Pamantasan ng Lungsod ng Maynila

(University of the City of Manila)

NUTRITIONAL CARE PROCESS (ADIME):

ASSESSMENT OF NUTRITIONAL STATUS
In Partial Fulfillment in Nutrition and Diet Therapy Lecture (NRS 2108-4)

Submitted by:

CORONA, CARLA MAE B.

PIMENTEL, HANNA LUISA T.
SANTOS, RICHELLE ANNE B.
BSN 2nd Year - Block 4

Submitted to:

PROFESSOR RIZA VILLAVICENCIO, RN, MAN

Nutrition and Diet Therapy Lecture Professor

August 25, 2019

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NUTRITIONAL CARE PROCESS (ADIME): ASSESSMENT OF NUTRITIONAL STATUS
What will be discussed:
Assessment of Nutritional Status
1. Nutritional History (to be presented by Santos)
 Dietary History
 Nutrient Intake Analysis (NIA)
 Food Diary
 Food Frequency
 24-Hour Recall
2. Physical Assessment
 Anthropometric Measurements (to be presented by Pimentel)
 Height and Weight
 BMI
 Body Composition
 Mid-arm Circumference (MAC)
 Fat-fold or Skin-fold Thickness
 Other Sources of Data (to be presented by Corona)
 Malnutrition Universal Screening Tools (MUST)
 Subjective Global Assessment (SGA)
 Mini Nutritional Assessment (MNA)
 Geriatric Nutritional Risk Index (GNRI)
What is Nutritional Status?
 It is also called as “nutriture”
 It is the degree to which the individual’s psychological need for nutrients is being met by the food
the person eats.
 It is also the state of balance in the individual between nutrient intake and the nutrient
expenditure.
How to evaluate one’s nutritional status?
 Examination of client’s physical condition
 Growth and Development
 Behavior
 Blood and tissue levels of nutrients
 Quality and Quantity of Nutrient Intake
A thorough Nutritional Status Assessment includes:
1. Dietary history and intake data
2. Biochemical data
3. Clinical Examination
4. Anthropometric data
5. Pyschosocial data
What is the Significance of a Nutritional Assessment?
 It is the first essential in meal planning.

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  It provides data and information for planning and evaluation.
 It helps define priorities and responsibilities of public health system at the national, regional,
provincial, city, municipal and barangay levels.
What are the methods of a Nutritional Assessment?
Methods that provide direct information
 Clinical Examination
 Biochemical examination
 Anthropometric Measurement
 Biophysical Technique
Methods that provide indirect information
 Studies on food consumption
 Studies on health conditions and vital statistics
 Studies on food supply situation
 Studies on socio-economic conditions
 Studies on cultural and anthropological influences
What is a Nutrition Survey?
An epidemiological investigation of the nutritional status of the population by various methods together
with an evaluation of the ecological factors of the community.
What are the Factors to Consider in Selecting a Nutrition Survey Method?

 Unit to Be Surveyed
 Types of Information Required
 Degree of Reliability and Accuracy Required
 Facilities and Equipment Available
 Human Resources
 Time Reference
 Funding/ Financial Support

NUTRITIONAL HISTORY: METHODS TO ASSESS DIETARY INTAKE

1) 24-hour Recall
 The client is asked to recall everything he/she has consumed within the last 24 hours or
the previous day.
Two ways of implementation:
 The client completes a questionnaire
24-HOUR RECALL QUESTIONNAIRE FORM

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 Food and Fluid Intake from Time of Awakening until the Next Morning 24-hour
Recall

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  The client is interviewed by a dietitian/nutritionist or a nurse that is well-experienced
in dietary interviewing
 Information acquired from client should be recorded in the chart by the end of the
interview.
 A sample of how to start the interview:
“In order to get a more complete picture of your family’s health, I need to know more
about your eating habits. Would you please tell me everything you ate or drank all day
yesterday? Let’s begin with.”
DIETARY INTERVIEWING SAMPLE QUESTIONS:
1) What time did you go to bed the night before last? Was this the usual time?
2) What time did you get up yesterday? Was this the usual time?
3) When was the first time you had anything to eat or drink? What did you have and how
much?
4) When did you eat again? Where? What and how much?
5) When did you eat next? What did you eat and how much?
6) Did you eat or drink anything else?
a) Anything from 1st to 2nd meal?
b) Anything from 2nd to 3rd meal?
c) Anything from 3rd to bedtime?
7) Was this day’s food intake different from usual? If so, why?
8) Is weekend eating different? If so, why?

2) Food Frequency Questionnaire

 A questionnaire similar to the 24-hour recall, but the questions are modified to attain the
frequency of consumption of certain food group.
 For example, If a patient said he/she had aglass of milk yesterday, the following question
to be asked should not be “Do you drink milk?” but “How much milk do you drink?”
 Answers should be recorded as 1/day, 1/wk, 3/mo, to be as accurate as possible.
FOOD FREQUENCY QUESTIONNAIRE

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 FOOD FREQUENCY SAMPLE QUESTIONS:
1. Do you drink milk? _ If so, how much? _ What kind? _
Whole _ Skim_
2. Do you use fat? _ If so, what kind? _ How much? _
3. How many times do you eat meat? _ 
Eggs? _ Cheese? _ Beans? _
4. Do you eat snack foods? _ If so, which ones? _ How often? _ How much? _
5. What vegetables do you eat? (in each group)
a. Broccoli _ Green Pepper _ Cooked greens _
Carrot _ Sweet Potato _
b. Tomato _ Raw Cabbage_ Asparagus _
Beets _ Cauliflower _ Cooked Cabbage _

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 Celery _ Peas _ Lettuce _
6. What fruits do you eat and how often?
a) Apples/Applesauce _ Apricots _ Banana _
Berries _ Cherries _ Grape/Grape juice _
Peaches _ Pears _ Pineapple _
Plums _ Raisins _
b)   Oranges _ Orange juice _
Grapefruit _ Grapefruit juice _
7. Bread and Cereal Products
a. How much bread do you usually eat with each meal? _ Between meals? _
b. Do you eat cereal? (daily, weekly) Cooked _ Dry_
c. How often do you eat foods such as macaroni, spaghetti, noodles and the like? _
8. Do you use salt? _ Do you “crave” salts or salty foods? _
9. How many tsp of sugar do you use/day?
(1 packet- 1 tsp) _
10. Do you drink water? _ How often during the day? _
How much each time? _ How much would you say you drink each day? _
11. Do you drink alcohol? _ How often? _
How much? _ Beer, wine, others? _

3) Dietary History
 It is a more complete method of nutrition assessment than the 24-hour recall or the food
frequency questionnaire, but usually includes both of the aforementioned methods.
ADDITIONAL INFORMATION INCLUDED IN THE DIETARY HISTORY METHOD:

1) Economics
a) Income
b) Amount of money for food each week or month and individual perception
of its adequacy for meeting food needs
2) Physical Activity
a) Occupation
b) Exercise
c) Sleep- hours/day
3) Ethnic and Cultural Background
a) Influence on eating habits
b) Religion
c) Education
4) Home life and Meal Patterns
a) Number of household members
b) Persons who does shopping
c) Person who does cooking and relationship with this person
d) Food storage and cooking facilities
e) Type of housing

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 f) Ability to shop and prepare food
5) Appetite
a) Good, poor, any changes
b) Factors that affect appetite
c) Taste and smell perception
6) Allergies, Intolerances, and Food Avoidances
a) Foods avoided and reason
b) Length of time and avoidance
7) Dental and Oral Health
a) Problems with eating
b) Foods that cannot be eaten
c) Problems with swallowing, salivation, and food sticking
8) Gastrointestinal Concerns
a) Problems with heartburn, bloating, gas, diarrhea, constipation, distention
b) Frequency of problems
c) Home remedies
d) Antacid, laxative, and other drugs used
9) Chronic Diseases
a) Treatment
b) Length of time of treatment
c) Dietary modification
10) Medication
a) Vitamin and/or mineral supplement
b) Medications

4) Food Diary/ Record

 This method involves time, understanding and motivation on the client’s part.
 The client is asked to write down everything he/she consumes for a certain time period.
 Three days, particularly (two weekdays and one weekend day) is usually the
representative time period for most people.
FOOD DIARY/RECORD SAMPLE FORM

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 5) Observation of Food Intake
 Also called Nutritional Intake Analysis (NIA).
 It is considered to be the most accurate method of dietary intake assessment.
 It is the most time-consuming, expensive, and difficult.
 This requires knowing the amount and kind of food presented to the person and the
record of the amount of food that was actually consumed.
SAMPLE OF NUTRIENT INTAKE ANALYSIS

Example of Assessing Dietary Adequacy of an Individual

  Thiamin Riboflavin Folate Calcium Phosphorus Vitamin

(mg) (mg) (μg)a (mg) (mg) D(μg)
Mr. G's Mean 1.3 1.1 200 600c 1,000 3
Intakeb
RDAd 1.2 1.3 400   700  
EARe 1.0 1.1 320   580  
D = Intake − EAR 0.3 0.0 −120   420  
SD Requirementf 0.1 0.11 32   58  
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SD withing 0.69 0.81 150 339 408  
SD of 0.28 0.33 65.1   165  
Difference (D)h
D/SDD 1.07 0.0 −1.6   2.5  
AIi   1,200   15
Intake − AI   −600   −12
c

Assessment About About 50% About 5%   Over 98%  

(confidence of 85%
adequacy)j
Assessment Likely to Intake Intake No Very likely No
k
(qualitative) be should be should be assessment to be assessmentk
adequate improved improved adequate
a
 Folate is based on μg of folate rather than Dietary Folate Equivalents for this example.
b
 Average of 7 days of intake.
c
 If Mr. G's mean calcium intake had been 1,300 mg instead of 600, one could determine
whether intake was adequate after calculating the z-statistic (1,300 − 1,200)/128, where 128 is
obtained as 339/7 days. In this case, the resulting z-statistic would have been 0.78, and one
would be unable, at any reasonable level of assurance, to conclude that Mr. G's calcium intake is
adequate.
d
 RDA = Recommended Dietary Allowance.
e
 EAR = Estimated Average Requirement.
f
 Estimated as EAR × CV.
g
 See Appendix Table B-2.
h
 The standard deviation (SD) of the difference
i
 AI = Adequate Intake.
j
 Estimated using the algorithms described in Appendix B; see the Appendix for details of these
calculations.
k
 One should use clinical judgment to obtain additional information if intake appears to be
extremely low relative to the AI.

Assessing Nutrient Intakes of Children 4 through 8 Years of Age—What Proportion Has

Inadequate Intake? What Proportion Is Potentially at Risk of Excessive Intake?

Nutrient Unit EARa Percentage Less than the ULb Percentage Greater than
EAR the UL
Calcium mg/d NAc NA 2,500 <1
Phosphorus mg/d 405 <1 3,000 <1
Magnesium mg/d 110 5 110d UKe
Thiamin mg/d 0.5 <1 NA NA
Riboflavin mg/d 0.5 <1 NA NA
Niacin mg/d 6 <1 15 UK
Vitamin B6 mg/d 0.5 <1 40 <1
Folatef μg/d 160 35 400 UK

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Vitamin B12 μg/d 1.0 <1 NA NA
Vitamin C mg/d 22 <1 650 <1
Vitamin Eg,h mg/d 6 60i 300j UK
Seleniumh μg/d 23 <1 150 <1
a
 EAR=Estimated Average Requirement.
b
 UL=Tolerable Upper Intake Level.
c
 NA = not applicable.
d
 UL for magnesium applies to supplements only, not diet plus supplement.
e
 UK = Unknown because the UL applies only to intakes from supplements (magnesium) or
from supplemental and fortification sources (niacin, folate, and vitamin E).
f
 The EAR and RDA for folate are expressed as μg dietary folate equivalents (DFE). However,
insufficient information was available to convert intake data from the Continuing Survey of
Food Intakes by Individuals to DFEs, thus for this example, folate intake is expressed in lag.
Intake data were collected prior to folate fortification of grain products and thus underestimate
current folate intake.
g
 The EAR is expressed in mg of α-tocopherol.
h
 Dietary intake data for selenium and vitamin E is from the Third National Health and Nutrition
Examination Survey, 1988–1994.
i
 Accurate measures of vitamin E intake are difficult to obtain due to underreporting of fat
intake; it is likely that the percent less than the EAR is an overestimate (IOM, 2000).
j
 Applies to any form of supplemental α-tocopherol.
SOURCE: 1994–1996 Continuing Survey of Food Intakes by Individuals.

PHYSICAL ASSESSMENT

Anthropometric Measures
Anthropometry is the measurement of variations of the physical dimensions and gross
composition of the human body at different age levels and degrees of nutrition.

COMMON ANTHROPOMETRIC MEASUREMENTS:

1. Weight (for age)
 Uses weighing scale such as beam balance scales or clinical scales which are ideal
or a bar scale in absence of the scales initially mentioned
 Assesses body mass
 Sensitive indicator of current nutritional status
 Uses reference values for age or height or both of population
 Key anthropometric measurement
Advantages:
 Commonly in use
 Weight can be determined fairly accurately by personnel with minimum training

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 Disadvantages:
 Depends on accurate age determination
 Interpretation on individual basis may be complicated by edema
 Does not distinguish between acute and chronic malnutrition but useful when
serial measurements are taken; useful also in children less than 1 year old

2. Height (for age)

 Assess linear dimensions of legs pelvis, spine, and the skull
 Less sensitive and generally an indicator of past nutritional status (chronicity of
malnutrition)
 Uses statiometer, anthropoetric steel rods fixed accurately and vertically to the
wall; for infants below 2 years, an infantometers is used
Advantages:
 Inexpensive tools may be used
 Simple to do in the field
Disadvantages:
 Less sensitive to changes in growth rate
 Errors in measurement are easily made
 Other factors play a role

3. Weight for height/length

 Most accurate indicator of present or current state of nutrition
 An expression of leanness of wasting
Advantages:
 Nearly independent of age from 1-10 y/o
 Probably independent of ethnic group especially in 1-5 y/o
Disadvantage:
 Includes disadvantage of height for age 1-10 y/o

4. Skinfold Thickness
 Assess body composition, fat distribution, and reserve of calories
 Must be compared against standards for age and sex of all ages
 Uses a reliable caliper (Harpenden, Lange, or USAMRNL)

5. Body Circumferences

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  Head/chest circumference ratio is of value in detecting PEM in early childhood.
The head and the chest circumference are the same at 6 months of age. After this
age, the school grows slowly and the chest grows rapidly
 Mid-upper arm circumference has been mainly used on 1-6 y/o. Between 1 and 4
y/o, the reference values change a little, and the age need not be accurately known

6. Birth Weight
 Related to maternal nutrition and socio-economic status
 Usually taken as cut-off point for “low birth-weight” babies is 2,500 grams
Advantages:
 Commonly in use
 Weight can be determined fairly accurately by personnel with minimum training
Disadvantages:
 Births often unattended by health personnel
 Other factors play a role (gestational age, infectious and toxemic episodes during
pregnancy, etc.)

REFERENCE/STANDARDS USED:
1. Weight-for-Age (Philippine classification of undernutrition based on Gomez’
classification) FNRI 1984

Depending on how far a child’s weight compares with his/her standard weight, a child is
classified as:
NORMAL 91% to 110% of child’s ideal
weight
1ST DEGREE/MODERATELY UNDERWEIGHT 76% to90% of child’s ideal weight
2ND DEGREE/MODERATELY 61% to 75% of child’s ideal weight
UNDERWEIGHT
3RD DEGREE/SEVERELY UNDERWEIGHT 60% or less of child’s ideal weight

2. Weight-for-Height (classification of nutritional status by McLaren and Read 1972)

OVERWEIGHT 110% of standard weight

NORMAL 90% to 109% of standard weight
MILD UNDERWEIGHT 85% TO 89% of standard weight
MODERATE UNDERNOURISHED 75% TO 84% of standard weight
SEVERE UNDERNOURISHED 75% or less of standard weight

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3. Weight-for-Age & Weight-for-Age (classification of under nutrition by FNRI 1984)

This combination permits further distinction between acute malnutrition (low weight-for-
height, normal height-for-age) and chronic malnutrition (low weight-for-height, low
height-for-age) as well as simple stunting/dwarfism. The diagram below shows the
classification of nutritional status using cut-off points for use in the Philippines.

WEIGHT FOR HEIGHT (WASTING)

85% OF REFERENCE STANDARDS
85% and above Below 85%

90% and ACUTE OR RECENT

NORMAL
above MALNUTRITION

NUTRITION SEVERE CHRONIC

Below 90%
DWARFISM MALNUTRITION

OTHER SOURCES OF DATA

1. Malnutrition Universal Screening Tools (MUST)

 MUST’ is a five-step screening tool to identify adults, who are malnourished, at

risk of malnutrition (under nutrition), or obese. It also includes management
guidelines which can be used to develop a care plan.
 It is for use in hospitals, community and other care settings and can be used by all
care workers.

The 5 ‘MUST’ Steps

STEP 1 Measure height and weight to get a BMI score using chart provided.
If unable to obtain height and weight, use the alternative procedures
shown in this guide.
STEP 2 Note percentage unplanned weight loss and score using tables
provided.
STEP 3 Establish acute disease effect and score.
STEP 4 Add scores from steps 1, 2 and 3 together to obtain overall
STEP 5 Use management guidelines and/or local policy to develop care plan.
 Alternative measurements and considerations

Step 1: BMI (Body Mass If height cannot be measured:

Index)  Use recently documented or self-reported height (if
reliable and realistic).

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  If the subject does not know or is unable to report
their height, use one of the alternative measurements
to estimate height (ulna, knee height or demispan).
Step 2: Recent unplanned If recent weight loss cannot be calculated, use self-
weight loss reported weight loss (if reliable and realistic).

Subjective Criteria:
If height, weight or BMI cannot be obtained, the following criteria which relate to them can
assist your professional judgement of the subject’s nutritional risk category. Please note, these
criteria should be used collectively not separately as alternatives to steps 1 and 2 of ‘MUST’ and
are not designed to assign a score. Mid upper arm circumference (MUAC) may be used to
estimate BMI category in order to support your overall impression of the subject’s nutritional
risk.
1. BMI
 Clinical impression – thin, acceptable weight, overweight. Obvious wasting (very
thin) and obesity (very overweight) can also be noted.
2. Unplanned weight loss
 Clothes and/or jewellery have become loose fitting (weight loss).
 History of decreased food intake, reduced appetite or swallowing problems over 3-6
months and underlying disease or psycho-social/physical disabilities likely to cause
weight loss.
3. Acute disease effect
 Acutely ill and no nutritional intake or likelihood of no intake for more than 5 days.

 Alternative measurements: instructions and tables

If height cannot be obtained, use length of forearm (ulna) to calculate height using tables
below

Estimating height from ulna length

Measure between the point of the elbow (olecranon

process) and the midpoint of the prominent bone of
the wrist (styloid process) (left side if possible).

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Estimating BMI category from mid upper arm circumference

The subject’s left arm should be bent at the elbow ar a 0 degree angle, with
the upper arm held parallel to the side of the body. Measure the distance
between the bony protrusion on the shoulder (acromion) and the of the
elbow (olecranon process). mark the mid-pont.

Ask the subject to let arm hang loose and measure around the upper
arm at the mid-point, making sure that the tape measure is snug but
not tight.

If MUAC is <23.5 cm, BMI is likely to be <20 kg/m2.

If MUAC is >32.0 cm, BMI is likely to be >30 kg/m2.

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CORONA, PIMENTEL, & SANTOS
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2. Subjective Global Assessment (SGA)”
 It is a proven nutritional assessment tool that has been found to be highly
predictive of nutrition-associated complications.
 SGA fulfills the requirements of a desirable system of nutritional assessment by:
 Identifying malnutrition
 Distinguishing malnutrition from a disease state
 Predicting outcome
 Identifying patients in whom nutritional therapy can alter outcome

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CORONA, PIMENTEL, & SANTOS
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3. Mini Nutritional Assessment (MNA)

 The Mini-Nutritional Assessment Short-Form (MNA®-SF) is a screening tool

used to identify older adults (> 65 years) who are  malnourished or at risk of
malnutrition.

 The MNA®-SF is based on the full MNA®, the original 18-item questionnaire
published in 1994 by Guigoz and colleagues.

  The most recent version of the MNA®-SF was developed in 2009 (Kaiser et al.,
2009) and consists of 6 questions on food intake, weight loss, mobility,
psychological stress or acute disease, presence of dementia or depression, and
body mass index (BMI).

 When height and/or weight cannot be assessed, then an alternate scoring for BMI
includes the measurement of calf circumference. Scores of 12-14 are considered
normal nutritional status; 8-11 indicate at risk of malnutrition; 0-7 indicate
malnutrition.

 An advantage of the tool is that no laboratory data are needed.

 An in-depth assessment and physical exam should be performed when patients are
identified to be malnourished or at nutritional risk. 

 A review of symptoms and objective clinical findings should be assessed in

addition to the patient’s cultural factors, preferences, social needs/desires
surrounding meals.

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CORONA, PIMENTEL, & SANTOS
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 4. Geriatric Nutritional Risk Index (GNRI)
 The Geriatric Nutritional Risk Index (GNRI) is a nutritional screening method
primarily developed for elderly people and is reported to be useful for
ascertaining disease prognosis.
 Its usefulness in predicting poor outcomes has also been reported for various co-
morbidities such as stroke, heart failure, and for hospitalized patients.
 Moreover, GNRI is useful in ascertaining disease prognosis in patients on
maintenance dialysis.
 However, it remains unclear whether this index is also beneficial at the time of
dialysis initiation, where the tendency exists for weight fluctuation due to fluid
retention and malnutrition because of uremia.

Method for calculating GNRI

Ideal body weight (IBW) was calculated from height, and GNRI was calculated
using IBW, albumin (ALB) level, and body weight (BW).

IBW=Height×Height×22 GNRI=14.89×ALB (g/dL)+41.7×(BW/IBW)

(If BW>IBW, we set BW/IBW=1)

REFERENCES:
 Basic Nutrition and Diet Therapy, Second Edition, by Maria Lourdes Cruz-Caudal, RND, MEM
 Nutrient Intake Analysis sample data retrieved from
https://www.nap.edu/read/9956/chapter/13#129
 Nutrient Intake Analysis retrieved from https://www.nap.edu/read/9956/chapter/8#68
 Subjective Global Assessment retrieved from http://subjectiveglobalassessment.com/
 Retrieved from https://rrtjournal.biomedcentral.com/articles/10.1186/s41100-017-0108-9
 General Assessment retrieved from https://consultgeri.org/try-this/general-assessment/issue-9

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