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Clinical Nutrition

Course content

1. Introduction: explanation of the terms - nutrition, clinical nutrition, nutrients, nutritional

status, under nutrition, malnutrition, obesity etc.

2. Epidemiology of nutritional disorders in Nepal: common nutritional disorders and their

prevalence rates and trends over the last ten years, causal factors.

3. Features of macro and micronutrient deficiency and excess states, problems, assessment

and prevention through dietary diversification, modification and fortification

4. Methods of assessing nutritional status: body mass index, anthropometry, clinical and

biochemical methods, growth standard charts: methods, development and interpretations

5. Clinical classification of nutritional status and features of mild, moderate and severe

malnutrition

References: (Available online)

1. Nikolaos Katsilambros . . . [et al.]. Clinical Nutrition in Practice, 2010 Blackwell Publishing Ltd

2. National Nutrition Policy and Strategy, Nutrition Section, CHD, DoHS, MoH&P. 24thDecember 2004.

3. Nepal Demographic and Health Survey 2011.Population Division, Ministry of Health and Population,

Government of Nepal.

4. Abhinav Vaidya, Suraj Shakya and Alexandra Krettek. Obesity Prevalence in Nepal: Public Health

Challenges in a Low-Income Nation during an Alarming Worldwide Trend. Int. J. Environ. Res. Public

Health 2010, 7, 2726-2744.LINES FOR SELECTIVE FEEDING::

5. GUIDELINES FOR SELECTIVE FEEDING:THE MANAGEMENT OF MALNUTRITION. UNHCR,

2011

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Clinical Nutrition

Clinical Nutrition

Central importance to the treatment of various diseases and health conditions

Importance in hospital settings: an appropriate dietary plan can shorten the treatment period and hence

the duration of a patient’s hospitalization

Clinical Nutrition aims at screening, assessment and nutrition therapy in general medical treatment of

patients and malnourished people who are at risk of severe health condition.

Dietitians are the health professionals specialized in human nutrition, meal planning, economics, and

preparation and are trained to provide safe, evidence-based dietary advice and management to

individuals (in health and disease), as well as to institutions. Clinical nutritionists are the health

professionals who focus more specifically on the role of nutrition in chronic disease, including possible

prevention or remediation by addressing nutritional deficiencies before resorting to drugs.

Nutrients: Nutrients are the nutritious components in foods that an organism utilizes to survive and grow.

Carbohydrates

The most prevalent organic molecules, a valuable source of energy (3.75 kcal/g) in the human diet.

A daily basis: 100 g – 400 g.

Severe deficiency: extensive breakdown of body protein, significant salt and water loss.

Very low carbohydrate diet may also lead to bone mineral loss, hypercholesterolaemia, ketogenesis and

ketone-body production in the mitochondria of liver cells; may not good for long term use.

Excessive glucose intake (>400 g): hyperglycaemia, adverse effects on health as it is related to dental

caries and chronic diseases, such as diabetes mellitus, obesity, heart disease, etc.

Plasma concentrations of glucose must be carefully regulated.

Dietary fibre and Health

Soluble fibres (e.g. pectins and ß-glucans): viscous in solution and form gels in the small intestine, affect

glucose and fat absorption.

Insoluble fibers (cellulose and lignin) influence on bowel function.

An insufficient consumption of dietary fibre: chronic disorders such as constipation, diabetes, obesity,

cardiovascular disease, cancer of the large bowel and various other cancers.

Recommendations for adult: 20–35 g/day.

Recommendation for children older than 2 years: amount equal to or greater than their age plus 5 g/day

and to until they achieve 20–35 g/day.

No defined guideline of desirable fibre intakes for infants and children younger than 2 years, a rational

approach would be to introduce a variety of fruits, vegetables and easily digested cereals as solid foods

are brought into the diet.

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Natural sources of various components of dietary fibre.

Fats and lipids

Lipids: fats, oils, waxes and various other compounds like lipoproteins, phospholipids and cholesterol.

Condensed source of energy (9 kcal/g), used by the organism as a long-term fuel reserve.

Role in the absorption of fat-soluble vitamins, precursors for hormone synthesis, form an integral

structural part of cell membranes, in which they play various specific roles (e.g. participating in cell

signalling, etc.).

Essential fatty acids

Linoleic acid, an omega-6 polyunsaturated fatty acid, and alpha-linolenic acid, an omega-3

polyunsaturated fatty acid

Linoleic acid is the precursor to arachidonic acid: a component of membrane structural lipids and is

important in cell signalling pathways. Lack of linoleic acid: skin rash, dermatitis and hair loss.

Lack of alpha-linolenic acid: adverse clinical symptoms, including neurological abnormalities and poor

growth.

Saturated and unsaturated fatty acids

Unsaturated : monounsaturated fatty acids (MUFA): one double bond, and polyunsaturated fatty acids:

(PUFA), more than one double bond.

MUFA (‘omega-9 fatty acids’): oleic acid in olive oil and peanut oil and they are believed to protect

against coronary heart disease and some types of cancer.

PUFA: omega-3 family and the omega-6 family, both of which are known to have positive effects on

human health.

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Omega-6 PUFA: liquid vegetable oils, including soybean oil, corn oil and sunflower oil.

Plant sources of omega-3 PUFA: soybean oil, canola oil, walnuts and flaxseed.

Animal sources of omega-3 PUFA: fatty fish (e.g. trout, mackerel, herrings, salmon)

Alpha-linolenic acid: precursor for synthesis of EPA and DHA, which are formed in varying amounts in

animal tissues, especially fatty fish, but not in plant cells. EPA: beneficial effects in preventing

coronary heart disease, and thrombosis, as well as to growth and neural development (DHA).

Trans fatty acids (majority derived from partially hydrogenated oils), found in Bakery foods, shortenings

and fried foods, such as potato chips, French fries, etc: associated with coronary heart disease,

hypertension and insulin resistance.

Saturated fats (animal fats, lard): in excess, coronary heart disease, hypertension and insulin resistance.

Omega-3 and Omega-6 Fatty Acids

Dietary allowance for fats

Saturated fatty acid (SFA): 10%, MUFA (predominately oleic acid): 12%, PUFA: 10% of total daily

energy intake. Linoleic acid (omega-6 PUFA): 1%, linolenic acid (omega-3 PUFA): at least 0.2% of

total energy intake.

Trans fatty acids:as low as possible.

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Higher intake (>35% of total energy intake): risk of overweight and obesity

Lower intake (<20% of total energy intake): a risk of inadequate intakes of essential fatty acids and fat-

soluble vitamins and the risk of an adverse effect on high-density lipoprotein cholesterol (HDLC).

Guideline: total fat intake, between 20 and 35% of total energy intake.SFA should not exceed 10% of

total energy intake, dietary cholesterol should be limited to 300 mg/day and consumption of trans fatty

acids should be as low as possible.

Proteins and amino acids

Proteins:essential for life processes, involved in acid–base balance, fluid regulation, immunity, growth,

differentiation, gene expression, metabolism and many other functions. Provide 4 kcal/g (16.7 kJ/g) of

energy.

Quality of proteins: essential amino acids, digestibility, absorptive capacity and biological value.

Animal proteins considered to be of higher quality than plant protein because the latter lack various

essential amino acids.

Vegetarian diets: protein complementation, bread and peanut butter.

Recommended daily protein intake: 0.8 g/kg body weight for adult men and women.

Protein energy malnutrition is the commonest type of malnutrition in developing countries.

Indispensable, dispensable and conditionally indispensable amino acids in the human diet.

Vitamins

Vitamins: the maintenance of normal metabolic functions

Water-soluble vitamins, rapidly depleted and must be regularly replenished, while fat-soluble (lipid-

soluble) vitamins are better stored in the body.

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Certain vitamins (beta-carotene, vitamin E and vitamin C): prevention of oxidative damage caused by

free radicals; potential prevention of cancer, atherosclerosis and heart disease.

vegans, who avoid animal products altogether, are at risk of developing B12 deficiency.

Vitamin Classification

Some examples of well-known side effects due to vitamin excess are:

1. headaches (vitamin A)

2. vomiting (vitamins A and D) 3. nausea (vitamins D, C, nicotinamide, vitamin B6)

4. spontaneous abortions and birth defects (vitamin A)

5. diarrhoea (vitamin C, pantothenic acid, choline, carnitine) 6. haemolytic anaemia and kernicterus (vitamin K)

7. hepatomegaly (vitamin A, niacin)

Which groups of people are at greatest risk of vitamin deficiency?

the very young, and especially premature infants

pregnant women

the very old

some categories of people suffering from chronic diseases, and especially chronically undernourished

patients and chronic alcoholics, who commonly develop thiamin deficiency

injured people, given the fact that vitamins (and especially ascorbic acid) play a role in wound healing

strict vegetarians (vegans), who may be at increased risk of developing specific vitamin (B12)

deficiencies.

Minerals and trace elements

1. Minerals and trace elements: required in only small or even trace quantities; essential for normal bodily

function.

2. Necessary for tissue structure, enzyme system function, fluid balance, cellular function and

neurotransmission.

3. The elements that are required in milligram quantities (sometimes several hundred milligrams) are

called ‘minerals’; those required in microgram quantities are known as ‘trace elements’.

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NUTRIENT TABLE (Self Service)

Nutrient Food Source RDI/RDA/RNI Function Deficiency

Symptom/Disease

Carbohydrates

Proteins

Malnutrition

The World Health Organization (WHO): malnutrition is the ‘cellular imbalance between supply of

nutrients and energy and the body’s demand for them to ensure growth, maintenance and specific

functions’, and is the greatest risk factor for illness and death worldwide. It can be associated with both

undernutrition and overnutrition.

Under-consumption refers to the long-term consumption of insufficient sustenance in relation to

the energy that an organism expends or expels, leading to poor health. Over-consumption refers to the

long-term consumption of excess sustenance in relation to the energy that an organism expends or

expels, leading to poor health and obesity.

Women and children: vulnerable to nutrition

Child: period from birth to age two, important for optimal physical, mental, and cognitive growth,

health, and development. Unfortunately, protein-energy and micronutrient deficiencies, childhood

illnesses such as diarrhea and acute respiratory infections are common.

A woman’s nutritional status reflects child’s.

Malnutrition in women: reduced productivity, increased susceptibility to infections, slowed recovery

from illness, risk of adverse pregnancy outcomes, a greater risk of obstructed labor, of having a baby

with a low birth weight, of producing low quality breast milk, of death from postpartum hemorrhage,

and of morbidity for both herself and her baby.

The most common causes of malnutrition:

o Anorexia, inadequate food intake or lack of food supplies and loss of appetite

o Different types of chronic and inflammatory diseases lead to reduced food intake and

malnutrition

o Psychological factors such as anxiety and depression or the presence of dementia

Protein and energy malnutrition

Protein–energy malnutrition (or protein–calorie malnutrition): inadequate protein intake.

Kwashiorkor (protein malnutrition predominant), a severe form of undernutrition, low protein/energy ratio.

The main symptoms: oedema, wasting, liver enlargement, hypoalbuminaemia, steatosis and the possible

depigmentation of skin and hair.

Marasmus (deficiency in calorie intake): inadequate intake of both protein and energy. The main symptoms:

severe wasting, with little or no oedema, minimal subcutaneous fat, severe muscle wasting and non-normal

serum albumin levels.

Marasmic Kwashiorkor :marked protein deficiency and marked calorie insufficiency signs present, sometimes

referred to as the most severe form of malnutrition.

The most common physical signs of protein and energy malnutrition (PEM) are:

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weight loss and cachexia1

decreased subcutaneous tissue and reduction in muscle and body tissue mass, which can be most often

observed in the legs, arms, buttocks and face

oedemas2

neurological problems and abnormalities

oral changes (red and usually swollen mouth, lips and gums)

muscle cramp and pain

skin changes (dry and peeling, frail, swollen, pale, loss of elasticity and poor healing)

hair changes (dry and discoloured).

Micronutrient Deficiencies

Profound adverse effects, may lead to increased risk of death, morbidity and susceptibility to infection,

blindness, adverse birth outcomes, stunting, low work capacity, decreased cognitive capacity and mental

retardation.

Reason:

o Lack of suitable diversification in rations

o Lack of access to fresh foods

o Rations based on highly refined cereals that may be low in B vitamins, iron, potassium,

magnesium and zinc

o High rates of infection and/or diarrhoea in children

o Anti-nutrients such as phytates present in many cereals can also inhibit absorption of certain

micronutrients and exacerbate the deficiencies

1 a condition marked by loss of appetite, weight loss, muscular wasting, and general mental and physical debilitation. It is associated with the advanced stage of diseases such as cancer 2 Oedema, also known as dropsy, is a fluid build-up in the body's tissues that often causes swelling in the feet and ankles

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Major Micronutrient Deficiencies in Emergencies: Clinical Signs and Biochemical Test

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Most common clinical signs of vitamin and mineral deficiencies (FYI)

Illnesses caused by improper nutrient consumption (FYI)

Nutrients Deficiency Excess

Macronutrients

Calories Starvation, marasmus Obesity, diabetes mellitus, cardiovascular disease

Simple

carbohydrates

Low energy levels. Obesity, diabetes mellitus, cardiovascular disease

Complex

carbohydrates

Micronutrient deficiency Obesity, cardiovascular disease (high glycemic index foods)

Protein Kwashiorkor Rabbit starvation, ketoacidosis (in diabetics)

Saturated fat

Low testosterone levels, vitamin

deficiencies. Obesity, cardiovascular disease

Trans fat None Obesity, cardiovascular disease

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Unsaturated

fat

Fat-soluble vitamin deficiency Obesity, cardiovascular disease

Micronutrients

Vitamin A

Xerophthalmia and night

blindness Hypervitaminosis A (cirrhosis, hair loss)

Vitamin B1 Beri-Beri ?

Vitamin B2 Skin and corneal lesions ?

Niacin Pellagra Dyspepsia, cardiac arrhythmias, birth defects

Vitamin B12 Pernicious anemia ?

Vitamin C Scurvy Diarrhea causing dehydration

Vitamin D Rickets Hypervitaminosis D (dehydration, vomiting, constipation)

Vitamin E Neurological disease Hypervitaminosis E (anticoagulant: excessive bleeding)

Vitamin K Hemorrhage Liver damage

Omega-3 fats Cardiovascular Disease

Bleeding, Hemorrhages, Hemorrhagic stroke, reduced glycemic control among

diabetics

Omega-6 fats None Cardiovascular Disease, Cancer

Cholesterol None Cardiovascular Disease

Macrominerals

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Calcium

Osteoporosis, tetany, carpopedal

spasm, laryngospasm,cardiac

arrhythmias

Fatigue, depression, confusion, nausea, vomiting, constipation, pancreatitis, increased

urination, kidney stones

Magnesium Hypertension Weakness, nausea, vomiting, impaired breathing, and hypotension

Potassium

Hypokalemia, cardiac

arrhythmias Hyperkalemia, palpitations

Sodium Hyponatremia Hypernatremia, hypertension

Trace minerals

Iron Anemia Cirrhosis, Hereditary hemochromatosis, heart disease

Iodine Goiter, hypothyroidism Iodine toxicity (goiter, hypothyroidism)

Source: Wikipedia

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Classification of malnutrition

Based on body weight:

Classification of malnutrition based on percentage of expected body weight

Type Percentage

Mild 85-90

Moderate 75-84

Severe <74

Classification of severe malnutrition in children (a system for classifying protein–energy malnutrition in

children based on percentage of expected weight-for-age and the presence or absence of oedema)

Classification of Acute Malnutrition for children of age 6-59 months:

Based on Mid Upper Arm Circumference (Children):

Severe Acute Malnutrition (SAM):

o SAM: MUAC < 115 mm

o Moderate Acute Malnutrition (MAM): MUAC > 115 and < 125 mm

For Adults:

For men:

SAM: MUAC < 224 mm

MAM: MUAC > 224 mm and < 231 mm

For women:

SAM: MUAC < 214 mm

MAM: MUAC > 214 mm and < 221 mm

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Based on Body Mass Index (BMI)

For adults: for both sexes:

SAM: BMI < 16

MAM: BMI > 16 and < 17

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Classification of Malnutrition in Adults based on BMI

Waist circumference:

Waist circumference is measured at the level of the umbilicus to the nearest 0.5 cm. The subject stands

erect with relaxed abdominal muscles, arms at the side, and feet together.

Waist circumference predicts mortality better than any other anthropometric measurement.

It has been proposed that waist measurement alone can be used to assess obesity, and two levels of risk

have been identified.

MALES FEMALE

LEVEL 1 > 94cm > 80cm

LEVEL2 > 102cm > 88cm

Level 1 is the maximum acceptable waist circumference irrespective of the adult age and there should be no

further weight gain.

Level 2 denotes obesity and requires weight management to reduce the risk of type 2 diabetes & CVS

complications.

Hip Circumference: Is measured at the point of greatest circumference around hips & buttocks to the nearest

0.5 cm. The subject should be standing and the measurer should squat beside him. Both measurement should be

taken with a flexible, non-stretchable tape in close contact with the skin, but without indenting the soft tissue.

Interpretation of waist/hip (ratioWHR)

A WHR of 0.7 for women and 0.9 for men has been shown to correlate strongly with a general status of

healthy.

High risk WHR= >0.80 for females & >0.95 for males i.e. waist measurement >80% of hip

measurement for women and >95% for men indicates central (upper body) obesity and is considered

high risk for diabetes & CVS disorders.

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A WHR below these cut-off levels is considered low risk.

Classification of risk of diabetes (type 2), hypertension and cardiovascular disease associated with body

weight.

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Nutritional Assessment

Purpose to:

Identify individuals or population groups at risk of becoming malnourished

Identify individuals or population groups who are malnourished

To develop health care programs that meet the community needs which are defined by the

assessment

To measure the effectiveness of the nutritional programs & intervention once initiated

Methods of Nutritional Assessment: Two types of methods: direct and indirect.

Direct Methods of Nutritional Assessment

Summarized as ABCD

Anthropometric methods

Biochemical, laboratory methods

Clinical methods

Dietary evaluation methods

Indirect Methods of Nutritional Assessment

These include three categories:

Ecological variables including crop production

Economic factors e.g. per capita income, population density & social habits

Vital health statistics particularly infant & under 5 mortality & fertility index

CLINICAL ASSESSMENT

simplest & most practical method

utilizes a number of physical signs, (specific & non specific): special attention to organs like

hair, angles of the mouth, gums, nails, skin, eyes, tongue, muscles, bones, & thyroid gland.

Detection of relevant signs helps in establishing the nutritional diagnosis

ADVANTAGES

Fast & Easy to perform

Inexpensive

Non-invasive

LIMITATIONS: Did not detect early cases

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Clinical signs of nutritional deficiency

HAIR

Spare & thin: Protein, zinc, biotin deficiency

Easy to pull out :Protein deficiency

Corkscrew, Coiled hair : Vit C & Vit A deficiency

MOUTH

Glossitis : Riboflavin, niacin, folic acid, B12 , pr.

Bleeding & spongy gums: Vit. C,A, K, folic acid & niacin

Angular stomatitis, cheilosis & fissured tongue: B 2,6,& niacin

leukoplakia : Vit.A,B12, B-complex, folic acid & niacin

Sore mouth & tongue: Vit B12,6,c, niacin ,folic acid & iron

EYES

Night blindness, exophthalmia: Vitamin A deficiency

Photophobia-blurring, conjunctival inflammation: Vit B2 & vit A deficiencies

NAILS

Spooning: Iron deficiency

Transverse lines: Protein deficiency

SKIN

Pallor : Folic acid, iron, B12

Follicular hyperkeratosis: Vitamin B & Vitamin C

Flaking dermatitis: PEM, Vit B2, Vitamin A, Zinc & Niacin

Pigmentation, desquamation: Niacin & PEM

Bruising, purpura: Vit K ,Vit C & folic acid

Thyroid gland :in mountainous areas and far from sea places Goiter is a reliable sign of iodine eficiency.

Joins & bones: Help detect signs of vitamin D deficiency (Rickets)

Anthropometric Methods

Anthropometry is the study and technique of human body measurement. It is used to measure and monitor the

nutritional status of an individual or population group.

extremely useful tool for the application of nutritional therapy.

measurement of body height, weight & proportions.

essential component of clinical examination of infants, children & pregnant women.

used to evaluate both under & over nutrition.

measured values reflects the current nutritional status.

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data used in order to identify the nutritional status of the individual, to design the appropriate nutritional

therapy and to investigate the need for greater nutritional support.

Other anthropometric Measurements

Waist circumference

Hip circumference

Hip/waist ratio

Mid-arm circumference

Skin fold thickness

Head circumference

Head/chest ratio

Anthropometry for children

Growth Monitoring Chart

Percentile chart

WHO Growth Charts Developed using data collected in the WHO Multicentre Growth Reference Study in

Brazil, Ghana, India, Norway, Oman, and the United States between 1997 and 2003 to generate new curves

for assessing the growth and development of children from birth to five years of age under optimal

environmental conditions. They are intended to be used to assess children everywhere, regardless

of ethnicity, socioeconomic status and type of feeding. They show how children should grow.

The WHO Child Growth Standards released in April 2006 depict normal early childhood growth under

optimal environmental conditions and can be used to assess children everywhere, regardless of ethnicity,

socioeconomic status and type of feeding. This is the more universal standards based on a more diverse and

international group of children, recognizing the fact that children everywhere grow similarly when their health

and care needs are met.

Z-score A score that indicates how far a measurement is from the median - also known as standard deviation

(SD) score. The reference lines on the growth charts (labelled 1, 2, 3, -1, -2, -3) are called z-score

lines; they indicate how far points are above or below the median (z-score 0).

Stunting Stunting, or chronic undernutrition, is a form of undernutrition. It is defined by a height-for-age

(HFA) z-score below two SDs of the median WHO standards). Stunting is a result of prolonged or repeated

episodes of undernutrition starting before birth. This type of undernutrition is best addressed through preventive

maternal health programmes aimed at pregnant women, infants, and children under age 2. Programme responses

to stunting require longer-term planning and policy development.

Underweight Underweight is a composite form of undernutrition including elements of stunting and wasting

and is defined by a weight-forage (WFA) z-score below 2 SDs of the median (WHO standards). This indicator

is commonly used in growth monitoring and promotion (GMP) and child health and nutrition programmes

aimed at the prevention and treatment of undernutrition.

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Wasting Wasting is a form of acute malnutrition. It is defined by a MUAC < 125 mm or a WFH < -2 z-score

(WHO standards) or WFH < 80% of the median.

Acute Malnutrition: Acute malnutrition is a form of undernutrition. It is caused by a decrease in food

consumption and/or illness resulting in bilateral pitting oedema or sudden weight loss. It is defined by the

presence of bilateral pitting oedema or wasting (low mid-upper arm circumference [MUAC] or low weight-for-

height [WFH]). The WFH indicator is expressed as a z-score below two standard deviations (SDs) of the

median (or WFH z-score < -2) of the World Health Organization (WHO) child growth standards (WHO

standards), or as a percentage of the median < 80% of the National Centre for Health Statistics (NCHS) child

growth references.

Severe Acute Malnutrition (SAM) SAM is defined by the presence of bilateral pitting oedema or severe

wasting (MUAC < 110 mm or a Severe Wasting WFH < -3 z-score or WFH < 70% of the median. A child with

SAM is highly vulnerable and has a high mortality risk. SAM can also be used as a population-based indicator

defined by the presence of bilateral pitting oedema or severe wasting (WFH < -3 z-score).

Moderate Acute Malnutrition (MAM) Moderate Wasting: MAM, or moderate wasting, is defined by a

MUAC ≥ 110 mm and < 125 mm or a WFH ≥ -3 z-score and < -2 z-score of the median (WHO standards) or

WFH as a percentage of the median ≥70% and < 80%. MAM can also be used as a population-level indicator

defined by WFH ≥ -3 z-score and < -2 z-score. .

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NUTRITIONAL STATUS OF CHILDREN

Height-for-age, Weight-for-height and Weight-for-age.

Height-for-age

Indicator of linear growth retardation and cumulative growth deficits in children.

Height-for-age Z-score: below minus two standard deviations (-2 SD) from the median of the WHO

reference population, short for their age (stunted), or chronically malnourished.

Below minus three standard deviations (-3 SD), severely stunted.

Stunting reflects failure to receive adequate nutrition over a long period of time and is affected by

recurrent and chronic illness.

Height-for-age: represents the long-term effects of malnutrition in a population; not sensitive to recent,

short-term changes in dietary intake.

Weight-for-height

reflects recent nutritional status (Acute malnutrition).

selection criterion for selective feeding programmes.

Z-scores below minus two standard deviations (-2 SD), thin (wasted) or acutely malnourished; below

minus three standard deviations (-3 SD), are considered severely wasted; more than two standard

deviations (+2 SD), overweight or obese.

Wasting: failure to receive adequate nutrition, inadequate food intake or a recent episode of illness.

Weight-for-age

Composite index of height-for-age and weight-for-height.

Both chronic and acute malnutrition.

Below minus two standard deviations (-2 SD), as underweight. Children whose weight-for-age is below

minus three standard deviations (-3 SD) are considered severely underweight.

Indicators to assess acute malnutrition:

Mid-Upper Arm Circumference (MUAC): commonly used to initially screen children (6-59 months) for

admission to feeding programmes, particularly in the acute phase of an emergency. It is simple to use, cheap

and acceptable to mothers.

Severe Acute Malnutrition (SAM), cut-off points to the following:

SAM: MUAC < 115 mm3

Moderate Acute Malnutrition (MAM): MUAC > 115 and < 125 mm

Bilateral Pitting Oedema:

a clinical sign of severe acute malnutrition

individuals with oedema cannot always be perfectly anthropometrically assessed.

A child is considered to have nutritional oedema if a depression (shallow print or pit) is left after normal

thumb pressure is applied on both feet for 3 seconds.

Measurements for adults

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Height: The subject stands erect & bare footed on a stadiometer with a movable head piece. The head piece is

leveled with skull vault & height is recorded to the nearest 0.5 cm.

WEIGHT: Use a regularly calibrated electronic or balanced-beam scale. Weigh in light clothes, no shoes. Read

to the nearest 100 gm (0.1kg)

MUAC

For pregnant women:

Since a MUAC < 230 mm has been shown to carry a risk of growth retardation of the foetus, using this cut-off

point for admission into feeding programmes would allow addressing the problem of malnutrition in both

mother and foetus by contributing to an improved birth outcome. In practice, MUAC < 210 mm is often used in

emergency interventions. The choice should be made according to proportions of women falling under each

category of MUAC and available resources.

For adults: for both sexes, the following cut-off points be used for screening adult admissions to feeding

centres:

SAM: BMI < 16

MAM: BMI > 16 and < 17

The following cut-off points proposed in the WHO Expert Consultation Report:

For men:

SAM: MUAC < 224 mm

MAM: MUAC > 224 mm and < 231 mm

For women:

SAM: MUAC < 214 mm

MAM: MUAC > 214 mm and < 221 mm

Nutritional Indices in Adults

Body Mass Index (BMI)

The international standard for assessing body size in adults.

formula: BMI = Weight (kg)/ Height (m²)

high BMI (obesity level): type 2 diabetes & high risk of cardiovascular morbidity & mortality

BMI (WHO - Classification):Classification of weight status by BMI

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Waist circumference: Waist circumference is measured at the level of the umbilicus to the nearest 0.5 cm. The

subject stands erect with relaxed abdominal muscles, arms at the side, and feet together. Waist circumference

predicts mortality better than any other anthropometric measurement. It has been proposed that waist

measurement alone can be used to assess obesity, and two levels of risk have been identified

MALES FEMALE

LEVEL 1 > 94cm > 80cm

LEVEL2 > 102cm > 88cm

Level 1 is the maximum acceptable waist circumference irrespective of the adult age and there should be no

further weight gain.

Level 2 denotes obesity and requires weight management to reduce the risk of type 2 diabetes & CVS

complications.

Hip Circumference: Is measured at the point of greatest circumference around hips & buttocks to the nearest

0.5 cm. The subject should be standing and the measurer should squat beside him. Both measurement should be

taken with a flexible, non-stretchable tape in close contact with the skin, but without indenting the soft tissue.

Interpretation of waist/hip (ratioWHR)

A WHR of 0.7 for women and 0.9 for men has been shown to correlate strongly with a general status of healthy.

High risk WHR= >0.80 for females & >0.95 for males i.e. waist measurement >80% of hip measurement for

women and >95% for men indicates central (upper body) obesity and is considered high risk for diabetes &

CVS disorders. A WHR below these cut-off levels is considered low risk.

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ADVANTAGES OF ANTHROPOMETRY

Measures many variables of nutritional significance (Ht, Wt, MAC, HC, skin fold thickness, waist & hip

ratio & BMI).

Readings are numerical & gradable on standard growth charts

Readings are reproducible.

Non-expensive & need minimal training

Limitations of Anthropometry

Inter-observers errors in measurement

Limited nutritional diagnosis

Problems with reference standards, i.e. local versus international standards

Arbitrary statistical cut-off levels for what considered as abnormal values

DIETARY ASSESSMENT

A dietary assessment can provide an information not only of a person’s normal food intake but also of the

quality of that diet. Nutritional intake of humans is assessed by five different methods.

24 hours dietary recall

Food frequency questionnaire

Dietary history since early life

Food dairy technique

Observed food consumption

24 Hours Dietary Recall: A trained interviewer asks the subject to recall all food & drink taken in the previous

24 hours. It is quick, easy, & depends on short-term memory, but may not be truly representative of the person’s

usual intake

Food Frequency Questionnaire: In this method the subject is given a list of around 100 food items to indicate

his or her intake (frequency & quantity) per day, per week & per month.

inexpensive, more representative & easy to use.

Limitations:

Long Questionnaire

Errors with estimating serving size

Needs updating with new commercial food products to keep pace with changing dietary habits

DIETARY HISTORY: It is an accurate method for assessing the nutritional status.The information should be

collected by a trained interviewer. Details about usual intake, types, amount, frequency & timing needs to be

obtained. Cross-checking to verify data is important.

FOOD DAIRY: Food intake (types & amounts) should be recorded by the subject at the time of consumption.

The length of the collection period range between 1-7 days. Reliable but difficult to maintain.

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Observed Food Consumption

The most unused method in clinical practice, but it is recommended for research purposes.

The meal eaten by the individual is weighed and contents are exactly calculated.

The method is characterized by having a high degree of accuracy but expensive & needs time & efforts.

Interpretation of Dietary Data

Qualitative Method

using the food pyramid & the basic food groups method.

Different nutrients are classified into 5 groups (fat & oils, bread & cereals, milk products, meat-fish-

poultry, vegetables & fruits) .determine the number of serving from each group & compare it with

minimum requirement.

The Food Guide Pyramid: the main sections, the food groups and the suggested servings of the pyramid.

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2. Quantitative Method

The amount of energy & specific nutrients in each food consumed can be calculated using food

composition tables & then compare it with the recommended daily intake.

Evaluation by this method is expensive & time consuming, unless computing facilities are available.

Biochemical Laboratory Assessment

The evaluation of vitamins and minerals levels in the body can be done by the measurement of these or their

products of metabolism, in the bloody fluids and other biological materials. Serum proteins seem to be useful

markers of nutritional status.

Serum albumin

The serum albumin level is an indicative marker, for the nutritional evaluation of a patient. Patients with low

serum albumin levels are in poor nutritional condition and at high risk of death.

Prealbumin

Malnourished patients have significantly lower levels of prealbumin. Thus, determining the levels of

prealbumin can be a sensitive and cost-effective method of assessing the severity of illness, which can result

from malnutrition in patients who are critically ill or have a chronic disease and may allow for earlier

recognition and intervention for malnutrition.

Serum creatinine

This protein is used as a nutritional marker, because of its relation to muscle mass.It is the most commonly used

indicator of renal function.

Serum transferrin

This is an iron-transport protein, which serves as a sensitive marker of total nutrition status and more

specifically as a marker of iron deficiency. Serum transferrin receptor (sTfR) level is a new specific and

sensitive indicator of tissue iron status and iron deficiency. Hemoglobin estimation is the most important test, &

useful index of the overall state of nutrition. Beside anemia it also tells about protein & trace element nutrition.

Advantages of Biochemical Method

It is useful in detecting early changes in body metabolism & nutrition before the appearance of overt

clinical signs.

It is precise, accurate and reproducible.

Useful to validate data obtained from dietary methods e.g. comparing salt intake with 24-hour urinary

excretion.

Limitations of Biochemical Method

Time consuming

Expensive

They cannot be applied on large scale

Needs trained personnel & facilities

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Epidemiology of nutritional disorders in Nepal: common

nutritional disorders and their prevalence rates and trends over

the last ten years, causal factors.

Source: Nepal Demographic and Health Survey 2011

Key Findings (Summary):Current nutritional situation of Nepalese mothers and children

• Forty-one percent of children under five years of age are stunted, 11 percent are wasted, and 29 percent are

underweight.

• Breastfeeding is nearly universal in Nepal.

• Seventy percent of children less than age 6 months are exclusively breastfed, and the median duration of

exclusive breastfeeding is 4.2 months.

• Complementary foods are not introduced in a timely fashion for all children. Seventy percent of breastfed

children have been given complementary foods by age 6-9 months.

• Only one-fourth of children age 6-23 months are fed appropriately based on recommended infant and young

child feeding (IYCF) practices.

• Forty-six percent of children age 6-59 months are anemic, 27 percent are mildly anemic, 18 percent are

moderately anemic, and less than 1 percent are severely anemic.

• Eighteen percent of women are malnourished, that is, they fall below the body mass index (BMI) cutoff of

18.5.

Fourteen percent of women are overweight or obese.

Women’s nutritional status has improved only slightly over the years.

• Thirty-five percent of women age 15-49 are anemic, 29 percent are mildly anemic, 6 percent are moderately

anemic, and less than 1 percent are severely anemic.

Measures of Child Nutrition Status in Nepal

Height-for-age

Nationally, 41% of children under age 5 are stunted, and 16 percent are severely stunted.

Weight-for-height

Overall, 11 percent of children are wasted and 3 percent are severely wasted.

Weight-for-age

29 percent of children under age 5 are underweight (low weight-for-age), and 8 percent are severely

underweight.

Trends in Children’s Nutritional Status

In general, the nutritional status of children in Nepal has improved over the past 15 years and is close to

achieving the Millennium Development Goal (MDG) target of reducing the percentage of underweight

children age 6-59 months to 29 percent by 2015 (National Planning Commission, 2010a).

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A downward trend in stunting and underweight over time.

The percentage of stunted children declined by 14 percent between 2001 and 2006 and declined by an

additional 16 percent between 2006 and 2011.

A similar pattern is observed for the percentage of underweight children, which dropped by 9 percent

between 2001 and 2006 and by 26 percent between 2006 and 2011.

Similarly, the percentage of wasting declined by 15 percent between 2006 and 2011.

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PREVALENCE OF ANEMIA IN CHILDREN

Anemia, characterized by a low level of hemoglobin in the blood, is a major health problem in Nepal, especially

among young children and pregnant women. Anemia may be an underlying cause of maternal mortality,

spontaneous abortions, premature births, and low birth weight. The most common cause of anemia is inadequate

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dietary intake of nutrients necessary for synthesis of hemoglobin, such as iron, folic acid, and vitamin B12.

Anemia also results from sickle cell disease, malaria, and parasitic infections.

46 percent of children in Nepal are anemic; 27 percent are mildly anemic, 18 percent are moderately

anemic, and less than 1 percent are severely anemic.

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NUTRITIONAL STATUS OF WOMEN

Short stature reflects poor socioeconomic conditions and inadequate nutrition during childhood and

adolescence. In a woman, short stature is a risk factor for poor birth outcomes and obstetric complications. For

example, short stature is associated with small pelvic size, which increases the likelihood of difficulty during

delivery and the risk of bearing low birth weight babies. A woman is considered to be at risk if her height is

below 145 cm.

12 percent of women are shorter than 145 cm.

BMI was used to measure thinness or obesity.

o A BMI below 18.5 indicates thinness or acute undernutrition, and a BMI of 25.0 or above

indicates overweight or obesity.

o A BMI below 16 kg/m2 indicates severe undernutrition and is associated with increased

mortality.

o Low pre-pregnancy BMI, as with short stature, is associated with poor birth outcomes and

obstetric complications.

The mean BMI among women age 15-49 is 21 kg/m2. Mean BMI generally increases with age.

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PREVALENCE OF ANEMIA IN WOMEN

In Nepal, a number of interventions have been put in place to address anemia in women. These include

supplementation of iron with folic acid tablets for pregnant women from the second trimester to 45

daysfollowing delivery, deworming of pregnant women after completion of the first trimester, postpartum

vitamin A supplements, and promotion of the use of insecticide-treated mosquito nets for pregnant women in

malariaendemic areas.

35 percent of women age 15-49 are anemic, 6 percent are moderately anemic, and a very small

proportion are severely anemic (0.3 percent).

Anemia prevalence has declined by only 1 percentage point since the 2006 NDHS.

There is also no difference in the prevalence of mild and moderate anemia between the two surveys.

The prevalence of anemia is associated with maternity status.

Compare NDHS 2011 with the one with 2001: National Nutrition Policy and Strategy, Nutrition Section, CHD,

DoHS, MoH&P. 24thDecember 2004.

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Compare NDHS 2011 with the one with 2001: National Nutrition Policy and Strategy, Nutrition Section, CHD,

DoHS, MoH&P. 24thDecember 2004

Prevalence of Hypertension, Obesity, Diabetes, and Metabolic Syndrome in Nepal

A double disease burden: infectious diseases as well as rising incidence of noncommunicable diseases

(e.g., cardiovascular disease and diabetes mellitus) frequently characterized by obesity.

Significant lifestyle changes. Ongoing urbanization promotes risk factors including sedentary lifestyle

and fat- and sugar-laden diets.

As diets rich in fibre and complex carbohydrates shift toward diets that include more sugars and fats, the

urbanization process precipitates greatly increased levels of lifestyle-related risk factors.

Changing dietary habits can shift a society’s disease pattern from infectious, communicable diseases’

dominance towards a status of double-disease burden with increasing prevalence of obesity and

noncommunicable diseases (NCDs).

The high incidence of dyslipidemia and abdominal obesity could be the major contributors to MS in

Nepal.

A study in urban Kathmandu showed a high prevalence of diabetes (19%). The Nepal Non-Communicable

Diseases Risk Factor Survey, which included 15 of 75 districts and represented all five administrative regions

and three ecological regions, estimated the prevalence of overweight at about 7% and the prevalence of obesity

at around 1.7% (Figure 1).

Other regional studies conducted since 2000 have shown a prevalence of overweight (between 20% and 34%),

but prevalence of obesity varied widely (0.4% to 10.14%; Table 1).

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The 2007 NCD Risk Factor survey estimated average male waist circumference in Nepal at 74.9 cm, in

females, it was 70.3 cm (68.9–71.8 cm).

The 2005 Dharan study reported a prevalence of both general and central obesity in 1,000 males (Table

2). At the waist-hip ratio cut-off (>0.90 cm), high levels of central obesity (between 40% and 60%)

occur across different demographic groups and exceed those for general obesity, as indicated by BMI, in

the same population. Urbanization in Nepal has been linked with increased occurrence of type 2

diabetes.

Prevalence of Overweight, Obesity, and Abdominal Obesity. Results are shown across selected demographic

parameters. Data given as percentages and adapted from a 2005 population-based study of 1,000 urban males of

the Eastern Nepalese town of Dharan.

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