PRINCIPLES OF NUTRITIONAL

ASSESSMENT
Objective: Introduction to basic concepts in nutritional research and
assessment methods.
Dr. Dalal U.Z. Alkazemi
Associate Professor
College of Life Sciences
Kuwait University
Email: dalal.alkazemi@ku.edu.kw
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Nutritional Assessment
• 1932 - (Health Organization of the League of Nations); survey populations on a
national basis assessing nutritional status.
• 1955 -(Interdepartmental Committee on Nutrition for National Defense- ICNND);
surveys- poor countries identify nutritional problems.
• 1963 – ICNND manual standardized methodology for data collection and
interpretation.
• 1966- WHO Expert Committee on Medical Assessment of Nutrition Status; 2nd
publication on nutritional assessment of the nutritional status of vulnerable groups
in low- income countries.
• Surveillance systems encompass all age groups; chronic diseases prevention.
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Nutritional Assessment
o is the process of identifying characteristics known to be
associated with nutrition problems.
o purpose: is to identify populations, sub-groups or
individuals who are malnourished or at nutritional risk; and
make decisions about the underlying cause of the problem.
o process: obtaining, verifying, and interpreting data.
o can take place for a nation, region, ethnic group, research
cohort or individual.
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Fig 1- What information needed for

the interpretation of Nutritional Assessment?

Dietary Biochemical
Nutritional history /current intake Lab tests

Nutrition
Assessment
Clinical
Anthropometric Physical exam
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Components of Nutritional Assessment

- Medical history and current medical record

• Clinical issues Consider/integrate
• Medications these when assessing
• Social issues diet, anthropometry,
• Previous management biochemistry

- Anthropometry
- Biochemistry Often referred to as
- Clinical/Physical examination the ABCD’s of
- Diet history/diet nutritional
assessment
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Nutritional Assessment Methods

Direct Methods
Dietary methods
 Laboratory methods
 Anthropometric methods
 Clinical methods
Indirect Methods
 Ecological studies (community health indices that reflect nutritional
influences e.g., per capita income, population density, social habits).
 Functional Assessment
 Vital and Health Statistics (infant mortality, fertility index)
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Nutrition Diagnosis Etiology

Etiologies are grouped by the type of cause or contributing risk factor.
• Beliefs-Attitudes
• Cultural
• Knowledge
• Physical Function
• Physiologic
• Social-Personal
• Treatment
For the following, the category alone may be the cause or contributing risk
factor of the Nutrition Dx (diagnosis)
• Access
• Behavior
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Common Parameters
• Anthropometry • Diet
- Height - Energy & protein intake,
- Weight macronutrient distribution
- Usual weight - BEE and TEE
- BMI - Intake vs BEE or TEE as %
- IBW
- Intake relative to DRI values
- % IBW
- % usual wt
- Etc………
- Skinfold assessments
- Circumferences
- Body composition
- Etc……
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Common Parameters
• Biochemistry • Physical Exam
• Serum albumin • Skin, Nails, Hair, Lips
• TIBC, transferrin, ferritin • Gums, Teeth, Tongue
• CBC • Eyes, Nose
• Nitrogen balance • Neck
• Creatinine clearance • GI
• Creatinine height index • Edema
• Liver function tests • Muscle
• Hematology in depth • Bone
• Chemistry in depth • CNS
• Disease specific tests • Breathing rate
• Etc………….. • Etc……………………
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Nutrition Screening vs. Assessment

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Validated Nutrition Assessment Tools

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Validated Nutrition Screening Tools

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Critical thinking skills are needed to:

• Determine appropriate data to collect
• Identify the need for additional data
• Select nutrition assessment tools and procedures that match
the situation
• Identify and use the appropriate measurement or data
collection tools
• Select appropriate data collection procedures
• Identify the appropriate comparative standards
• Recognize relevant and important data
• Determine the process for validating data (e.g., from patient
interview, medical record, surveillance report)
 Prepared by Dr. Dalal U.Z. Alkazemi, Kuwait University
Nutritional Assessment (Stages)
Initial Assessment
• Determine whether nutrition diagnosis
(problem) exists
• Identify the need for additional
information
• Determine if the patient or group
requires nutrition care at this time
15
Re-Assessment
• Determine whether the monitoring and evaluation
parameters previously identified have changed
• Identify the status of the previous nutrition
diagnosis using the following language:
- no improvement/improvement, diagnosis no longer appropriate, resolved
• Ask if there is a new nutrition diagnosis (problem)?
• Determine whether additional data of any kind is
needed
• If goals were met and no further care is needed,
patient can be discharged from care.
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Nutrition Assessment Data comes from two sources:

1. Health Record System:
– Laboratory data
– Medical diagnoses
– Epidemiological studies
– Administrative reports

2. Created during assessment, to be added to medical record

– Nutritional intake
– Current anthropometric measures
– Additional client history gathered in interview
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Nutrition Care Indicators

are markers that can be observed and measured
• Food/Nutrition Related History
• Anthropometric measurements
• Biochemical data, Medical tests and Procedures
• Nutrition-Focused Physical Findings
• Client history
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Nutrition Care Indicators

When assessing a nutrition indicator, compare current data against a
• Nutrition prescription
• Reference standard or comparative standard
– National Standards for populations such as DRIs, US Dietary Guidelines
– Guidelines for specific disease conditions, e.g., A.S.P.E.N., E.S.P.E.N.,
U.S. National Kidney Foundation
– Institutional Standards, e.g., established guidelines specifying weight
change in geriatric clients
– Regulatory standards that are legal boundaries for specific populations,
such as those developed by Joint Commission
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When choosing a Comparative Standard, there are three factors to consider:

2. Population 3. Disease state and

1. Practice setting
characteristics severity

- Acute care - Age - Renal disease

- Long term care - Gender - Diabetes, type and
community severity
- Ambulatory care - Critical illness
Public health
community
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There are a few issues and limitations when using Reference or Comparative
Standards during Assessment:

o Accurate measurement for dietary intake is often difficult due to the

subjective nature of the assessment tools
o The U.S. Institute of Medicine advises combining dietary intake data with
clinical, biochemical, and other supporting information to lend validity to
the nutritional assessment.
o The Reference or Comparative Standards are population based and do not
represent any one individual.
o It is important to understand the population for whom the standard is
developed, e.g., the DRIs are developed for healthy individuals
o The individual or population you are assessing may or may not be healthy
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Important to Remember:
An assessment of inadequate intake does not always lead to
nutrient deficiency
• Inadequate intake should be considered in combination with other
factors (such as clinical, biochemical, anthropometric information,
medical diagnosis, clinical status)
• Bioactive substances do not have established DRIs because they are not
considered essential nutrients
- Criteria for evaluation of intake must be the patient/client goal or nutrition
prescription
- Practitioners from countries that do not use the DRIs should refer to their own
established dietary reference standards
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Tool for Assessment

Nutrition Diagnosis Reference Sheets
• Signs
• Symptoms
• Potential etiologies

Matrices
• Nutrition Assessment
– Identifies potential Nutrition Diagnoses by looking at a list of signs and symptoms
• Nutrition Diagnosis Etiology
– Provides options for etiologies in each nutrition diagnosis
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Nutritional Assessment is Used:

• To establish health of individuals or groups
• As a basis for planning or interventions
i.e. how much of a food or nutrient should be used in a research design
or public policy
• To establish entry criteria for:
Intervention studies
Controlled trials
• To determine response to treatment
• To clarify response to other treatments
Post-surgery recovery
Cancer treatment
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Nutrition Assessment Systems

• Cross sectional; baseline or overall nutritional
Nutrition status; 1st step in most investigations, identifies
populations at risk; not acute conditions, snap
Surveys shot.

• Continuous monitoring of selected groups over an

Nutrition extended period of time; can identifies possible
Surveillance causes of both chronic and acute malnutrition.
Monitor efficacy of policies or interventions.

Nutrition • Using established cutoffs (predetermined risk

levels); whole population or targeted groups; less
Screening comprehensive than surveys or surveillance.

• Targeted population identified at risk during survey

Nutrition or screening; includes supplementation,
Interventions fortification and dietary approaches; includes
monitoring and evaluations.
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Evaluation of Nutrition Interventions

1. Within-group distribution of the intervention
• Adequacy evaluation, ex: distributing iron supp to all preschool kids with iron
deficiency anemia; assessing <10% prevalence of anemia met after 2yrs.
• Uncontrolled design cannot infer causality
2. Between-group quasi experimental design
• Plausibility evaluation, only experimental group receives intervention,
control doesn’t.
• Preferably blinded; no randomization, multivariate adjustment
3. Randomized* controlled, double blind experimental trial
• Probability evaluation, *ensures within the limits of chance treatment and
control groups will be comparable at the start of the study.
• Highest level of confidence to infer causality
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1. Dietary 2. Decreased levels

inadequacy in stores
Clinical Setting • Dietary • Biochemical

• High prevalence of protein-energy 3. Decreased levels 4. Decreased

in body fluids functional level in
malnutrition among patients with tissues
• Biochemical
acute traumatic injury, undergoing • Anthropometric
surgery, chronically ill patients and /Biochem
elderly patients. 5. Decreased activity
of nutrient 6. Functional
dependent enzyme change
• Fig 2– Generalized scheme for the or mRNA for some • Behavio/
development of nutritional proteins Physiological
• Biochem molecular
deficiency (adopted from: Gibson P5, table 1.1) technique

7. Clinical 8. Anatomical sign

symptoms • Clinical
• Clinical
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Nutrition Assessment of
patients; when?
• Identify and treat malnourished patients.
• Determine most effective methods to
diagnose, evaluate and monitor nutritional
status.
• Improve techniques for assessing
nutritional status and evaluating nutrition
interventions.
• Maintenance of health, reduction of risk of
chronic disease, detection hazardous or
toxic levels.

Fig 3 - Components of Nutritional Care

Process of Hospitalized patient
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Nutritional Indices and indicators

• Raw measurements have no meaning; combined with indices: age and sex, e.g.
ht-for-age %ile, nutrient density, BMI, etc.
• Indices should be all continuous variables.
• Evaluated at the population level by comparison with established cutoffs or
reference limits.
• Both the index and its reference limit or cutoff become “an indicator”.
• Chosen in relation to study objectives and their attributes.
• Several factors influence magnitude of expected outcome or response of an
indicator.
• Indicators vary in their validity, sensitivity, specificity, and predictive value.
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Validity
• Adequacy with which any measurement, index, or an indicator reflects what its
intended to measure.
• Both systemic or random errors are associated with a measurements; reduce validity.
• Valid measures are free from random and systemic errors and both sensitive and
specific.
• Internal validity – valid only for a particular group of individuals; vs. external validity =
generalizable to wider universe.
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Reproducibility or Precision
• Degree to which repeated measurements of the same variable give the same value.
• Reliability or precision
• Repeated but independent measurements on the same subject or sample.
• Coefficient of variation (CV%): SD*100/mean
• Fxn of random errors that occurs during the actual analytical process and within
subject biological variation in the biochemical measure – cannot be distinguished
from random errors.
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Accuracy
• Statistical sense to describe the extent o which the measurement is close
to the true value.
• Can a measurement be reproducible or precise but not accurate?
• The greater the systematic error or bias in measurements the less
accurate the measurements.
• Important validity both Internally and externally.
• Controlled by using reference materials with certified values for the
nutrients of interest (standards).
• To avoid bias: calibration, blinding, etc.
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Random Error
• Generate deviation from the correct result due to chance alone.
• Lead to imprecise measurement in an unpredictable way = less
certain conclusion.
• Increase variability around the mean, but do not influence mean or
median value.
• 3 main sources:
1. Individual biological variation (major)
2. Sampling error
3. Measurement error
• Increase sample size, use standard techniques and quality control
procedures to reduce this error.
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Systematic Errors or Bias

• A condition that causes a result to depart from the true value in a
consistent direction.
• Affects the mean and median value reducing accuracy.
• No effect on variance = don’t change precision or reproducibility

Type selection bias measurement (or

classification) bias
Occurs where? All types of nutritional assessment systems
Consequence Impossible to generalize results Cannot be removed from
to target population analysis
Examples Self-esteem, referral, Equipment, analytical, social
nonresponse, diagnostic, desirability, interviewer, recall
dropout (table 1.3) (pages 14-5)

Strategy to control Cannot! provide information on Choose appropriate design and

it? dropouts from or refusals of or careful attention to the
failure to continue the study. equipment and method
selected.
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Confounding
• Bias affects the validity of the study= Confounding
variable
masks the true effect
(cigarette
• characteristic or a variable smoking)
distributed differently in the study
and control groups affecting the
study outcome.
• Not the same as outcome modifiers Exposure Disease
or effect modifiers. (coffee (heart
drinking) disease)
• Have to be known and measured to
be controlled for.
• Controlling for confounders or
Figure 1.2- Relationship btn
modifiers can be applied to the exposure, disease and a
design or at the analytical stage. confounding variable
examples? Page 16
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Sensitivity vs. Specificity (table 1.6)

Test Result The True Situation

Malnutrition Present No Malnutrition

Positive True positive (TP) False positive (FP)
Negative False negative (FN) True negative (TN)
Sensitivity (Se) = TP/(TP+FN)
Specificity (Sp) = TN/(FP+TN)
Predictive Value (V) = (TP+TN)/(TP+FP+TN+FN)
Positive Predictive Value (V+) = TP/ (TP +FP)
Negative predictive value (V-) = TN/ (TN+FN)
Prevalence (P) = (TP + FN)/(TP+FP+TN+FN)

Factors modifying sensitivity and specificity? (Page 17)

• Cutoff points, extent of random errors, non-nutritional factors, biological and behavioral processes.