Anthropometry

Anthropometry
• Physical measurement
• Comparing data collected with age and gender
specific standards
• Useful for evaluating over and undernutrition
• Monitors effects of nutrition intervention
• It should be conducted by trained individual for
accuracy
• Are most valuable when accurately measured for a
period of time
 Cont....
• Indicate nutritional status in general but does
not use to identify specific nutritional problem
or deficiencies
 Advantages of anthropometry
1. High sensitivity and specificity
2. Measures many variables of nutritional
significance (ht, wt, BMI, MUAC, TSF, etc)
3. Readings are numerical and gradable on
growth charts
4. Non-invasive
5. Less expansive and require minimal training
 Limitations of anthropometry
1. Inter-observer and intra-observer errors of
measurement
2. Limited nutritional diagnosis
3. Problems with references/standards (local vs
international)
 Medical and social history
• Medical history: diagnosis, past medical and surgical
history, pertinent medications, alcohol and drug
use, drug and nutrient interaction, bowel habits,
use of herbal products and supplements
• Social History: economic status, occupation,
education level, living and cooking arrangements,
mental status, environmental changes, lack of
socialization at meals
• Others: age, gender, AT, NEAT
 Clinical assessment
An essential feature of all nutritional surveys
It is the simplest and most practical method of
ascertaining the nutritional training of a
group/individual
It utilizes a no of physical signs (specific or non-
specific) associated with malnutrition or
deficiency diseases
Signs do not appear unless severe deficiencies
exist
 Cont..
Most signs/symptoms indicate two or more
deficiencies
Examples:
Hair: easily plucked, thin; protein or biotin
deficiency
Mouth: tongue fissuring (niacin), decreased
taste/smell (zinc)
Alimentary
• Abdominal pain, nausea, vomiting
• Changes in bowel pattern (normal or baseline)
• Diarrhea (consistency, frequency, volume, color,)
• Difficulty swallowing (solids vs. liquids, intermittent vs.
continuous)
• Early satiety
• Indigestion or heartburn
• Food intolerance or preferences
• Mouth sores (ulcers, tooth decay)
• Pain in swallowing
• Sore tongue or gums
Neurologic
• Confusion or memory loss
• Difficulty with night vision
• Numbness and/or weakness
Skin
• Appearance of a diagnostic rash
• Breaking of nails
• Dry skin
• Hair loss, recent change in texture
Advantages
1. Fast and easy
2. Inexpensive
3. Non-invasive

Limitations
• Did not detect early cases
 Dietary assessment
• Evaluate what and how much person is eating, as
well as habits, beliefs and social conditions that may
put person at risk
• Estimated by five different methods
1. 24 hour dietary recall method
2. Food frequency questionnaire (FFQ)
3. Dietary history
4. Food dairy
5. Observed food consumption
 24 hour 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
• Requires knowledge of portion sizes
• Require interviewing skills
 Food Frequency 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. It is
inexpensive, more representative & easy to use.
Limitations:
1. Long questionnaire
2. Errors with estimating serving size.
3. Need updating with new commercial food products
to keep pace with changing dietary habits.
 Cont ..
4. Does not provide meal pattern data
Advantages
1. Easily standardized
2. Provides overall picture of intakes
 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
1. The first part includes overall eating pattern
and a 24 hour recall: subjects are asked to
estimate portion sizes in household measures
with the aid of standard spoons and cups,
photographs or food models
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
etc to verify the info given in the first part
Advantages:
It estimates nutrient intake over a long period of
time
Disadvantage
Time consuming
Require trained interviewer
 Food diary
• Food intakes (types and amount) recorded by
client at time of consumption
• Can provide info regarding quantity of food, food
preparation method and meal and snack timing
• Data collected between 1-7 days
• Reliable but difficult to maintain
• Actual food intake influenced by recording process
• Requires literacy skills
 Observed food consumption or nutrient
intake analysis (NIA)
• The most unused method in clinical practice
• Recommended for research purpose
• The meal eaten by individual is weighed and
contents are exactly calculated
• Recorded for at least 72 hours
• If used allows actual observation in clinical settings
• High degree of accuracy but expensive and need
time and effort
 Interpretation of dietary data
Qualitative method
Using food guide pyramid and basic food group
method.
Different nutrients classified into food groups,
servings from each group is determined and
compared with minimum requirement
Quantitative
Using food composition table and DRI: the amount
of nutrients and energy calculated
 Laboratory assessment
Laboratory-based nutritional testing, used to estimate
nutrient availability in biologic fluids and tissues, is
critical for assessment of both clinical and subclinical
nutrient deficiencies.
• Diagnose diseases
• Evaluate treatment plans,
• Monitor medication effectiveness, and
• Evaluate medical nutrition therapy (MNT).
• Helps in planning nutritional before frank deficiency
Occurs.
• Provide information about protein-energy
nutrition, vitamin and mineral status, fluid and
electrolyte balance, and organ function.
• Acute illness or injury can trigger dramatic
changes in laboratory test results, including
rapidly deteriorating nutrition status.
• Mostly based on analyses of blood or urine
samples
• Other specimen used are skin, hair, nails,
saliva, stool, tissues for biopsy and sweat
 Factors affecting laboratory assessment

• Patient‘s current medical condition, medications,

• Lifestyle choices,
• Age of the patient,
• Hydration status,
• Fasting status at the time of the specimen
collection, and
• Reference standards used by the clinical
laboratory.
 Advantages of Biochemical Methods

• It is useful in detecting early changes in body

metabolism & nutrition appearance of overt
clinical signs.
• It is precise, accurate and reproducible.
• Useful to validate data obtained from dietary
methods 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
 NCP
• Nutrition care is an organized group of activities
allowing identification of nutritional needs and
provision of care to meet these needs
Includes four steps:
• Assessment of nutritional status,
• Diagnosis (problems),
• Interventions,
• Monitoring and Evaluation
Referred to as ADIME
 3. Nutrition Diagnosis
• Using the available data, nutrition problems or
needs are identified, prioritized, and
documented in the medical record.
• Standardized formats are used to facilitate
communication of information gathered in the
nutrition assessment and nutrition diagnosis.
• It includes identification of the problem,
etiology, and signs/symptoms (PES)
 Nutrition Intervention
• Nutrition problem is identified and objectives
determined accordingly
• Translates assessment data into activities that will meet
the established objectives
• The care process is a continuous one: the initial plan
may change as
1. The condition of the patient changes
2. New needs are identified, or
3. The patient does not respond to interventions
implemented.
 Cont..
Interventions may include:
1. Food and nutrition therapies (changing the diet
prescription, providing food or nutrition
supplements, initiating a tube feeding for a
patient who cannot eat)
2. Nutrition education,
3. Counselling,
4. Coordination of care such as providing referral
for financial or food resources
 Cont..
Interventions should be specific; they are the
"what, where, when, and how" of the care plan.
Example: PEM
Objective: to increase protein caloric intake
Activities: 1. diet plan provision of high-
calorie, high-protein foods via small, frequent
meals and snacks; or by providing a supplement
or milk shake between meals
 Cont..
2. Plans should be communicated to the health
care team and the patient to ensure
understanding of the plan and its rationale.
 4. Monitoring and Evaluation of Nutrition Care

• This step makes the nutrition care plan dynamic and

responsive to the patient's needs.
• If objectives are written in measurable behavioural
terms, evaluation becomes relatively easy
• Interventions needs to be monitored to ensure that
the goal of nutrition care is met or not
• If not or new needs identified, NCP will be repeated
 Example:
• JW is a 70-year-old white man admitted for
cardiac bypass surgery. The nutrition risk
screen reveals that he has lost weight without
trying and has been eating poorly for several
weeks before admission, leading to referral to
the registered dietitian (RD) for nutrition
assessment
 Assessment
1. Laboratory data and medications:
Glucose and electrolytes: within normal limits
(WNL)
Albumin: 3.8 g/dl
Cholesterol/triglycerides: WNL
2. Anthropometric data:
Height: 70"
Weight: 110 lb (15 lb weight loss over 3 months
 Cont..
3. Medical history:
• History of hypertension, thyroid dysfunction,
asthma,
• prostate surgery
• Medications: lnderal
Psychosocial data:
• JW lives alone in his own home. He lost his wife 3
months ago, and for the past 6 months he rarely
sits down to a cooked meal
 Cont..
4. Nutrition interview findings:
• Caloric intake: 1200 kcal/day (less than energy
requirements as stated in the recommended
dietary allowances)
• Meals: irregular throughout the day; drinks
coffee frequently
 Nutritional diagnosis
Nutrition Diagnosis 1: Involuntary weight loss

Objectives:
I. During the hospitalization, will maintain his current
weight; following discharge he will begin to slowly
gain weight up to a target weight of 145 lb.
II. JW will modify his diet to include adequate calories
and protein through the use of nutrient-dense foods
to prevent further weight loss and eventually
promote weight gain.
Nutrition Diagnosis 2: Inadequate oral food and
beverage intake
Objectives:
I. While in the hospital JW will include nutrient-
dense foods in his diet, especially when his
appetite is limited.
II. Following discharge JW will attend a local
senior center for lunch on a daily basis to help
improve his socialization and caloric intake.
 Cont..
• one goal would be to increase JWs caloric intake by 300-500
kcal/day to facilitate weight gain
• Goals must be agreeable to the patient
• Offer several choices to the client to choose
• Objectives should reflect the educational level and the economic
and social resources available to the patient and the family.
• Objectives should also be stated in quantifiable terms to facilitate
evaluation.
• For example, a patient-centered objective in this case would be:
"After instruction JW will be able to identify three nutrient-dense
foods."
 Monitoring
• weekly weight measurements and nutrient
intake analyses while he is in the hospital
• biweekly weight measurements at the senior
center or clinic when he is back at home.
 Evaluation
• It will provide the RD with information on
outcomes.
• If nutrition status is not improving, (evidenced
by JWs weight records), and the goals are not
being met'
• Reassess JW and perhaps develop new goals
and definitely create plans for new
interventions
 Documentation: the nutrition care record

• It is important in all aspects of the care plan.

• It ensures communication between all disciplines
involved in the care of the patient or client.
• The medical record is a legal document; if
interventions are not recorded, it is assumed that they
have not occurred.
• The medical record serve as a communication tool,
verifying important information for evaluation of
health care delivery, as well as for accreditation and
peer review
 Advantages
1. Ensures that nutrition care will be relevant,
thorough, and effective by providing a record
that identifies the problems and sets criteria
for evaluating the care
2. Allows the entire health care team to
understand the rationale for nutrition care,
the means by which it will be provided, and
the role each team member must play to
reinforce the plan and ensure its success
 Cont..
It includes
1. Sections for physician orders,
2. Medical history and physical examinations,
3. laboratory test results,
4. consults and progress reports
• Can either be paper based or electronic as electronic
health records (EHRs) that offer several benefits
over paper charts, including accessibility, legibility,
data management, and efficiency in providing care
 Clinical information systems
1. Electronic health records (EHR): information
system that contain all the health information
for an individual.
2. Electronic medical record (EMR): clinical
information system used by health care
organization to document patient care
3. Personal health record (PFR): a system used
by the consumer to maintain health
information
 Guidelines for documentation
1. All entries should be written in black pen or typewritten
2. Documentation should be complete, clear, concise, objective,
legible, and accurate.
3. Entries should include date, time, and service. Each page should
include the patient's name and hospital number
4. Entries should be in chronologic order and be consecutive.
5. The first word of every statement should be capitalized
6. Complete sentences are not necessary but grammar and spelling
should be correct.
7. All entries should be consistent and non-contradictory.
8. All entries must be signed at the end and should include
credentials (e.g., J. Wilson, R.D.).
9. Medical record entries should always be legible. When
correcting an error, NEVER:
a. Use White-Out, correction tape, or self-adhesive labels.
b. Obliterate an entry by use of a thick marker or pen
strokes.
c. Add notes after the fact without accurately
authenticating, dating, and referencing the original
entry.
d. Remove the original and replace it with a copy
10. Minor errors (e.g., in transcription, spelling,
one word) can be corrected by drawing a
single line through the error, entering the
correction, and initialing and dating the
correction.
 Normal and therapeutic diet
Normal diet
A diet which is designed to meet the needs of
all healthy persons and may not meet the
needs of sick persons
Planned according to the recommended daily
dietary intakes.
Forms the basis of all modifications of diets
for age and sickness
 Modification of normal diet
• Normal diet is modified to feed young
children, elderly members and sick members
of the family.
• The basic objective of diet planning—to
maintain, or restore the good health of the
person through a proper diet.
• The modifications are based on the changed
needs of the individual, due to age or sickness.
The normal diet may be modified in the following ways:
1. Change in consistency of foods (liquid diet, pureed diet, low-fiber
diet, high-fiber diet)
2. Increase or decrease in energy value of diet (weight reduction diet,
high-calorie diet)
3. Increase or decrease in the type of food or nutrient consumed
(sodium-restricted diet, lactose-restricted diet, fiber-enhanced diet,
high-potassium diet)
4. Elimination of specific foods (allergy diet, gluten-free diet)
5. Adjustment in the level, ratio, or balance of protein, fat, and
carbohydrate (diet for diabetes, ketogenic diet, renal diet, cholesterol-
lowering diet)
6. Rearrangement of the number and frequency of meals (diet for
diabetes, post-gastrectomy diet)
7. Change in route of delivery of nutrients (enteral or parenteral
nutrition).
 Therapeutic diet
Diet Therapy is use of appropriate foods as a tool in the recovery
from illness

Therapeutic diets are modifications of the normal diet made in order to meet
the altered needs resulting from disease
Therapeutic diet is planned to meet or exceed the dietary allowances of a
normal person
The aim of diet therapy is to maintain health and help the patient to regain
nutritional wellbeing.
Therapeutic diets consider three aspects:
1. Composition 2. Consistency 3. manner and route
 Food Acceptance in Illness
Illness leads to poor food acceptance due to:
1. Reduced desire or interest in food due to lack of appetite,
gastrointestinal disturbances or discomfort after eating.
2. Reduced appetite due to inactivity.
3. Reduced appetite due to some drugs.
In addition a patient in hospital faces a number of stressors. These
include:
(i) Altered time of eating and rest as compared to home.
(ii) A lot of questions are asked; some of these are very personal.
 Cont..
(iii) Movements to various laboratories for investigations or tests.
(iv) A lot of waiting for tests to be done.
(v) Fear of tests and their results.
(vi) Hospital staff, who monitor the patient, may intrude on privacy.
(vii) Other patients in the ward or room may cause anxiety
In this stressful situation, the only comfort for the patient may
be food
 Modified diets
The type of modification relates to the condition
and need of the individual concerned.
1. Liquid diet
Divided into Clear-liquid Diet and Full-liquid Diet
• Liquid diet helps to maintain liquid and electrolyte balance, relieve thirst
and stimulate the digestion system to function, after an operation or
disturbance in the system due to infection.
• If the fluids are chosen well, the diet can provide 200-500 kcal, some
sodium, potassium and ascorbic acid.
• It does not meet the requirement of most nutrients and is given only for a
day or two during a transient phase before moving on to soft and then full
diet.
A. Clear-liquid Diet or Clear-fluid Diet
 Includes drinks such as tea, coffee, clear fruit juices, coconut water,
sherbets, extracts of dal, rice, popped cereals, fat-free broth,
carbonated drinks.
 Milk is not included, as it is not a clear liquid.
 prohibited items are orange juice; tomato juice; creamy drinks such
as milkshakes, buttermilk or cream;
 Feeds are offered in small portions of about 20-25 ml every hour or
two
 The volume is increased gradually as the condition of the patient
improves.
A clear-liquid diet is given :
(a) For a patient suffering from nausea, vomiting or loss of
appetite (anorexia).
(b) During acute stage of diarrhea
(c) Post-operative first stage,
(d) After tube or parenteral feeding before resuming oral
feeding.
(e) Preparation for colonoscopy
 B. Full liquid diet
• foods included are –liquids and foods which are liquid
at body temperature.
• It can provide adequate nutrition, with the exception
of iron.
• Due to low nutrient-density six or more feedings are
given.
• Skim milk powder is added to increase the protein
content of the diet.
• This diet has high calcium and fat content and is low in
fiber.
Full-liquid diet is prescribed for patients:
(i) post-operatively after clear-liquid diet phase,
(ii) in acute infections of short duration,
(iii) in acute gastrointestinal upset, after clear-liquid diet
phase, and
(iv) in situations when patient is unable to chew food.

The energy content of the diet can be increased by adding

(a) cream to milk,
(b) butter/oil to cereal gruels and dal soups,
(c) glucose to juices, milk,
(d) using cream in desserts.
 Mechanical Soft Diet
• For many people, including infants
• This is also called Dental Soft Diet, those who
cannot chew, due to absence or removal of
teeth or ill-fitting dentures.
• only change made is in the consistency of the
foods served.
• No restriction is placed on food selection.
• The method of preparation or the seasonings
used are not restricted.
 Soft diet
• It is a step between the full liquid and the normal
diet.
• Served to persons: acute infections,
gastrointestinal disturbances or post surgery.
• Diet: soft foods, easy to chew and easy to digest.
• To Avoid: Harsh fibre, fatty or highly spiced
foods are avoided.
It is nutritionally adequate, when planned according
to the Daily Food Guide.
 Foods to Avoid in soft Diet
• Legumes (whole).
• Egg (fried).
• Meat, tough, salted, smoked fish or meat.
• Vegetables and fruits raw, except those mentioned
above; strongly flavoured ones.
• Bread and cereals coarse, with bran, whole-grain
preparations and fatty recipes.
• Soups—fatty or highly seasoned.
• Fats—fried foods, e.g., potato chips.
• Miscellaneous: hot spices, pickles, nuts
 Pureed Diets
• Include foods, which are smooth, soft and need hardly any
chewing.
• These are good for patients who have difficulty in swallowing.
• A pureed diet is in between a full liquid diet and a mechanical
soft diet. 
• All foods (except those that are already soft or smooth) are
blended or pureed in a mixer.
• Liquids are added to get the consistency needed by the
patient.
• To increase calories, fat and/or sugars are added
 Cont..
• Foods to Avoid:
Raw or dried fruits and vegetables, eggs, peanut butter, pasta, rice,
dry bread, cookies, crackers, coconuts, nuts, and seeds.
• Foods Allowed
1. All liquids and beverages (nothing lumpy)
2. Yogurt (without fruit)
3. Pureed cooked fruits
4. Pureed ripe banana
5. Pureed cooked vegetables
6. Cottage cheese
7. Cooked cereals such as cream of rice or cream of wheat, etc
 Bland Diet
• A bland diet includes foods that are soft, not very
spicy, and low in fiber.
• Used alongside lifestyle changes to help treat
ulcers, heartburn, nausea, vomiting, diarrhea,
and gas, stomach or intestinal surgery.
• Such a diet is called bland because
1. It is soothing to the digestive tract (it minimizes
irritation of tissues).
2. In the sense of "lacking flavor"
 Foods you can eat on a bland diet include:

• Milk and other dairy products, low-fat or fat-free only

• Cooked, canned, or frozen vegetables
• Fruit juices and vegetable juices (some people, especially those with GERD, may
want to avoid citrus)
• Breads, crackers, and pasta made with refined white flour
• Refined, hot cereals, such as Cream of Wheat (farina cereal)
• Lean, tender meats, such as poultry, whitefish, and shellfish that are steamed,
baked, or grilled with no added fat
• Creamy peanut butter
• Pudding and custard
• Eggs
• Tofu
• Soup, especially broth
• Weak tea
 Foods to Avoid
• Fatty dairy foods, such as whipped cream or high-fat ice cream
• Strong cheeses, such as bleu or Roquefort cheese
• Raw vegetables
• Vegetables that make you gassy, such as broccoli, cabbage, cauliflower, cucumber, green peppers,
and corn
• Seedy fruits such as berries or figs
• Dried fruits
• Whole-grain or bran cereals
• Whole-grain breads, crackers, or pasta
• Pickles and similar foods
• Spices, such as hot pepper and garlic
• Foods with a lot of sugar in them
• Seeds and nuts
• Highly seasoned, cured or smoked meats and fish
• Fried foods
• Alcoholic beverages and drinks with caffeine in them
Nutritional counselling
• Handling food list and meticulously calculating
diet is not enough
• Produces only first order change- removal of
the symptoms
• Goal: to produce second order change: to
address and change the cause of the problem
• Human nature, will and mental health play a
very important role in change process
 Nutrition counselling
• It is a process, a sequence of events and the elements
of interpersonal relationship between the counsellor
and client.
• Interpersonal relationship: most important aspect,
most difficult to understand and master
• Counsellor: one who can help client explore new ways
of thinking, try new actions, respond to stimuli
differently, choose foods based on new criteria,
handle stress without turning to food, and take more
responsibility for their lifestyle choices.
 Counseling Skills
Counselling skills include:
1. Relationship building skills-empathy, warmth and
genuineness
2. Helping skills- attending, helping a client explore,
active listening responses
3. Ability to gain collaboration and empower the client
4. Sensitivity to multicultural and other client specific
uniqueness .
5. Ability to sustain a long-term counselling relationship
6. Ability to assess and teach developmental skills
• The client has the right and responsibility to
make choices
Therapist's role is:
1. to facilitate the process,
2. help identify the pros and cons of the
various options, and
3. provide step-by-step guidance on how to
get to where they want to be.
To accomplish the facilitator role, the therapist
must become a trainer or coach instead of a
teacher
Nutrition education Psychotherapeutic Counseling
Short-term Open ended
Content-based Process (continuous series of interdependent
events)
Goal-oriented Relationship-oriented
Improve knowledge and skills Resolution of issues and barriers that inhibit a
person from making healthy choices
Work on behaviors Work on thoughts, feelings, behaviors
Address cognitive deficits Addresses motivation, denial, resistance
Success measured objectively Success measured subjectively (e.g., happiness,
(e.g., knowledge, behavior change, mood shift, movement, relationships)
or health parameters
 Ethics and Responsibility
The core of ethical responsibility is to
1. do nothing that will harm the client,
2. allow the clients to make their own decisions
based on good information,
3. be fair and just, and
4. keep your work with them confidential