TERESA S.

MENDOZA, MSPH
Planning Officer
Food and Nutrition Research Institute
Department of science and Technology
Disordered nutrition of any kind, can be categorized in
a number of ways (McLaren)

Cause: Primary (exogenous)

Secondary (endogenous)

Type: Excess (overnutrition)

Deficiency (undernutrition)
Imbalance

Nutrient: Energy sources, vitamins, minerals

Degree: Mild, moderate, & severe or depleted stores,

biochemical lesions, functional lesion & structural lesion

Duration: Acute, sub-acute, & chronic

Outcome: Reversible and irreversible

 STAGES OF DEFICIENCY ASSESSMENT TOOL

INADEQUATE FOOD INTAKE Dietary evaluation

(Primary)

(Secondary)
Impaired food absorption,
utilization, or transport
Increased requirements,
destruction or excretion
Biochemical
Nutrient levels in blood,
urine tissues
DECREASED TISSUE LEVELS Anthropometry
Weight for height, fat folds,
circumferences
ALTERED PHYSIOLOGICAL/ Blood, urine and tissue levels
BIOCHEMICAL FUNCTIONS of enzymes, coenzymes and
metabolites

SIGNS AND SYMPTOMS

OF DEFICIENCY Clinical evaluation
The interpretation of information
obtained from dietary, biochemical,
anthropometric, clinical studies
and/or other studies to determine the
nutritional status of individuals/
groups and identify those at
nutritional risk
SURVEY

Provides information/description on the

nutritional status of individuals/groups
SURVEILLANCE

Continuous monitoring of the nutritional

status of selected population groups to
assess change over time
SCREENING
Identifies individuals who may benefit
from assessment and intervention
Appraisal of available information to provide a
description of existing nutritional situation.

Methods that provide direct information

 Anthropometric measurement
 Biochemical examination
 Biophysical technique
 Clinical examination
Methods that provide indirect information

 Food consumption studies

 Studies on physical activities
 Studies on food supply
 Studies on demographic, socio-economic
conditions
 Studies on cultural and anthropological
influences
Measurement of the
physical dimensions
and gross
composition of the
body

Provides a profile of Height

growth or body size
attained or of change
over time

Measurement of Mid-Upper Arm

Circumference (MUAC)
Reflect body levels of
specific nutrient

Measurements of nutrients
of their metabolites
Performed usually on blood or urine

Most objective and quantitative

measures of NS

May be influenced by non-nutrition

factors, e.g. diseases, medications
Involve measuring the production of an
abnormal metabolite, or changes in the
activities of certain enzymes/blood
components, dependent on a specific
nutrient

Measure physiological or behavioral

functions dependent on specific nutrients

Examples of functional tests: dark adaptation

for Vit. A, muscle function for protein-energy
cognitive performance for iron.
Consists of medical history
and physical examination

Many physical signs and

symptoms are non-specific;
more difficult to identify
because of age-related
changes in the skin, hair, etc.

Most subjective of the

measures of NS

May not correlate well

with dietary intakes or
blood levels
Determines inadequacy of dietary
and/or nutrient intakes, either
because of primary or
secondary deficiency

Survey data collected

at the national,
e.g. food balance sheet;
household, e.g. inventory method;
or individual level, e.g. 24 hour food
recall
 Measurements
- Basic anthropometric measures such as age,
weight and height

 Index/Indices
- Combination(s) of measurements;
e.g. weight-for-age, weight-for-height and
height-for-age

 Indicator
- Relates to the use or application of indices;
e.g. infant mortality rate (ratio of deaths to births)
 Reference data
- Population characteristic or distribution properly
derived from a large representative sample of the
population which is reasonably healthy and well
nourished, against which indices are compared

 Cut-off Points
- Based on the relationship between nutritional
assessment indices and functional impairment
and/or clinical signs of deficiency; used to classify
malnourished individuals and determine prevalence
of malnutrition
Factors in choosing a method
Objective/ goal of =P
==
the study
Resources
a. funds
b. time
c. manpower
Desired reliability
concerns with measurements
of the variations of the
physical dimensions and
gross composition of the
human body at different age
levels and degrees of
nutrition
Growth Measurements

Body Composition
Measurements
most widely used anthropometric
measurements in the assessment
of growth are those of stature
(length or height) & body weight;
in addition, circumferences and
diameters (breadth) of some parts
of the body, e.g., head, elbow, etc.
 can be subdivided into measurements of
body fat and fat-free mass
- the fat-free mass consists of the skeletal
muscle, non-skeletal muscle and soft lean
tissues, and the skeleton
- body fat, on the other hand, is deposited in
two types of storage sites: one for essential
lipids and the other general fat storage.
Anthropometric techniques can indirectly
assess these two body compartments
Weight
 measure of total body mass

 summation of fat, body fluids,

skeleton & lean cell mass

Weight-for-age

 simplest & most common indicator for

assessment of growth & nutritional
status

 gives overall picture of malnutrition

Advantages of weight-for-age
good basic indicator combining
both acute and chronic malnutrition
measure is objective and repeatable
sole tool (scale) is portable and
inexpensive
relatively easy for health worker
measure is not time consuming
sensitive to small change
Disadvantages of weight-for-age

does not distinguish between acute

and chronic malnutrition

relies on age data which are often

subject to error

interpretation on individual basis

may be complicated by edema
http://www.fotosearch.com/illustration/weighing_4.html
Length/Height

growth or degree of
skeletal
development,
measures the
amount of linear
growth
Length - refers to the
measurement in a recumbent
position, and is measured in
laying position for children under
2 years of age

Height - often referred to as ‘stature’

and is measured in standing position
for children 2 years and above
Length/Height-for-Age
indicator of chronic or long term
nutritional deprivation (stunting)

gives an indication of stunting and

therefore of past nutritional status
(chronicity of malnutrition)
neither decreases nor changes
rapidly, but is arrested by long-term
deprivation
Stunting

slowing in skeletal growth

growth rate may be reduced from
birth, but effect may not be evident
for some years
manifestations of poor economic
conditions, extended food deficits
and increased morbidity
prevalent in 2nd year of life
 Advantages of
length/height-for-age
good indicator of past nutritional
problems

measure is objective, repeatable

and has low variability when done
properly

instruments can easily be

transported
Disadvantages of length/ height-for-age
should be supplemented by another
indicator because changes in height
occur relatively slow
requires two different techniques:
recumbent length (0-<2 years old
children) & standing height (2 years
old & above)
requires two persons to take the
measurement
relies on age data
 Headboard
Head, shoulder rest on crown
blades of head
and buttocks against Looks
the wall arm at sides straight
ahead

Feet flat keep

close together
against the wall

Ismail & Manandhar, 1999

Weight-for-height

indicator of current
nutritional status or
acute undernutrition
(wasting)
Wasting
deficit in tissue and fat mass

results from failure to gain weight

or actual weight loss

often depends on seasons of year

develops rapidly; highest during 2nd

year of life or post weaning period
Advantages of weight-for-length or height:
good indicator to distinguish
those well proportioned
(weight/height) from those who
are thin (or heavy) for their height

does not require age data

measures are objective and

repeatable
Disadvantages of weight-for-length or height
can underestimate undernutrition by
classifying those who are short and
thin as normal for their height
requires taking two measurements:
weight and recumbent length/height
requires more training time for
inexperienced health worker due to
complicated measurements
requires two persons to measure
length or height
 Alternative measures
are used to estimate
stature in older adults
who have
contractures or
curvatures of the
spine or unable to
Ismail & Manandhar, 1999 stand
 OSTEOPOROSIS
AT WORK

Fractured
vertebrae
Rib
cage

Pelvis

Mitchell, 1997
Blade on anterior surface of thigh,
proximal to the patella
Subject
supine

Blade under heel

of left foot

Gibson, 1990
 Stature
For Women Gibson, 1990
Knee Stature (cm)
height For Men
190
(cm) (cm)
70 203

180
65 193

60 183
Age 170
(years)
90 55 173

50 163 160
80

70 45 153
150

60 40 143

140
35 133 Formulae - Developed by
Chumlea et al.
130

Male stature (cm) = (2.02 x knee height [cm]) - (0.04 x age [yr]) + 64.19

Female stature (cm) = (1.83 x knee height [cm]) - (0.24 x age [yr]) + 84.88
 Armspan - distance
between outstretched
fingers of right and left
hands, with arms
extended laterally and
maximally to the level
of the shoulders

Halfspan - distance
between middle finger
of stretched hand and
arm to the mid u bone
at the base o f the
neck
Ismail & Manandhar, 1999
Weight-for-height ratios

measure body weight

corrected for height ; highly
correlated w/ obesity

frequently called obesity or

body mass indices (BMI)
Types of weight-for-height ratios

 Relative weight

- expresses weight as percentage of

the average weight of a person of the
same height

 Power-type indices

- expresses weight relative to power

function of height or vice-versa
Power-type indices for weight-
for-height ratios
wt
 Weight/height ratio = ht
wt
 Quetelet’s index = (ht)2

ht
Ponderal index = 3/wt
wt
Benn’s index = (ht) p
Body Mass Index
also known as Quetelet’s index

considered to be the best body mass index

for adult population groups

least biased by height and easily calculated

used to classify overweight and obesity

used to estimate prevalence of obesity and

risks associated with it

does not account for the variation in the

nature of obesity & differences in body
build and proportion
 Assessment of BMI Using Weight and Height
HEIGHT in cms

BMI: Chart
1

W W
E E
I I
G G
H H
T T

k k
g g
s s

Ismail & Manandhar,

1999
Assessment of BMI Using Weight and Armspan
ARMSPAN in cms

BMI: Chart
2

W W
E E
I I
G G
H H
T T

k k
g g
s s

Ismail & Manandhar,

1999
 the BMI spectrum in adults
BMI score
<16 16-<17 17-<18.5 18.5-<25 25-<30 30-<40 40

Severely Moderately Mildly Healthy Mildly Moderately Severely

underweight underweight underweight range over obese obese
Physical symptoms Physical Physical symptoms
become more symptoms that increase in
pronounced as BMI of healthy BMI frequency as BMI
declines levels increases

 Thin for their height  Normal,  Sedentary lifestyle

 Inadequate energy for active life  Cardiovascular
normal activity  Less risk diseases
 Listless, lethargic of illness  Diabetes
 Susceptible to disease  No nutrition-  Risk of certain cancers
 Poor maternal and infant related  Health problems caused
health health by macro-and
 Health problems caused problems, micronutrient
by macro- and given a well- imbalances
micronutrient deficiencies balanced diet FAO 2000
Classification BMI (kg/m2) Risk of co-morbidities

Underweight < 18.5 Low

(but risk of other
clinical problems
increased)

Normal range 18.5 - 24.9 Average

Overweight  25 Increased
Pre-obese 25 - 29.9 Moderate
Obese class I 30.0 - 34.9 Severe
Obese class II 35.0 - 39.9 Very Severe
Obese class III  40.0
 1.8
1.6
Mortality

1.4
1.2
1.0
0.8
0.6
15 20 25 30* 35
Body mass index (kg/m2)

Source: Lew & Garfinkel, 1979

 Males Females
Caucasians Asians Caucasians Asians
mean sd mean sd mean sd mean sd
BMI 25.1 3.0 23.4 3.0 23.9 3.4 22.5 3.3

BF% 19.3 6.4 21.4 6.3 30.1 8.7 31.6 6.5

Source: Wang et al, 1994

<18.5 Underweight
18.5 to <23.0 Low to moderate risk
23.0 to <27.5 Moderate to high risk
=>27.5 High to very high risk
Waist Circumference (WC)
waist circumference is taken over one layer of
light clothing using a fiberglass tape measure
Measurement is taken with the tape in a
horizontal position pulled firmly but not causing
indentation
WC is measured on women by positioning
horizontally the measuring tape halfway
between the lower rib margin and the superior
anterior iliac crest and for men, at the level of
the umbilicus
Measurement is taken at the end of normal
expiration and will be recorded to the nearest
0.1 cm
 Sex-specific Waist Circumference that Denote
“Increased Risk” and “Substantially Increased Risk”
of Metabolic Complications Associated
with Obesity in Caucasians

Risk of Obesity-Associated Metabolic Complications

Increased Substantially Increased

Men  94 cm (~ 37 inches)  102 cm (~ 40 inches)

Women  80 cm (~32 inches)  88 cm (~ 35 inches)

Hip Circumference (HC)

HC is be measured by positioning
the measuring by positioning the
measuring tape around the hips
at the level of the great
trochanters

measurements will be recorded to

the nearest 0.1 cm
Waist/hip ratio (WHR)
provides an index of both subcutaneous and
intra-abdominal adipose tissue and therefore
a valuable indicator of fat distribution

can be measured precisely than skinfold

WHR >1.0 for men or 0.8 for women indicates

increased risk of cardiovascular complications
stroke and diabetes mellitus

WHR = waist circumference (cm)

hip circumference (cm)
Mid-Upper Arm Circumference (MUAC)
indicates fat and muscle development as
well as wasting

used to assess nutritional status when

rapid screening of population is required
esp. when scales are not available or when
age determination is difficult

indicator of severe current undernutrition

whether or not stunting is present

proxy indicator of weight

Measurement of Mid-Upper
Arm Circumference (MUAC)

Location of the Midpoint

of the Upper Arm

Acromion
process
on shoulder
blade

Mid-upper arm
circumference is Forearm, mid-point
palm down Olecranon
measured at the midpoint across process of
of the upper arm and body the ulna

recorded to the nearest

millimeter
Gibson, 1990
mid-upper arm muscle circumference and
mid-upper arm muscle area are used to
predict changes in total body muscle
mass and hence protein nutritional status

arm muscle circumference and muscle

area are both derived from the mid-upper
arm circumference and triceps skinfold
measurements
skinfold thickness measurements,
e.g. triceps, biceps, subscapular,
etc., provide an estimate of the size
of the sub-cutaneous fat depot
which in turn estimates the total
body fat. Waist-hip circumference
ratio and limb fat area may also be
used as anthropometric indices of
body fat.
 Fat
Bone

Muscle
Double
fold of
skin
and fat

Mitchell, 199
 Measurement
of Triceps Skinfold
Location of the
Subscapular and
Suprailiac Skinfold Sites
Mid-Axillary
Line
Left shoulder
blade
Suprailiac
skinfold
site

Left arm behind back

Gibson, 1990
MAMC = MAC - ( x TFF)

MAMA for females = [MAC ( x TFF)2]

- 6.5
4
MAMA for males = [MAC ( x TFF)2]
- 10
4

with MAC and TFF given in cm and  is 3.14

International
The Boston or Harvard Reference
Tanner Reference Population
NCHS/WHO Reference Data (IRS)
WHO Child Growth Standards

Local
Bulatao-Jayme, et. al.
FNRI-PPS Standards
a means to check child’s size
measures deviations from the normal
or average pattern of growth
serves as reference to measure change
in health and nutritional status
evaluates results of intervention
programs
defines extent and severity of under or
over-nutrition
provides basis for program planning
Percentile System

Z-score or Standard Deviation

(SD) Value System

Percent of Mean or Median

System
‘Normal’ (Gaussian) Distribution Curve

F
r
e
q
u
e
n
c
y

3 10 25 50 75 90 97

-3 SD -2 SD -1 SD Median +1 SD +2 SD +3 SD

Conventionally, individuals less than the third percentile or centile

(approximately -2 SD) are regarded as probably abnormally low. In
fact, by definition, three out of 100 of a normal or reference population
will fall into this group. Number 3-97 are centiles.
 refers to the rank position of
the measurement value in
relation to all (or 100%) of
the measurements for the
reference population ranked
in order of magnitude
number of standard
deviations or Z-scores
below or above the
reference mean or
median value
For population group
Individual’s value - median value of
reference population
Standard deviation value of ref. population
For individual
Individual’s value - median value of
reference population
Median reference - 1SD below median
value reference population
 A Portion of FNRI -PPS Standard
for Weight-for-Height
Height in cm -3SD -2SD -1SD Median +1SD +2SD +3SD
81-82 8.53 9.00 9.90 10.59 11.37 12.15 12.93

For example, for a boy 81 cm tall, weighing 9.0

kg (Table3 ) (i.e. with a weight below the
reference population median), the SD score of
the individual corresponds to:

SD score = 9.0 - 10.59 = 1.59 = -2.30

10.59 - 9.90 0.69

(Note that the values below & above the median are different. This is explained by the fact that the
distribution of weight in the reference are not symmetrical and that separate standard deviations were
calculated for the upper and lower halves of the distributions.)
ratio of a measured value in
the individual for instance
weight, to the median value of
the reference data for the
same age or height,
expressed as a percentage
 Comparison of Percentage Below Median (reference)
Corresponding Approximately to 3rd Centile (-2 SD) & to 97th
Centile (+2 SD) in Young Children up to 60 Months of Age.

97th centile Median 3rd centile

(+2 SD) (Reference) (-2 SD)
(percent) (percent) (percent)

Weight/age* 120 100 80

Weight/height^ 120 100 80

Height/age 110 100 90

115 100 85
Arm
* Severecircumference/
underweight for age: 60 per cent often used - simple to remember; long clinical use.
age
^ Severe underweight for height: 70 per cent (-3 SD)
 The Gomez Classification
% Expected Category of
Weight Classification Nutritional
for Age Status
> 90% Normal Normal
Mild 1st degree
76-90% malnutrition
malnutrition

61-75% Moderate 2nd degree

malnutrition malnutrition

 60% Severe 3rd degree

malnutrition malnutrition
Source: Gomez et al. (1956)
. The Wellcome Classification
% Expected EDEMA
Weight
for Age Present Absent

80-60% Kwashiorkor Underweight

<60% Marasmic- Marasmus

kwashiorkor

Source: Wellcome Trust Working Party (1970)

 The Waterlow Classification
Height/Age WEIGHT/HEIGHT
Degree of
Stunting  80% < 80%

 90% Normal Wasting

<90% Stunting Stunting &

Wasting

Source: Waterlow (1972)

Advantages of Anthropometric Assessment
Use simple, safe and noninvasive techniques,
applicable to large sample sizes
Is inexpensive, portable and durable
Can be performed by relatively unskilled personnel
Is precise and accurate when standardized techniques
are used
Can assist in the identification to mild, moderate and
severe states of malnutrition
Can be used to evaluate changes in NS over time and
from one generation to the next (secular trend)
Can be used for screening to individuals at high risk to
malnutrition
Limitations of Anthropometric
Assessment
Can not detect disturbances in NS
over short periods of time;
relatively insensitive method

Can not identify specific nutrient

deficiencies; unable to distinguish
differences in growth or body
composition induced by nutrient
deficiency from those caused by
imbalances in protein and energy
intakes
Evaluating impact of programs
- effectiveness of intervention

Sequential measurements
- serial measurements to calculate
growth velocity
Growth monitoring of individuals
- consecutive measurements to
determine faltering or flattening of
growth curve
Predictor of mortality risk
BIOCHEMICAL
ASSESSMENT
 METHODS TO ASSESS
NUTRITIONAL STATUS
a. Physical examination of subjects for
presence or absence of signs and
symptoms of nutrient deficiency
b. Inquiry into dietary history
c. Biochemical test on easily available
fluids:
e.g., blood and urine
RATIONALE
Biochemical tests provide specific nutrition
information as well as identify borderline nutritional
conditions prior to the development of perceptible
or clinical symptoms of malnutrition. Biochemical
survey data, when considered with the dietary
intake and clinical findings, can be of considerable
value in assessing the nutritional status of
population groups.
Advantages of Biochemical Test

 Identify nutrient deficiency before

clinical signs becomes apparent

 Confirm clinical diagnosis since

clinical signs are often not
specific
TYPES OF BIOCHEMICAL TESTS
1. Measurement of nutrient or its metabolites in:
a. Blood
 Whole blood
 Plasma
 Erythrocytes
 Leukocytes

b. Urine
 Random sample - convenient but
undependable
 First voided morning sample
 24 - hr specimen - desirable but difficult
to collect
TYPES OF BIOCHEMICAL TESTS
2. Measurements of one or more functions
of the nutrient

a. Enzymatic Test - measures the activity of an

enzyme which requires the vitamin as a
coenzyme added in vitro
AC = Enzyme activity with added coenzyme
Enzyme activity without added coenzyme
 b. Metabolic Test - measures the rise in
concentration of metabolite in blood or urine
after administering a load of an appropriate
precursor

Example:
Glucose load test for thiamine where
blood levels of pyruvate and lactate are
determined
 CLINICAL
ASSESSMENT
 Clinical Assessment

 Routine medical history and physical

examination to detect physical signs
(observations made by the examiner) and
symptoms (manifestations reported by the
patient).
 Some physical signs are non-specific and
must be interpreted together with data
obtained from anthropometric, biochemical
and/or dietary assessment.
 Medical/Clinical History

 Collection of detailed personal information

by interview and/or use of medical records
to obtain a comprehensive picture of the
person’s health and nutritional status and
their determinants.
 Medical/Clinical History

Information collected:
 Patient’s description, including current
illness
 Personal, social, and medical history
including use of medications
 Review of body’s physiological systems
 Family medical history
 Dietary history including use of dietary
supplements
 Medical/Clinical History

Other pertinent information:

 Birth weight and length
 Immunization details
 Presence of parasites
 Use of tobacco and drugs
 Intake of alcohol
 Level of habitual physical activity
 Medical/Clinical History

Other pertinent information for women:

 Age of menarche

 History of pregnancy

 Use of oral contraceptives

 Medical/Clinical History

Information will establish:

 Whether nutrient deficiency is primary (due to
inadequate intake) or

 Whether it is secondary (due to conditioning factors

such as drugs, nutrients and/or diseases which
interfere with its digestion, absorption, utilization
and excretion)
 Physical Examination

 “Examines those changes, believed to be related to

inadequate nutrition, that can be seen or felt in
superficial epithelial tissue, especially the skin, eyes,
hair and buccal mucosa, or in organs near the
surface of the body (e.g. parotid and thyroid glands)”
-Jelliffe, 1966
 Limitations of Physical Examinations
 No specificity of the physical signs
 Multiple physical signs/co-existing with other
deficiencies
 Signs may be two-directional (may occur during the
development of a deficiency and/or recovery)
 Examiner inconsistencies/bias
 Inter-observer variability
 Intra-observer variability
Variation in the Pattern of Physical Signs

Pattern of physical lesions associated with

nutrient deficiencies varies according to:
 Age
 Genetic Factors
 Activity Level
 Dietary Pattern
 Environment
 Degree, duration and speed of onset of malnutrition
Physical Signs and Symptoms that been associated
with Malnutrition may categorized in to two groups:

 Group 1: Signs that are often associated with

nutritional deficiencies and, in fact, appear to be
caused by deficiencies. Some signs are unique or
specific manifestations of deficiency of a single
nutrient; most reflect deficiencies of two or more
nutrients.
 Group 2: Signs that may be related to
malnutrition and that need further investigation.
 Forms of malnutrition with clinical
manifestations

 Overnutrition
 Undernutrition
 Iron deficiency anemia
 Iodine deficiency anemia
 Zinc deficiency
Physical Signs Indicative/Suggestive
of Malnutrition
Chronic Energy Deficiency – deficiency of energy intake for a
prolonged period of time.
Protein Energy Malnutrition – deficiency of protein and energy caused
by severe recent or long term restriction or deprivation
acute – characterized by thinness for height (wasting)
chronic – characterized by short height for age
(stunting)
Overnutrition

Overweight – more than 110%* of DBW but less than 120%

Obesity – increased amount of body fat or adipose tissue more than
120%* of Desirable Body Weight

*Determined by the computation: ABW / DBW x 100

Iron Deficiency Anemia – severe depletion of iron stores that results in low
hemoglobin concentration. It is characterized by fatigue, pallor, poor memory,
insomnia, weakness, apathy and poor resistance to cold.
Iodine Deficiency Disorder – characterized by poor thyroid hormone production
which results to enlargement of the thyroid gland or goiter. It may also cause
physical and mental retardation and poor fetal development during pregnancy;
weight gain and sluggishness among adults.
Grade 3 goiter
with mental
retardation
(woman on the
right)
Manifestations of
Zinc Deficiency
Undernutrition
Classifications of PEM

Marasmus – chronic PEM, which is

characterized by looking old and just skin
and bones.

Kwashiorkor – acute PEM, caused by

severe protein deficiency, characterized by
muscle wasting, edema, fatty liver, large
belly, infections.
Marasmus
•Severe wasting
• contraction of
hands
Marasmic-kwashiorkor
wasting with edema
Hair dyspigmentation, scrotal
edema,puffy face, wasting
Hair appears
dry, lacks
normal
luster; finer
texture,
sparse,
easily
plucked
“flag sign”
alternating
bands of
light and
darkly
pigmented
hair
 “wizened
old man’s
facial
appearance”
“moon
face”
Vitamin A Deficiency - severe depletion of vitamin A stores which can
cause blindness, visual problems, dry rough skin, reproductive and
susceptibility to infections.

Keratomalacia Dry skin Follicular

hyperkeratosis
Early conjunctival xerosis (X1A)
Dryness, wrinkling, increased
pigmentation
Bitot’s spot: yellowish,
cheesy appearance
“flaky-paint
appearance
of skin” with
edema
Marasmus with skin lesions of
measles
 loose skin in
buttocks due to
chronic wasting
Pellagra: Niacin Deficiency
Magenta Tongue: Riboflavin
Deficiency
 Scorbutic Gums:
Vitamin C Deficiency
“koilonychia”
(spoon-shaped
nails)
Scurvy: Vitamin C
Deficiency
 Rickets:
Vitamin D and
Calcium
Deficiencies
DIETARY
ASSESSMENT
 PURPOSE OF FOOD
CONSUMPTION STUDIES
PURPOSES ASSOCIATED WITH NATIONAL
FOOD AND NUTRITION PLANNING
Adequacy of food supply
Food regulations, food fortification, and
nutrition education
PURPOSES WITH NUTRITIONAL STATUS
Estimation of adequacy of dietary intakes of population groups
Investigation of relationships of diet to health and nutritional
status
Evaluation of nutrition education, nutrition
intervention and fortification programs
 PURPOSE OF FOOD
CONSUMPTION STUDIES

PURPOSES ASSOCIATED WITH TOXICOLOGICAL

ASPECTS OF THE FOOD SUPPLY

Estimation of average intakes of food

additives and contaminants
Estimation of habitual high and low levels of
consumption of foods containing nutrients
and food additives
DIMENSION IN DIETARY
SURVEY METHODS
OBSERVATION UNIT
Individual
Household
Other groups
National
MODE OF ADMINISTRATION
Record with or without check
Interview face to face, by telephone, by
computer
 DIETARY ASSESSMENT IN
SPECIAL POPULATION

Surrogate reporters Ethnic populations

Children Elderly
 DIMENSION IN DIETARY
SURVEY METHODS
TIME FRAME
Usual
Current

MEASUREMENT OF AMOUNTS OF FOODS

Weighing
Estimating with or without models

CONVERSION INTO NUTRIENTS

Nutrient databases
Direct chemical analyses
DIETARY ASSESSMENT IN
SPECIFIC SITUATIONS

Cross-sectional surveys
Case control (retrospective) studies
Cohort (prospective) studies
Intervention studies
Dietary screening in clinical settings
Dietary surveillance
FOOD CONSUMPTION:
NATIONAL LEVEL

1. Food Balance Sheets

2. Market Databases

Universal product code

Electronic scanning device
FOOD CONSUMPTION:
HOUSEHOLD LEVEL

Food account
Food inventory
Food record/weighing
Food recall
FOOD CONSUMPTION:
INDIVIDUAL LEVEL

Food record
weighed
estimated
24-hour food recall
Dietary history
Food frequency questionnaire
CONCERNS IN THE ESTIMATION
OF DIETARY INTAKE

Fortified foods
Dietary supplements
Functional
food/bioactive
components
Alcohol
DIETARY ASSESSMENT

METHODS
Twenty-four hour recall
Food frequency questionnaire
Dietary history
VALIDITY
Use of biochemical markers: 24-
hr urinary N excretion as a
measure of protein intake
 DIETARY ASSESSMENT

MEASUREMENT CONCERNS
Age associated decline in short-term memory/memory
lapse
Incorrect estimation
Respondent biases
Flat slope syndrome
Supplement usage
Others: Use of alcohol, tobacco and drugs, dietary
restriction/food avoidance
CONVERSION INTO NUTRIENTS
1. USE OF FCT
data banks
INFOODS
2. DIRECT CHEMICAL ANALYSIS