SESSION 2019 2020 PROGRAM NEME B SC NUTRITION

SESSION : 2019 – 2020 PROGRAM NEME: B. SC. NUTRITION HONOURS COURSE NAME: COMMUNITY NUTRITION & NUTRITIONAL EPIDEMIOLOGY SEMESTER - III

PAPER – C 6 T TOPIC : ASSESSMENT OF NUTRITIONAL STATUS

NUTRITIONAL STATUS Concept: q Nutritional status is a condition of the body as it relates the consumption & utilization of food. q The nutritional status of a person was defined by George Christakes (1973) as the “health condition of an individual was influenced by his intake & utilization of nutrient determined from the correlation of information obtained from physical, biochemical & dietary studies”. q Nutritional status of a person may be either good or poor. q Good nutritional status refers to intake of a well-balanced diet which supplies all essential nutrients to meet the body’s requirements.

NUTRITIONAL STATUS Such a person is said to be receiving optimum nutrition. q The signs of good nutritional status of an individual are reflected by – § Shiny hair § Smooth skin § Alert expression § Clear eyes § A well-developed stature § Firm flesh etc. q The person must be of correct body weight in relation to height. q

NUTRITIONAL STATUS His responses should be normal & has sound sleep. q Good nutritional status is reflected by stamina & resistance to diseases. q It may increase the life span of a person. q In short, a person with good nutritional status can enjoy life fully. q

NUTRITIONAL ASSESSMENT Concept: Assessment of nutritional status of communities is one of the preliminary steps in formulation of any public health strategy to combat malnutrition. The nutritional assessment is a systematic process in which the state of nutrition & health of individual or group of individuals is determined. Goal: The goal of nutritional assessment of communities is to discover facts about nutrition situation & guide action to improve health & nutrition.

NUTRITIONAL ASSESSMENT Aims: v The principal aims of the nutritional assessment of a community are – v To map out the magnitude & geographical distribution of malnutrition as a public health problem. v To discover & analyze the ecological factors that are directly or indirectly responsible. v To suggest appropriate corrective measures not only for the control & eradication of malnutrition, but also for subsequent food – nutrition.

NUTRITIONAL ASSESSMENT Objectives: q The major objectives of nutritional assessment are – • To determine the type of malnutrition (What? ) • To quantify the magnitude of the prevailing malnutrition (How much? ) • To identify the ‘at-risk’ groups (Who? ) • To determine the contributory factors (Why? ) q In short, the nutritional assessment of a community should aim at discovering facts & guiding action intended to improve nutrition & health.

NUTRITIONAL ASSESSMENT Methods: Nutritional status of a community can be assessed by following two types of methods – 1. Indirect Methods: Ø Vital statistics Ø Ecological Factors Assessment 2. Direct Methods: Ø Anthropometry (A) Ø Biochemical & Laboratory estimation (B) Ø Clinical Examination (C) Ø Diet Survey (D) The above methods together known as ABCD method.

NUTRITIONAL ANTHROPOMETRY Concept – Ø Nutritional anthropometry is the tool concerned with the measurement of the variations of the physical dimensions & the gross composition of the human body at different age levels & degrees of nutrition. Ø It is based on the concept that an appropriate measurement should reflect any morphological variation occurring due to significant functional physiological change. Ø It is an important component of routine nutritional assessment. Ø It is used commonly in a routine survey due to its simplicity & it needs least sophisticated equipment.

NUTRITIONAL ANTHROPOMETRY Ø Anthropometric measurements can help in the assessment of sub clinical forms of malnutrition & has been recognized as a reliable tool to identify ‘at – risk’ groups, monitoring changes in extent of malnutrition, selection of beneficiaries for intervention programmes & evaluating the impact of interventions. Application / uses – Nutritional anthropometry is a very useful tool. It’s application includes : ü Assessment of extent of under nutrition in vulnerable group of population.

NUTRITIONAL ANTHROPOMETRY ü ü ü Monitoring of individual children at regular intervals (monthly or quarterly) to find out whethere is any faltering in growth during the intervals & to help in early detection & in initiating prompt remedial measures. Identification of children who are ‘at – risk’ of under nutrition, to target & prioritize nutrition action programmes, so as to control the extent of under nutrition. Anthropometric measurements are useful in mid-term appraisal or terminal evaluation to assess whether intervention programmes have achieved the objectives or not.

NUTRITIONAL ANTHROPOMETRY ü ü It is also useful in assessing an individual’s response to nutritional rehabilitation. It is used to assess the impact of seasonal variation of food supplies on nutritional status of the community. Common Anthropometric Measurements – Body Weight: It is the most widely used & the simplest reproducible anthropometric measurement for overall nutritional status of individuals, especially fro children.

NUTRITIONAL ANTHROPOMETRY Body weight is a composite of all body constituents like water, minerals, fat, protein, bones etc. & indicates the total body mass. The serial measurements of body weight in growing children give a better index for growth monitoring. The choice of suitable weighing scales is very important to obtain accurate measurements of the body weight. Two types of weighing instruments are available. These are – Salter Scale : It is a spring balance. It is very light & portable & can be hung from a roof. The child is placed in the sling & then the weight is recorded.

NUTRITIONAL ANTHROPOMETRY Beam or Lever Scale : These are manufactured in India & has been found to be reliable & is currently in use in ICDS projects. Technique : q Weight should be taken as far as possible with minimum clothing, without shoes & without holding any support. q In case of infant & non-cooperative children, the weight could be taken with an elder person carrying the infant & subtracting the weight of elder to get the correct weight of infant. q In case of adult person, weighing machine is used to measure the body weight.

NUTRITIONAL ANTHROPOMETRY The zero error of the weighing scale should be checked before taking measurement & corrected as & when required. q The mean of 3 successive measurements will give the final body weight of the subject. q Height: Length or height is a very reliable measure that reflects the total increase in size of the individual. The height of an individual is influenced both by genetic (hereditary) & environmental factors. The environmental factors, the most important being nutrition & illness (morbidity), determine the extent up to which the genetic potential is expressed.

NUTRITIONAL ANTHROPOMETRY Optimum nutrition & good health care result the achievement of maximum height. Inadequate dietary intake results growth retardation. Severe nutritional deprivation slows down the growth of height (stunting results). Thus, stunting is a consequence of chronic food deficiency. For this reason, height measurement is very significant or essential to determine the nutritional status of the individual.

NUTRITIONAL ANTHROPOMETRY Technique : Ø The standing height is measured by Anthropometer rods or Stadiometer scales, whereas in case of infant & early preschool children, recumbent length is measured with the help of Infantometer. Ø Height is taken without shoes with the subject standing erect on a flat surface or a platform of a measuring scale with arm hanging naturally or freely at the sides. Ø The head should be positioned firmly against the fixed head board. Ø The head piece of the anthropometer rod should be held without much pressure.

NUTRITIONAL ANTHROPOMETRY Ø Ø In case of infant or young children who cannot stand or who don't stand, then height is measured with an infantometer. The child should be laid on the infantometer board with his head touching the fixed head piece & assistant should held child’s head in proper position. The investigator should ensure that child’s body is straight & flat & should press the knees & ankles flat against the board & bring the moveable piece of the board flat against the heels with optimum pressure.

NUTRITIONAL ANTHROPOMETRY Mid Upper Arm Circumference: It is an useful indicator of nutritional status assessment of an individual & communities. Poor muscle development or muscle wasting are cardinal feature of all forms of protein-energy malnutrition in early childhood. It is recognized to indicate the status of muscle development. It is useful not only to identify malnutrition but also in determining the mortality risk in children. The MUAC is considered more feasible as it is simpler & easily accessible in any age & gender & so is practical to measure.

NUTRITIONAL ANTHROPOMETRY Technique – Ø The MUAC is taken on the left hand. Ø The midpoint between the tip of the acromion of scapula & the tip of the olecranon of the fore arm bone ulna with the arm flexed at the elbow at right angle & marked with a marker pen. Ø The arm should hang freely & the measurement is taken using a fibre glass flexible non-stretch measuring tape. Ø The tape should not exert too much pressure on soft tissue. Ø The reading is taken to the nearest millimetre with the tape still in position.

NUTRITIONAL ANTHROPOMETRY Ø Ø Reading below 12. 5 cm indicates severe PEM, 12. 5 to 13. 5 cm moderate PEM & above 13. 5 cm is normal. It is 27 – 30 cm in adult women & 30 – 33 cm in adult men. Subcutaneous Body Fat Measurement: The adipose tissue is widely distributed over a large number of sites in the body. Subcutaneous fat constitute the body’s main store of energy reserves. The measurement of subcutaneous fat reflects the nutritional status of the individual.

NUTRITIONAL ANTHROPOMETRY There are close association between fatness & calorie reserves & between muscularity & protein status. This relationship can be used as a tool to assess the gross nutritional status of persons at specific stages of life. The subcutaneous adiposity is measured by skin fold thickness measurement in nutritional anthropometry. Fat distribution in an around the body varies with age, sex, physiological condition, nutritional & health status etc. The measurement of fatness is considered to be the simplest & feasible in community survey.

NUTRITIONAL ANTHROPOMETRY Technique – Ø Fat fold triceps is taken at the same point where MUAC is taken. Ø Various types of skin fold calipers are available in the market. These are – Harpenden calipers, Lange calipers, USA-MRNL calipers etc. Ø One of the important factors to be considered while selecting the calipers is that the pinch area should be 20 – 40 mm & an accuracy of 0. 1 mm. Ø It should exert a constant pressure of 10 g/square mm. Ø The measurement is made with the arm hanging loosely by the side.

NUTRITIONAL ANTHROPOMETRY Head Circumference: The measurement of head circumference is a stand & procedure in paediatric, usually to detect pathological conditions accompanied by a large head or one of increasing size, as for example, with hydro cephalous or too small a skull, as with micro cephalous. Head circumference is related mainly to size of brain, which increases quite rapidly during infancy. Head circumference normally reflects age rather than health or nutrition. The head circumference increases rapidly during first year of life, but it is slightly affected in second year of life due to PEM, although much less than chest circumference.

NUTRITIONAL ANTHROPOMETRY In nutritional anthropometry, the chest/head circumference ratio is of value in detecting PEM in early childhood. The head circumference may also be used as a rough additional guide in age assessment. Technique – Ø Measurement of head circumference should be done with a narrow, flexible, non-stretch measuring tape (made of fibre glass). Ø By place the tape firmly round the frontal bone just superior to the supra orbital ridges, passing it to head at the same level on each side & laying it over the maximum occipital prominence at the back. Ø Measurement should be made to the nearest 0. 1 cm.

NUTRITIONAL ANTHROPOMETRY Chest Circumference: The chest in normally nourished child grows faster than head during the second & third year of life. As a result, the chest circumference overtakes head circumference by out one year of age. Therefore, between the ages of six months & 5 years, a chest/head circumference ratio of <1 may be due to failure to develop or to wasting of muscle & fat of the chest wall & can be used as community indicator of PEM of early childhood. Technique – Ø A narrow, flexible & non-stretch fibre glass tape should be used.

NUTRITIONAL ANTHROPOMETRY Ø Ø Measurement made at the nipple line, preferably in mid inspiration. Measurement should be made to the nearest 0. 1 cm. BMI: After the cessation of linear growth around 21 years of age, weight for height indicates muscle-fat mass in the adult body. It is also called Quetlet Index. It provides a reasonable indication of nutritional status of adults. The BMI has good correlation with adiposity.

NUTRITIONAL ANTHROPOMETRY BMI is defined as the weight in kg divided by the height in metre square. BMI (Kg/m 2) Presumptive Diagnosis <16. 0 Chronic energy deficiency – Grade III (severe) 16. 0 – 17. 0 Chronic energy deficiency – Grade II (moderate) 17. 0 – 18. 5 Chronic energy deficiency – Grade I (mild) 18. 5 – 20. 0 Low weight (normal) 20. 0 – 23. 0 Normal >23. 0 Overweight >25. 0 – 29. 0 30. 0 – 40. 0 >40. 0 Obesity Obese – Grade III

NUTRITIONAL ANTHROPOMETRY Assessment of PEM children / Anthropometric measurement of Normal & PEM children – Anthropometric measurement (parameter) Normal Children PEM Children Rao & Singh Index >0. 15 0. 13 – 0. 15 (moderate) <0. 13 (severe) Weight/age Welcome Classification >80% 80 – 60% - Kwashiorkor (oedema) <60% - Marasmus (without oedema) MUAC >13. 5 cm Mild : <13. 5 cm Moderate : 12. 5 – 13. 5 cm Severe : <12. 5 cm

NUTRITIONAL ANTHROPOMETRY Anthropometric measurement (parameter) Normal Children PEM Children Bangle test Does not pass up to elbow Passes or crosses the elbow Skin fold thickness >10 mm <6 mm Kanawati MUAC Index >0. 32 Mild : 0. 28 – 0. 32 Moderate : 0. 25 – 0. 38 Severe : <0. 25 Chest / head circumference >1. 0 <1. 0

NUTRITIONAL ANTHROPOMETRY Advantages – v Measurement can easily be carried out without much technical knowledge. v The results of the assessment can be used immediately. v This is the most inexpensive method. v It is very faster & not time consuming & a large community can be observed in a short time. v This method can be done in a remote village where no facilities are available. v It has no side effects. v It is non invasive & better cooperation can be achieved from community.

NUTRITIONAL ANTHROPOMETRY Limitations – v The results may not be accurate if the instruments used are not calibrated properly. v This may not be the conclusive method & another method may be needed to support it. v Reference standard should be revised constantly. v Sometime age of the child is difficult to determine.