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1.Faculty of MedicineIntroduction to Community Medicine Course(31505201)Unit 2 Nutrition and Nutrition Assessment and DietAssessment of Nutritional Status.Anthropometric Assessment.ByHatim JaberMD MPH JBCM PhD4-10-2016
2.Presentation outlineTimeWhat is Nutritional assessment andWhy?Tools and Methods of NutritionalAssessmentsAnthropometric Assessment : Obesity12:00 to 12:1012:10 to 12:2012:20 to 12:50
3. انتباه ؟؟؟؟؟؟ First assessment (exam)Sunday23-10-201612:00-13:00 في نفس القاعة
4.Quiz 2 minutes سمم وامملرقمم امملجاممعي اممال •3Differences betweenkwashiorkorMarasmus-1-2-3
5.INTRODUCTIONThe nutritional status of an individual is oftenthe result of many inter-related factors.It is influenced by food intake, quantity &quality, & physical health.The spectrum of nutritional status spreadfrom obesity to severe malnutrition
6.What is Nutritional Assessment?“the evaluation of nutrition needs of individualsbased upon appropriate biochemical,anthropometric, physical, and dietary data todetermine nutrient needs and recommendedappropriate nutrition intake including enteraland parenteral nutrition”- American Dietetic Association
7.The purpose of nutritional assessment Identify individuals or population groups at risk ofbecoming malnourished To obtain precise information about the prevalence andgeographic distribution of nutritional problems of acommunity To develop health care programs that meet thecommunity needs To measure the effectiveness of the nutritionalprograms & intervention once initiated
9.Nutritional Assessment Tools• No single / standard way of assessing nutritional status• Various validated assessment tools developed– some disease specific– some age specific• 2 examples– Mini Nutritional Assessment (MNA)– Subjective Global Assessment (SGA)
10.Mini Nutritional Assessment (MNA)• Screening and Assessment tool for the identificationof malnutrition in the elderly• Considers:– Dietary Intake – foods, patterns– Weight change, BMI, Muscle circumferences– Functional impairment, Independence, Livingarrangements– Psychological issues, Self assessment
11.Subjective Global Assessment• Valid assessment tool• Strong correlation with other subjective andobjective measures of nutrition• Highly predictive of nutritional status in a number ofdifferent patient groups• Quick, simple and reliable
12.Subjective Global Assessment…features• Medical History– Weight change– Dietary intake– GI symptoms– Functional impairment• Physical Examination– Loss of subcutaneous fat– Muscle wasting– Oedema and ascites
13.Subjective Global Assessment…ClassificationsABCWell nourishedModerately malnourished orof malnutritionSeverely malnourishedsuspected
14.Full Nutrition AssessmentStep 1…Data collection• Systematic Approach• Assessment based on clinical/psychosocial/physicalinformation––––DietaryAnthropometricBiochemicalPhysical• Including– Subjective (eg. signs/symptoms of nutritional problem, appetite)– Objective (eg. Lab results)
15.Data Collection…An Example… A B C D EABCDEAnthropometryBiochemical DataClinical signs and symptoms, medical conditionDietary IntakeExercise (Energy balance – expenditure)Consider current level, history and changes
17.Methods of Nutritional AssessmentNutrition is assessed by two types ofmethods; direct and indirect.- The direct methods deal with the individualand measure objective criteria,- while indirect methods use community healthindices that reflects nutritional influences.
18.Direct MethodsThese are ABCDE Anthropometric methodsBiochemical, laboratory methodsClinical methodsDietary evaluation methods E Exercise (Energy balance – expenditure)
19.Indirect MethodsThese include three categories:Economic factors e.g. per capita income,population density & social habitsVital health statistics particularly infant &under 5 mortality & fertility indexEcological variables including crop production
21.Anthropometric MethodsAnthropometry is the measurement of bodyheight, weight & proportions.It is an essential component of clinicalexamination of infants, children & pregnantwomen.It is used to evaluate both under & overnutrition.The measured values reflects the currentnutritional status & don’t differentiatebetween acute & chronic changes .
22.Anthropometry for childrenAccurate measurement of height andweight is essential. The results canthen be used to evaluate the physicalgrowth of the child.For growth monitoring the data areplotted on growth charts over a periodof time that is enough to calculategrowth velocity, which can then becompared to international standards
23.Other anthropometric Measurements• Mid-arm circumference• Skin fold thickness• Head circumference• Head/chest ratio• Hip/waist ratio
24.Growth Monitoring ChartPercentile chart
25.Measurements for adultsHeight:The subject stands erect & bare footedon a stadiometer with a movable headpiece. The head piece is leveled withskull vault & height is recorded to thenearest 0.5 cm.
26.Nutritional Indices in Adults• The international standard for assessing body size inadults is the body mass index (BMI).• BMI is computed using the following formula: BMI Weight (kg)/ Height (m²)• Evidence shows that high BMI (obesity level) isassociated with type 2 diabetes & high risk ofcardiovascular morbidity & mortality
27.WEIGHT MEASUREMENTUse a regularly calibrated electronic orbalanced-beam scale. Spring scales are lessreliable.Weigh in light clothes, no shoesRead to the nearest 100 gm (0.1kg)
28.BMI (WHO - Classification) BMI 18.5 Under Weight BMI 18.5-24.5 Healthy weight range BMI 25-30 Overweight (grade 1obesity) BMI 30-40 Obese (grade 2 obesity) BMI 40 Very obese (morbid orgrade 3 obesity)
29.Waist/Hip Ratio• Waist circumference is measured at thelevel of the umbilicus to the nearest 0.5cm.The subject stands erect with relaxedabdominal muscles, arms at the side,and feet together.The measurement should be taken atthe end of a normal expiration.
30.Waist circumferenceWaist circumference predicts mortality better than anyother anthropometric measurement.It has been proposed that waist measurement alonecan be used to assess obesity, and two levels of riskhave been identifiedMALESFEMALELEVEL 1LEVEL2 94cm 80cm 102cm 88cm
31.Waist circumference/2Level 1 is the maximum acceptable waistcircumference irrespective of the adult ageand there should be no further weight gain.Level 2 denotes obesity and requires weightmanagement to reduce the risk of type 2diabetes & CVS complications.
32.Hip CircumferenceIs measured at the point of greatest circumferencearound hips & buttocks to the nearest 0.5 cm.The subject should be standing and the measurershould squat beside him.Both measurement should taken with a flexible,non-stretchable tape in close contact with the skin,but without indenting the soft tissue.
33.Interpretation of WHRHigh risk WHR 0.80 for females & 0.95 formales i.e. waist measurement 80% of hipmeasurement for women and 95% for menindicates central (upper body) obesity and isconsidered high risk for diabetes & CVSdisorders.A WHR below these cut-off levels isconsidered low risk.
34.Anthropometry• Height• Weight• Weight history / pattern(% weight change)• Weight for Height• BMI• Growth Pattern, headcircumference(paediatrics)•••••MAMCTSFWaist circumferenceHip circumferenceWHRBe aware of fluid status,presence of oedema.
35.Anthropometry – Body CompositionMuscle, Fat, Bone, WaterBody Mass:• LBM – Body mass thatcontains small % ( 3%)essential fat[Essential fat Muscle Water Bone]• Fat Free Mass (FFM)Fat Store:• Essential Fat forphysiological function,eg. fat stored in muscle,liver, heart• Storage fat in adiposetissue – visceral fat andsubcutaneous fat
36.ADVANTAGES OF ANTHROPOMETRY• Objective with high specificity & sensitivity• Measures many variables of nutritionalsignificance (Ht, Wt, MAC, HC, skin foldthickness, waist & hip ratio & BMI).• Readings are numerical & gradable on standardgrowth charts• Readings are reproducible.• Non-expensive & need minimal training
37.Limitations of Anthropometry Inter-observers errors in measurement Limited nutritional diagnosis Problems with reference standards, i.e. localversus international standards. Arbitrary statistical cut-off levels for whatconsidered as abnormal values.
39.DIETARY ASSESSMENT• Nutritional intake of humans is assessed byfive different methods. These are:– 24 hours dietary recall– Food frequency questionnaire– Dietary history since early life– Food dairy technique– Observed food consumption
40.24 Hours Dietary RecallA trained interviewer asks the subject torecall all food & drink taken in the previous24 hours.It is quick, easy, & depends on short-termmemory, but may not be truly representativeof the person’s usual intake
41.Food Frequency QuestionnaireIn this method the subject is given a list ofaround 100 food items to indicate his or herintake (frequency & quantity) per day, perweek & per month.inexpensive, more representative & easy touse.
42.Food Frequency Questionnaire/2Limitations: long Questionnaire Errors with estimating serving size. Needs updating with new commercial foodproducts to keep pace with changing dietaryhabits.
43.DIETARY HISTORYIt is an accurate method for assessing thenutritional status.The information should be collected by atrained interviewer.Details about usual intake, types, amount,frequency & timing needs to be obtained.Cross-checking to verify data is important.
44.FOOD DAIRYFood intake (types & amounts) should berecorded by the subject at the time ofconsumption.The length of the collection period rangebetween 1-7 days.Reliable but difficult to maintain.
45.Observed Food Consumption The most unused method in clinical practice, but it isrecommended for research purposes. The meal eaten by the individual is weighed and contentsare exactly calculated. The method is characterized by having a high degree ofaccuracy but expensive & needs time & efforts.
46.Interpretation of Dietary Data1. Qualitative Method•••using the food pyramid & the basic foodgroups method.Different nutrients are classified into 5groups (fat & oils, bread & cereals, milkproducts, meat-fish-poultry, vegetables &fruits)determine the number of serving from eachgroup & compare it with minimumrequirement.
47.Interpretation of Dietary Data/22. Quantitative Method•The amount of energy & specific nutrients in eachfood consumed can be calculated using foodcomposition tables & then compare it with therecommended daily intake.•Evaluation by this method is expensive & timeconsuming, unless computing facilities are available.
49.Initial Laboratory AssessmentHemoglobin estimation is the mostimportant test, & useful index of the overallstate of nutrition. Beside anemia it also tellsabout protein & trace element nutrition.Stool examination for the presence of ovaand/or intestinal parasites• Urine dipstick & microscopy for albumin,sugar and blood
50.Specific Lab TestsMeasurement of individual nutrient in bodyfluids (e.g. serum retinol, serum iron, urinaryiodine, vitamin D)Detection of abnormal amount ofmetabolites in the urine (e.g. urinarycreatinine/hydroxyproline ratio)Analysis of hair, nails & skin for micronutrients.
51.Advantages of Biochemical MethodIt is useful in detecting early changes in bodymetabolism & nutrition before the appearanceof overt clinical signs.It is precise, accurate and reproducible.Useful to validate data obtained from dietarymethods e.g. comparing salt intake with 24hour urinary excretion.
52.Limitations of Biochemical MethodTime consumingExpensiveThey cannot be applied on large scaleNeeds trained personnel & facilities
54.CLINICAL ASSESSMENTIt is an essential features of all nutritionalsurveysIt is the simplest & most practical method ofascertaining the nutritional status of a group ofindividualsIt utilizes a number of physical signs, (specific &non specific),associated with malnutritiondeficiency of vitamins & micronutrients.
55.CLINICAL ASSESSMENT Good nutritional history should be obtained General clinical examination, with specialattention to organs like hair, angles of themouth, gums, nails, skin, eyes, tongue,muscles, bones, & thyroid gland. Detection of relevant signs helps inestablishing the nutritional diagnosis
56.CLINICAL ASSESSMENT• ADVANTAGES–Fast & Easy to perform–Inexpensive–Non-invasive• LIMITATIONS–Did not detect early cases
57.Clinical signs of nutritional deficiencyHAIRProtein, zinc, biotindeficiencySpare & thinProtein deficiencyEasy to pull outVit C & Vit AdeficiencyCorkscrewCoiled hair
58.Clinical signs of nutritional deficiencyMOUTHRiboflavin, niacin, folic acid,B12 , pr.Vit. C,A, K, folic acid & niacinGlossitisBleeding & spongy gumsB 2,6,& niacinAngular stomatitis,cheilosis & fissuredtongueVit.A,B12, B-complex, folic acid leukoplakia& niacinVit B12,6,c, niacin ,folic acid &ironSore mouth & tongue
59.Clinical signs of nutritional deficiencyEYESVitamin A deficiencyNight blindness,exophthalmiaVit B2 & vit AdeficienciesPhotophobia-blurring,conjunctival inflammation
60.Clinical signs of nutritional deficiencyNAILSIron deficiencySpooningProtein deficiencyTransverse lines
61.Clinical signs of nutritional deficiencySKINFolic acid, iron, B12PallorVitamin B & Vitamin CFollicularhyperkeratosisFlaking dermatitisPEM, Vit B2, Vitamin A,Zinc & NiacinNiacin & PEMVit K ,Vit C & folic acidPigmentation,desquamationBruising, purpura
62.Clinical signs of nutritional deficiencyThyroid gland• in mountainous areasand far from seaplaces Goiter is areliable sign of iodinedeficiency.
63.Clinical signs of nutritional deficiencyJoins & bones• Help detect signs ofvitamin D deficiency(Rickets) & vitamin Cdeficiency (Scurvy)
64.Clinical issues to consider:• Medical history, treatment and medications• Significant