Assessment of nutritional status of a community _2024.pptx

Assessment

1. Assessment of nutritional status Dr Ekaete Tobin

2. LEARNING OBJECTIVES By the end of this lecture you should be able to: - T o know the different methods for assessing the nutritional status - To understand the basic anthropometric techniques, applications, & reference standards

3. INTRODUCTION Nutritional status of community is sum of the Nutritional status of individuals It is often the result of many inter-related factors which are predominantly influenced by food intake, quantity & quality, & physical health. The nutritional status of an individual is often the result of many inter-related factors. It is influenced by food intake, quantity & quality, & physical health. The spectrum of nutritional status spread from obesity to severe malnutrition

4. Introduction The nutritional assessment is done to obtain information about the prevalence and geographic distribution of nutritional disorders within a community or a specified population group. It can also be used to identify high-risk groups and to assess the role of different epidemiological factors in nutritional deficiencies. Such nutritional assessment has a significant role in policy-making and nutritional recommendations . The goal is not to examine the entire population in the community, but limit the survey to a representative group so that the results can be generalized to the entire community.

5. PURPOSE OF NUTRITIONAL ASSESSMENT To obtain precise information on the Prevalence and Geographical distribution of nutritional problems of a given community. To identify the population group ‘at risk’ or in greatest need of assistance Assess epidemiological contributory factors to nutritional disorders To track child growth To detect practices that can increase the risk of malnutrition and infection To inform nutrition education and counselling To establish appropriate nutrition care plans Evaluate the effectiveness of nutritional intervention

6. 1. Clinical Assessment 2. Laboratory Tests 3. Functional status 4. Anthropometry 5. Dietary Assessment 1. Vital Statistics - Age Specific Mortality - Cause specific Morbidity 2. Ecological factors 6

7. ABCDEFGH of Nutritional assessment A nthropometry B iochemical analysis C linical examination D ietary habits E cological Studies F unctional Assessment H ealth related Vital Statistics Direct methods deal with the individual and measure objective criteria. Indirect methods use community health indices that reflects nutritional influences. The different methods are not mutually exclusive but complementary. 7

8. Direct Methods of Nutritional Assessment Anthropometric methods Biochemical, laboratory methods Clinical methods Dietary evaluation methods

9. Indirect Methods of Nutritional Assessment These include three categories: Ecological variables including crop production Economic factors e.g. per capita income, population density & social habits Vital health statistics particularly infant & under 5 mortality & fertility index

10. METHODS OF NUTRITIONAL ASSSSMENT

11. Clinical Assessment It is an essential feature of all nutritional surveys with the primary goal to assess the health status of individuals or groups within a population in accordance with the type of food consumed.  It can be applied to a large group of the population. However, its limitation is that it cannot quantify the exact level of nutrient deficiency because most of these clinical signs for nutrient deficiency are nonspecific and require biochemical analysis to identify the nutritional status

12. CLINICAL ASSESSMENT It is an essential features of all nutritional surveys It is the simplest & most practical method of ascertaining the nutritional status of a group of individuals It utilizes a number of physical signs, (specific & non specific), that are known to be associated with malnutrition and deficiency of vitamins & micronutrients. The presence of two or more clinical signs of a specific nutritional deficiency increases the diagnostic significance.

13. CLINICAL ASSESSMENT Good nutritional history should be obtained General clinical examination, with special attention to organs like hair, angles of the mouth, gums, nails, skin, eyes, tongue, muscles, bones, & thyroid gland. Detection of relevant signs helps in establishing the nutritional diagnosis Head to toe examination should be performed to detect the signs of nutritional deficiency states such as hair changes, anemia , edema , xerosis , etc

14. CLINICAL ASSESSMENT ADVANTAGES Fast & Easy to perform Inexpensive Non-invasive LIMITATIONS Does not detect early cases

15. CLINICAL EXAMINATION

16. Clinical signs of nutritional deficiency HAIR Protein, zinc, biotin deficiency Sparce & thin Protein deficiency Easy to pull out Vit C & Vit A deficiency Corkscrew Coiled hair

17. CLINICAL EXAMINATION

18. CLINICAL EXAMINATION

19. Clinical signs of nutritional deficiency MOUTH Riboflavin, niacin, folic acid, B12 , pr. Glossitis Vit. C,A, K, folic acid & niacin Bleeding & spongy gums B 2,6,& niacin Angular stomatitis, cheilosis & fissured tongue Vit.A,B12, B-complex, folic acid & niacin leukoplakia Vit B12,6,c, niacin ,folic acid & iron Sore mouth & tongue

20. Clinical signs of nutritional deficiency SKIN Folic acid, iron, B12 Pallor Vitamin B & Vitamin C Follicular hyperkeratosis PEM, Vit B2, Vitamin A, Zinc & Niacin Flaking dermatitis Niacin & PEM Pigmentation, desquamation Vit K ,Vit C & folic acid Bruising, purpura

21. CLINICAL EXAMINATION Body system or Region Signs or Symptoms Implication 1. Conjunctival inflammation : Present or Absent Vitamin A Deficiency 2. Corneal Vascularization : Present or Absent Riboflavin deficiency EYES 3. Xerosis , Bitot’s spot, Keratomalacia : Present or absent Vitamin A Deficiency 4. Night Blindness History : Present or absent Vitamin A and Zinc Deficiency

22. CLINICAL EXAMINATION Body system or Region Signs or symptoms Implication 1 , Glossitis : Present or absent Riboflavin, niacin, folic acid, vitamin B 12 Pyridoxine deficiency 2. Bleeding Gums : Present or Absent Vitamin C , Riboflavin Deficiency MOUTH 3. Chelilosis : Present or Absent Riboflavin, pyridoxine, niacin deficiency 4. Angular Stomatitis : Present or Absent Riboflavin, pyridoxine, niacin deficiency 5. Tongue fissuring : Present or Absent niacin deficiency 6. Tongue Atrophy : Present or Absent Riboflavin, iron, niacin deficiency

23. CLINICAL EXAMINATION Body system or Region Signs or symptoms Implication 6, Magenta Tongue : Present or absent Riboflavin deficiency MOUTH 7. Beefy Red tongue : Present or Absent vitamin B 12 Deficiency 8. Sore mouth and tongue : Present or Absent vitamin B 12 , B 6 Niacin Folic acid Iron And vitamin – C Deficiency 9. Leukoplakia : Present or Absent vitamin B 12 , B complex Niacin, Folic acid And vitamin – A Deficiency

24. CLINICAL EXAMINATION Body system or Region Signs or symptoms Implication MOUTH 10, Naso labial seborrhea : Present or absent Pyridoxine deficiency 11. Hypogeusia : Present or Absent Zinc Deficiency 12 . Poor dentition : Present or Absent Overconsumption of refined sugar or acidic carbonated beverages, illicit drug use NECK 1. Goiter : Present or Absent Iodine deficiency 2. Parotid Enlargement : Present or Absent Protein deficiency THORAX Thoracic Rosary : Present or Absent Vitamin - D deficiency

25. CLINICAL EXAMINATION Body system or Region Signs or symptoms Implication 1, Diarrhea : Present or absent Niacin, folate , vitamin B 12 deficiency ABDOMEN 2.Distension : Present or Absent Protein Energy Deficiency 3.Hepatomegaly : Present or Absent Protein Energy Deficiency EXREMITIES 1. Edema: Present or Absent Protein , Thiamine deficiency 2. Softening of bones : Present or Absent Vitamin - D , Calcium, Phosphorus deficiency

26. CLINICAL EXAMINATION Body system or Region Signs or symptoms Implication 3, Bone tenderness : Present or absent Vitamin – D deficiency 4.Bone ache , Joint Pain : Present or Absent Vitamin - C Deficiency EXREMITIES 5.Muscle wasting & weakness : Present or Absent Protein , Calorie, Vitamin - D, selenium, Sodium chloride Deficiency 6. Muscle Tenderness and Muscle Pain : Present or Absent Thiamine deficiency 2. Softening of bones : Present or Absent Vitamin - D , Calcium, Phosphorus deficiency

27. CLINICAL EXAMINATION Body system or Region Signs or symptoms Implication NAILS 1 , Koilonychia ( Spooning) : Present or absent Iron deficiency 2. Transverse line : Present or Absent Protein Deficiency NEUROLOGIC 1. Tetany : Present or Absent Calcium , magnesium deficiency 2 . Paresthesias : Present or Absent Thiamine , Vitamin - B 12 deficiency 3. Loss of reflexes, Wrist drop, Foot drop : Present or Absent Thiamine deficiency

28. CLINICAL EXAMINATION Body system or Region Signs or symptoms Implication 4, Loss of Vibratory and Position sense : Present or absent vitamin B 12 deficiency NEUROLOGIC 5. Ataxia : Present or Absent vitamin B 12 deficiency 6. Dementia , Disorientation : Present or Absent Niacin deficiency BLOOD 1. Anemia : Present or Absent vitamin B 12 , Folate , pyridoxine, deficiency 2. Hemolysis : Present or Absent Phosphorus , Vitamin - E deficiency

29. Anthropometric measurements The word  anthropometry  comes from two words:   Anthropo  means ‘human’ and  metry  means ‘measurement’.  Anthropometry is the measurement of the size, weight, and proportions of the body. Anthropometric measurements such as height, weight, skinfold thickness and arm circumference are valuable indicators of nutritional status. In young children, additional measurements such as head and chest circumference are made. If anthropometric measurements are recorded over a period of time, they reflect the patterns of growth and development and how individuals deviate from the average at various ages in body size, build, and nutritional status. Anthropometric measurement can be collected by non-medical personnel, given sufficient training. It is the best indicator of nutritional status . Analysis of growth (weight, height, and/or growth velocity) using growth charts remains the simplest tool for assessing changes in the nutritional status in children

30. Anthropometry for children For growth monitoring the data are plotted on growth charts over a period of time that is enough to calculate growth velocity, which can then be compared to international standards.

31. Growth Monitoring Chart Percentile chart

32. Weight a) Weight Weighing is usually the first step in anthropometric assessment and a prerequisite for finding weight-for-height z-score ( WHZ ) for children and BMI for adults. Weight is strongly correlated with health status. Unintentional weight loss can mean poor health and reduced ability to fight infection. Weighing requires a functional weighing scale that measures weight in kg to within the nearest 100 g. Accurate weight measurement is important because errors can lead to incorrect classification of nutritional status and the wrong care and treatment.

33. Weight Birth weight is weight of the child at birth and is classified as follows: more than 2500 grams = normal birth weight 1500–2499 grams = low birth weight less than 1500 grams = very low birth weight Infants with low birth weight (less than 2,500 g) are at higher risk of physical and cognitive impairments and nutrition-related chronic diseases in later life. 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, or digital scale is used and the measurement is also to the nearest 0.1 kg. The scale if a manual one, should be adjusted to zero before each weighing. Also calibrate the scale to be sure it is measuring correctly by weighing an object of known weight.

34. Height / Length   Measuring length or height requires a height board or measuring tape marked in centimeters (cm). Measure length for children under 2 years of age or less than 87 cm long. Measure height for children 2 years and older who are more than 87 cm tall and for adults. The subject stands erect & bare footed on a stadiometer with a movable head piece or portable anthropometer The 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) during measurement, and the shoulders, buttocks and the heels should touch the vertical stand. The head piece is leveled with skull vault & height is recorded to the nearest 0.5 cm.

35. c) Occipitofrontal circumference The OFC is the 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. It is measured to the nearest millimetre using flexible, non-stretchable measuring tape around 0.6cm wide. OFC is useful in assessing chronic nutritional problems in children under two years old as the brain grows faster during the first two years of life. But after two years the growth of the brain is more sluggish

36. d) Mid Upper Arm Circumference ( MUAC ) MUAC is the circumference of the left upper arm measured at the mid-point between the tip of the shoulder and the tip of the elbow, using a measuring or MUAC tape. MUAC is a proxy measure of nutrient reserves in muscle and fat that are unaffected by pregnancy and independent of height. In other words, MUAC Indirectly assess muscle mass and fat stores in the arm providing an idea of protein and energy reserve. MUAC is constant in children between 1 and 5 years, and is not currently recommended for infants under 6 months and should not be used to assess nutritional status in people with oedema.

37. MUAC   Severe acute malnutrition (SAM) Moderate acute malnutrition (MAM) Normal nutritional status 6-59 months < 115 mm ≥ 115 to < 125 mm ≥ 125 mm 5–9 years < 135 mm ≥ 135 to < 145 mm ≥ 145 mm 10–14 years < 160 mm ≥ 160 to < 185 mm ≥ 185 mm MUAC cut-offs to classify nutritional status in children 6 months to 14 years of age

38. MUAC Measuring the MUAC of children A special tape called Shakir’s strip is used for measuring the MUAC of a The tape has three colours, with the red indicating severe acute malnutrition, the yellow indicating moderate acute malnutrition and the green indicating normal nutritional status Interpretation of Mid-Upper Arm Circumference MUAC indicators MUAC < 12.5 – RED COLOUR Severe Acute Malnutrition (SAM). The child should be immediately referred for treatment. MUAC 12.5cm to 13.5cm - YELLOW COLOUR, indicates mild to moderate malnutrition . MUAC > 13.5cm ), GREEN COLOUR, indicates that the child is well nourished.

39. MUAC

40. Body mass index It is a practical marker of optimal weight for height and indicator of obesity or under nutrition. BMI = Weight in (kg ) Height in ( M 2 ) BMI < 18.5 = Under Weight BMI 18.5-24.5 = Healthy weight range BMI 25-30 = Overweight (grade 1 obesity) BMI >30-40 = Obese (grade 2 obesity) BMI >40 =Very obese (morbid or grade 3 obesity)

41. Waist circumference Waist circumference predicts mortality better than any other anthropometric measurement. It has been proposed that waist measurement alone can be used to assess obesity, and two levels of risk have been identified MALES FEMALE LEVEL 1 > 94cm > 80cm LEVEL2 > 102cm > 88cm

42. Waist circumference Level 1 is the maximum acceptable waist circumference irrespective of the adult age and there should be no further weight gain. Level 2 denotes obesity and requires weight management to reduce the risk of type 2 diabetes & CVS complications .

43. Hip Circumference Is measured at the point of greatest circumference around hips & buttocks to the nearest 0.5 cm. The subject should be standing and the measurer should squat beside him. Both measurement should taken with a flexible, non-stretchable tape in close contact with the skin, but without indenting the soft tissue .

44. WAIST – HIP RATIO Used to assess body fat distribution. WHR = Waist circumference Hip circumference Waist circumference is measured at the level of the umbilicus to the nearest 0.5 cm. The subject stands erect with relaxed abdominal muscles, arms at the side, and feet together The measurement should be taken at the end of a normal expiration. Waist- Hip ratio

45. Interpretation of WHR High risk WHR = >0.80 for females & >0.95 for males i.e. waist measurement >80% of hip measurement for women and >95% for men indicates central (upper body) obesity and is considered high risk for diabetes & CVS disorders. A WHR below these cut-off levels is considered low risk.

46. Skin fold thickness This measurement provide an estimate of body fat stores or the extend of obesity or under nutrition. (biceps, subcapsular, supra-iliac skin fold). skin fold calipers are used (Harpenden and Lange) measures the thickness of the skin and subcutaneous fat using constant pressure applied over a known area Common sites: triceps and in the sub-scapular region It has value in assessing the amount of fat and therefore the reserve of energy in the body

47. Skin fold thickness

48. Weight for age Weight for age is an index used in growth monitoring for children which may be underweight. Weight-for-age is assessed for all children under two years old when community based nutrition activities are carried out.

49. Height-for-age Height-for age is an index used for assessing  stunting  (chronic malnutrition in children). Stunting is defined as a low height for age of the child compared to the standard child of the same age. Stunted children have decreased mental and physical productivity capacity. Stunted children have poor physical and intellectual performance and lower work output leading to lower productivity at individual level and poor socioeconomic development at the community level. Stunting of children in a given population indicates the fact that the children have suffered from chronic malnutrition so much so that it has affected their linear growth.  

50. Weight-for-height Weight-for-height is an index that is used to assess the nutritional status of children from birth to 59 months of age. Weight-for-height  is an index used for assessing  wasting  (acute malnutrition ). Wasting is defined as a low weight for the height of the child compared to the standard child of the same height. Wasted children are vulnerable to infection and stand a greater chance of dying . It compares a child’s weight to the weight of a child of the same length/height and sex in the WHO Child Growth Standards to classify the child’s nutritional status. There are separate WHO Child Growth Standards for boys and girls. WHZ can be used for infants under 6 months, but there are no globally agreed cut-off points for classification of nutritional status.

51. Classification of malnutrition using anthropometric indicators GOMEZ weight for age Normal nutrition >80% Mild or grade 1 PEM 70-80% Moderate or grade 2 60-69% Severe or grade 3 <60% Wellcome Uses weight for age with presence or absence of edema %Weight for age Edema Nutritional Status >80% - normal 80-60 - underweight 80-60 + Kwashiorkor <60 - Marasmus <60 + Marasmic kwashiorkor

52. Indices Waterlow Uses weight for height as an index nutritional status Wt for Ht Ht for age nutritional status 110-90% 105-95 Normal 89-90 94-90 Mild PEM 79-70 89-85 Moderate PEM <70 <85 Severe PEM  

53. ADVANTAGES OF ANTHROPOMETRY Objective with high specificity & sensitivity Measures many variables of nutritional significance ( Ht , Wt , MAC, HC, skin fold thickness, waist & hip ratio & BMI). Readings are numerical & gradable on standard growth charts Readings are reproducible. Non-expensive & need minimal training

54. Limitations of Anthropometry Inter-observers errors in measurement Limited nutritional diagnosis Problems with reference standards, i.e. local versus international standards.

55. Laboratory and biochemical investigations These investigations are helpful in detecting early changes in body metabolism and nutrition before the appearance of overt clinical signs. In addition, the results obtained are precise, accurate and reproducible. The limitations are that these investigations are time-consuming and expensive, which cannot be used on a large scale.

56. LABORATORY AND BIOCHEMICAL EVALUATION Biochemical Test: A ssessment of nutritional status can be done by biochemical tests which may be applied to measure individual nutrient concentration in body fluids (e.g. serum retinol, serum iron) or detection of abnormal amounts of metabolites in urine. a) Haemoglobin estimation. It is the most important laboratory test is carried out in nutrition surveys. Haemoglobin level is a useful index of the overall state of nutrition irrespective of its significance in anaemia. An RBC count and a haematocrit determination are also valuable. b) Stools Stools should be examined for intestinal parasites. History of parasitic infestation, chronic dysentery and diarrhoea provides useful background information about the nutritional status of persons. c) Urine dipstick & microscopy Urine should also be examined for albumin and sugar.

57. Lab tests Measurement of individual nutrient in body fluids (e.g. serum retinol, serum iron, urinary iodine, vitamin D) Detection of abnormal amount of metabolites in the urine (e.g. urinary creatinine/hydroxyproline ratio) Analysis of hair, nails & skin for micro-nutrients.

58. Some Biochemical tests used in nutritional surveys NUTRIENT METHOD NORMAL VALUE Vitamin A Serum retinol 20mcg/dl Thiamine Thiamine pyrophosphate (TPP) stimulation of RBC transketolase activity 1.00 – 1.23 (ratio) Riboflavin RBC glutathione reductase activity stimulated by flavine adenine dinucleotide . 1.0 – 1.2 (ratio) Niacin Urine N-methyl nicotinamide (not very reliable) Folate Serum folate Red cell folate 6.0 mcg/ml 160 mcg/ml

59. Some Biochemical tests used in nutritional surveys NUTRIENT METHOD NORMAL VALUE Vitamin B 12 Serum vitamin B 12 Concentration 160mg/L Vitamin C Leucocyte ascorbic acid 15 mcg/ 10 8 cells Vitamin K Prothrombin time 11 – 16 seconds Protein Serum albumin serumTransferrin Thyroid – binding pre – albumin 3.5 – 5.5 g/dl 170 – 250 (mg/dl) 15 – 25 mg /dl

60. Advantages of Biochemical Method It is useful in detecting early changes in body metabolism & nutrition before the appearance of overt clinical signs. It is precise, accurate and reproducible. Useful to validate data obtained from dietary methods e.g. comparing salt intake with 24-hour urinary excretion .

61. Limitations of Biochemical Method Time consuming Expensive They cannot be applied on large scale Needs trained personnel & facilities

62. Functional indicators These indicators for nutritional status are emerging as an important category of diagnostic tools and supporting the biochemical investigations. Some of the commonly used functional indices are for hemostasis and nerve conduction Although these indicators are been used in different physiological components, they are time-consuming and expensive.

63. Functional indicators Structural integrity Erythrocyte fragility – Vitamin E, Se Capillary fragility – Vitamin C Tensile strength – Cu Host defence Leucocyte chemotaxis – Vitamin E, Zn Leucocyte phagocytic capacity – Vitamin E, Fe Leucocyte bactericidal capacity - Vitamin E, Fe, Se Haemostasis Prothrombin time - Vitamin K

64. Functional indicators Reproductive Sperm count – Energy, Zn Nerve function Nerve conduction – Vitamin E, B1 and B12 EEG – Vitamin E Work capacity Heart rate – Vitamin E, Fe Vasopressor response – vitamin C

65. Vital statistics Vital statistics is obtained from the community, health facilities, local public health offices, national statistics offices, professionals, and surveillance network etc. Analysis of morbidity and mortality data can be used in estimating the prevalence of the disease in the community and identifying the high-risk groups. Data on morbidity (e.g., hospital data or data from community health and morbidity surveys) particularly in relation to PEM, Anaemia, xerophthalmia , other vitamin deficiencies, goitre , diarrhoea etc .

66. Vital Health Statistics Analysis of vital statistics - mortality and morbidity data - will identify groups at high risk and indicate the extent of risk to the community. These rates are influenced by nutritional status and may thus be indices of nutritional status. Source of data: Analysis of birth and death records Calculation from census figures Questionnaire at field level 67

67. Age/ Cause specific mortality rates 2 to 5 months Mortality Rate - relative high mortality due to Infantile beriberi. Infant Mortality Rates (< 1 year) - LBW combined with RTI, Acute GE  PEM 1 to 4 Year Mortality Rate (CDR) - Pre school age: Rapid growth and high nutritional needs - Nutritional, infective, parasitism and malnutrition. Cause specific deaths - PEM (Kwashiorkor, Marasmus), Diarrheal disease, ARI, Measles, Whooping cough, 68

68. DIETARY INTAKE ASSESSMENT Nutritional intake of humans is assessed by five different methods. These are: 24 hours dietary recall Food frequency questionnaire Dietary history since early life Food dairy technique Observed food consumption

69. 24 Hours Dietary Recall A trained interviewer asks the subject to recall all food & drink taken in the previous 24 hours. It is quick, easy, & depends on short-term memory, but may not be truly representative of the person’s usual intake ADVANTAGES:- Easy to administer Easy for the client to Participate DISADVANTAGES :- Only assess one day intake Doesn’t reflect different season or holidays Relies on Memory

70. Food Frequency Questionnaire In this method the subject is given a list of around 100 food items to indicate his or her intake (frequency & quantity) per day, per week & per month . inexpensive, more representative & easy to use.

71. Food Frequency Questionnaire Limitations: May require a long Questionnaire Errors may arise with estimating serving size. Needs updating with new commercial food products to keep pace with changing dietary habits.

72. DIETARY HISTORY It is an accurate method for assessing the nutritional status. The diet history aims to discover the usual food intake pattern of individuals over a relatively long period of time. It is an interview method composed of two parts. The first part establishes the overall eating pattern and includes a 24hr recall: questions such as;What did you have for breakfast yesterday? What do you usually have for breakfast Subjects are asked to estimate portion sizes in household measures with the aid of standard spoons and cups, food photographs or food models.

73. Dietary history The second part is known as the cross-check : This is a detailed list of foods that are checked with the subject. Questions concerning food preferences, purchasing and the use of each food serve to verify and clarify information given in the first part. Questions about purchasing can also provide a check on portion estimates. The diet history has advantages over other methods in that it estimates nutrient intakes over a long period of time. Its disadvantages are that it takes about one hour of careful questioning, and the interviewer must be a nutritionist or dietitian experienced in obtaining diet histories. The most common fault of an inexperienced interviewer is probably that of suggesting answers.

74. FOOD DAIRY Food intake (types & amounts) should be recorded by the subject at the time of consumption. The length of the collection period range between 1-7 days. Reliable but difficult to maintain.

75. Observed Food Consumption The most unused method in clinical practice, but it is recommended for research purposes. The meal eaten by the individual is weighed and contents are exactly calculated. The method is characterized by having a high degree of accuracy but expensive & needs time & efforts.

76. Interpretation of Dietary Data 1. Qualitative Method using the food pyramid & the basic food groups method. Different nutrients are classified into 5 groups (fat & oils, bread & cereals, milk products, meat-fish-poultry, vegetables & fruits) determine the number of serving from each group & compare it with minimum requirement.

77. Interpretation of Dietary Data 2. Quantitative Method The amount of energy & specific nutrients in each food consumed can be calculated using food composition tables & compared with the recommended daily intake. Evaluation by this method is expensive & time consuming, unless computing facilities are available.

78. Ecological factors Malnutrition is usually the final results from to the interaction of different ecological factors such as socio-economic factors, quality, accessibility, availability of health care services, and diseases.  It is important to make an “ecological diagnosis” to identify, which factors will affect the nutrition status of the community. May be difficult to quantify the influence of ecological factors, which precipitates unfavorable nutritional outcomes.

79. A study of the ecological factors comprise the following ECOLOGICAL FACTORS

80. Ecological factors Socio economic status - Family : size, stability, interval between children, - Housing: type floor, ventilation, kitchen, food storage - Education : Literacy of parents, Accessibility to knowledge, school attendance. - Occupation: primary, secondary, income, budgeting Cultural factors - Age group, sex, disease linked, celebration, modern prestige foods, super food.. 82

81. Ecological factors Health and educational service utilization - Hospital and Health centres - Educational facilities (School, clubs, voluntary organization, mass media) Food production - Land (fertility) Family food supply, farming methods, livestock availability, finance, distribution Nutrition related infections - Intestinal helminthes, Malaria, Tuberculosis, Measles, etc., 83

82. Nutritional surveillance This on-going process of constant scrutiny of the nutritional situation and factors influencing them and its application in the public health. Vital to keeping a constant watch over all the factors, to identify early warning and take appropriate decisions Commonly used approaches: 1. Longitudinal incidence studies 2. Cross sectional prevalence studies 84

83. Conducting a nutritional assessment Conducting a nutritional assessment of a community involves several steps to collect, analyze , and interpret data about the nutritional status and dietary intake of the population. 1. Define the Objectives Identify the purpose of the assessment (e.g., to determine the prevalence of malnutrition, assess dietary intake, or evaluate the impact of a nutrition program). Set specific goals and outcomes you want to achieve.

84. Assessment 2. Select the Population Define the target population (e.g., children, adults, pregnant women). Determine the sample size and sampling method (random sampling, stratified sampling, etc.).

85. Assessment 3. Collect Data A. Nutritional Status Anthropometric Measurements : Collect data on height, weight, BMI, mid-upper arm circumference ( MUAC ), etc. Biochemical Indicators : Analyze blood, urine, or tissue samples for biomarkers such as hemoglobin , serum iron, vitamin levels, etc. Clinical Assessments : Conduct physical examinations to identify signs of nutritional deficiencies (e.g., goiter , anemia , scurvy).

86. Assessement B. Dietary Intake 24-Hour Recall : Interview individuals to recall all foods and beverages consumed in the past 24 hours. Food Frequency Questionnaire. Assess how often specific foods or food groups are consumed over a certain period. Dietary Records : Ask individuals to record everything they eat and drink over several days. Weighed Food Records : Weigh and record all foods and beverages consumed over a specific period. C. Socioeconomic and Demographic Data Household Income : Assess income levels and sources. Education Level : Collect data on the education levels of household members. Occupation : Determine the occupations of household members. Access to Food : Evaluate food security and access to markets.

87. Assessment 4. Analyze the Data Anthropometric Data : Compare measurements to growth standards (e.g., WHO growth charts) to determine the prevalence of undernutrition or overnutrition. Biochemical Data : Analyze biomarker levels against reference values to identify deficiencies. Dietary Intake Data : Calculate nutrient intake and compare to recommended dietary allowances (RDAs). Socioeconomic Data : Analyze correlations between socioeconomic factors and nutritional status.

88. Assessment 5. Interpret the Results Identify Key Findings : Highlight the main issues, such as high prevalence of malnutrition, specific nutrient deficiencies, or dietary inadequacies. Assess Trends : Look for patterns and trends in the data, such as age or gender differences. Determine Risk Factors : Identify factors that are associated with poor nutritional status.

89. Assessment 6. Report and Disseminate Findings Prepare a Report : Summarize the methodology, findings, interpretations, and recommendations in a comprehensive report. Share with Stakeholders : Present findings to community leaders, health professionals, policymakers, and the community itself. Develop Action Plans : Based on the findings, create targeted interventions to address identified nutritional issues. 7. Monitor and Evaluate Follow-Up : Implement interventions and regularly monitor their impact on the community’s nutritional status. Adjust Programs : Make necessary adjustments based on monitoring data to improve the effectiveness of interventions. Local Resources : Engage local health departments, NGOs, and community organizations for support and collaboration.

90. Thank you