Basic Nutrition

and
Nutritional Assessment
OUTLINE
Objectives
Introduction
Dietary Reference Intakes
National Feeding recommendation
Nutritional assessment
Dietary
Anthropometric
Clinical
Laboratory
OBJECTIVES
Define dietary reference intakes.
Know national nutritional
recommendation.
Assess nutrition clinically,
anthropometric, dietary and
biochemically
INTRODUCTION

Nutrition is the bodys presses of

taking food; using it for growth,
reproduction, immunity, breathing,
work, and health; and storing
nutrients and energy in
appropriate parts of the body
 ETHIOPIA
50
45
40
35
30
25
20
15
10
5
0
H/A W/H W/A
Ethiopia Demographic and Health survey 2011
DIETARY REFERENCE
INTAKES
Estimated Average Requirement (EAR):
The average daily nutrient intake
level estimated to meet the
requirements of half of the healthy
members.
For some, it may be excessive, but
for others, it may be inadequate
Usually defined experimentally, often
over a relatively short period and in
a relatively small study population.
Recommended Dietary Allowance (RDA):
The average daily dietary nutrient intake
level sufficient to meet the nutritional
requirements of nearly all (97-98%) healthy
persons.
the RDA for that nutrient usually is set at the
mean requirement (the EAR) plus 2 standard
deviations.
RDAs are useful for assessing the nutrient
intakes of individuals or groups,
But not for ascertaining the adequacy,
inadequacy, or excess.
 Mean requirement for many nutrients is not
known with certainty,.
The recommendations of the Food and
Nutrition Board, National Academy of
Sciences, are termed dietary reference
intakes (DRIs).
These include RDAs for those nutrients for
which an EAR has been established and for
which an RDA can reliably be established, as
well as other reference intakes.
These latter include adequate intake (AI) and
tolerable upper intake level (UL).
Adequate Intake (AI):
Observed or approximated daily intake of that
nutrient by a group of healthy individuals
It is used when an RDA cannot be
determined.
Tolerable Upper Intake Level (UL):
The average daily nutrient intake that is likely
to pose no risk of adverse health effects.
As intake increases above the UL, the
potential of adverse effects can increase.
DRI of Selected Nutrients
ENEGRY
Energy is thought of in terms of both intake and
expenditure.
The 3 components of energy expenditure in adults
are
The basal metabolic rate,
The thermal effect of food,
Energy for physical activity.
The nutrients that provide energy intake in the
child's diet are fats ( 9 kcal/g), carbohydrates (
4 kcal/g), and proteins ( 4 kcal/g)- macronutrients.
Alcohol intake can also contribute to energy intake
( 7 kcal/g).
Estimated Energy Requirement
(EER)
The average dietary energy intake
that is predicted by energy balance
in a healthy adult of a defined age,
gender, weight, height, and level of
physical activity that is consistent
with good health.
In children, the EER is taken to
include the needs associated with
the deposition of tissues at rates
NATIONAL FEEDING
RECOMMENDATION
 For infants up to 6 months of
age
Breastfeed as often as the child wants, day and
night.
About 8-12 times per day including night.
Feed your child only breast milk for the first 6
months,
Empty one breast before switching to the other.
During illness and for at least up to 2 weeks
after the illness increase the frequency of
breastfeeding.
Do not give other foods or fluids including water
Expose child to sunshine for 20 to 30 minutes
 For infants 6-12 months of age
Breastfeed as often as the child wants.
Start complementary foods at 6 months
Give adequate servings of freshly prepared and enriched;
Enrich the food by adding some oil or butter every time; give
also animal foods and yellow fruits.
Give these foods; 3 times per day if breastfed, 5 times per day
if not breastfed
 Babies who stopped breastfeeding
at 6 months should also get
adequate milk replacement besides
complementary feeding
Increase intake of food and fluids
during illness, and give one
additional meal of solid food for
about 2 weeks after illness for fast
recovery
Give Vitamin A supplements
Expose child to sunshine
Principle of weaning

Spoon feeding thick with semisolid food

It started after 6 month
High energy food from breast
Single food at a time to detect allergy it will
stay3-4days with this food
Another food after first single food
It has to made of serial
with whom he is feeding
For children 12 months up to 2
years
Breastfeed as often as the child
wants.
Give adequate servings of enriched
family foods
Add some extra butter or oil to
childs food.
Give also animal foods legumes,
vegetables and yellow fruits Give
these food sat least 5 times per day
Babies who stopped breast feeding
at early age should also get
 Give your baby his/her own servings
and actively feed the child.
Give freshly prepared food and use
clean utensils
Increase intake of food and fluids
during illness, and give one
additional meal of solid food for
about 2 weeks after illness
Give Vitamin A supplements and
Mebendazole every 6 months
For children 2 years and older
Give adequate servings of freshly prepared
enriched family foods, 3-4 meals a day.
Twice daily, give nutritious food between meals,
ripe yellow fruits
Give your baby his/her own servings and actively
feed the child.
Give freshly prepared food and use clean
utensils
Increase intake of food and fluids during illness,
and give one additional meal of solid food for
about 2 weeks after illness
Give Vitamin A supplements and Mebendazole
every 6 months.
NUTRITIONAL ASSESSMENT
The process of determining the
nutritional status of individuals or
population through collection and
interpretation of data from dietary,
laboratory, anthropometric and
clinical studies

The quantitative measurement of

nutrition!
Nutritional assessment is the tool by which
the nutritionist evaluates the patient for
Maintenance of normal growth and
health,
Risk factors contributing to disease, and
Early detection and treatment of
nutritional deficiencies and excesses.
 Historically used in schools and Military.
Comparison of an individual with an
established norm provides a basis for
objective recommendations and
evaluation of nutrition therapy.
clinical judgment and perceptive history
taking remain important overall
components of nutritional assessment
 Four types
Anthropometric
Biochemical
Clinical
Dietary
Various tests monitor different
aspects of nutritional status in each
category.
Standards that are relevant to a
specific population are important.
Stage Depletion stage Method (s) used
1 Dietary inadequacy Dietary

2 Decreased level in reserve Biochemical

tissue store
3 Decreased level in body fluids Biochemical

4 Decreased functional level in Anthropometry/Bio

tissues chemical
5 Decreased activity in nutrient- Biochemical
dependent enzymes
6 Functional change Behavioural/Physiol
ogical
7 Clinical symptoms Clinical

8 Anatomical signs clinical

1. Dietary Assessment
Dietary insufficiency or excess generally precedes
signs of biochemical ,anthropometric, or clinical
deficiency
Quality and quantity of food intake and the macro and
micronutrients provided can be measured.
A number of methods are available for the collection of
information about food consumption.
The most common dietary assessment tools in clinical
practice are the
24hour recall,
3- to 7-day food records or
Usual patterns" described by the patient or
caregiver.
It is helpful to use a combination of methods!
2. ANTHROPOMETRICS
EVALUATION
Anthropometry is the measurement of physical
dimensions of the human body at different ages.
Comparison with standard references for age and
sex helps determine abnormalities in growth and
development.
Reference standards are derived from
measurements of a normal population.
Repeated measurements of an individual over
time provide objective data on nutrition, health,
and well-being.
Simple safe non invasive, less skill
Errors can be caused by poor technique and
equipment.
Anthropometry

Limitations:
Relatively insensitive and cant detect
changes in nutnal status over short
periods of time

Cant identify specific nutrient

deficiencies (e.g. stunting from Zn def
Vs PEM)
Weight
A good index of acute and chronic nutritional status.
An accurate age, sex, and reference standard is
necessary for evaluation.
Three ways: W/A, W/H, BMI
W/A compares the individual to reference data for
weight attained at any given age
W/H looks at the appropriateness of the individuals
weight compared to his or her own height.
W/H assesses body build and distinguishes wasting
(acute malnutrition) from stunting (chronic
malnutrition).
Useful when the exact age are difficult to determine.
 Technique
Standards
Interpretation
<10th percentile>>>>Weight deficit
>90th percentile>>>>Weight excess
% Standard= Actual weight X 100
Standard weight
> 120% standard = Excess
80 to 90% standard = Marginal deficiency
60 to 80% standard = Moderate deficiency
< 60% standard = Severe deficiency
Length
Length is a simple and reproducible
growth parameter that provides, in
conjunction with weight, significant
information.
Length assesses growth failure and
chronic under nutrition.
Measurement of length is frequently
erroneous because of improper technique
or equipment.
Techniques
ARM CIRCUMFERENCE/MUAC
Used to determine cross-
sectional midarm muscle and
fat areas.
Colour-coded in
red/yellow/green, non-tear,
stretch-resistant plasticized
paper.
Head circumference
HC can be influenced by
nutritional status until the age of
36 months.
Deficiencies are manifest in
weight and height before being
seen in brain growth.
Growth Velocity
Growth velocity is a simple and
reproducible measure that evaluates
change in rate of growth over a
specified time period.
It is a more sensitive way of
assessing growth failure or slowed
growth.
Helpful in the early identification of
children with under nutrition.
BMI
Determined by dividing the person's
weight in kilograms by their height in
meters squared.
BMI correlates well with adiposity in
adults and older children.
In the pediatric population use of
BMI is still being evaluated.
Percentiles be used rather than an
absolute number.
BMI
Obesity and overweight are defined using
BMI percentiles
children >2 yr old with a BMI 95th
percentile meet the criterion for obesity.
Those with a BMI between the 85th and
95th percentiles fall in the overweight
range.
Percentage of the Median
The median is the value at exactly
the midpoint between the largest
and smallest.
If a childs measurement is exactly
the same as the median of the
reference population we say that
they are 100% of the median.
PERCENTILE
The percentile is the rank
position of an individual on a
given reference distribution,
stated in terms of what
percentage of the group the
individual equals or exceeds.
The distribution of Z-scores
follows a normal (bell-shaped or
Gaussian) distribution.
Sever acute malnutrition
MUAC<11CM
W/H< 70th centile
Nutritional edema /kwash or edematous
malnutrition
Marasmic kwash
Visible wasting in under six month of age
NB ;MUAC used from 6moonth -5 yrs
Marasmas is sign of chronic malnutrition
but may be used as sign of acute in under
six month.
3. Clinical Evaluation
Severe nutritional deprivation is easily
detectable in most instances.
More subtle physical signs, which suggest
less severe chronic or subacute
deficiencies, are often nonspecific for
individual nutrients.
Thorough medical and dental histories and
physical examinations that show signs
suggestive of nutrient deficiency or excess
should be recorded and described as
precisely as possible.
4. Laboratory Assessment
Confirmation by biochemical
means is crucial to
Diagnose subclinical
deficiencies
Substantiate clinically evident
over or undernutrition.
Provide baseline data for
monitoring response .
1. Hemoglobin and Red blood cell
indices
2. Serum proteins
3. Cellular immunity
4. Vitamin concentration
5. Minerals
6. Nitrogen balance
7. Radiologic evaluation
8. Histopathology
CBC with differential
The most useful and least expensive
laboratory measure of nutritional
status.
Hgb and RBC indices can be used
to identify children with nutritional
deficiencies of iron, folate, or vitamin
B12 or with anemia of chronic
disease.
Lymphopenia is a well-known
feature of PEM resulting from a
reduction in circulating T
Iymphocytes.
Serum Proteins
Positive Acute Phase Negative acute phase
C reactive proteins Albumin
Fibrinogen Prealbumin
Ferritin Retinol binding
Ceruloplasmin protein
Alpha1-antitrypsin Transferrin
Alpha1-glycoprotein
 Albumin
Most abundant, least expensive and easiest to
measure.
More than half of body albumin is extravascular.
Maintenance of normal serum levels can occur
from mobilization of these stores .
Combined with its long half-life of 20 days, these
factors make serum albumin a relatively
insensitive marker of nutritional status.
Hypoalbuminemia is not necessarily a definitive
indicator of malnutrition.
Prealbumin
Named for its proximity to albumin
on electrophoretic strip.
A transport molecule for thyroxine;
transthyretin.
It circulates in plasma in a 1 : 1 ratio
with retinol-binding protein.
Its short half-life (2 days) and high
ratio of essential to nonessential
amino acids make it a good
measure of visceral protein status
and more sensitive than albumin as
Nitrogen Balance
One of the oldest methods of
assessing nutritional.
It has classically been used to
define amino acid requirements.
Children should normally be in
positive N balance whereas healthy
adults may be said to be in nitrogen
equilibrium if N loss is within 5% of
N intake.
Positive N balance does not
disclose any information about N
 N Balance = N intake N output
=(24hr dietary protein intake
in gm/6.25 - 24hr UUN factor)
Negative Balance: Inadequate energy and
protein intake, catabolic stress and lean
body mass breakdown.
Positive Balance: Adequate energy and/or
protein intake
Need 24 hour collection of urine and feces!!
Partial nitrogen balance!
REFERENCES
Nelson text book of pediatrics