Nutritional Assessment in Under-fives

Dr. Sunil Malhar Kulkarni

BVDU, CON,Sangli.
1
 Introduction

• Nutrition is science of food and its relationship

to health.
• The nutrients are protein, carbohydrate, fat,
vitamins, minerals, roughage and water.
• The functions of food are , body building,
energy production and protection of health.
• Food is the basic need of human.

2
 Outline of presentation

• Terminology
• Nutritional assessment- definition, goals, purposes
• Techniques of nutritional assessment
• Choice of methods of nutritional assessment
• Methods of nutritional assessment.
• Summary
• Conclusion
• References

3
 Terminology

• Nutritional status : It is result of qualitative

and quantitative food intake and physical
health of individual
• Nutritional status affected by many factors ,
including physiologic, psychical,
developmental, cultural, economic and
geographic.

4
• Optimal nutrition : sufficient nutrients are
consumed
• Under-nutrition: Nutrient intake is inadequate
to meet the day to day need Prone for diseases
• Over-nutrition : consumption of nutrient in
excess of body need . The health problems are
obesity , DM, HTN,stroke , arthritis and gall
bladder diseases.
5
 Definition

• Nutritional assessment is a comprehensive

analysis of a person's nutrition status that uses
historical information , food intake data ,
anthropometric measurements , physical
examination & biochemical data.

6
 Goals of nutritional assessment

1) To identify the presence and type of

malnutrition.
2) To adevise suitable diets as prophylaxis
against disease later in life.

7
 Purposes

1.Identify individuals who are malnourished or

are at risk for developing malnutrition.
2.Provide data for designing a nutrition plan of
care to prevent or treat the development
malnutrition.
3.Establish baseline data for evaluating the
efficacy of nutritional care/ programs .

8
 Techniques of nutritional assessment

• Physical examination
• Interview
• Questionnaire Techniques of assessment
• Observation
• Diaries
• Investigations

9
 Methods of nutritional assessment

1. Anthropometry
2. Biochemical Evaluation
3. Clinical Examination
4. Individual food consumption survey
5. Ecological Studies
6. Functional Assessment
7. Vital and Health Statistics

10
 Methods of nutritional assessment

8. Inventory /log book

9. Dietary assessment
10. Measuring body composition
11. Miscellaneous

***Direct Methods
***Indirect methods

11
The choice of appropriate method for nutritional
assessment
• The purpose for which it is needed
• Level of information -Individual, family,
community, country
• Availability of time
• Availability of resources - trained manpower ,
equipment & transport facility

12
 Anthropometric measurements

a. Height
b. Weight
c. Head circumference
d. Chest circumference
e. Head –chest Ratio
f. Mid arm circumference
g. Hip circumference
h. Waist circumference
i. Hip –waist ratio
j. Skin fold thickness
13
 Height/ length

A wooden measuring board (also called sliding

board) is used for measuring the length of
children under 2 yrs old to the nearest
millimetre

14
15
 Height

•Measured with the child or adult in a standing position

(usually children who are two years old or more).
•Head should be in the frankfurt position(a position
where the line passing from the external ear hole to
the lower eye lid is parallel to the floor) the
shoulders, buttocks and the heels should touch the
vertical stand.
•Either a stadio-meter or a portable anthropo-meter can
be used for measuring.

16
17
• Measuring with measuring tape

18
 Weight

• A weighing sling (spring balance), also called the ‘Salter

Scale’ is used for measuring the weight of children
under two years old, to the nearest 0.1 kg.
• In adults and children over two years a beam balance is
used and the measurement is also to the nearest 0.1 kg.
• In both cases a digital electronic scale can be used if you
have one available.
•Do not forget to re-adjust the scale to zero before each
weighing.
• Weight the child with bare foot.
19
• Weight with beam
scalee

20
• If no salter scale
• Use beam scale /Electronic weighing machine
• Weigh mother with and without child.
• Child weight = weight of mother with child –
weight of mother

21
22
The head circumference (HC)

•Measurement of the head along the supra orbital

ridge (forehead) anteriorly and occipital
prominence(the prominent area on the back
part of the head) posteriorly and both side
upper level of ear pinna
•Measured using flexible, non-stretchable
measuring tape around 0.6cm wide.

23
24
 Chest Circumference
1. Whilst the child is standing, feel for the xiphi-
sternum where the ribs meet the sternum and mark
with a short horizontal line./ Anterior- Line of
nipple and posterior- line of mid scapula
2. Pass the tape around so that the mark is at the upper
border of the tape.
3. Make sure the tape is level. It should rest on the
skin but not indenting it/not pulled too tight.
4. Take the reading at the end of expiration.
5. Measure to the nearest 0.1cm (1mm). Take 3 times
25
26
 Ratio of Head and Chest circumference

a. Head –chest Ratio

27
 Mid arm circumference
An accurate way to measure fat-free mass is to
measure the Mid Upper Arm Circumference
(MUAC).
•The MUAC is the circumference of the upper arm at
the midway between the shoulder tip / acromion
process and the elbow tip / olecrenon process on
the left arm and dividing it by two.
Target Group MUAC/ CM Malnutrition
13-15
Normal
Children under five 11-11.9 Moderate 28
29
 Hip circumference
• - It is measured at the level of the greater
trochanter. (Is measured at the point of greatest
circumference around hips & buttocks to the
nearest 0.5 cm.)

30
31
 Waist circumference
• - It is measured at the level of the umbilicus
and measured at end of normal expiration
• - It gives and indication of the degree of
abdominal obesity.

32
33
 Waist : hip ratio
• To assess body fat distribution whether android
(apple shaped, central, visceral, abdominal)
obesity or gynoid (pear shaped) obesity
– 1.0 or more in men the person is obese .
– If the women .8 or more the women is obese
– High risk WHR= >0.80 for females &
>0.95 for males

34
 Skin fold thickness:
• Measurements provide an estimate of body fat
stores or the extent of obesity or under
nutrition. (Skinfold Caliper device / mm)
• (Biceps, sub-capsular, supra-iliac skin folds).

35
36
 Body mass index (BMI)
• •Body mass index is the weight of a child or
adult in kg divided by their height in metres
squared:
• BMI = Weight (kg) / (Height in metres)2

37
38
 2. Biochemical & Radiological Evaluation
• Important because it can detect preclinical
nutritional deficiencies and can be used to
confirm subjective finding .

39
40
 Clinical /physical examination
• Physical examination can help the assessor
detect signs of nutrition deficiency and fluid
imbalances.
• Clinical signs of malnutrition: signs of
malnutrition tends to appear most often in
parts of the body where cells replacement
occurs at rapid rate such as: eyes hair skin
lips nails tongue

41
42
43
• Ct chart

44
 4 Individual food consumption survey

a. Weighment of raw food

b. Weighment of cooked food
c. Oral questionnaire
Importance
1. Know the dietary pattern and give health
education
2. Give advices to agriculture and food sources
industries
45
 Weighment row or cooked food
1. Convince the housewife of the need of the survey
for the benefit of the family .
2. It should be carried out for 3 to 7 days
consecutively.
3. At least two visits a day for lunch and dinner have
to be made.
4. Two investigators should be available - one talks
and weighs and the other records observations.
5. Both raw and cooked food are weighed.
46
47
3.Oral questionnaire method
• Face to face interview, telephone or by self
administration .
• Describes dietary patterns or food habits not
nutrient intake .
• Semi quantified tools can obtain information on
portion size using household measures .

48
• Food intake questionnaire

49
 Ecological Studies

Food Balance Sheet:

• Supplies are related to census population to

derive levels of food consumption in terms of
per capita supply availability.

Health and Education Services:

• Primary health care services, feeding and

immunization program.
50
Conditioning Influences:

• Parasitic, bacterial & viral infections which

precipitate mal-nutrition among that community.

Socio-Economic Factors:

• Family size, occupation, income, education

customs, cultural patterns in relation to feeding
practice of children, mother etc.
51
52
 Functional Assessment

• The main purpose of these tests are to assess the

degree of alteration in physiological functions
associated with under and malnutrition

53
 Function Nutrient
Reproduction
(Sperm Count) Energy, Zinc
Nerve Function
Nerve conduction Vit. B1,Vit. B12
Dark adaptation Vit. A , Zinc
Hemostasis
Prothrombin time Vit.K
Work capasity
Heart rate Fe
54
 Vital and Health Statistics

• Analysis of mortality and morbidity data will

identify groups at high risk and indicate the extent
of risk to the community.
• Mortality in age group. 1—4 yrs. related to
malnutrition & other nutritional health problem

55
56
 Inventory / log book / food list method

• Carried out at an institutional level

• Actual amount of food stuffs issued by the in
charge of institute are taken into account for
consumption . OR
• Investigator makes two visits,
– One at the beginning of survey-checklist of
food stocks is prepared and handed over to
housewife /in-charge
– Other visit at the end of a week
• Purchased /discarded food is taken into account
57
• Average intake of food/person/ day
= stock at beginning –(minus) stock at
the end of week of week / (divide) total
inmates participating in meal x (multiply)
number of days of survey

58
Nutritional intake of
human is assessed by
five different methods .
These are

1. 24 hours dietary
recall
2. Food frequency
questionnaire
3. Food history since
early life
4. Food diary technique
5. Observed food
consumption
59
 A trained
interviewer asks the
subject to recall all
food and drinks
taken in previous 24
hours

60
 This method is
subject is given a list
of around 100 food
items to indicate
child’s intake
(frequency and
quantify) per / day /
week/ month.

61
 D

Usual food intake pattern of individual over long

period of time
The first part establishes the overall eating
pattern and includes a 24 hours recall questions
such as what was breakfast, lunch dinner
yesterday. The household measures.
Second part – Every food item is clarified and
verified with individual

62
Food intake (types and amounts) should
be recorded by the subject at the time of
consumption.
The length of the collection period range
between 1-7 days

63
 The most unused
method in clinical
practice , but
recommended for
research purpose.

Each food item is

weighed and contents
are exacted
calculated.
64
 Measuring body composition

1) Anthropometry (weight, BMI, skinfold thickness,

waist circumference).
2) Isotope dilution.
3) Underwater weighing.
4) Bioelectrical impedance analysis (BIA).
5) Whole body counting.
6) In vivo neutron activation.
7) Dual energy X-ray absorptiometry (DEXA).
8) CT, MRI.
65
1) Isotope dilution (hydrometry)
• - It is used to measure total body water,
allowing estimation of lean body mass

2) Underwater weighing (hydro-densitometry,

hydrostatic weighing)
• - It is used to measure body density,
allowing calculation of body fat

66
3) Bioelectrical impedance
analysis (BIA)
• Produces estimates of total
body water, lean body mass
and fat mass
4) Whole body counting (total
body potassium)
• Measures the amount of naturally
radioactive potassium 40 (40K) in
the body . 67
5) In vivo neutron activation analysis
- By this technique, many elements in the body
can be measured, including C, N, Na, Ca, Cl, P.

6) Dual energy X-ray absorptio-metry (DEXA)

- It is developed originally for the measurement of
bone density and mass

68
 Miscellaneous tests
• - Hand grip strength (hand dynamometry)
• - Several studies have confirmed the
importance of muscle strength as a predictive
factor for malnutrition.
• - It is more useful when taken serially.

69
 • Research Articles
1. Nutritional assessment among children (1–5 years of age) using
various anthropometric indices in a rural area of Haryana, India
. Vikas Gupta1, Suraj Chawla2, Debjyoti Mohapatra3
Year : 2019  |  Volume : 5  |  Issue : 1  |  Page : 39-43
https://www.ijcfm.org/article.asp?issn=2395-2113;year=2019;volume=5;
issue=1;spage=39;epage=43;aulast=Gupta

2. A study on nutritional status and morbidity pattern among primary

school children in Sullia town, South India. Amruth M, Kumar S,
Kulkarni AG, Kamble SV, Ismail IM .
Indian Journal of Basic and Applied Medical Research; September 2015:
Vol.-4, Issue- 4, P. 100-112
https://shridevimedical.org/articles/amruth-sunil-1.pdf
70
3. Study of nutritional assessment of children between 6 months
to 5 years Sunil Pathak1 , Tarun Yadav2 , Charmee Joshi2 ,
Nishant Sharma2* , Sumit Gulabani2 , Dulari Gandhi3
IAIM, 2017; 4(2): 42-52. Page 42
http://iaimjournal.com/wp-content/uploads/2017/02/iaim_2017_0
402_08.pdf

4.  A comparative study to assess nutritional status among 3 to 5

years children of working and non-working
mothers. Ranjane Bhagyesh Vijay*, Kulkarni Sunil Malhar
https://www.indianjournals.com/ijor.aspx?target=ijor:ijone&volu
me=10&issue=4&article=006

71
 Summary

• Today we have discussed nutritional

assessment by anthropometry, clinical
assessment, bio-chemisty, and inventory.

72
 Conclusion

• Nutritional assessment tool are useful for

apply nursing process health of disease status.
• It is also useful for nutritional education,
evaluation of nutritional services, data for
research and planning of nutritional programs.

73
 References
1. Ghai O P, Paul V K, Bagga A. Essential Pediatrics. 7 th Ed. New Delhi: CBS
Publishers & Distributors PVT.LTD; 2010.pg.57-76

2. Park K. Preventive and Social Medicine.22 nd ed. Jabalpur: M/S Banarasidas

Bhanot Publishers; 2013.Pg. 500-504 &563-620

3. Moore M C.Mosbey’s Nutritional Assessment and Care.6 th ed.Missouri; Mobey

Elsever Publisher;2018.Pg.41-63 https://www.amazon.in/Mosbys-Pocket-

Nutritional-Assessment-Nursing/dp/0323052657?asin=0323052657

&revisionId=&format=4&depth=1
4. NHANES.Antropomety Procedure Manual. CDC publishers; 2019. Pg. 2-20.

5. https://www.slideshare.net/soharashed/assessment-of-nutritional-status

6. https://www.slideserve.com/tammy/nutrition-assessment-dietary
74
• Dr.Smt Sudha Raddi, Principal, KLEU,INS,Belgavi

• Prof.Mrs.Sumitra.A. Dean, & HOD,Child Health Nsg.

• Dr.Mrs.Nililima Bhore Dean & Principal.BVDU,CON,Sangli

& All My Dear Students 75