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Anganwadi Supervisor Paper-2: Food Science and Nutrition · Chapter 8

Nutritional status assessment

What to remember

  • Nutritional assessment is done by four direct methods, remembered as ABCD: Anthropometric, Biochemical, Clinical and Dietary. Indirect methods use vital and health statistics, and ecological factors.
  • Weight-for-height shows wasting (recent loss), height-for-age shows stunting (long-term), and weight-for-age shows underweight (overall). Anganwadi workers measure weight and height and plot them on growth charts.
  • BMI = weight in kg divided by height in metres squared. A BMI below 18.5 means underweight in adults.

Why assess nutritional status

Assessment finds who is malnourished, how severe it is, and why. It helps in screening, planning programmes, monitoring growth, giving timely referral, and judging whether a programme works. In the Anganwadi, regular growth monitoring is the heart of nutritional surveillance. It is done for children from birth up to six years.

Anthropometry

Anthropometry means measurement of the body's size and make-up. It is cheap, non-invasive, quick and suitable for field use. Its limits: it cannot find specific nutrient deficiencies early, and measurement errors are common.

Common measurements:

  • Weight: the most useful measure for children. Use a calibrated scale (such as a Salter hanging scale or a digital scale), zero check before use, light clothing and no shoes. Record to the nearest 100 g for children.
  • Length and height: length is measured lying down for children below two years (infantometer); standing height after two years (stadiometer). Standing measures are about 0.7 cm less than lying length.
  • Head circumference: reflects brain growth, especially in the first two to three years. Very small head (microcephaly) may be due to poor nutrition or other causes.
  • Chest circumference: at birth, chest and head are about the same; after one year chest exceeds the head. If the head is still larger after the age of about one year, malnutrition is suspected.
  • Mid-upper arm circumference (MUAC): measured on the left arm at the mid-point between shoulder tip (acromion) and elbow tip (olecranon). It is a quick screening tool for children six to 59 months. Standard colour-coded tapes (Shakir tape) are used: red for severe, yellow for moderate, green for normal.
  • Skinfold thickness: measured with calipers at the triceps, subscapular and other sites; shows body fat.
  • Waist circumference and waist-hip ratio: show central (abdominal) obesity and risk of heart disease and diabetes.

MUAC cut-offs for children six to 59 months:

MUACInterpretation
Below 11.5 cmSevere acute malnutrition (SAM)
11.5 to below 12.5 cmModerate acute malnutrition (MAM)
12.5 cm and aboveNormal

Bilateral pitting oedema (swelling of both feet) is also a sign of severe acute malnutrition irrespective of weight or MUAC.

Body mass index (BMI): BMI = weight (kg) ÷ height² (m²). Worked example: weight 60 kg and height 1.5 m gives 60 ÷ 2.25 = 26.7. Another: 45 kg and 1.5 m gives 20.

BMI (WHO adult)Class
Below 18.5Underweight
18.5 to 24.9Normal
25 to 29.9Overweight
30 and aboveObese

Asian populations have a higher risk at lower BMI, so lower cut-offs for overweight and obesity are suggested for Asians. BMI cannot tell fat from muscle.

Indices and classification in children

Three indices:

IndexReflectsLow value means
Weight-for-ageOverall (past and present)Underweight
Height-for-ageLong-term or chronic undernutritionStunting
Weight-for-heightRecent or acute undernutritionWasting

Z-score (standard deviation score) compares a child with the WHO Child Growth Standards. A value of below minus 2 SD is moderate, and below minus 3 SD is severe malnutrition. The WHO standards were built on healthy, breastfed children from several countries, and are used worldwide, including India.

Gomez classification uses weight-for-age as a percentage of the reference median:

  • 90 per cent and above: normal
  • 75 to 89 per cent: first degree (mild)
  • 60 to 74 per cent: second degree (moderate)
  • Below 60 per cent: third degree (severe)

Its weakness is that it does not separate wasting from stunting. Waterlow classification does it, using height-for-age (stunting) and weight-for-height (wasting). IAP classification (Indian Academy of Paediatrics) also uses weight-for-age grades and is widely used in India.

Stunted children are short for age; wasted children are thin for height. Both may occur together.

Growth charts: a child's weight is plotted each month on the growth chart (as in the mother and child protection card). A rising line parallel to the reference curve shows normal growth. A flat line or a falling line is a warning that needs counselling, feeding review and referral. Under ICDS, children below three years are weighed every month and children of three to six years every three months (Poshan Tracker now records monthly growth measurement for all).

Biochemical (laboratory) methods

These detect deficiency before clinical signs appear. They are more costly and need a laboratory.

  • Haemoglobin: for anaemia. Standard lower limits are about 11 g/dl for children six months to five years and for pregnant women, 12 g/dl for non-pregnant women and 13 g/dl for adult men. The simple field test is the Sahli (haemoglobinometer) method or a digital haemoglobinometer; the colour scale method is also used.
  • Serum retinol: for vitamin A.
  • Urinary iodine: for iodine status in a population.
  • Serum albumin: for protein status; low in kwashiorkor.
  • Serum ferritin: for iron stores.
  • Blood glucose and lipid profile: for diabetes and heart risk.
  • Stool or urine tests for parasites and infection.

Clinical examination

A trained observer looks for signs of deficiency in hair, eyes, lips, tongue, skin, nails, teeth, gums, thyroid and bones. Clinical signs appear late, when deficiency is already established, and may be non-specific.

SignPossible deficiency
Bitot's spots, night blindness, xerophthalmiaVitamin A
Pallor, spoon-shaped nails (koilonychia)Iron
GoitreIodine
Bleeding gumsVitamin C
Angular stomatitis, cheilosisRiboflavin (B2)
Bow legs, rickets, beaded ribsVitamin D or calcium
Flaky paint skin, pitting oedema, sparse hairProtein (kwashiorkor)
Dermatitis, diarrhoea, dementiaNiacin (pellagra)
Peripheral neuritis, beriberiThiamine (B1)

Dietary assessment

Used to know what a person or family eats and how it compares with the RDA.

  • 24-hour recall: the person recalls everything eaten in the last 24 hours. Quick, but depends on memory; repeating on several days improves accuracy.
  • Food frequency questionnaire: how often each food is eaten. Good for habitual diet and disease links.
  • Weighment (weighing) method: all raw foods are weighed. Accurate but slow and costly. It is used for family level surveys.
  • Diet history: a detailed interview about long-term habits.
  • Food balance sheets and household consumption surveys: used at national level.
  • Duplicate meal analysis: used in research.

Indirect (community) indicators

Vital statistics tell about the nutrition of a community: infant mortality rate, under-five mortality rate, maternal mortality ratio, low birth weight, and disease rates. Ecological factors like food production, agriculture, income, education, sanitation and health services also give indirect information.

Surveys and surveillance

Large national surveys such as the National Family Health Survey record prevalence of stunting, wasting, underweight and anaemia. Nutritional surveillance means continuous watching of nutrition to take quick decisions. At the Anganwadi level, it is done through monthly growth monitoring and use of the Poshan Tracker app or registers.

Steps of growth monitoring at the Anganwadi

  • 1. Prepare the scale and check its zero reading before weighing.
  • 2. Weigh each child with light clothing, and record the weight in kilograms to the nearest 100 g.
  • 3. Plot the point on the child's growth chart against the age in months, and join it with the previous point.
  • 4. Read the trend: rising line is good growth; flat or falling line is growth faltering.
  • 5. Counsel the mother on feeding, give the supplementary food and refer severely malnourished children for medical care.
  • 6. Record the findings and follow up at the next visit.

Regular and accurate weighing is more important than a single measurement, because the direction of the line matters more than one point.

Exam traps

  • Stunting is chronic (height-for-age); wasting is acute (weight-for-height).
  • MUAC below 11.5 cm is severe; 11.5 to 12.5 cm is moderate.
  • Gomez uses weight-for-age; Waterlow uses height-for-age and weight-for-height.
  • BMI uses height in metres squared, not centimetres.
  • In Gomez, below 60 per cent is third degree; 75 to 89 per cent is first degree.
  • Biochemical tests detect deficiency early; clinical signs appear late.
  • The 24-hour recall depends on memory; the weighment method is the most accurate.
  • Bitot's spots indicate vitamin A deficiency, not vitamin D.

One-liners

  • 1. ABCD of nutritional assessment: anthropometry, biochemical, clinical, dietary.
  • 2. BMI is weight in kg divided by height in metres squared.
  • 3. Adult underweight is a BMI below 18.5.
  • 4. MUAC is used to screen children aged six to 59 months.
  • 5. A Z-score below minus 3 shows severe malnutrition.
  • 6. Stunting shows long-term undernutrition.
  • 7. Wasting shows recent undernutrition.
  • 8. Gomez classification is based on weight-for-age.
  • 9. Bitot's spots indicate vitamin A deficiency.
  • 10. Goitre indicates iodine deficiency.
  • 11. Growth monitoring charts are the heart of Anganwadi nutrition surveillance.
  • 12. Weighment is the most accurate method of dietary survey but is slow.

Practice questions

  1. The four direct methods of nutritional assessment are

    1. agricultural, biochemical, dietary and social
    2. anthropometric, behavioural, cultural and economic
    3. anthropometric, biochemical, clinical and dietary
    4. biological, clinical, chemical and demographic
    Answer

    C. anthropometric, biochemical, clinical and dietary

    ABCD: Anthropometry, Biochemical, Clinical, Dietary.

  2. Height-for-age is a measure of

    1. stunting
    2. anaemia
    3. wasting
    4. obesity
    Answer

    A. stunting

    Low height-for-age shows chronic undernutrition (stunting).

  3. Low weight-for-height indicates

    1. overweight
    2. goitre
    3. stunting
    4. wasting
    Answer

    D. wasting

    Weight-for-height reflects recent or acute undernutrition.

  4. Low weight-for-age is called

    1. stunting
    2. underweight
    3. wasting
    4. oedema
    Answer

    B. underweight

    It reflects both past and present undernutrition.

  5. Body mass index is calculated as

    1. height divided by weight
    2. weight in kg divided by height in cm
    3. weight in kg divided by height in metres squared
    4. weight multiplied by height
    Answer

    C. weight in kg divided by height in metres squared

    BMI = kg / m².

  6. An adult with BMI below 18.5 is classified as

    1. obese
    2. underweight
    3. overweight
    4. normal
    Answer

    B. underweight

    WHO classifies BMI below 18.5 as underweight.

  7. The MUAC tape is used for screening children aged

    1. 13 to 18 years
    2. 6 to 12 years
    3. 6 to 59 months
    4. 0 to 6 weeks
    Answer

    C. 6 to 59 months

    MUAC is a quick screening tool for young children.

  8. MUAC is measured at the mid-point between

    1. the shoulder tip and the elbow tip
    2. the elbow and the wrist
    3. the wrist and the finger tip
    4. the shoulder and the neck
    Answer

    A. the shoulder tip and the elbow tip

    It is measured on the left upper arm at the mid-point between the acromion and olecranon.

  9. Bitot's spots are a sign of deficiency of

    1. iron
    2. vitamin D
    3. vitamin C
    4. vitamin A
    Answer

    D. vitamin A

    Bitot's spots are foamy patches on the conjunctiva in vitamin A deficiency.

  10. Enlargement of the thyroid gland (goitre) indicates deficiency of

    1. iron
    2. iodine
    3. zinc
    4. calcium
    Answer

    B. iodine

    Iodine deficiency leads to goitre.

  11. Bleeding gums are a clinical sign of deficiency of

    1. vitamin C
    2. niacin
    3. iodine
    4. vitamin A
    Answer

    A. vitamin C

    Vitamin C deficiency causes scurvy with bleeding gums.

  12. The classification of malnutrition based on weight-for-age as a percentage of the reference median is the

    1. Apgar score
    2. Kuppuswamy scale
    3. Waterlow classification
    4. Gomez classification
    Answer

    D. Gomez classification

    Gomez uses weight-for-age percentage of the reference.

  13. Which classification separates wasting from stunting?

    1. Bloom classification
    2. Mehrabian scale
    3. Waterlow classification
    4. Gomez classification
    Answer

    C. Waterlow classification

    Waterlow uses weight-for-height and height-for-age.

  14. A Z-score below minus 3 SD of the WHO growth standard indicates

    1. severe malnutrition
    2. moderate obesity
    3. normal growth
    4. mild overweight
    Answer

    A. severe malnutrition

    Below minus 2 SD is moderate and below minus 3 SD is severe.

  15. Which dietary survey method is the most accurate but slow and costly?

    1. 24-hour recall
    2. diet history
    3. weighment method
    4. food frequency questionnaire
    Answer

    C. weighment method

    Weighing all raw foods gives accurate intake data.

  16. The 24-hour recall method mainly depends on

    1. weighing every food
    2. skinfold callipers
    3. laboratory tests
    4. the memory of the respondent
    Answer

    D. the memory of the respondent

    Its accuracy depends on how well foods eaten are remembered.

  17. Biochemical tests are useful because they

    1. need no equipment
    2. detect deficiency before clinical signs appear
    3. are free of cost
    4. replace dietary survey
    Answer

    B. detect deficiency before clinical signs appear

    They find sub-clinical deficiency early, but they cost more.

  18. Which is a limitation of clinical examination as a nutritional assessment tool?

    1. signs appear late and may be non-specific
    2. it cannot be done in the field
    3. it needs a laboratory
    4. it needs a computer
    Answer

    A. signs appear late and may be non-specific

    Clinical signs appear after the deficiency is established.

  19. Which finding in a growth chart is a warning sign?

    1. a rising line parallel to the reference curve
    2. a line within the normal band
    3. a flat or falling line over months
    4. a line moving up with age
    Answer

    C. a flat or falling line over months

    A flat or falling line shows growth faltering.

  20. Which of these is an indirect indicator of the nutritional status of a community?

    1. skinfold thickness
    2. infant mortality rate
    3. serum retinol
    4. 24-hour recall
    Answer

    B. infant mortality rate

    Vital statistics such as infant mortality are indirect indicators.

  21. The best tool for dietary assessment of an individual's usual long-term intake pattern is

    1. one-day weighment
    2. serum albumin
    3. chest circumference
    4. diet history
    Answer

    D. diet history

    A diet history interview covers long-term habits.

  22. A woman weighs 60 kg and her height is 1.5 m. Her BMI is about

    1. 26.7
    2. 20.0
    3. 90.0
    4. 40.0
    Answer

    A. 26.7

    60 / (1.5 x 1.5) = 60 / 2.25 = 26.7, which is overweight.

  23. A man weighs 72 kg and is 1.8 m tall. His BMI is about

    1. 25.6
    2. 22.2
    3. 40.0
    4. 18.0
    Answer

    B. 22.2

    72 / (1.8 x 1.8) = 72 / 3.24 = 22.2, which is normal.

  24. A woman weighs 45 kg and her height is 150 cm. Her BMI is

    1. 15
    2. 30
    3. 20
    4. 67.5
    Answer

    C. 20

    Height is 1.5 m; 45 / 2.25 = 20.

  25. A person weighs 40 kg and is 1.6 m tall. The BMI is about 15.6, which means

    1. normal weight
    2. overweight
    3. obese
    4. underweight
    Answer

    D. underweight

    40 / 2.56 = 15.6, below 18.5.

  26. A child weighs 7 kg while the reference median weight for age is 10 kg. By Gomez classification the child is

    1. third degree malnutrition
    2. first degree malnutrition
    3. normal
    4. second degree (moderate) malnutrition
    Answer

    D. second degree (moderate) malnutrition

    7 / 10 = 70%, which falls in the 60 to 74 per cent band.

  27. A child weighs 5.4 kg and the reference median is 10 kg. By Gomez classification the child has

    1. third degree (severe) malnutrition
    2. normal nutrition
    3. second degree malnutrition
    4. first degree malnutrition
    Answer

    A. third degree (severe) malnutrition

    54% is below 60%, so it is third degree.

  28. A child weighs 8 kg against a reference median of 10 kg. This is what percentage of the reference?

    1. 20 per cent
    2. 80 per cent
    3. 125 per cent
    4. 8 per cent
    Answer

    B. 80 per cent

    8 / 10 x 100 = 80%, first degree malnutrition (75 to 89 per cent).

  29. A toddler has a MUAC of 11.0 cm. The child is classified as having

    1. normal nutrition
    2. overnutrition
    3. severe acute malnutrition
    4. moderate acute malnutrition
    Answer

    C. severe acute malnutrition

    Below 11.5 cm is severe acute malnutrition.

  30. A toddler has a MUAC of 12.0 cm. The child is classified as having

    1. moderate acute malnutrition
    2. normal nutrition
    3. no risk at all
    4. severe acute malnutrition
    Answer

    A. moderate acute malnutrition

    11.5 to below 12.5 cm is moderate acute malnutrition.

  31. A woman has a waist of 80 cm and a hip of 100 cm. Her waist-hip ratio is

    1. 1.25
    2. 1.8
    3. 0.8
    4. 20
    Answer

    C. 0.8

    80 / 100 = 0.8.

  32. Consider: 1. Stunting reflects chronic undernutrition. 2. Wasting reflects chronic undernutrition. Which is/are correct?

    1. 1 only
    2. 2 only
    3. Both 1 and 2
    4. Neither 1 nor 2
    Answer

    A. 1 only

    Wasting reflects recent or acute undernutrition.

  33. Consider: 1. Gomez classification uses weight-for-age. 2. Waterlow classification uses height-for-age and weight-for-height. Which is/are correct?

    1. 1 only
    2. 2 only
    3. Both 1 and 2
    4. Neither 1 nor 2
    Answer

    C. Both 1 and 2

    Both are correct.

  34. Consider: 1. It is a sign of vitamin C deficiency. 2. Bilateral pitting oedema of both feet is a sign of severe acute malnutrition. Which is/are correct?

    1. 1 only
    2. 2 only
    3. Both 1 and 2
    4. Neither 1 nor 2
    Answer

    B. 2 only

    Bilateral pitting oedema indicates severe acute malnutrition.

  35. Consider: 1. Clinical signs of deficiency appear early. 2. Biochemical tests can detect deficiency before signs appear. Which is/are correct?

    1. 1 only
    2. 2 only
    3. Both 1 and 2
    4. Neither 1 nor 2
    Answer

    B. 2 only

    Clinical signs generally appear late.

  36. Consider: 1. Chest circumference exceeds head circumference after about one year in a well-nourished child. 2. Head circumference reflects brain growth. Which is/are correct?

    1. 1 only
    2. 2 only
    3. Both 1 and 2
    4. Neither 1 nor 2
    Answer

    C. Both 1 and 2

    Both statements are correct.

  37. Consider: 1. Weight and height are used for BMI. 2. BMI can separate fat from muscle. Which is/are correct?

    1. 1 only
    2. 2 only
    3. Both 1 and 2
    4. Neither 1 nor 2
    Answer

    A. 1 only

    BMI cannot tell fat from muscle.

  38. Consider: 1. Length is measured lying down for a child below two years. 2. Standing height is measured after two years. Which is/are correct?

    1. 1 only
    2. 2 only
    3. Both 1 and 2
    4. Neither 1 nor 2
    Answer

    C. Both 1 and 2

    Both statements are correct.

  39. Match the sign (I) with deficiency (II). I: a. Goitre b. Bitot's spots c. Koilonychia d. Rickets. II: 1. Vitamin A 2. Vitamin D 3. Iron 4. Iodine.

    1. a-1, b-4, c-3, d-2
    2. a-4, b-3, c-1, d-2
    3. a-3, b-1, c-4, d-2
    4. a-4, b-1, c-3, d-2
    Answer

    D. a-4, b-1, c-3, d-2

    Goitre-iodine; Bitot's spots-vitamin A; koilonychia-iron; rickets-vitamin D.

  40. Match the index (I) with what it shows (II). I: a. Weight-for-age b. Height-for-age c. Weight-for-height d. MUAC. II: 1. Wasting 2. Stunting 3. Underweight 4. Quick screening of acute malnutrition.

    1. a-1, b-2, c-3, d-4
    2. a-2, b-3, c-1, d-4
    3. a-3, b-1, c-2, d-4
    4. a-3, b-2, c-1, d-4
    Answer

    D. a-3, b-2, c-1, d-4

    Underweight, stunting, wasting and MUAC screening respectively.

  41. Match the MUAC reading (I) with the class (II) in a young child. I: a. 11.0 cm b. 12.0 cm c. 13.0 cm. II: 1. Normal 2. Severe acute malnutrition 3. Moderate acute malnutrition.

    1. a-3, b-2, c-1
    2. a-1, b-3, c-2
    3. a-2, b-1, c-3
    4. a-2, b-3, c-1
    Answer

    D. a-2, b-3, c-1

    Below 11.5 is severe; 11.5 to below 12.5 is moderate; 12.5 and above is normal.

  42. An adult has Hb 10 g/dl. For a non-pregnant woman this indicates

    1. normal haemoglobin
    2. anaemia
    3. iron overload
    4. dehydration
    Answer

    B. anaemia

    The usual lower limit is about 12 g/dl for non-pregnant women.

  43. Which index would best detect a child who has recently lost weight due to illness but has normal height?

    1. head circumference
    2. weight-for-height
    3. height-for-age
    4. chest circumference
    Answer

    B. weight-for-height

    Weight-for-height falls first in recent illness.

  44. The Anganwadi worker plots a child's weight each month on the

    1. ration card
    2. immunisation register only
    3. voter list
    4. growth chart
    Answer

    D. growth chart

    Growth monitoring on the chart shows the trend of the child's growth.

  45. Standing height compared with lying length is about

    1. 0.7 cm less
    2. equal exactly
    3. 5 cm more
    4. 10 cm more
    Answer

    A. 0.7 cm less

    Lying length is slightly more than standing height.

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