315+67.5+150+ 45+45 = 622.5 =10.8+2.4 =13.2 26.1 Evening (4:00pm 1 cup tea + 4 parle-G biscuits 75 ml buffalo milk +1 tsf = 5g sugar + 4 biscuits =87+ 20+ 63.6 = 170.6 =3.2 + biscuit pr 157.5 Dinner 2 chapati with ghee+ 1 bowl(200ml) Moong dal+ 1 glass milk + 2 tsp sugar 2*30=60gm wheat + 5ml ghee+ 50g dal + 5 ml oil+ 250 ml buffalo milk + 10 g sugar =210+45+174+45 + 292.5+40 =806.5 = 7.2+ 12.3+10.8 =30.3 17.4+37.5+5 25 =579.9 Total = 1961.6 (1900) excess = 61.6 = 57.3 (58) Deficit=0.3 938.4 (600) excess= 338.4
- 82. 24 HOUR RECALL METHOD ADVANTAGES Low respondent burden Easy in administration Minimum of biases associated with altering food intake because of knowledge that one is being observed. DISADVANTAGES Forgetting Deliberate misreporting Need for a trained observer to administer Costs associated with computerized analysis of records Need for several days of intake to estimate usual diet
- 84. DIETARY SCORE METHOD Assign arbitrary score to the food on the basis of its nutrient content. Consumption of the particular food is estimated through frequency method Frequency of consumption of foods, the total score and percentages are calculated. Better value if combined with quantitative methods.
- 86. FOOD FREQUENCY QUESTIONNARIE Based on principle as to how frequently an item is consumed over a period of time. A retrospective review of intake frequency that is food consumed per day, week, per 15 days, per month. Report usual frequency of consumption of each food item from a list of food items in reference to a specified period (past week/ month/ year)
- 87. FOOD FREQUENCY QUESTIONNARIE Organizes foods into groups that have common nutrients. Face to face interview, telephone or by self administration. Describes dietary patterns or food habits not nutrient intake. Semi qualified tools can obtain information on portion size using household measures.
- 90. FOOD FREQUENCY QUESTIONNARIE LIMITATIONS Relies on memory Require complex calculations to estimate frequencies Requires literacy Does not quantify intake Questionnaires need to be adapted and validated to reflect the study population and purpose. Not suitable for a population where people have distinctly different dietary patterns.
- 92. DUPLICATE SAMPLES METHOD Chemical analysis What is consumed in the family, the same amount of each food item is kept separately per day as a duplicate sample These samples can be weighed and also sent to lab for analysis of nutrients ADVANTAGE : Most accurate method DISADVANTAGE : Costly method, needs good laboratory support
- 94. EXPEDITURE PATTERN METHOD Determine money spent on food and non food items by questionnaire and compare the two Reference period is fixed (eg. Previous month/ week) Indirect method DISADVANTAGES: Food wasted or food given away is not accounted for: consumption may be overestimated The size of the household may be different from the number of people who actually consumed the food over the reference period
- 96. DIET HISTORY METHOD Respondent reports all food and beverages consumed on a usual day to a trained interviewer. It is an accurate method for assessing the nutritional status. The interviewer probes the further on frequency, amount and portion size consumed. Diet diaries are sometimes used to assist respondents in recalling their intakes. Assess qualitative and frequency intake of food Used to study : Meal pattern Dietary habits Peoples’ food preference and avoidance during special physiological conditions
- 97. DIET HISTORY METHOD ADVANTAGES Respondent burden is low Complete intakes are provided LIMITATIONS Time consuming Need for trained interviewers Lack of standardization
- 98. RECORDING METHOD
- 99. RECORDING METHOD Record of all items of food eaten by a family / individual is maintained by weighing of quantities eaten. ADVANTAGES: If followed with proper instructions a large sample can be covered in short time. Mailed questionnaire can also be used for it. DISADVANTAGE: Validity not established
- 100. FOOD DAIRY Food intake (types & amounts) should be recorded by the subject at the time of consumption. The length of the collection period range between 1- 7 days. Reliable but difficult to maintain.
- 101. OBSERVED FOOD CONSUMPTION The most unused method in clinical practice, but it is recommended for research purposes. The meal eaten by the individual is weighed and contents are exactly calculated. The method is characterized by having a high degree of accuracy but expensive & needs time & efforts.
- 102. INTERPRETATION OF DIETARY D ATA 1. Qualitative Method using the food pyramid & the basic food groups method. Different nutrients are classified into 5 groups (fat & oils, bread & cereals, milk products, meat-fish- poultry, vegetables & fruits) determine the number of serving from each group & compare it with minimum requirement.
- 103. INTERPRETATION OF DIETARY DATA 2. Quantitative Method The amount of energy & specific nutrients in each food consumed can be calculated using food composition tables & then compare it with the recommended daily intake. Evaluation by this method is expensive & time consuming, unless computing facilities are available.
- 104. Type of Dietary Survey
- 105. PROBLEMS IN DIETARY SURVEYS PROBLEM IN DATA COLLECTION Area of survey (interior/ unapproachable) Distance Lack of rapport with respondent / community Duration and inconvenient timings of survey PROBLEM IN ANALYSIS Lack of trained personnel Delay in analysis due to improper tabulation
- 106. NUTRITION SURVEYS IN INDIA National Nutrition Monitoring Bureau India Nutrition Profile (INP) Survey National Family Health Survey (NFHS) Micronutrients Surveys District Level Household Survey
- 107. FUNCTIONAL ASSESSMENT Functional indicators of nutritional status are diagnostic tests to determine the sufficiency of host nutritional status Functional indices of nutritional status include cognitive ability, disease response, reproductive competence, physical activity, work performance Increased severity of malnutrition is associated with an increased heart rate Lactation performance Growth velocity Social performance Prenatally undernourished infants show several behavioural impairments
- 108. RADIOLOGICAL EXAMINATION These tests are used in specific studies where additional information regarding change in the bone or muscular performance is requiredWhen clinical examination is suggestive rickets, there is healed concave line of increased density at distal ends of long bones usually the radius and ulna. In infantile scurvy there is ground glass appearance of long bones with loss of density. In beriberi there is increased cardiac size as visible through X-rays. Drawback, sophisticated and expensive equipments along with technical knowledge are required in the interpreting data.
- 109. What method is the most practical and accurate way to measure regional adiposity? A. Waist and hip circumference B. Skin-fold thickness testing C. Body mass index (BMI) D. Impedance measurement
- 110. What is the best way to measure nutritional status in a pregnant female? A. Waist circumference B. Body mass index (BMI) C. Mid-upper arm circumference D. Triceps skinfold measurement
- 111. 12/18/2016