Assessment of the Nutritional

Status of the Community

Deepak Joshi
Sumit Karn
 Introduction
• NA procedures were first used in surveys designed to
describe the nutritional status of populations on a
national basis

• The methods used were initially described following a

conference held in 1932 by the Health Organization of
the League of Nations

• In 1955, ICNND was organized to assist low income

countries in assessing the nutritional status of their
populations and to identify problems of malnutrition
and the ways they could be solved
 Introduction….
• ICNND teams conducted medical nutrition surveys in 24
countries

• A comprehensive manual was produced (ICNND, 1963)

with the intention of standardizing both the methods used for
collection of nutrition survey data and the interpretation of
the results

• On the recommendation of a WHO Expert Committee on

Medical Assessment of Nutritional Status, a 2nd publication
was prepared by Jeliffe (1966) in consultation with 25
consultants from various countries
 Introduction…
• Nutrition surveillance system – targeted high
risk population in the past

• Growing awareness of the role of nutrition as a

risk factor for chronic illness- now encompass
all age groups
 Introduction…
• Today, NA in many low income countries
emphasize new simple, non invasive
approaches that can be used to measure the
risk of both nutrient deficits and excesses, as
well as to monitor and evaluate the effects of
nutrition interventions
 Significance of Nutritional
Assessment
“Nutritional assessment is the first step in the treatment
of malnutrition. An optimal scheme of nutritional
assessment enables the clinician to quickly detect the
presence of malnutrition and provides guidelines for
nutritional therapy. Although advanced cases of
malnutrition are often obvious to inspection, nutritional
assessment provides an objective characterization for
the detection of premorbid states.” (Blackburn, 1977)
 What is NA….
• Interpretation of information from dietary,
laboratory, anthropometric and clinical studies
which is used to determine the nutritional
status of individuals or population groups as
influenced by the intake and utilization of
nutrients
 NA System
• Can take one of four forms:
– Surveys
– Surveillance
– Screening
– Interventions
 Nutrition Surveys
• Often assesses by means of a cross sectional survey in a
selected population group

• Survey may either establish baseline nutritional data or

ascertain the overall nutritional status of the population

• Can also identify and describe population sub groups

“at risk” for chronic malnutrition

• Are unlikely to identify acute malnutrition or provide

information on the possible causes of malnutrition
 Nutrition Surveillance
• Continuous monitoring of the nutritional status
of selected population groups

• Differ from NS because the data are collected,

analyzed and utilized over an extended period
of time

• Sometimes, it only involves specific at-risk

sub groups
 Nutrition Surveillance…
• Unlike C/S NS, it identifies the possible causes of
both chronic and acute malnutrition and hence can
be used to initiate intervention measures at either
the population or sub population level

• Additionally, it may include monitoring the effect

of government nutrition policies and evaluating
the efficacy and effectiveness of nutrition
intervention programs
 Nutrition Screening
• Identification of malnourished individuals
requiring intervention can be accomplished by
nutrition screening

• Involves a comparison of measurements on

individuals with predetermined risk levels or
“cutoff” points using measurements that are
simple and cheap and that can be applied
rapidly on a large scale
 Nutrition Screening…
• Can be carried out on the whole population,
targeted to a specific sub population
considered to be at risk, or on selected
individuals

• Measurement generally includes height,

weight, infant feeding practices by self report
from mother
 Nutrition Intervention
• Often target population sub groups identified
as “at-risk” during nutrition surveys or by
nutrition screening

• 3 types of nutrition interventions:

– Supplementation
– Fortification
– Dietary approaches
 NA Methods
Depletion Stage Methods used
• In the past, NA Dietary inadequacy Dietary

systems have Decreased level in

reserve tissue store
Biochemical

focused on Decreased level in body Biochemical

fluids
methods to Decreased functional Anthropometric/Bioche
characterize each level in tissues mical
Decreased activity of Biochemical/Molecular
stage in the nutrient dependent techniques
development of a enzyme or mRNA for
scene proteins
nutritional Functional change Biochemical/Physiologi
cal
deficiency state Clinical symptom Clinical
Anatomical sign Clinical
 Dietary Methods
• First stage of any nutritional deficiency is identified by
dietary methods

• During this stage, the dietary intake of one or more

nutrients is inadequate, either because of a primary
deficiency (low level in the diet) or because of a
secondary deficiency

• Several dietary methods are available, the choice

depending primarily on the objectives of the study and
the characteristics of the study group
 Dietary Methods….
• KAP and reported food related behaviors are
also investigated

• Involves observation as well as in-depth

interviews and focus groups
 Laboratory Methods
• Include both static biochemical and functional
tests

• Static biochemical tests measure either a nutrient

in biological fluids or tissues or the urinary
excretion rate of the nutrient or its metabolite

• Especially useful for second and third stages in

the development of nutritional deficiency
 Laboratory Methods…
• Functional tests can be further categorized into
functional biochemical tests and functional
physiological or behavioral tests

• Example:
– Papillary and visual threshold for Vit. A and taste
acuity for zinc

• Functional tests provide a measure of the biological

importance of a given nutrient
 Laboratory Methods…
• In general, functional physiological tests are
not suitable for large scale nutrition surveys
– Too invasive
– May require elaborate equipment
– Results tend to be difficult to interpret because of
lack of cut off points
– Less responsive than biochemical tests to small
changes in nutritional status
– Other non-nutritional factors may influence the
performance
 Anthropometric Methods
• Involve measurements of the physical
dimensions and gross composition of the body

• Measurement vary with age (and sometimes

with sex and race) and degree of nutrition

• Are particularly useful in circumstances where

chronic imbalance of protein and energy are
likely to have occured
 Anthropometric Methods…
• In some cases, they can detect moderate and
severe degrees of malnutrition but the methods
can not be used to identify specific nutrient
deficiency states

• AM have the additional advantage of providing

information on past nutritional history which
can not be obtained with equal confidence
using other assessment techniques
 Anthropometric Methods…
• Can be performed relatively quickly, easily
and reliably using portable equipment,
provided standardized methods and calibrated
equipment are used
 Clinical Methods
• A medical history and physical examination are
the CMs to detect signs and symptoms associated
with malnutrition

• S/Ss are often non-specific and only develop

during the advanced stages of nutritional
depletion

• For this reason, diagnosis of nutritional deficiency

should not rely exclusively on clinical methods
 Ecological Factors
• NA methods often include the collection of
information on variety of other factors known
to influence the nutritional status of
individuals or population, including relevant
socioeconomic and demographic data
• Variables – HH composition, material resuorces, water
supply and HH sanitation, Health and agriculture
services, Land ownership
• Food prices, Adequacy of food preparation equipment,
degree of food reserves, cash earning opportunities
• % of HH income spent on certain foods
• Data on health and vital statistics
• Proportion of children immunized against measles
• LBW, mothers with breastfeeding
• Non nutritional variables- birth order, breakdown of
marriage, death of either parent, episodes of infectious
diseases, disaster and emergency situation
 NA indices and Indicators
• Raw measurements alone have no meaning unless
they are related to

• Hence, raw measurements derived from each of the 4

methods are often (but not always) combined to form
“indices”

• Examples : Height for age percentile, Mean cell

volume
 Nutritional Indicator Application
Dietary Indicators
Proportion of children with dietary phytate: Zn Assessment of dietary
molar ratios > 15 quality
Proportion of population with nutrient intakes below Risk of dietary inadequacy
EAR
Anthropometric Indicators
Proportion of children (of defined age and sex) with Prevalence of wasting
WHZ < -2SD
Proportion of children (of defined age and sex) with Prevalence of stunting
HAZ < -2SD
Laboratory Indicaors
Prevalence of serum retinol <0.70 umol/L in children 6- Vit A likely to be a PH
71 mo problem
Median urinary iodine < 20 ug/L based on > 300 casual Risk of severe IDD in the
urine samples population
Clinical Indicators
Proportion of children with goitre rate > 30% Severe risk of IDD
Prevalence of maternal night blindness > 5% Vit A is severe PH problem