NUTRITIONAL ASSESSMENT: CLINICAL ASSESSMENT

Rechel Ann Benitez

Lady Heart Canuod
Luoisse Alexa Macadenden,
Jeralvin Natad
Keith Andre Salvador
Rishelle Mae Tolin

BS in Nutrition and Dietetics I

A written report submitted to Prof. Karyne June D. Simon in partial

fulfilment for the course
HE 54 – Basic Nutrition

June 28, 2023

 Table of Contents
Page
Introduction 1
Objectives 1
Clinical Assessment
Physical Examination 2
Medical History 5
Clinical Assessment Advantages and Disadvantages 6
Clinical Assessment Indicators 6
Clinical Signs 6
Conclusion 7
References 8
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Introduction
To be healthy, people need to consume combinations of foods that provide appropriate
amounts of nutrients. Scientists have developed standards for the amounts of nutrients needed
and tools for planning diets to meet these needs. Evaluating the nutritional status of individuals
and populations can identify nutritional needs and be used to plan diets, and through evaluation,
it will give assurance that the needs of an individual or the population are being met. In a clinical
setting, a detailed, systematic assessment of a patient's nutritional status conducted by
healthcare providers in a team-based setting to diagnose malnutrition and identify underlying
pathologies to plan intervention constitutes a nutritional assessment (Kesari and Noel, 2023).

Objectives
At the end of the report, students must be able to:
1. comprehend the importance of evaluating nutritional status of an individual;
2. determine the difference of clinical assessment from other nutritional assessment; and
3. understand the concepts of clinical assessment in assessing nutritional health.
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An individual nutritional assessment helps to determine if a person has a nutrient

deficiency or excess or is at risk of one, or if that individual is at risk of chronic diseases that are
affected by diet. One of the general methods to evaluate nutriture is through clinical assessment
which includes a physical examination to detect physical signs (observations made by a qualified
examiner) and symptoms (manifestations reported by the patient) and medical history. It is most
useful during the advanced stages of nutritional depletion, when overt disease is present (British
Association for Parenteral and Enteral Nutrition, 2022). Moreover, it is the simplest and most
practical method of ascertaining the nutritional well-being of a patient.

A. Physical Examination
According to Claudio and Ruiz (2010), clinical assessment is the physical examination
(P.E.) of an individual for signs and symptoms suggestive of nutritional health and/or clinical
pathology. Signs usually come late in the pathogenesis of a disease, unlike biochemical tests that
can detect early malnutrition states. This is conducted by the physician (or a trained/experienced
clinical staff), which pertains to those changes believed to be related to inadequate nutrition, that
can be seen or felt in superficial epithelial tissues, especially the skin, eyes, hair and buccal
mucosa or organs near the surface of the body. The use of a stethoscope, blood pressure and
pulse rate measurements, height and weight are standard procedures in P.E. charting.

Limitation of Physical Examinations

1. No specificity of the physical signs
Physical signs observed during an examination may not be specific to a particular
nutritional deficiency or condition. For example, dry skin or brittle nails can be indicators
of various nutritional deficiencies or non-nutritional factors. Therefore, relying solely on
physical signs may not provide a definitive diagnosis of a specific nutrient deficiency.

2. Multiple physical signs or co-existing with other deficiencies

Nutritional deficiencies often do not occur in isolation. A patient may have multiple
deficiencies simultaneously or co-existing with other medical conditions, making it difficult
to attribute specific physical signs solely to a particular nutrient deficiency. This
complicates the interpretation of physical examination findings in relation to nutritional
status.

3. Signs may be two: directional (may occur during the development of a deficiency and/ or
recovery)
Some physical signs observed during an examination can occur both during the
development of a deficiency and during recovery. For example, hair loss can be
associated with both acute malnutrition and recovery from malnutrition. This makes it
challenging to determine the exact stage or progression of a nutritional deficiency based
solely on physical examination findings.
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4. Examiner inconsistencies or bias

Physical examinations rely on the skills and expertise of the examiner. However,
there can be variations in the interpretation of physical signs among different examiners,
leading to inconsistencies and potential bias in the assessment. Inter-observer variability
can affect the reliability and accuracy of the assessment, making it important to ensure
standardization and training of examiners.

Variation in the Pattern of Physical Signs

Pattern of physical lesions associated with nutrient deficiencies varies according to:
1. Age 5. Environment
2. Genetic factors 6. Degree, duration and speed of
3. Activity level onset of malnutrition
4. Dietary pattern

Classification of Physical Signs

1. Signs indicating malnutrition - provide valuable information about an individual's nutritional
status. Examples include: poor wound healing, muscle wasting, edema, etc.
2. Signs in combination with other factors - may be influenced by multiple factors, including
nutritional deficiencies and other underlying conditions. They require a comprehensive
evaluation to determine the exact cause.
3. Signs unrelated to nutritional status - can be caused by other factors such as genetic traits,
diseases, or medications.

Source: Irwan – AA Pharmacy (2019)

Further Examples for Physical Indications:

Examine the patient carefully for the following physical indications of malnutrition (Chu &
Delmore, 2020; Cleveland Clinic, 2022):

1. Low body mass index, prominent
bones
2. Muscle atrophy
3. Skin integrity problems, dry, inelastic
skin, rashes, and lesions
4. Subcutaneous fat tissue loss
5. Body temperature that is too low
6. Low blood pressure and heart rate
7. Arms and legs that are thin, with
edema in the belly and face
8. Handgrip strength, weakness, and
weariness
9. Anger, apathy, or inattention
10. Dental problems
11. Brittle hair, hair loss, or loss of hair
color
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These bodily indications, on the other hand, may suggest overnutrition (Chu & Delmore, 2020;
Cleveland Clinic, 2022):

1. Obesity
2. Is adipose tissue equally distributed, concentrated across the upper torso, or
concentrated around the hips?
3. High blood pressure

NOTE: We also can detect nutrient deficiencies with NFPE (Nutrition-Focused Physical
Examination)

a. It is a requirement for all nutritional surveys.

b. It is the simplest and most practical approach of determining a group's nutritional status.
c. It employs a variety of physical symptoms (both particular and non-specific) that are known
to be related with malnutrition and vitamin and micronutrient deficiencies.
d. General clinical examination (similar to physical examination), with specific care paid to
organs such as hair, mouth angles, gums, nails, skin, eyes, tongue, muscles, bones, and
thyroid gland.
e. Detection of relevant signs aids in the establishment of the nutritional diagnosis (by
performing clinical assessments, we learn about the various types of symptoms that cause
nutritional deficiency, and once we identify the symptoms, we can meet the nutritional
diagnoses of the patient).

Techniques based on NFPE:

Source: Raymond and Morrow (2021)

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B. Medical History
Clinical assessment also includes medical history of the client, like past surgeries and
previous diagnoses by other physicians, number of child births (for adult mothers), and disorders
of other family members (parents, siblings, e.g., history of hypertension, cardiovascular accident
and diabetes mellitus). It is a collection of detailed personal information by interview and/or use
of medical records to obtain a comprehensive picture of the person’s health and nutritional status
and their determinants.

Main Information to be Collected:

1. Patient’s description (example: current illness)
2. Personal, social, and medical history (example: use of medications)
3. Review of body’s physiological systems
4. Family medical history
5. Dietary history (example: use of dietary supplements)

Other Patient Information:

1. Birth weight and length
2. Immunization details
3. Lifestyle (example: use of tobacco and drugs, intake of alcohol, level of habitual physical
activity

Other pertinent information for women:

1. Age of menarche
2. History of pregnancy
3. Use of oral contraceptives

This information will establish, whether nutrient deficiency is primary (due to inadequate intake)
or whether it is secondary (due to conditioning factors such as drugs, nutrients and/ or diseases
which interfere with its digestion, absorption, utilization and excretion)

Furthermore, on the book of Grosvenor and Smolin (2010), a medical history is an

important component of a clinical assessment because in relation to dietary needs, it depend on
genetic background, life stage, and health status.

a. Genetic Background
Family history is important because the risk of developing some nutrition-related
diseases is affected by an individual’s genes. For instance, if your mother died of a heart
attack at age 50, you have a higher-than-average risk of developing heart disease. If you
have a family history of diabetes, you have an increased risk of developing this disease.
If both of your parents are overweight it increases the chances that you, too, will have a
weight problem.
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b. Life Stages
Life stage is important because nutrient needs vary at different stages. Pregnant
women need more of some nutrients and energy to support the development of a healthy
newborn. Young infants have higher energy and protein needs per unit body weight than
at any other time of life. The needs of older adults change as their body composition
changes and the ability to digest and absorb certain nutrients declines.

c. Health Status
Existing health conditions also affect dietary needs. Some conditions, such as
arthritis, affect the ability to acquire and prepare food. Others affect the kinds of foods that
should be consumed or the way nutrients are handled by the body. For example,
gastrointestinal disorders may decrease the ability to digest foods and absorb nutrients.
Kidney disease alters the ability to excrete nitrogen and so affects the amount of protein
that should be consumed.

Table 1. Overall pros and cons of clinical assessment

Clinical Assessment
Advantages Disadvantages
Can be performed in a large number of individuals Deficiency may not be clearly manifested – needs
in a short period of time. further investigation
Less expensive; do not require special equipment
Overlapping of deficiency states
or laboratory set-up.
Other clinical staff may perform physical
Bias of observation
examinations given the proper training
Reliability of patient’s recollection and medical
history

Clinical Assessment is based on 3 different indicators:

1. Symptoms - any change in body’s health experienced by an individual

2. Physical Signs - any detectable change in body’s health detected by an individual or the
examiner
3. Functional Test - test which is based on the consequences of body’s function

Categories of Clinical Signs: According to the WHO Expert Committee on Medical Assessment
of Nutritional Status Signs, cited by National Institutes of Health

1. Group 1: Signs that are of value in nutritional assessment.

These are often associated with nutritional deficiency status. Signs of malnutrition
may often be mixed and may be due to the deficiency of two or more micronutrients.

2. Group 2: Signs that need further investigation.

They may be related to malnutrition, perhaps of a chronic type, but are often found
in populations of developing countries where other health and environmental problems,
such as poverty and illiteracy, are co-existent.
 3. Group Three - Signs not related to nutrition
These include physical signs that have no relation to malnutrition, although they
may be similar to physical signs found in persons with malnutrition and must be carefully
delineated from them. This usually takes the particular expertise of a physician or other
health worker expertly trained in nutritional diagnosis.

Selected physical/clinical signs of nutrient deficiencies (partial list)

Source: Claudio and Ruiz (2010)

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Conclusion
In conclusion, every individual has a different nutritional status. One of the ways that one
can assess a person's nutritional status is through a clinical assessment. With the help of
healthcare professionals, dietary evaluations, biochemical tests, and checking for signs of
malnutrition can be performed, and nutrient deficiencies will be identified. Through this,
appropriate interventions will be developed to address these deficiencies. It is crucial to assess
nutritional status accurately to avoid serious implications for an individual's health and well-being.
Therefore, employing reliable clinical assessment techniques is essential to identifying and
managing nutritional deficiencies effectively.
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References

British Association for Parenteral and Enteral Nutrition. (2022, November 2). Nutrition
Assessment. https://www.bapen.org.uk/nutrition-support/assessment-and-
planning/nutritional-assessment?showall=1
Claudio, V. S., & Ruiz, A. J. (2010). Basic Nutrition for Filipinos (6th ed.). Merriam & Webster
Bookstore, Inc.
Grosvenor, M., & Smolin, L. (2010). Nutrition Science & Application (2nd ed.). John Wiley & Sons,
Inc.
National Institutes of Health. (n.d.). Clinical Assessment Nutritional Status.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1775325/pdf/amjph00827-0027.pdf