2-Nutritional Assessment_Biochemical_Clinical_Dietary.pptx

MODULE 1
Introduction to nutrition in emergencies


PART 2: TECHNICAL NOTES

The technical notes are the second of four parts contained in this module. They provide an introduction to nutrition in emergencies. The technical notes are intended for people involved in nutrition programme planning and implementation. They provide technical details, highlight challenging areas and provide clear guidance on accepted current practices. Words in italics are defined in the glossary.


These technical notes are based on the other HTP modules as well as the following references and related Sphere standards in the box below:
• Lancet Nutrition Series, 2008. http://www.thelancet.com/series/maternal-and-child-undernutrition
• Integrated Phase Classification system, www.ipcinfo.org
• SMART guidelines, www.smartmethodology.org
• Young, H., A. Borrel, Hollard, D. & Salama, P. (2004). Public nutrition in complex emergencies. The Lancet, 364: 1899-909. http://www.who.int/hac/techguidance/training/predeployment/Public%20health%20nutrition%20in%20complex%20emergencies.pdf
• Young & Jaspars (2006). The Meaning and Measurement of Malnutrition in Acute Emergencies. Network Paper Number 56. London: ODI. http://www.ipcinfo.org/attachments/Meaning_and_measurement_of_acute_malnutrition_in_emergencies.pdf
• Sphere Handbook, 2011. http://www.sphereproject.org/component/option,com_docman/task,cat_view/gid,70/Itemid,203
• IASC Global Nutrition Cluster, http://oneresponse.info/globalclusters/nutrition/Pages/default.aspx
• Emergency Nutrition Network publication, Field Exchange. www.ennonline.net/fex
• United Nations Office for the Coordination of Humanitarian Affairs, http://www.unocha.org
• Nutrition Information in Crisis Situations, NICS, http://www.unscn.org/en/publications/nics/
• Famine Early Warning System Network (FEWS NET) , http://www.fews.net/Pages/default.aspx


Sphere standards
Food security and nutrition assessment standard 1: Food Security
Where people are at increased risk of food insecurity, assessments are conducted using accepted methods to understand the type, degree and extent of food insecurity, to identify those most affected and to define the most appropriate response.

Food security and nutrition assessment standard 2: Nutrition
Where people are at increased risk of undernutrition, assessments are conducted using internationally accepted methods to understand the type, degree and extent of undernutrition and identify those most affected, those most at risk and the appropriate response.

Infant and young child feeding standard 1: Policy guidance and coordination
Safe and appropriate infant and young child feeding for the population is protected through implementation of key policy guidance and strong coordination.

Infant and young child feeding standard 2: Basic and skilled support
Mothers and caregivers of infants and young children have access to timely and appropriate feeding support that minimises risks and optimises nutrition, healt

1. School of the Public Health Department of Public Health Nutrition Biochemical/Physical, clinical and Dietary methods Dr. Haji Aman (PhD, Ass. Professor in Human Nutrition) February ,2023 AHMC Adama 4/25/24 1 Dr. HAJI AMAN(PhD,Asst.Professor in Human Nutrition)

2. Applications of biomarkers in public health Nutrition surveys Assess overall nutritional status of population Nutrition screening identify persons “at risk” via cut-offs via simple, rapid biomarkers Surveillance Continuous monitoring of nutritional status of selected population groups over time. Monitoring and Evaluation monitor coverage/compliance/use of nutrition policies evaluate efficacy/effectiveness of nutrition intervention programs over time NB: Population-level biomarkers may not provide certainty about an individual’s true status( Ecological fallacy?) 4/25/24 Dr. Haji Aman(PhD & assistant professor of Human Nutrition) 2

3. BIOCHEMICAL / BIOPHYSICAL (LABORATORY) METHODS This involves measurement of either t otal amount of the nutrient in the body , or its concentration in a particular storage site (organ) in the body or in the body fluids. This group includes those that are indicative of defect in intermediary metabolism in other words they occur when there is a biochemical lesion (Depletion). The depletion could be detected by biochemical tests and/or by tests that measure physiological or behavioral functions dependent on specific nutrient . 4/25/24 Dr. HAJI AMAN(PhD,Asst.Professor in Human Nutrition) 3

4. Nutritional Biomarkers 4/25/24 Dr. Haji Aman(PhD & assistant professor of Human Nutrition) 4

5. Definition of a nutritional biomarker A biological characteristic that can be objectively measured and evaluated as an indicator of normal biological processes, pathogenic processes, or responses to nutritional interventions. The value of a nutritional biomarker for public health rests in its ability to accurately assess the nutritional status of populations From BOND 4/25/24 Dr. Haji Aman(PhD & assistant professor of Human Nutrition) 5

6. Biomarker and dietary exposure 4/25/24 Dr. Haji Aman(PhD & assistant professor of Human Nutrition) 6

7. Why use a biomarker to assess dietary exposure? Estimating nutrient intakes at individual level difficult and complex. Relies on respondent’s motivation and ability to accurately describe foods. 24-hr recalls & FFQs rely on memory : often misreporting. Tendency to deviate from “habitual” diet during assessment period, especially when time period is long i.e., “ reactivity bias known as  the observer effect ” Especially difficult to assess “usual intake” over the distant past 4/25/24 Dr. Haji Aman(PhD & assistant professor of Human Nutrition) 7

8. Types of Laboratory assessment using biomarkers Biomarkers of “exposure : food or nutrient intakes Biomarkers of “status ”: body fluids (serum, RBCs, WBCs, urine, breast milk); tissues (hair, nails) 3, Biomarkers of function : measure the extent of the functional consequences of a nutrient deficiency: 4/25/24 Dr. Haji Aman(PhD & assistant professor of Human Nutrition) 8

9. Assessments of Biomarkers 4/25/24 Dr. Haji Aman(PhD & assistant professor of Human Nutrition) 9

10. 1. Biomarkers of exposure Recovery biomarkers : Nitrogen (for protein); , Na, K, iodine: all in 24-hr urines, Doubly-labeled water for short-term energy expenditure, Concentration biomarkers ; Serum carotenoids (fruits + veg): Plasma vit C; fatty acids in adipose tissue Predictive biomarkers : Sucrose in 24 hr urine for sugar intake, Plasma pentadecanoic acid for dairy fat consumption 4/25/24 Dr. Haji Aman(PhD & assistant professor of Human Nutrition) 10

11. Use of fatty acids in adipose tissue as dietary biomarkers of long-term fatty acid intake From TjØnneland et al. (1993) Correlations between fatty acid composition of adipose tissue and fatty acid content of dietary intakes for 86 subjects expressed as % total fat intake 4/25/24 Dr. Haji Aman(PhD & assistant professor of Human Nutrition) 11

12. 2. Biomarkers of “status ” Body fluids (serum, RBCs, WBCs, urine, breast milk); tissues (hair, nails) 4/25/24 Dr. Haji Aman(PhD & assistant professor of Human Nutrition) 12

13. Nutrient/metabolite in fluid : Whole blood: Se; Plasma: Zn, Cu, 25-OHD, Erythrocytes: folate; Leucocytes: vit C, Mg, breast milk: vit A; I; saliva: IgG 4/25/24 Dr. Haji Aman(PhD & assistant professor of Human Nutrition) 13

14. Nutrient/metabolite in tissue : A dipose tissue: fatty acids, vitamin E, Liver: vitamin A, Fe, vitamin E, Bone: Ca, Zn; Hair: Zn, Se; Nails: Se 4/25/24 Dr. Haji Aman(PhD & assistant professor of Human Nutrition) 14

15. Nutrient/metabolites in urine : Nutrients: B-1, B-2, vit C; Se, I, Metabolites: N- methylnicotinamide 4/25/24 Dr. Haji Aman(PhD & assistant professor of Human Nutrition) 15

16. 3. Biomarkers of function Functional biochemical: enzyme stimulation assays; DNA damage; abnormal metabolites Functional physiological Functional behavioral : N.B. Functional physiological and behavioral are more directly related to health status or disease : vision, growth, immune function, cognition 4/25/24 Dr. Haji Aman(PhD & assistant professor of Human Nutrition) 16

17. Factors affecting the validity of static biochemical tests Physiological factors(pregnancy, diurnal variation, homeostatic regulation, physical exercise, age, sex, recent dietary intake) Pathological(inflammatory stress, infection, weight loss) Analytical(sample collection, sensitivity & specificity of the test, hemolysis, sample contamination, accuracy and precision of the method) 4/25/24 Dr. HAJI AMAN(PhD,Asst.Professor in Human Nutrition) 17

18. Load and Tolerance Tests Load Test : This test is usually performed for water-soluble vitamins. The principle is that after loading a person with a dose of the nutrient (vitamin) orally, IM or IV. Then a timed sample of urine is collected and excretion/retention level assessed. In carrying out this test it is assumed that there will be increased retention of the nutrient if the person is deficient of it and vice versa.   4/25/24 Dr. HAJI AMAN(PhD,Asst.Professor in Human Nutrition) 18

19. Tolerance Tests Tolerance Test: This is also called plasma appearance test and is performed based on the assumption that there will be increased absorption of the nutrient if the person is deficient of it. E.g.: absorption of nutrients (Zn, Fe, and Manganese) is increased in the deficiency states. 4/25/24 Dr. HAJI AMAN(PhD,Asst.Professor in Human Nutrition) 19

20. Tolerance Test: Relative dose response test This is also called plasma appearance test and is performed based on the assumption that there will be increased absorption of the nutrient if the person is deficient of it. E.g.: absorption of nutrients (Zn, Fe, and Manganese) is increased in the deficiency states. Baseline blood sample for plasma retinol analysis Oral dose of vitamin A plus high fat snack Second blood sample 5 hr later for retinol analysis RDR (as %) is: (plasma retinol at 5 h – plasma retinol at 0 h) ______________________________________ X 100 % (plasma retinol at 5 h ) Vitamin A replete subjects: RDR = 0 – 14% Vitamin A deplete subjects: RDR > 15% Enhanced response in plasma in deficiency due to increased intestinal absorption 4/25/24 Dr. Haji Aman(PhD & assistant professor of Human Nutrition) 20

21. In vitro tests of in vivo functions A test performed in vitro ("in the glass") means that  it is done outside of a living organism  and it usually involves isolated tissues, organs or cells. NB: Tissues/cells must be isolated and maintained under physiological condition Immune function tests Assess total T-lymphocytes Assess lymphocyte function 4/25/24 Dr. Haji Aman(PhD & assistant professor of Human Nutrition) 21

22. Spontaneous in vivo responses This includes impairment of some body functions resulting from deficiency of a particular nutrient, E.g. Capillary fragility in Vitamin C deficiency Dark adaptation in Vitamin A deficiency Taste acuity in zinc deficiency Muscle function in PEM(Acute malnutrition) 4/25/24 Dr. HAJI AMAN(PhD,Asst.Professor in Human Nutrition) 22

23. Dark Adaptation Threshold (DAT) is a vision test that measures the adjustment of the eye occurring under low levels of illumination. When light enters the eye, it ultimately reaches the rods and cones , which are two types of cells in the retina . The test determines the threshold, or minimum light intensity required to produce a visual sensation in the child's eye. The DAT test lasts for about 10 to 15 minutes. 4/25/24 Dr. HAJI AMAN(PhD,Asst.Professor in Human Nutrition) 23

24. Rapid dark adaptation test: depends on timing of Purkinje shift In dim light wavelength sensitivity of retina shifts such that blue appears brighter than red as rods become activated: normally occurs < 10 mins in dark Test requires: light-proof room; very dim light source; dark, non-reflective work surface, standard X-ray view box; sets of 6 of red, blue, & white discs Method: Subjects adapted to bright-light for 1 min Subject then sits in darkness at table on which coloured discs placed Time taken to accurately separate blue from red chips recorded Advantages/limitations: Only simple equipment needed; fast not very sensitive to early vitamin A deficiency test not appropriate for children < 4y: need to be literate between-examiner variability: inconsistency 4/25/24 Dr. Haji Aman(PhD & assistant professor of Human Nutrition) 24

25. Pupillary threshold test Measures pupillary thresholds: intensity of light at which pupil contracts for high- intensity illuminator under dark adapted conditions using special pair of goggles High scores: reflects a response at a greater light intensity; hence poorer dark adaptability Pupillary threshold of < -0.575 log cd/m 2 normal for children 3-5 y Persons > 3 years can be tested in ~ 20 min in darkened tent Test is noninvasive with minimal co-operation from subjects. Useful in the field. Use of new goggles does not require a dark room 4/25/24 Dr. Haji Aman(PhD & assistant professor of Human Nutrition) 25

26. Dark Adaptometer(DAM) 4/25/24 Dr. Haji Aman(PhD & assistant professor of Human Nutrition) 26

27. Capillary Fragility/resistance test(tourniquet test) Sphygmomanometer cuff above the cubital fossa and raise the pressure to 100 mm Hg (or midway between systolic & diastolic if systolic pressure <100) for 5 - 7' minutes-  deflation  '3 minutes later  count the number of petichea in area of 3 cm diameter, 1 cm below the cubital fossa  Normally it will be upto 10 if more than 20, means platelets or capillary wall defect 4/25/24 Dr. HAJI AMAN(PhD,Asst.Professor in Human Nutrition) 27

28. Scurvy A positive tourniquet test on the right side of a patient with scurvy. Note the increased number of petechial. 4/25/24 Dr. HAJI AMAN(PhD,Asst.Professor in Human Nutrition) 28

29. Muscle strength Testing Dynamometer 4/25/24 Dr. HAJI AMAN(PhD,Asst.Professor in Human Nutrition) 29

30. Muscle strength…… 4/25/24 Dr. HAJI AMAN(PhD,Asst.Professor in Human Nutrition) 30

31. Biophysical Methods These methods include measurement of alterations cell, Organ or tissues structures that are dependent on specific nutrient Bone X-ray = calcium deficiency Corneal impression cytology= Vit. A Buccal smear cytology = Vit.A Hair root morphology =Vitamin A. 4/25/24 Dr. HAJI AMAN(PhD,Asst.Professor in Human Nutrition) 31

32. Calcium Deficiency in Rickets 4/25/24 Dr. HAJI AMAN(PhD,Asst.Professor in Human Nutrition) 32

33. Squamous metaplasia in vitamin A deficiency 4/25/24 Dr. HAJI AMAN(PhD,Asst.Professor in Human Nutrition) 33

34. Functional physiological biomarkers Growth responses Morbidity Diarrhea; Respiratory infections etc Appetite Developmental responses Motor milestones: see WHO data Cognitive function Night blindness test Sleep behavior 4/25/24 Dr. Haji Aman(PhD & assistant professor of Human Nutrition) 34

35. Linear growth velocity from 0 to 6 months of male infants consuming cow’s milk-based formulae ± zinc From Hambidge et al. (1985) 1.3 mg/L 5.8 mg/L mm/y 4/25/24 Dr. Haji Aman(PhD & assistant professor of Human Nutrition) 35

36. ADVANTAGES AND DISADVANTAGES OF BIOCHEMICAL TESTS Advantages Detect sub-clinical Malnutrition Give gradable nutritional Information Are more objective 4/25/24 Dr. HAJI AMAN(PhD,Asst.Professor in Human Nutrition) 36

37. Disadvantages No ideal specimen or storage site Many quality control problems during sample taking, carrying out the test, analysis Etc Some times low values may not have any health Implication No ideal biomarker for each nutrient Need sophisticated instruments Need highly trained staff Involve invasive procedures 4/25/24 Dr. HAJI AMAN(PhD,Asst.Professor in Human Nutrition) 37

38. CLINICAL METHODS #1 This are detection of deviations from the normal state of nutrition just by observing and interpreting clinical signs and symptoms of deficiency or under intake, for instance, see the following 4/25/24 Dr. HAJI AMAN(PhD,Asst.Professor in Human Nutrition) 38

39. MULTINUTRIENT DEFICIENT DISORDERS Marasmus……….Bone and Skin appearance Kwarshiorkor……Pitting Edema, Dermtosis in pressure areas 4/25/24 Dr. HAJI AMAN(PhD,Asst.Professor in Human Nutrition) 39

40. ANGULAR STOMATITIS Bitot`s spot 4/25/24 Dr. HAJI AMAN(PhD,Asst.Professor in Human Nutrition) 40

41. Pellagra and scurvy 4/25/24 Dr. HAJI AMAN(PhD,Asst.Professor in Human Nutrition) 41

42. Marasmus and Kwashiorkor 4/25/24 Dr. HAJI AMAN(PhD,Asst.Professor in Human Nutrition) 42

43. Bilateral edema 4/25/24 Dr. HAJI AMAN(PhD,Asst.Professor in Human Nutrition) 43

44. Koilonychia 4/25/24 Dr. HAJI AMAN(PhD,Asst.Professor in Human Nutrition) 44

45. Can we do nutrition surveys using Clinical signs and symptoms? Palmar pallor Bitot’s Spots Night Blindness Endemicity of goiter among School age children 4/25/24 Dr. HAJI AMAN(PhD,Asst.Professor in Human Nutrition) 45

46. WHO’s Recommendation of using pallor for low Diagnostic Facility Areas No palmar pallor = No problem Moderate palmar pallor = treat with Iron tablet Severe Pallor = Refer 4/25/24 Dr. HAJI AMAN(PhD,Asst.Professor in Human Nutrition) 46

47. Dietary methods 4/25/24 Dr. HAJI AMAN(PhD,Asst.Professor in Human Nutrition) 47

48. M easuring D ietary E xposure 4/25/24 Dr. HAJI AMAN(PhD,Asst.Professor in Human Nutrition) 48

49. Methods Used to Assess Current Intake (Household or national Level) 4/25/24 Dr. HAJI AMAN(PhD,Asst.Professor in Human Nutrition) 49

50. DIETARY METHODS Is the assessment of food availability at national and household level Assessment of past or current intakes of nutrients from food at by individuals or households in order to know food availability, consumption, and nutrient adequacy. At national level:- Food balance Sheet also called National food disappearance data or Food going in to consumption Market data bases(for fortified foods by FDA) 4/25/24 Dr. HAJI AMAN(PhD,Asst.Professor in Human Nutrition) 50

51. Food Consumption at the National Level Is measured based on food balance sheets (disappearance data). Does not measure the food actually ingested by the population. Measure food available for consumption from imports and domestic food production minus the food lost through exports, waste, or spoilage, on a per capita basis. The per capita figures are obtained from the population estimates for the country. 4/25/24 Dr. HAJI AMAN(PhD,Asst.Professor in Human Nutrition) 51

52. Food Balance Sheet Imports; food taken from stocks + Domestic food production Export  Nonfood uses; predictable waste Total food available or Gross national supply Net food supply Manufacturing, storage And Distribution losses Waste Manufacture, storage and distribution Commercial + institutional + Household food purchases Food consumed 4/25/24 Dr. HAJI AMAN(PhD,Asst.Professor in Human Nutrition) 52

53. Food Balance Sheets Divided by 365 4/25/24 Dr. HAJI AMAN(PhD,Asst.Professor in Human Nutrition) 53

54. Food Consumption at the National Level Useful for correlation (ecological) studies. Used to formulate agricultural policies concerned with food production and consumption. Prone to errors 4/25/24 Dr. HAJI AMAN(PhD,Asst.Professor in Human Nutrition) 54

55. National Food Consumption Surveys Using household methods Regular: every 4-10 years Allow for wastage 4-6% in UK 7-35% in USA Can include food consumption of individuals 4/25/24 Dr. HAJI AMAN(PhD,Asst.Professor in Human Nutrition) 55

56. Use of Household Food-Consumption Data Many countries use household methods for their national food consumption surveys . Sampling design must be carefully planned so as to obtain a representative sample of the nation, accounting for influences of socio-economic status, region, season , and weekends. 4/25/24 Dr. HAJI AMAN(PhD,Asst.Professor in Human Nutrition) 56

57. Food Consumption of Individuals Current Intake Assessment methods Weighed food records Observed weighed records Estimated food records (Food Diary method) Past Intake Assessment Methods 24 hours recalls Repeated 24 hour recalls Dietary history Food Frequency Questionnaire(FFQ) 4/25/24 Dr. HAJI AMAN(PhD,Asst.Professor in Human Nutrition) 57

58. M ETHODS U SED TO A SSESS C URRENT I NTAKE AT INDIVIDUAL LEVEL 4/25/24 Dr. HAJI AMAN(PhD,Asst.Professor in Human Nutrition) 58

59. I. Weighed record method : In this method the subject will be asked to weigh whatever he/she consumes including drinks both before cooking and after cooking and the portion sizes he consumed and the left over. Seven-day  records  were historically used as the “ gold standard ” for of the  method  is limited because it would be difficult to always  weigh the foods. Current Intake... 4/25/24 Dr. HAJI AMAN(PhD,Asst.Professor in Human Nutrition) 59

60. Advantages: It is more accurate(considered as gold standard) There is no respondent memory loss Disadvantages High respondent burden Change of the dietary habit during the survey due fear of burden Needs literate and numerate respondents Costly 4/25/24 Dr. HAJI AMAN(PhD,Asst.Professor in Human Nutrition) 60

61. II. Observed Weighed Record Method In this method the investigator him/herself records the amount and type of food consumed by the study subjects over specified period of time. This method is usually applied for disabled people, infants and small children, mentally ill people or institutionalized elderly people or patients admitted to a hospital. Advantage VS disadvantages The same as the observed weighed 4/25/24 Dr. HAJI AMAN(PhD,Asst.Professor in Human Nutrition) 61

62. Food Diary(estimated record) Method In this method the subject/s are asked to record what ever they eat including beverages for specified period of time with estimation of the portion sizes consumed. Advantage May give relatively accurate estimate to the nutrient intake if done properly Disadvantage High respondent burden Literacy and numeracy of subjects needed High coding burden 4/25/24 Dr. HAJI AMAN(PhD,Asst.Professor in Human Nutrition) 62

63. Food diary : record exact amounts of foods consumed 4/25/24 Dr. HAJI AMAN(PhD,Asst.Professor in Human Nutrition) 63

64. Appropriate Applications for Dietary Records Practical dietary assessment method with small numbers of literate, highly motivated subjects: to obtain information about the frequency and consistency of eating To characterize specific food frequencies To determine food quality To calculate nutrient data Optimal method for validating food frequency questionnaires or dietary histories 4/25/24 Dr. HAJI AMAN(PhD,Asst.Professor in Human Nutrition) 64

65. 24 Hours Dietary Recall In this method, the subjects are requested to remember whatever they consumed within the last 24 hours. This involves all beverages, snacks deserts etc. that have been ingested from sunrise time yesterday to Sunrise today. The portion sizes consumed during this time should also be determined by the respondents by assessing them to use either photographs or the common food being consumed at different sizes or by using a line graph etc. Currently- Multiple pass 24 hours is used to improve the quality 4/25/24 Dr. HAJI AMAN(PhD,Asst.Professor in Human Nutrition) 65

66. Multiple-pass-24 hour recall First Pass : Quick List Second Pass : Detailed Description Third Pass : Review 4/25/24 Dr. HAJI AMAN(PhD,Asst.Professor in Human Nutrition) 66

67. Repeated 24 hour dietary Recall The number of days the recall has to be repeated is determined by Nelson’s formula D = r 2 x Sw 2 1-r 2 Sb 2 Where, D = # of days of dietary data collection required Sw = is within person variances of dietary intake Sb = Between person variation of dietary intakes r = correlation between the observed and true mean intake of individuals 4/25/24 Dr. HAJI AMAN(PhD,Asst.Professor in Human Nutrition) 67

68. Repeated 24 hour … cont . For example, for poly unsaturated fatty acids the Sw 2 /sb 2 = 3.5, If we want to get correlation of between measured intake and true intake of 0.9, how many days of data collection are needed? D = r 2 x Sw 2 1-r 2 Sb 2 D= (0.9 x 0.9) X 3.5 = 14.9 =15 days 1-(0.9 x 0.9) 4/25/24 Dr. HAJI AMAN(PhD,Asst.Professor in Human Nutrition) 68

69. Practical activity on Dietary methods #2 How many days of dietary data collection are required to get a correlation of 0.9 between the true and and measured intake using the following Sw 2 /sb 2 for males and females ? Sw 2 /sb 2 Nutrient Male Female Iron 2.35 2.14 Retinol 4.6 4.9 Zinc 2.8 2.2 Protein 1.3 1.7 Energy 0.9 1.4 Fat 1.3 1.5 4/25/24 Dr. HAJI AMAN(PhD,Asst.Professor in Human Nutrition) 69

70. Reasons why a single day assessment does not give the true mean intake ? Day of the week effect Seasonal effects Consecutive /nonconsecutive days Random within person variance Holiday effects(feasts and fasts) 4/25/24 Dr. HAJI AMAN(PhD,Asst.Professor in Human Nutrition) 70

71. Advantages and disadvantages of 24 hours dietary recall method Advantages Relatively cheap  Quick Less respondent burden No chance for the respondents to change their dietary habit The usual intake of a group can be determined from a single 24 hours recall Disadvantages A single day 24 hours recall does not indicate the usual intake of individuals Respondent memory laps Social desirability bias (the flat slop syndrome) Has less precision Accuracy depends on the respondent’s ability to estimate portion sizes 4/25/24 Dr. HAJI AMAN(PhD,Asst.Professor in Human Nutrition) 71

72. II. Dietary history This method is used to assess the nutrient intake of an individual or a group from food over a longer period of time, usually to see the association between diet and disease. 4/25/24 Dr. HAJI AMAN(PhD,Asst.Professor in Human Nutrition) 72

73. Typical dietary history form 4/25/24 Dr. HAJI AMAN(PhD,Asst.Professor in Human Nutrition) 73

74. Typical dietary history form … 4/25/24 Dr. HAJI AMAN(PhD,Asst.Professor in Human Nutrition) 74

75. Advantages and disadvantages of Dietary history Advantages It gives the dietary habits of an individual or a group of people over a longer periods of time It is possible to target the dietary questions to specific dietary habits or intake of specific nutrients of interest Less respondent burden Disadvantages It over emphasizes the regularity of the dietary pattern It is very difficult to validate It needs a very highly trained interviewer It gives just a relative if not an absolute information 4/25/24 Dr. HAJI AMAN(PhD,Asst.Professor in Human Nutrition) 75

76. Food Frequency Questionnaire Assesses energy or nutrient intake by determining the frequency of consumption of a limited number of foods . Consists of a list of approximately 100 or fewer individual foods or food groups (important contributors to energy or nutrients) and a frequency response section. Subjects indicate how many times a day, week, month, or year that they usually consume the foods. 4/25/24 Dr. HAJI AMAN(PhD,Asst.Professor in Human Nutrition) 76

77. Example of semi quantitative FFQ for Vitamin A friendly foods 4/25/24 Dr. HAJI AMAN(PhD,Asst.Professor in Human Nutrition) 77

78. Advantages and Disadvantages of FFQ Advantage s It is usually used for areas where there is a geographically widely scattered study population It is less costly especially if self administered Less respondent burden Disadvantages It is very difficult to develop especially in multi-cultural society where different staple foods are consumed It needs literate and numerate subjects 4/25/24 Dr. HAJI AMAN(PhD,Asst.Professor in Human Nutrition) 78

79. Anthropometric Data Analysis

80. Software used for analyzing Anthropometric data WHO Anthro , is a software which was published in 2006 together with the first set of the WHO Child Growth Standards (i.e. weight-for-age, height-for-age, weight-for-height, BMI-for-age and windows of achievement for six gross motor milestones). In 2008 WHO Anthro was updated to include the second set of attained growth indicators: Head-circumference-for-age, arm-circumference-for-age, triceps and subscapular skinfold-for-age, and to allow users to choose a French or Spanish language version.

81. WHO AnthroPlus was developed to facilitate the application of the WHO Reference 2007 for 5-19 years to monitor the growth of school-age children and adolescents . Thus AnthroPlus facilitates the detection of thinness, underweight, overweight and obesity in individuals and populations from 0-19 years .

82. Other Softwares ENASmart EPINFO

83. WHO AnthroPlus consists of three modules: Anthropometric calculator (AC) Individual assessment (IA) Nutritional survey (NS) Each module has specific functions, i.e. to assess an individual's nutritional status , follow a child's growth from birth to 19 years , and conduct nutritional surveys covering the same age group , respectively.

84. WHO AnthroPlus

85. Data required The child's age weight edema status (yes/no) length/height and type of measurement (recumbent or standing ) for 0-60 months are the basic variables required to derive the nutritional status in terms of weight-for-age, height-for-age and BMI-for-age. For children 61 months and older the "type of measurement " information is not required, hence the box appears greyed out. Tab and Enter keys as well as the mouse-click allow the user to move from one field to the next.

86. The software uses date of birth (DoB) and date of visit (DoV) to derive and display age in years and completed months (total completed months in parenthesis). Age in days is derived using the formula =: Number of months × 30.4375 . For example age in days at 24 months is: 24 × 30.4375 = 730.5 (rounded to 731 days). Given that the WHO standards are in units of days and WHO reference tables are in months , the age information is derived accordingly.

87. Age calculation To apply the WHO standards for 0-5 years the software uses DoB and DoV to calculate the precise age in days: Age (in days) = DoV-DoB To apply the WHO reference 2007 for 5-19 years, the software uses DoB and DoV to calculate the age in months. Age (in months) = DoV-DoB If the exact day of birth is unknown, the user should fill in the year and month of birth and tick the box next to "Approximate date ". When that field is ticked, the software attributes a random day to complete the date of birth. This date is then used to derive an exact age in months.

88. If the year and month of birth are not known the observer is advised to use a local events calendar to identify two events between which the birth took place and thus estimate an approximate month and year of birth A slider control gives the percentile position of the measurement within the range 0-100% The individual module enables the user to collect and save data for children who are repeatedly examined up to the age of 19 years.

89. Local Events Calendar Year & Month of Birth Age in moths Season & legend Legend/crop Local Events 2005 Yekatit Bega Tir 1 Bega Timiket (11) Mewulid (16) Tahisas 2 Bega Kulubi Gabriel (19) Hidar 3 Tseday Michael (12) Tikimit 4 Tseday Land Preparation Eid al-Adha/Arafa (16) Gena (29) Meskerem 5 Tseday Land Preparation New year (01) Meskel (17) Start of schools

90. Length / height Adjustments For children less than 61 months (1857 days), the child's age influences how the software handles the variables Length/Height and Measured . For example, if a child is 24-60 months old (731-1856 days) and has a length measurement, 0.7 cm is subtracted to derive an estimated height. Similarly, if a child is younger than 24 months and is measured standing, the software adds 0.7 cm to derive an estimated length.

91. This conversion applies only to children 0-60 months. If a child belongs to that age group the user must always specify and tick the appropriate button, indicating how the child was measured, i.e. in recumbent or standing position .

92. To enhance validity at data-entry and data-import, the software is programmed to accept the following measurement ranges (inclusive for minimum and maximum limits). Should the user enter a value outside those ranges, the entry field returns to blank.

93. Indicators based on the WHO standards for preschool children and based on the WHO reference for the older children

94. For older children the interpretation of height-for-age and weight-for-age is as for children 0-60 months, However, for BMI-for-age the recommended cut-offs for overweight and obesity are not the same as in preschool children. For children 5-19 years the +1 SD in the WHO reference (equivalent to the 85 th percentile) coincides at 19 years with the adults cut-off of BMI =25 [kg/m2], which is the cut-off for overweight.

95. Similarly, the +2 SD (equivalent to the 97 th centile) coincides at 19 years with the adults cut-off of BMI =30 [kg/m2]==obesity, Consequently the +3 SD cut-off will be considered severely obese ( corresponding to a BMI of above 35 [kg/m2]). For thinness and severe thinness the cut-offs are -2 and -3 SD, respectively

96. No values for z-scores The z-scores appear as not available (NA) when : Child's age is above 120 completed months, consequently weight-for-age is NA Child's age is above 228 completed months, consequently all indicators are NA child's age is unknown, consequently WAZ, HAZ and BAZ are NA

97. Flags and errors When there are errors in measurement, reporting of age, coding, or data entry analysts may get biologically implausible values, Therefore WHO recommends that, for the purpose of the analysis, values outside a certain range should be treated as missing values. These results are flagged and can then be removed from the data set.

98. Flags and error tracking

99. Explanation of flags for people using the WHO Anthro software Code Indicator flagged Error tracking Weight-for­length/height Length/height -for-age Weight-for­age BMI-for-age No indicators flagged 1 Y WHZ flagged 2 Y HAZ flagged 3 Y WAZ flagged 4 Y Y WHZ and HAZ flagged 5 Y Y WHZ and WAZ flagged 6 Y Y HAZ and WAZ flagged 7 Y Y Y WHZ, HAZ and WAZ flagged 8 Y Only BAZ flagged

100. What could the flags indicate

101. Exporting and merging anthropometric data with other data Eliminating Flags/outliers

102. Errors in Dietary Measurement 4/25/24 Dr. HAJI AMAN(PhD,Asst.Professor in Human Nutrition) 104

103. Sources of Errors in Short-Term Recalls and Records Respondent and recorder errors. Interviewer and reviewer errors Nutrient database errors. 4/25/24 Dr. HAJI AMAN(PhD,Asst.Professor in Human Nutrition) 105

104. Errors in dietary surveys result from Response bias Reporting errors ( memory laps ) Change in dietary habit Social Desirability bias (the flat slop syndrome) Interviewer bias Coding and computation errors Wrong weight of foods Wrong frequency of consumption Sampling bias Food tables (nutrient data bases) 4/25/24 Dr. HAJI AMAN(PhD,Asst.Professor in Human Nutrition) 106

105. Thank You 4/25/24 Dr. HAJI AMAN(PhD,Asst.Professor in Human Nutrition) 107