ASSESSMENT OF NUTRITIONAL STATUS
Mgr. Dana Hrnčířová, Ph.D.
Dpt. of Nutrition, 3rd Faculty of Medicine, Charles University
NUTRITIONAL STATUS (NS)

A part of general health status
Adequate = good balance between the body's needs and
the intake of nutrients

Malnutrition

imbalance between the body's needs and the intake of
nutrients

MALNUTRITION (broadly)

undernutrition,
overnutrition
specific deficiencies

develops in stages:



nutrient levels in blood and/or tissues change

intracellular changes in biochemical functions and structure

symptoms and signs appear (morbidity and mortality can
result)
clinically intoxicated person
well-nourished person
clinically under-nourished person
irreversible changes
UNDERNUTRITION - PEM

Marasmus




Energy deficiency
Severe deficiency of nearly all nutrients, esp. protein and
carbohydrates
Extreme weight loss, thinness
Kwashiorkor


protein deficiency (oedema, large fatty liver, swollen abdomen)
Sufficient calorie intake (carbohydrates mainly)
Marasmic kwashiorkor

combined form
Causes of malnutrition

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Loss of appetite, anorexia
Digestion and absorption disorders
Catabolic state – surgery, injuries, endocrine disorders
Loss of proteins and liquids by fistulas, injuries …
Pain
Stress
Infection
…
Consequences of Undernutrition
PRIMARY:
 Protracted wound healing
 Increased tendency to infections (impaired immune
functions)
 Hypoproteinosis (oedema)
 Decreased gut motility
 Myosthenia (muscle failing)
 Tendency to thrombosis, embolism
 Urinary tract infections
Consequences of Undernutrition
SECONDARY:
 increased morbidity
 prolonged hospitalization time
 prolonged recovery time
 increased mortality
ASSESSMENT OF NUTRITIONAL STATUS

1) Clinical assessment

nutritional and medical history, dietary assessment

physical examination

2) Biochemical Laboratory Tests

3) Anthropometric Measurements
NUTRITIONAL HISTORY









Inevitably intertwined with the medical history
Nutritional disorders
Basic illnesses
Nutrition related illnesses
Digestion (diarrhoea, constipation)
Weight (stable, variable)
Weight loss / gain
Loss of liquids?
Increased energy demand?
DIETARY ASSESSMENT

Past intake




Current intake

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24-hour recall (week and weekend day)
Food-frequency questionaire
Diet history / dietary patterns in last 6 months
Estimated food records
Weighed food records
Smoking habits
Alcohol consumption
Cooking techniques (boiling, frying, grilling, roasting, …)
24 – Hour Record
Sex: _________
Date of birth: _____________
Weight: _____ kg
Height: _____ cm
Today’s date: ___________
List all foods and beverages you consumed in past 24 hours:
night meal
late
evening
meal
evening meal
snack 2
noon meal
snack 1
morning meal
food/drink
quantity eaten
food/drink
quantity eaten
PHYSICAL EXAMINATION

Blood pressure (HT>140/90)

Fragility of gum capillaries (paradontosis, vit. C def.)

Somatoscopy
PHYSICAL EXAMINATION - somatoscopy

Skin – petechia, dermatitis, hyperkeratosis, seborea,
hyperpigmentation, dry skin, oedema

Head – hair quality, xerophthalmia, lips-angular cheilitis, tongueglositis, papilla atrophy, gums-bleeding, teeth-caries, spots

Neck – examination of thyroid gland

Chest – rib abnormalities, exudate

Abdomen – acsites, liver size

Limbs – oedemas, reflexes, sensation

Skeleton – deformities, fractures, pain

Skeletal muscle – atrophy
BIOCHEMICAL LABORATORY TESTS
Plasma proteins



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Total protein: 65-85 g/l
Albumin: > 35 g/l (malnutrition < 28 g/l)
Prealbumin
Transferin
Retinol binding protein
BIOCHEMICAL LABORATORY TESTS


Complete blood count (haematocrit, haemoglobin,
RBC,WBC, lymphocytes, and differential count)
Lymphocyte count:
Normal values
Mildly reduced
> 1800/μl
1800 - 1500
Moderately reduced
1500 - 900
Severely reduced
< 900
BIOCHEMICAL LABORATORY TESTS
Plasma lipids

Triacylglycerides < 1,7 mmol/l

Total cholesterol < 5,0 mmol/l

LDL-cholesterol < 3,0 mmol/l

HDL-cholesterol > 1,0 mmol/l men
> 1,2 mmol/l women
ANTHROPOMETRIC MEASUREMENTS



Indexes (to assess body weight)
Body circumferences
SkinFolds
Rohrer’s index (RI)

RI = body weight (gr) / height (cm)3 x 100

standards: men
women
1,2 – 1,4
1,25 – 1,5
Body Mass Index (BMI)

BMI is often used as a predictor of future disease risk.

BMI = BODY WEIGHT (kg) / HEIGHT (m)2
WHO Classification
Underweight

BMI
< 18,5
Desirable
18,5 - 24,9
Overweight
25,0 - 29,9
Grade 1 Obesity
30,0 - 34,9
Grade 2 Obesity
35,0 - 39,9
Grade 3 Obesity
>40
BMI as the sole criterion indicating overweight and obesity is
only informative up to a certain point!
BODY FAT DISTRIBUTION

Not whole body fat but its distribution determines risk of
mortality and morbidity

ABDOMINAL FAT




Hyperinsulinemia, dyslipidaemia, hypertension, glucose
intolerance
Increases risk of DM II., cardiovascular diseases
Waist circumference (WC)
Waist/hip ratio /WHR)
Waist Circumference

Perhaps better indicator of cardiovascular and metabolic
risks of obesity compared with WHR
Classification
Moderately high risk
High risk
Men
> 94 cm
> 102 cm
Women
> 80 cm
> 88 cm
Classification of overweight and obesity according to BMI and WC
In connection with the risk of some diseases
RISK OF DISEASES
(relative to normal body weight
Classification
of body weight
BMI
(kg/m2)
Classification
and waist circumference)
of obesity
WAIST CIRCUMFERENCE
men ≤ 102 cm
men > 102 cm
women ≤ 88 cm
women > 88 cm
underweight
< 18,5
–
–
norm
18,5 - 24,9
–
–
overweight
25,0 - 29,9
increased
high
obesity
30,0 - 34,9
I
high
very high
35,0 - 39,9
II
very high
very high
≥ 40
III
extremely high
extremely high
extreme obesity
Waist to Hip Ratio (WHR)

Indicator of cardiovascular disease risk

Fat distributed mostly in the abdominal area is associated with higher
morbidity and mortality due to cardiovascular disease.

Waist – with abdomen relaxed, horizontal measure taken at the level of the
narrowest part of waist below bottom of rib cage and above umbilicus

Hips – while standing erect, horizontal measure taken at a level of
maximum circumference of hips

WHR = waist circumference / hip circumference
Classification
Moderately high risk
High risk
Men
0,9 - 1,0
> 1,0
Women
0,8 - 0,85
> 0,85
Mid–arm muscle area

Used to estimate lean body muscle mass

Derived from the TSF and the mid-arm circumference

Mid-arm circumference - midway between the olecranon process and
the acromium, right arm in a relaxed position

Triceps skin fold - midway between the olecranon process and the
acromium, on the posterior of the arm over the long head of the triceps
brachii.

Mid–Arm Circumference (cm) – 0,314 x Triceps Skinfold (mm)
Muscle Mass
Adequate
Marginal
Depleted
Wasted
Men
25,3 - 22,8 22,8 - 20,8 20,8 - 17,7
< 17,7
Women
23,2 - 20,9 20,9 - 18,6 18,6 - 16,2
< 16,2
Measurement of skinfolds

Cheek – horizontal fold on a join tragus – nostrils, right bellow the temple

Jowl – vertical fold between chin and laryngeal prominence

Chest – anterior axillary fold (oblique). Diagonal fold taken ½ the distance between the anterior axillary
line and the nipple (1/3 distance women).

Axilla – at the intersection of a horizontal line level with the 10th rib and the anterior axillary line.

Triceps – vertical fold on posterior midline of upper arm, midway between the acromion (bony tip of
shoulder) and olecranon processes (elbow joint).

Biceps – the pinch position is at the same level as for triceps, though on the anterior (front) surface of
arm.

Subscapula - 2 cm below the lower angle of the scapula (bottom point of shoulder blade) on a line
running laterally and downwards (at about 45 degrees).

Abdominal – vertical fold, is made 5 cm adjacent to the umbilicus (belly-button) taken on a line running
laterally to the spina iliaca anterior

Suprailiac – taken in the anterior axillary line immediately superior to the iliac crest

Thigh – vertical fold above patella

Calf – 5 cm below popliteal fossa
Practical training
Body circumferences
1.
2.
3.
Mid-Arm Circumference
Mid-Arm Muscle Area
Waist Circumference
Hip Circumference
WHR
Skinfolds
1.
2.
10 skinfolds
4 skinfolds
% of body fat
% of body fat
Bioelectric impedance (BIA)
Thank you for your attention.