INTRODUCTION

Food and nutrition are basic indispensable needs of humans. Nutrition plays a critical role
in maintaining the health and well-being of individuals and is also an essential
component of the healthcare delivery system. The nutritional status of individuals affects
the clinical outcomes. Essential nutrients are classified into six groups, namely
carbohydrates, proteins, lipids, minerals, vitamins, and water.

Nutritional requirements of healthy individuals depend on various factors, such as age,

sex, and activity. Hence, recommended values of dietary intakes vary for each group of
individuals. In the United States, the Food and Nutrition Board of the Institutes of
Medicine (IOM) under the National Academy of Sciences issues nutrition
recommendations for populations throughout the life span called Dietary Reference
Intakes (DRIs).

An imbalance in nutritional intake leads to malnutrition. The word ‘malnutrition’ is

defined in multiple ways, and there is still no consensus. Traditionally, the term
malnutrition has been used in the context of lack of energy intake or deficiencies of
nutrients, under which two main conditions, namely marasmus, and kwashiorkor, are
discussed. Marasmus primarily refers to energy or calorie deficiency, whereas
kwashiorkor refers to protein deficiency characterized by peripheral edema

Nutritional assessment is the systematic process of collecting and interpreting

information in order to make decisions about the nature and cause of nutrition related
health issues that affect an individual (British Dietetic Association (BDA), 2012).

Following a structured assessment path enables health professionals to carry out a quality
nutritional assessment in order to identify those who need nutritional intervention, and to
improve clinical decision making using a person centred approach. The process promotes
consistent quality of practice; is user friendly; and allows effective monitoring of
patients. A structured assessment pathway does not remove autonomy; it encourages
professional judgement and informed decision making at every stage. The process

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provides a rationale for the nutritional intervention, and allows for revision of the plan as
individual circumstances change over time.

DEFINITION

Nutritional assessment can be defined as the interpretation from dietary, laboratory,

anthropometric, and clinical studies. It is used to determine the nutritional status of
individual or population groups as influenced by the intake and utilization of nutrients
(Gibson, 2005).

A Nutritional Assessment can be defined as: a structured way to establish the nutritional

status and energy requirements by objective measurements and whereby, accompanied
by objective parameters and in relation to specific disease indications, an adequate
(nutritional) treatment can be developed for the patient. 

Nutritional assessment allows healthcare providers to systematically assess the overall

nutritional status of patients, diagnose malnutrition, identify underlying pathologies that
lead to malnutrition, and plan necessary interventions.

NUTRITION AND DIETETIC CARE PROCESS (BDA, 2012)

Assessment

A: Anthropometry

Anthropometry allows for an assessment of the different component parts of the human
body. Body composition refers to the anatomical makeup of the body in terms of bone,
muscle, water and fat. A single measure will not provide a comprehensive overview of
the patients’ condition and so a number of measurements are required to form a more
reasoned assessment.  In malnutrition, changes in body composition lead to Introduction
to Malnutrition.

Anthropometric measurements that can be used to assess body composition.

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Measurement Equation/ method Interpretation of results

Weight and % weight change = (previous A patient is indicated for nutrition

% weight weight - current weight / previous support if they have:
change weight) x 100  BMI <18.5kg/m
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 Unintentional weight loss of

>10% in the previous 3-6 months
 BMI <20kg/m  and unintentional
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weight loss >5% in the previous

3-6 months.
(NICE, 2006)

Body mass BMI (kg/m2) = weight (kg) /  If BMI <18.5kg/m2 patient is

index (BMI) height 2 (m2) underweight
 If BMI 18.5-25kg/m  patient is in
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normal BMI range

 If BMI >25kg/m2 patient is
overweight
(WHO, 2016)

Mid upper Involves measuring the  If MUAC is >23.5cm the patient

arm circumference of the mid-point on is likely to have a healthy BMI
circumferenc upper arm using a tape measure. and is at low risk of malnutrition.
e (MUAC) This is a surrogate measure of both  If MUAC is <23.5cm the patient
fat mass and fat free mass. It is a is likely to have a BMI
useful measure when a person <20kg/m2 and may be at risk of
cannot be weighed or if their weight malnutrition.
is not likely to be a true reflection (BAPEN, 2011)
of the persons’ actual weight, e.g. if
the patient has oedema or ascites.

Skin fold Measurement requires a trained Centile tables can be used to interpret
thickness person using skin fold callipers skin fold thickness measurements.
which have been calibrated. Skin
fold measurements can be taken at 4
different sites: suprailliac,
subscapular, biceps, triceps (TSF;
most commonly used).
Measurement should be repeated 3
times and the mean result recorded.
This is a surrogate measure of total
fat mass. Longitudinal

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Measurement Equation/ method Interpretation of results

measurements can be used to

identify any changes in fat mass.

Mid arm MAMC is a surrogate measure of Centile tables allow assessment of

muscle fat free mass and is calculated using changes in total body muscle mass over
circumferenc MUAC and TSF. time.
e (MAMC)
MAMC (cm) = MUAC (cm) – 3.14
x TSF (cm)

Other visual signs may indicate recent weight loss such as loose jewellery, baggy clothes,
extra notch in belt, ill-fitting dentures, loose or thin looking skin, and prominent bony
features.

B. Biochemistry

The blood tests conducted within a nutrition assessment are interpreted in conjunction
with a clinical examination; previous medical history; and current medications.
Biochemistry tests measure levels of chemical substances present in the blood. Functional
tests measure the function of vital organs such as the kidneys or liver.

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 Normal range (note that different
laboratories may use different
Measurement Rationale reference ranges)

Haemoglobin (Hb) Assess for iron status or Women = 12.0 to 15.5 g/dl
indicate anaemia. Men = 13.5 to 17.5 g/dl

Albumin (Alb) A low level may indicate 35 - 50 g/L (3.5 - 5.0 g/dL)
inflammation or infection is
present, therefore should not be
used to determine nutritional
status.

C-Reactive Protein This is an inflammatory marker Ideally <10 mg/L

(CRP) which is raised when infection
or inflammation is present.

White cell count Immune system marker; is 4-11 x109/L (4000-11,000 per cubic
(WCC) raised if infection is present. millimetre of blood)

Glycated Indicates an average blood Ideally <48 mmol/mol or <6.5%

Haemoglobin sugar level over a period of (Diabetes UK)
(HbA1c) months.

Sodium (Na) This is an indication of 135-145 mmol/L

hydration status and kidney
function. A raised sodium level
may indicate dehydration.

Urea (Ur) Used to assess kidney function. 2.5-7.1 mmol/L

High urea and other markers
levels in combination may
indicate dehydration.

Calcium and Used as a baseline when Adjusted Ca 2.0-2.6 mmol/l

Phosphate assessing risk of refeeding Phosphate 0.7-1.4 mmol/l
syndrome Calcium is adjusted
for albumin level

Magnesium Likely to be low if there are 0.7-1.0 mmol/l

large GI losses

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 Normal range (note that different
laboratories may use different
Measurement Rationale reference ranges)

Micronutrients Include vitamins and trace

elements. These are affected by
the acute phase response if
inflammation or infection is
present and so best measured
when CRP is low
C. Clinical

A person’s disease state may increase the risk of malnutrition due to increased energy
requirements; reduced energy intake; or increased nutritional losses. Examples of
diseases/conditions where this may occur include:

 Cancer

 Chronic Obstructive Pulmonary Disease

 Heart failure

 Gastrointestinal disorders such as Crohns disease, liver disease, coeliac disease

 Neurological conditions such as stroke, Motor Neurone Disease, Parkinsons

Disease, multiple sclerosis, dementia

 Burns, surgery or trauma

 Mental health conditions (such as depression)

Symptoms that may impact on a person’s nutritional status either through reducing
nutritional intake or increasing nutritional losses include:

 altered bowel movements e.g. diarrhoea, constipation

 upper gastrointestinal upset e.g. reflux, bloating, nausea, and vomiting.

 early satiety

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  dysphagia

 lethargy

D. Dietary

Energy requirements

1. Estimate Basal Metabolic Rate (BMR) using Henry Equations (2005) based on
age, gender and weight (Henry, 2005) or estimate requirements for stable patients
using 25-35kcal/kg (NICE 2006).

2. Add factor when patient is metabolically stressed

3. Add factor for activity and diet induced thermogenesis

4. If aiming for weight gain, add 400-600 kcal/day. Only add this for patients who
are metabolically stable (i.e. not acutely unwell).

5. There are a number of alternative methods to calculate energy requirements in

patients who are obese, with care required not to over-estimate requirements.

Fluid requirements:

Aged >60 years = 30ml/kg body weight

Aged <60 years = 35ml/kg body weight (Todorovic and Micklewright, 2011)

Dietary assessment:

An estimation of the total daily calorie intake, as well as overall quality of diet should be
assessed. Asking the patient (or their family/carer if patient unable) about their daily
dietary intake will help understand patterns of eating, portion sizes, cooking methods and
types of food and drink taken. Consider asking the following questions to help form a
better understanding of the patients’ overall diet:

 What is the patients’ typical food and fluid intake? This can be recorded using
food record charts; 24-hour recall; 3-day food diary; or typical day diet history.

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  Is the patient eating 3 meals a day?

 Do they have pudding after at least one meal per day?

 Are they eating snacks in between meals?

 Are they eating smaller meals than they used to when they were feeling well?

 Are they having regular drinks, at least 6-8 glasses of fluid/ day?

 Are they having nutritious drinks such as milky tea/coffee, fruit juice, milky
drinks?

 Are they having carbohydrate foods (bread, potatoes, pasta, rice, breakfast cereals
etc) and protein foods (meat, cheese, beans, egg, fish, milk, yoghurt, cream) at
each meal time? Portion sizes should be at least the size of the patient’s fist and
amount to 1/3 each on the plate (carbohydrate, protein, vegetables).

 Are they eating at least one portion of fruit or vegetable each day?

 If food is being blended, are they adding nutritious liquids such as milk, cream or
gravy to aid blending, rather than water?

 Are they able to cook for themselves?

 Do they have access to essentials such as bread, milk and cheese on a daily basis?

 Do they have a hot/cooked meal each day?

 Are they taking any nutritional supplements? Do they take them as recommended?
Do they like them?

E. Environment

Social Physical

Ability to shop, cook, assistance with eating Appetite, dentures, dexterity, use of cutlery,

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Social Physical

and drinking, mobility, budget restraints, sight, taste changes, nausea, vomiting, heart
limited storage facilities, meal timings, burn, bloating, early satiety, diarrhoea,
family support. constipation, pain, breathing difficulties,
dysphagia (swallowing problems), food
intolerances, special diets, diminished thirst,
taste preferences.
USE OF MID-UPPER ARM CIRCUMFERENCE STRIP

MUAC is a measure to assess nutritional status. It is measured on a straight left arm, mid-
way between the tip of the shoulder and the tip of the elbow. It identifies acute
malnutrition and is commonly used in children 6-59 months of age as well as pregnant
women. MUAC less than 115 mm indicates severe wasting or severe acute malnutrition
(SAM). MUAC greater than or equal to 115 mm and less than 125 mm indicates
moderate wasting or moderate acute malnutrition (MAM).

 Mid-Upper Arm Circumference (MUAC) is the circumference of the left upper

arm, measured at the mid-point between the tip of the shoulder and the tip of the
elbow (olecranon process and the acromium).
 MUAC is used for the assessment of nutritional status. It is a good predictor of
mortality and in many studies, MUAC predicted death in children better than any
other anthropometric indicator. This advantage of MUAC was greatest when the
period of follow-up was short.
 The MUAC measurement requires little equipment and is easy to perform even on
the most debilitated individuals. Although it is important to give workers training in
how to take the measurement, the correct technique can be readily taught to minimally
trained health workers and community-based volunteers. It is thus suited to screening
admissions to feeding programs during emergencies.
 MUAC is recommended for use with children between six and fifty-nine months of
age and for assessing acute energy deficiency in adults during famine.

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 The major determinants of MUAC, arm muscle and sub-cutaneous fat, are both
important determinants of survival in starvation. MUAC is less affected than weight
and height based indices (e.g. WHZ, WHM, BMI) by the localised accumulation of
fluid (i.e. bipedal or nutritional oedema, periorbital oedema, and ascites) common in
famine and is a more sensitive index of tissue atrophy than low body weight. It is also
relatively independent of height and body-shape.

SUMMARY/CONCLUSION

A Nutritional Assessment can be defined as: a structured way to establish the nutritional

status and energy requirements by objective measurements and whereby, accompanied
by objective parameters and in relation to specific disease indications, an adequate
(nutritional) treatment can be developed for the patient. 

Nutritional assessment allows healthcare providers to systematically assess the overall

nutritional status of patients, diagnose malnutrition, identify underlying pathologies that
lead to malnutrition, and plan necessary interventions.

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REFERENCES

British Association of Parenteral and Enteral Nutrition (BAPEN) Malnutrition Universal

Screening Tool (MUST) http://www.bapen.org.uk/pdfs/must/must_full.pdf

British Dietetics Association (BDA) (2012) Model and Process for Nutrition and Dietetic
Practice. https://www.bda.uk.com/publications/professional/model

Gillis C, Wischmeyer PE. Pre-operative nutrition and the elective surgical patient: why,
how and what? Anaesthesia. 2019 Jan;74 Suppl 1:27-35.

Henry (2005) Basal metabolic rate studies in humans: measurement and development of
new equations. Public Health Nutrition. 8: 1133-1152

National Institute of Clinical Excellence (NICE) (2006) Nutritional Support in

Adults https://www.nice.org.uk/guidance/cg32/resources/nutrition-support-for-
adults-oral-nutrition-support-enteral-tube-feeding-and-parenteral-nutrition-
975383198917

Scientific Advisory Committee on Nutrition (SACN) (2011) Dietary Reference Values

for Energy. London: TSO

Todorovic, V.E., and Micklewright, A. (2011) A pocket guide to clinical nutrition fourth
edition. Parenteral and Enteral Group of the British Dietetic Association.

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Weekes, L and Soulsby C (2011), in Todorovic, V.E., and Micklewright, A. (2011) A
pocket guide to clinical nutrition fourth edition. Parenteral and Enteral Group of
the British Dietetic Association.

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