Nutrition Assessment

Dr. Ola Elazazy, Ph. D.

Lecturer of Biochemistry and
Molecular Biology
Overview of nutritional assessment

Direct Assessment Methods

• Anthropometric Assessment
• Biochemical testing
• Clinical examination
• Dietary Assessment

Indirect Assessment Methods

Nutritional Support

Weight Changes
 Overview of nutritional assessment
• A systematic approach to evaluating dietary intake and nutritional status.
• The nutritional status of an individual is often the result of many inter-
related factors.
• It is affected by food intake, quantity, quality, and physical health.
• The spectrum of nutritional status spread from obesity to severe
malnutrition.
• The purposes of nutritional assessment are:
• To identify individuals or population groups at risk of becoming 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 and intervention
once initiated
 Nutrition is assessed by two types of methods; direct and indirect.

 The direct methods deal with the individual and measure objective criteria,

 While indirect methods use community health indices that reflects nutritional
influences.
 A) Anthropometric methods
 Anthropometry is the measurement of body height, weight and proportions.
 It is an essential component of clinical examination of infants, children and pregnant women.
 It is used to evaluate both under and over-nutrition.
 The measured values reflects the current nutritional status and don’t differentiate between acute and
chronic changes.
1. Height and Weight
2. Skin fold thickness
3. Waist Circumference (WC)
4. Hip Circumference (HC)
5. Waist-to-Hip Ratio (WHR)
6. Index of Central Obesity (ICO)
7. Head and chest circumferences
1. Height and Weight:
 These are the most frequently recorded in nutritional surveys.

 Height should be taken in a standard position without footwear, and is recorded to the nearest 0.5
cm (steel-measuring tape is recommended).

 Weight should be taken with minimum of clothing and recorded to the nearest 0.1 kg.

a) Weight for age index: is used as index of malnutrition in children (index of current nutritional
status)

b) Height for age index: is very important in children (index of past nutritional history)

c) Weight for height index: it is independent of age and is an index of current nutritional status

 In children: use growth charts

 In adults: Body Mass Index (BMI)

WHO Classification Popular Description BMI (kg/m2)

Underweight Thin <18.5

Normal Range Normal 18.5 - 24.9

Overweight (Pre-obese) Overweight 25.0 - 29.9

Obese ≥ 30.0

Obese Class I Obese 30.0 - 34.9

Obese Class II Obese 35.0 - 39.9

Obese Class III Morbidly Obese ≥ 40.0

These percentile curves
can be used to identify
the child's rank relative
to other children of
similar age and sex.
Increasing weight - weight-for-age-girls

Phoebe was born at term weighing 3.4 kg and measuring 49.5 cm. She is now 2 years old and has been

attending your clinic regularly for monitoring of her health and development. She has reached all

developmental milestones as expected. Her weight and length measurements are shown in the table

below.

Age Weight (kg) Length(cm)

Birth 3.40 49.5
1 month 4.30 54.0
3 months 6.00 59.5
5.5 months 7.25 64.5
9 months 8.70 70.0
12 months 9.80 74.2
18 months 12.2 82.0
24 months 14.3 88.5
Case study questions and activities
• Plot Phoebe's growth?
The WHO weight-for-age and length-for-age charts are used from birth to 2 years of age.
• How would you describe Phoebe’s growth pattern?
From birth to age 6 months Phoebe’s weight tracked around the 50th percentile on the WHO growth
chart.
After 6 months weight percentiles began to increase. Between 18 months and 2 years, the increase
became more rapid with weight nearing the 97th percentile. From birth to age 12 months her length
tracked around the 50th percentile. After this time it steadily increased towards the 85th percentile on
the WHO charts.
Case Example 1: Low Weight-for-Length
Maya is a healthy 9-month-old girl who was exclusively breastfed for 6 months and continues to breastfed. Maya’s
mother began feeding her solid foods at 6 months of age. Maya’s mother reports that Maya “is a good eater”.

Maya has seen her healthcare provider regularly. Her weight and length measurements were recorded and plotted
on the growth chart at each visit.

Case study questions and activities

Age (months) Weight (kg) Length (cm)
 Plot Maya's growth?
Birth 2.7 51
 How would you describe Maya’s growth pattern?
 Given her current measurements, Maya’s weight-for-length is 2 4.2 57

considered to be within the healthy range. (T or F) 4 5.3 63

6 6.8 65
9 7.5 72
 Comment
 When Maya’s weight-for-age measurements are plotted on the WHO weight-for-age
growth chart, her measurements fall above the 3rd percentile curve for the first 4
months of age and fall above the 15th percentile at 6 and 9 months of age.

 When Maya’s length-for-age measurements are plotted on the WHO length-for-age

growth chart, her length from birth to age 9 months is tracked around the 50th
percentile.

 Maya's growth indicator falls between the 3rd and the 97th percentiles on the WHO
weight-for-age & length-for-age growth chart which is within the healthy range.
2. Skin fold thickness (mm):

• With special calipers, a pinch of subcutaneous fat is gently taken up and the width measured.
Caught between the jaws of the calipers is a double layer of fat and skin.

• Skin fold thickness provides a measurement of considerable value in assessing the amount of
fat and therefore the reserve of calories in the body

• Skin folds could be measured at many sites but the best established are: Triceps, Biceps,
Subscapular and Suprailiac skin fold.
3. Waist circumference (cm):
• Predicts mortality better than any other anthropometric measurement.
• Waist circumference is a simple measurement used to assess abdominal (visceral) fat.
• The larger the waist, the greater the risk of obesity-related complications, especially diabetes
mellitus, cardiovascular disease, and all-cause mortality.
• Waist circumference is determined by measuring the distance around the smallest area
below the rib cage and the top of the iliac crest
• Men are at increased risk if the waist circumference is greater than 40 inches (102 cm);
Women are at increased risk if the waist circumference is greater than 35 inches (89 cm)
4. Hip circumference (cm):

• It is measured at the point of greatest circumference around hips and buttocks to the
nearest 0.5 cm using a non-stretch flexible fiberglass tape in close contact with the
skin, but without indenting the soft tissue.

5. Waist-to-Hip Ratio (WHR):

• WHR more precisely measures abdominal adipose tissue and

fat distribution.

• A WHR of greater than 0.9 in men and 0.80 in women is

considered a risk factor for obesity-related conditions
6. Index of Central Obesity (ICO):
• It is defined as a ratio of WC (cm) and height (cm) correlates better with central obesity
than WC alone.
• It is important to include height as a denominator, as other areas in body have effects
opposite to that of fat in central region.
• Utility of ICO over WC is analogous that of BMI over crude weight measurement as a
parameter of obesity.
• The ICO cutoffs obtained ranged from 0.51 to 0.58 among males and 0.47 to 0.54
among females.

7. Head and chest circumferences:

• They are additional measurements for assessing the growth of children

 B) Biochemical and laboratory methods
The most common tests include

1) Serum albumin: widely used but insensitive indicator because it is affected by many factors other than nutrition
(hepatic and renal diseases hydration status)

2) Blood glucose concentration

3) Plasma lipids: Fasting plasma TAG, essential fatty acids determination, faecal fat in the assessment of
malabsorption

4) Haemoglobin estimation is the most important test, and useful index of the overall state of nutrition.

5) Stool examination for the presence of ova and/or intestinal parasites

6) Urine examination and microscopy for albumin sugar and blood.

7) Vitamins, minerals (> 5 gm in the body) and trace elements (< 5 gm) assay
C) Clinical examination methods:
 There are a number of physical signs, either specific or non specific, known to be
associated with the status of malnutrition.
 The subject is examined from head to foot in good illumination for presence or
absence of these signs

D) Dietary Assessment:
 Nutritional intake of humans is assessed by different methods. These are:
1. 24 hours dietary recall
2. Dietary record using questionnaire
3. Dietary history since early life
 Nutritional Support
 Nutritional support may range from simple dietary advice to long term total
parenteral nutrition (TPN).
 In between is whole spectrum of clinical conditions that need special nutritional
support
 As we move to right, climbing the scale of severity of disease, we increase the
level of support.
o Daily Energy Requirements: The daily diet should contain enough energy to provide
for the basal metabolic rate and to sustain a level of activity

o Two factors determine your calorie needs:

1. Basal metabolic rate (BMR), (metabolism) is the energy needed to maintain your
body's functions at rest.
• It accounts for 50 to 70% of all the energy you need each day. For example
respiration, circulation, liver, and kidney function.
• Can be calculated from the Harris-Benedict equation

2. Physical activity. Your

 The Harris–Benedict equation

• The Harris–Benedict equations is a method used to estimate an

individual's basal metabolic rate (BMR) and daily calorie requirements.

• The estimated BMR value is multiplied by a number that corresponds to

the individual's activity level.

• The resulting number is the recommended daily calorie (kilocalorie)

intake to maintain current body weight.
 The Harris–Benedict equations

BMR= [10 (weight in kg) + 6.25 (height in cm) – 5 (age in years) + Sex] x L

Sex (Males add 5)

(Females subtract 161)

L= Activity level
 Sedentary = BMR x 1.2
 Lightly Active = BMR x 1.375
 Moderately Active = BMR x 1.55
 Very Active = BMR x 1.725
 Extra Active = BMR x 1.9
BMR calculations

 For example
• We’ll calculate BMR first. I’m going to be using a 25 year old woman who is 68.18 kg and 165.1 cm in
sedentary and moderately active.

BMR = (10 × weight in kg) + (6.25 × height in cm) - (5 × age in years) - 161

BMR = (10 × 68.18) + (6.25 × 165.1) - (5 × 25) – 161= 1427.68 Calorie

Women Her BMR is 1,427.68 . Now she needs to account for her activity level (L).

Rest days = 1427.68 x 1.2= 1,714 calories

Workout days (moderately active)= 1427.68 x 1.55= 2,213 calories

So 1,714 calories she need each day to maintain her weight in rest
and 2,213 calories she need each day to maintain her weight in moderately
active day
 The BMR is affected by:

1. Growing children have increased BMR

2. Exposure to cold increases BMR

3. Exercise increases BMR (table)

4. Starvation decreases BMR

5. Fever increases BMR (12% for each degree Celsius rise in temperature)

6. Hormonal abnormalities (hyperthyroidism increases & hypothyroidism decreases BMR)

 Weight Changes
A) Weight Loss:
 Weight loss occurs when energy consumed is greater than energy intake.

 First loss occurs from stored carbohydrates and an initial loss of tissue proteins.

 However, adaptation quickly takes place to conserve protein, and the adipose tissue fat
becomes the predominant source of missing energy.

 Adipose tissue contains roughly 85% TAG and 15% water, so 1 Kg of adipose tissue can be
metabolized to produce:

1 Kg = 850 gm TAG  850 X 9 Cal/gm = 7650 Cal  7500 Cal/Kg fat

 A person who expends about 7500 Cal more than the dietary intake over a period of time loses
one Kg body weight.
B) Weight Gain:
 It is more complicated to calculate the energy required for weight gain in healthy adult
because the added weight may be adipose tissues or muscles, depending on the individual’s
nutrition, health and activity.
 Gain of 1 kg in adipose tissues requires 7500 Cal. However, energy also is needed to
synthesize the TAG, transport it to the proper location in the body and to store it in the
adipocytes. The amount of energy required for these processes is equal to 7500 Cal for each 1
kg.
 Therefore to gain 1 kg of body weight, a person needs to consume about 15000 Cal more than
the energy expended by the body over a period of time.
 Muscles are composed of roughly 20% proteins and 80% water. To gain 1 kg muscles, 200 gm
protein must be added, which has energetic value 200 X 4 = 800 Cal
 However, additional energy (varies widely) is needed to synthesize and store the protein, and
build the muscle mass. This make the estimate is inaccurate
 Furthermore, weight gain often results in a combination of adipose tissue and muscles
 Nutritional Support for patients
 Patients requirements:

1) Energy: the principal energy sources in the diet are carbohydrates and fats. The entire calories load
may be administered using carbohydrates, but using mixture of carbohydrates and lipids is more
physiological and serves to reduce the volume of diet.

2) Nitrogen: it is recommended that protein intake should constitute 10-15% of the total calorie
requirements

3) Vitamins and trace elements: are micronutrients because they are required in relatively small
amounts. They are used in the make-up of artificial diets.

 Route of administration:

1) Oral feeding: should be used whenever possible

2) Tube feeding: use small nasogastric tubes
3) Parenteral nutrition: