ERC/2020

NUTRITIONAL ASSESSMENT
ENRIQUEZ R. CAYABAN, RN, LPT, MAN
Clinical Instructor
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OBJECTIVES
 Todiscuss the methods of
assessing nutritional
status
 Toexplain the
significance and purpose
of nutritional assessment
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RECOMMENDED ENERGY AND NUTRIENTS

ALLOWANCES (RENI)
 Basically, it is known as Recommended Dietary Allowance
(RDA) before
 To emphasize that the standard is in terms of nutrients
not the food or diet.
 Are levels of intakes of energy and nutrients which, on the
basis of current scientific knowledge, are considered
adequate for the maintenance of health and well- being
of nearly all healthy persons in the population.
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ESSENTIALS OF AN ADEQUATE DIET

MILK GROUP MEAT GROUP
 Is counted on to provide  Provides generous amount
most of the calcium of high-quality protein.
requirements.  Iron, thiamine, riboflavin,
 Provides riboflavin, high- niacin, phosphorus and
quality protein, other zinc are supplied.
minerals and vitamins,
carbohydrates and fats.
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ESSENTIALS OF AN ADEQUATE DIET

BREAD AND CEREAL GROUP VEGETARIAN- FRUIT GROUP
 Furnishes thiamine, protein,  Is an important supplier of
iron, niacin, carbohydrate and
fiber, minerals and
cellulose at a relatively low cost.
vitamins particularly
 The enrichment of bread and
cereals with iron, thiamine,
vitamin A and C.
riboflavin and niacin
substantially contributes
additional amounts of these
nutrients to the diet.
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ASSESSMENT OF
NUTRITIONAL
STATUS
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NUTRITIONAL STATUS
 Nutriture
 Is the degree to which the individual’s psychological need
for nutrients s being met by the food the person eats.
 It is the state of balance in the individual between the
nutrient intake and the nutrient expenditures or need.
 In thorough nutritional status assessment, all of the
following aspects are considered:
 Dietary history and intake data
 Biochemical data
 Clinical examination
 Anthropometric data
 Psychosocial data
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METHODS OF ASSESSING DIETARY INTAKE

24- HOUR RECALL

FOOD FREQUENCY QUESTIONNAIRE

DIETARY HISTORY

FOOD DIARY OR RECORD

OBSERVATION OF FOOD INTAKE

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24- HOUR RECALL

 The individual completes a questionnaire or is interviewed
by a dietician/ nutritionist or a nurse experienced in
dietary interviewing and is asked to recall everything that
he/ she ate within the last 24 hours or the previous day.
24 hour Recall Form and Food Group Evaluation
 What time did you go to bed the night before last? Was
this the usual time?
 What time did you get up yesterday? Was this the usual time?
 When was the first time you had anything to eat or drink? What did
you have and how much?
 When did you eat again? Where? What and how much?
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24- HOUR RECALL

24 hour Recall Form and Food Group Evaluation
 When did you eat next? What did you eat and how much?
 Did you eat of drink anything else? Anything from 1st to 2nd
meal? Anything from 2nd to 3rd meal? Anything from 3rd to
bedtime?
 Was this day’s food intake different from usual? If so, why?
 Is weekend eating different? If so, why?
FOOD AND FLUID INTAKE FROM TIME OF AWAKENING UNTIL THE NEXT MORNING 24- HOUR RECALL
Food & drink Number of Servings in the Food Groups
consumed
Time Name & type Amou Milk Group Meat Group Vit. A Group Vit. C Group Veg-Fruits Bread & Cereal Butter, Misc
nt Group Group Fat & Oil

Total
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24- HOUR RECALL

EVALUATION

Reccomended No. Amount Milk Meat Vit. A Vit. C Veg- Fruits Bread & Butter, Mis
of Servings Daily group Group group group group Cereal fat & oil
group
Children 6 yo or < 2-3 c 2 3/ wk 1 2 4 2 tsbp
Adolescent 4c 2 3/ wk 1 2 4 2 tsbp
Adult 2c 2 3/ wk 1 2 4 2 tsbp
Pregnant & 4c 2 3/ wk 1 2 4 2 tsbp
Lactating

L= Low
A= Adequate
E= Excessive
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FOOD FREQUENY QUESTIONNAIRE

 In this method the subject is given a list of around 100
food items to indicate his or her intake (frequency &
quantity) per day, per week & per month.
 inexpensive, more representative & easy to use.

LIMITATIONS:
 long Questionnaire
 Errors with estimating serving size.
 Needs updating with new commercial food products to
keep pace with changing dietary habits
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FOOD FREQUENY QUESTIONNAIRE

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DIETARY HISTORY
 It is an accurate method for assessing the nutritional
status.
 The information should be collected by a trained
interviewer.
 Details about usual intake, types, amount, frequency &
timing needs to be obtained.
 Cross-checking to verify data is important.
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DIETARY HISTORY
 ECONOMICS
 Income
 Amount of money for food each week or month and individual
perception of its adequacy for meeting food needs
 PHYSICAL ACTIVITY
 Occupation
 Exercise
 Sleep- hours/ day
 ETHNIC AND CULTURAL BACKGROUND
 Influence on eating habits
 Religion
 Education
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DIETARY HISTORY
 HOME LIFE and MEAL PATTERN
 No. of household members
 Person who does shopping
 Person who does cooking and relationship with this person
 Food storage and cooking facilities
 Ability to shop and prepare food
 APPETITE
 Good, poor, any changes
 Factors that affect appetite
 Taste and smell perception
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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.
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OBSERVATION OF FOOD INTAKE

 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.
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EVALUATION
OF FOOD
INTAKE
Evaluation by Food Group Method
 The simplest, fastest, yet
crudest way to evaluate food
intake data is to determine how
many servings from each of the
four food groups were consumed
during the recorded day.
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GENERAL RULES FOR MEAL PLANNING

1. Use the whole day as a unit rather that the individual

meal.
2. Use some food from each of the food groups daily (energy-
giving foods, body- building foods and body regulating
foods).
3. Use some raw fruits and vegetables at least once a day.
4. Plan to have for each meal at least one food with staying
power or high in satiety value, one which contains
roughage and generally some hot food or drinks.
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GENERAL RULES FOR MEAL PLANNING

1. Combine and alternate foods of bland form with those of

a more pronounced flavour.
2. Combine and alternate soft and crisp foods.
3. Have a variety of color, food, an food arrangement
4. When more foods are served at one meal, decrease the
size of portions and use fewer rich foods.
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Some Don’ts for Menu Planning

1. Avoid using the same kind of food twice a day without

varying the form in which it is served excepts staples like
rice, bread and milk.
2. Do not use the same food twice in the same meal even in
the different forms
3. Do not use the same food too often from day to day.
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OTHER CONSIDERATIONS
MEAL PATTERNS PLANNING FOR A WEEK
 Are helpful in planning but  Is the best to have a weekly
they must take into account menu plan. In hospitals, the
the family’s habits and practice of dieticians is to
needs. prepare a so-called “CYCLE
MENU”.
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NUTRITION
SURVEY
 Is an epidemiological
investigation of the nutritional
status of the population by
various methods together with
an evaluation of the ecological
factors of the community.
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Significance 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 &

intervention once initiated
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Methods of Nutritional Assessment

• Clinical Examination
• Biochemical Examination

Direct
• Anthropometric Measurement
• Biophysical Technique

• Studies on Food Consumption

• Studies on Health Conditions and Vital

Indirect
Statistics
• Studies on Food Supply Condition
• Studies on Socio- economic Condition
• Studies on Cultural & Anthropological
Influences
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Factors Considered in the Selection of Nutritional Survey Method

Unit to be Surveyed

Types in information Required

Degree of Reliability and Accuracy Required

Facilities and Equipment available

Human Resources

Time Reference

Funding & Financial Support

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CLINICAL ASSESSMENT
 It is an essential features 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.
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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
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CLINICAL ASSESSMENT
 ADVANTAGES
 Fast & Easy to perform
 Inexpensive
 Non-invasive

 LIMITATIONS
 Did not detect early cases
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Clinical Signs of Nutritional Deficiency

 PROTEIN- ENERGY MALNUTRITION
 Classification
Mild
Severe
 Marasmus (Dry Form)
 Kwashiorkor (Edematous Form)
 Marasmic Kwashiorkor
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Clinical Signs of Nutritional Deficiency

 XEROPHTHALMIA
 Itaffects the eyes, gradually beginning with an
impairment of night vision.
 Initialstage may be treated by supplementation of the
daily diet with Vitamin A.
A severe case need large supplements and simultaneous
treatment of the eye problem with antibiotics
 SYMPTOMS: Impaired night vision; Smokey Conjunctiva;
Dry eyes and Cornea softening and ulcers
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Clinical Signs of Nutritional Deficiency

 ANEMIA
 Solereliance on breast milk for children beyond six
months leads to anemia.
 SYMPTOMS:
 Tiredness

 Paleness under the eyelid

 Breathlessness

 Heart Palpitations
 Paleness under the nail
 Edema
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Clinical Signs of Nutritional Deficiency

 GOITER
 The enlargement of the thyroid glands is due to its
need for iodine.
 Itis more common in females, especially in puberty
and doing pregnancy.
 Giotrogenic Agents- are substances that disrupt the
production of thyroid hormones by interfering with
iodine uptake in the thyroid gland (kale, turnips,
cabbage)
 SYMPTOMS: Swelling of the neck; Difficulty in
swallowing; Difficulty in breathing and Tight feeling in
throat
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Clinical Signs of Nutritional Deficiency

 GOITER
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Clinical Signs of Nutritional Deficiency

 VITAMIN B12 or RIBOFLAVIN DEFICIENCY
 SYMPTOMS:
 Magenta re tongue
 Sores at the angle of the mouth and folds of the nose
 Itchingand scaling of skin around nose, mouth, scrotum,
forehead, ears, scalp
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BIOCHEMICAL ASSESSMENT
 Estimation if time desaturation, enzyme activity or
blood composition
 Test are confined to two fairly easily obtainable fluids
 BLOOD
 URINE
 ADVANTAGES:
 Objectivity, independent of the emotional and subjective
factors that usually affect the investigator
 Can detect early subclinical states of nutritional deficiency
 DISADVANTAGES:
 Costly, usually requiring expensive equipment
 Time- consuming
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BIOCHEMICAL ASSESSMENT
 FACTORS AFFECTING ACCURACY OR RESULTS
 Standards of Collection
 Methods of transport and storage of samples
 Technique employed
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 COMMON BIOCHEMICAL PARAMETERS

FLUID PARAMETER NUTRITION DEFICIENCY

BLOOD Serum Albumin Protein Deficiency
Amino Acid Imbalance Protein Deficiency
Serum Vitamin A Vitamin A Deficiency
Serum Carotene Vitamin A Deficiency
Serum Alkaline Phosphatase Vitamin D Deficiency
Serum Ascorbic Acid Vitamin C Deficiency
Hemoglobin Iron & Vitamin B12 Deficiency
Hematocrit Iron Deficiency
URINE Hydroxyproline ecretion Protein Deficiency
Urinary Urea Protein Deficiency
Urinary Creatinine Protein Deficiency
Urinary Thiamine Thiamine Deficiency
Urinary Riboflavin Riboflavin Deficiency
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Biological test applicable and Interpretation

 PROTEIN
 METHODS:
 Urea Nitrogen/ Creatinine Nitrogen Ratio
 Index of dietary adequacy
 From over two-to 24 hour urine sample
 Index of 30 or lower in a random sample indicative of malnutrition

 Amino Acid imbalance Test

 Ratio of 4 dispensable amino acids and 4 indispensable amino acids is serum by
paper chromatography
 High (5-10) in Kwashiorkor and Low (less than 2) in well- fed children

 Hydroxyproline excretion in random urine High 4.25

 Low (0.5-1.5) in clinically malmourished children; Normal: 2.0- 5.0
Acceptable 3.52-4.24
 Serum Albumin
Low 2.80-3.51
 Lowered in severe protein depletion
Deficient < 2.80
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Biological test applicable and Interpretation

 IRON
 Hemoglobin Determination
 Cyanmethemoglobin method by spectrophotometry

 A.O. hemoglobinometer- simple technique, handy equipment

 OTHERS: Sahli’s method; Tallquist method; Copper Sulfate Speciifc Gravity method

 Hematocrit- obtained from a finger prick

 A measure of red cell volume

 Values below which Anemia is said to exist

AGE HgB
6 mos- 6 yo 11
6 yo- 14 yo 12
Adult males 13
Adult females- Non- pregnant 12
Adult females- Pregnant 11
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Biological test applicable and Interpretation

 VITAMIN A
 Serum Vitamin A and Serum Carotene level by Spectrophotometry using
micro and macro methods.
 Low in Serum Vitamin A reflects prolonged severe dietary deficiency
probably up to 1 year in adults and up to 4 months in young children.
 Serum Carotene levels is not indicative of Vitamin A status per se bit it is
useful because it reflects recent ingestion of carotene- containing foods.
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ANTHROPOMETRIC MEASUREMENTS
 It is the measurement of variations of the physical dimension and
gross composition of the human body at different age levels and
degree of nutrition.
 It is an essential component of clinical examination of infants,
children & pregnant women.
 It is used to evaluate both under & over nutrition.
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
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Common Anthropometric Measurements
ANTHROPOMETRIC MEASUREMENTS ADVANTAGES DISADVANTAGES
WEIGHT -Uses weighing scale such as beam balance -simple and is commonly -depends on accurate age
scales or clinical scales used determination
-Assess body mass -weight can be determined -interpretation on individual
-A sensitive indicator of current nutritional fairly accurately by basis may be complicated by
status personnel with minimum edema
-Uses as reference values for age or height training -does not distinguish between
or both of population acute and chronic malnutrition
-key anthropometric measurement but useful when serial
measurements are taken; useful
in children < 1 yo
HEIGHT -Assesses linear dimensions of the -Inexpensive tools may be -less sensitive to changes in
following: Leg, pelvis, spine, and the skull used growth rate
-Less sensitive and generally indicator of -Simple to do in the field Errors in measurement are easily
past nutritional status (chronicity of made
malnutrition)
-Uses statiometer, anthropometric steel
rods fixed accurately and vertically to the
wall; for infants (below 2), an
infantometer is used.
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Common Anthropometric Measurements
ANTHROPOMETRIC MEASUREMENTS ADVANTAGES DISADVANTAGES
WEIGHT -most accurate indicator of present or -is nearly independent of age -height for age is a disadvantage
FOR current state of nutrition from 1-10 years
HEIGHT/ -an expression of leanness or wasting -probably independent of
LENGTH ethnic group especially in
ages 1-5 years
SKINFOLD -assesses body composition, fat distribution
THICKNESS and hence reserve calories
-Must be compared against standards for
age and sex at all ages
-uses a reliable caliper
BODY -the head/ chest circumference ratio is if
CIRCUMFERE value is detecting PEM in early childhood.
NCE -the mid-upper arm circumference (MUAC)
has been mainly used on children from 1-6
yo. Between 1-4 years, the reference
values change a little, and the age need
not be accurately known
BIRTH -is related to maternal nutrition and socio- Same as that in weight -births are often unattended
WEIGHT economic status for age by health personnel
-usually taken as cut-off for “low- birth
weight babies” is 2500 grams
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