UNIT 4 ASSESSMENT OF NUTRITIONAL STATUS
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1 UNIT 4 ASSESSMENT OF NUTRITIONAL STATUS COMMUNITY HEALTH NUTRITION BSPH 314 CHITUNDU KASASE BACHELOR OF SCIENCE IN PUBLIC HEALTH UNIVERSITY OF LUSAKA 1. Measurement of dietary intake 2. Anthropometry 3. Nutritional indices 4. Growth monitoring INTRODUCTION The nutritional status of an individual is often the result of many inter-related factors. It is influenced by food intake, quantity & quality, & physical health. The spectrum of nutritional status spread from obesity to severe malnutrition Purpose of Nutritional Assessment 1. Identify individuals or population groups at risk of becoming malnourished 2. Identify individuals or population groups who are malnourished 3. To develop health care programs that meet the community needs which are defined by the assessment 4. To measure the effectiveness of the nutritional programs & intervention once initiated 1
2 Methods of Nutritional Assessment Nutrition is assessed by two types of methods; direct and indirect. 1. Direct Methods of Nutritional Assessment These are summarized as ABCD Direct methods deal with the individual and measure objective criteria Indirect methods use community health indices that reflects nutritional influences. 1. Anthropometric methods 2. Biochemical, laboratory methods 3. Clinical methods 4. Dietary evaluation methods 2.Indirect Methods of Nutritional Assessment i. Ecological variables including crop production ii. Economic factors e.g. per capita income, population density & social habits iii. Vital health statistics particularly infant & under 5 mortality & fertility index 1. Anthropometric Methods Anthropometry is the measurement of body height, weight & proportions. It is an essential component of clinical examination of infants, children & pregnant women. It is used to evaluate both under & over nutrition. The measured values reflects the current nutritional status & don t differentiate between acute & chronic changes. 2
3 Weight Height Age Anthropometric Measurements Mid-arm Circumference Skin Fold Thickness Head Circumference Head/Chest Ratio Hip/Waist Ratio A. 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 ASSESSMENT OF NUTRITIONAL STATUS OF CHILDREN 1. History Dietary history of mother & child History of height & weight changes 2. Anthropometric indicators Evidence of deviations from average height & weight Evidence of depletion of fat depots Evidence of decrease in muscle mass 3. Change in psychic reaction 4. Reaction to infection 5. Evidence of specific deficiencies Nutritional indices 3
4 1. WEIGHT-FOR-AGE This index is frequently used as an index of acute malnutrition for children from 6 months to 7 years provided the exact age of the child is known. Weight-for-age, however, overestimates the prevalence of malnutrition in small children because it does not take into account height differences. WEIGHT FOR AGE Malnutrition (Gomez Classification) W/A= W/W(N) x = Normal = 1 st, Mild = 2 nd, Moderate <60 = 3 rd, Severe 2. WEIGHT-FOR-HEIGHT This index has been recommended by theworld Health Organization (WHO) instead of weight-for-age because it differentiates between nutritional stunting, when weight may be appropriate for height, and wasting, when weight is very low for height as a result of deficits in both tissue and fat mass. For children weight-for-height is relatively independent of age between 1 and 10 years and ethnic group for those aged 1 5 years. 2. WEIGHT-FOR-HEIGHT Unfortunately, oedema and obesity may complicate the interpretation of weight-for-height measurements. A further disadvantage is that it classifies children with poor linear growth as normal. Weight-for-height is more sensitive to changes in current nutritional status than height-for-age. 4
5 WEIGHT FOR HEIGHT Wasting W/H= W/W(at same H) x 100 > < 70 = Normal = Mild = Moderate = Severe 3. LENGTH- OR HEIGHT-FOR-AGE Stunting This index has been recommended for use by WHO to detect stunted children in combination with weight-for-height. Stunting is a slowing of skeletal growth and of stature, defined as the end result of a reduced rate of linear growth. 3. LENGTH- OR HEIGHT-FOR-AGE Stunting The condition results from extended periods of inadequate food intake and increased morbidity and hence is an index of chronic nutritional status. The highest prevalence of stunting is between 2 and 3 years of age, whereas it is during the post-weaning period (i.e. from 12 to 3 months) for wasting. HEIGHT FOR AGE Stunting H/A=H/H(N) x 100 > 95 = Normal = Mild = Moderate < 80 = Severe 5
6 Evaluation of anthropometric indices Anthropometric indices can be used to identify malnourished individuals and/or to assess the nutritional status of population groups. Such procedures require the selection of appropriate anthropometric reference data for comparison. Both local and international reference data may be used. Evaluation of anthropometric indices The World Health Organization (WHO) have recommended the use of the United States National Centre forhealth Statistics (NCHS) reference growth data as an international standard for comparisons of health and nutritional status of children among countries Use of an international reference data set for body composition measurements is not appropriate because they are more influenced by ethnic and genetic differences than growth measurements. 1. PERCENTILES Refer to the position of the measurement values in relation to all (100%) of the measurements for the reference population, ranked in order of magnitude. The percentiles often used as cutoff points to classify individuals as at risk to malnutrition are either belowthe 3rd or 5th percentiles or above the 95th or 97th percentiles depending on the reference data. 1. PERCENTILES The percentile for a subject of known age and sex can be calculated exactly, provided the numerical percentile values are available for the reference data. Alternatively, the percentile range within which the measurement of an individual falls can be read from graphs of the reference data. 6
7 2. STANDARD DEVIATION (SD) Standard deviation (SD) score is a measure of an individual s value with respect to the distribution of the reference population. It is recommended for evaluating anthropometric data from developing countries because SD scores can be defined beyond the percentile limits of the original reference data. Cutoff points used with SD scores vary; often scores of below -2.0 are designated as indicating risk of severe protein-energy malnutrition whereas scores above +2.0 are taken to indicate risk of obesity. An important advantage of cutoff points based on SD scores is that the same SD score values (e.g SD) represent the same degree of malnutrition, irrespective of the anthropometric index used (e.g. weight-for-age or weight-for-height) or the age of the child. Standard deviation scores can be calculated for individuals using selected reference standard deviation values and the equation Z-scores are more commonly used by the international nutrition community because they offer two major advantages. i. Using Z-scores allows us to identify a fixed point in the distributions of different indices and across different ages. The Z-score or standard deviation unit (SD) is defined as the difference between the value for an individual and the median value of the reference population for the same age or height, divided by the standard deviation of the reference population. ii.using Z-scores allows us to identify a fixed point in the distributions across different ages. 7
8 3. PERCENTAGE Percentage of the reference median is used as a cutoff point by many of the older classification schemes. For example, a scheme such as the Gomez classification utilizes weight-for-age for the anthropometric index and cutoff points corresponding to <60% severe malnutrition % moderate malnutrition % mild malnutrition. of the Harvard weight-for-age reference median The percentage of the median is defined as the ratio of a measured or observed value in the individual to the median value of the reference data for the same age or height for the specific sex, expressed as a percentage. 3. Cutoff 1. HEIGHT: Measurements For Adults The subject stands erect & bare footed on a stadiometer with a movable head piece. The head piece is leveled with skull vault & height is recorded to the nearest 0.5 cm. 8
9 Nutritional Indices in Adults 2.WEIGHT Use a regularly calibrated electronic or balanced-beam scale. Spring scales are less reliable. Weigh in light clothes, no shoes Read to the nearest 100 gm (0.1kg) 1. Body Mass Index (BMI). The international standard for assessing body size in adults is the body mass index (BMI). BMI is computed using the following formula: BMI = Weight (kg)/ Height (m²) BMI (WHO - Classification) BMI < 18.5 = Under Weight BMI = Healthy weight range BMI = Overweight (grade 1 obesity) BMI >30-40 = Obese (grade 2 obesity) BMI >40 =Very obese (morbid or grade 3 obesity) 2. WAIST CIRCUMFERENCE Waist circumference predicts mortality better than any other anthropometric measurement. It has been proposed that waist measurement alone can be used to assess obesity, and two levels of risk have been identified MALES FEMALE LEVEL 1 > 94cm > 80cm LEVEL2 > 102cm > 88cm Level 1 is the maximum acceptable waist circumference irrespective of the adult age and there should be no further weight gain. Level 2 denotes obesity and requires weight management to reduce the risk of type 2 diabetes & CVS complications. 9
10 Waist circumference is measured at the level of the umbilicus to the nearest 0.5 cm. The subject stands erect with relaxed abdominal muscles, arms at the side, and feet together. The measurement should be taken at the end of a normal expiration. 3. HIP CIRCUMFERENCE Is measured at the point of greatest circumference around hips & buttocks to the nearest 0.5 cm. The subject should be standing and the measurer should squat beside him. Both measurement should taken with a flexible, nonstretchable tape in close contact with the skin, but without indenting the soft tissue. 4. WAIST-TO-HIP RATIO (WHR) Apple vs Pear Obesity Male Female Health Risk Based on WHR 0.95 or below 0.80 or below Low Risk 0.96 to to 0.85 Moderate Risk High Risk i.e. waist measurement >80% of hip measurement for women and >95% for men indicates central (upper body) obesity and is considered high risk for diabetes & CVS disorders. AWHR below these cut-off levels is considered low risk. 10
11 ADVANTAGES OF ANTHROPOMETRY 1.The procedures use simple, safe, non-invasive techniques which can be used at the bedside and are applicable to large sample sizes. 2. Equipment required is inexpensive, portable, and durable and can be made or purchased locally. 3. Relatively unskilled personnel can perform measurement procedures. 4. The methods are precise and accurate, provided that standardized techniques are used. 5. Information is generated on past long-term nutritional history, which cannot be obtained with equal confidence using other techniques. ADVANTAGES OF ANTHROPOMETRY 6. The procedures can assist in the identification of mild to moderate malnutrition, as well as severe states of malnutrition. 7. The methods may be used to evaluate changes in nutritional status over time and from one generation to the next, a phenomenon known as the secular trend. 8. Screening tests, to identify individuals at high risk to malnutrition, can be devised. LIMITATIONS OF ANTHROPOMETRY 1. Inter-observers errors in measurement 2. Limited nutritional diagnosis 3. Problems with reference standards, i.e. local versus international standards. 4. Arbitrary statistical cut-off levels for what considered as abnormal values. 11
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