NUTRITIONAL ASSESSMENT

MALNUTRITION,and OBESITY
Anik Puryatni

NUTRITION MODULE 2016

Sub Module
Nutritional Assessment
Under Nutrition : Malnutrition
Over Nutrition: Obesity

NUTRITIONAL
ASSESSMENT

Assessment of
nutritional status in clinic
Dietary assessment
Laboratory assessment
Anthropometric assessment
Clinical assessment

Nutritional status interpretation

If all 4 modalities can be
performed more accurate
diagnosis can be determined
The fact : very difficult
clinically + simple anthropometry

NUTRITIONAL STATUS
CLASSIFICATION
GOMEZ (195..)

: W/A

MacLarren (196..)

: Clinical + laboratory

The Wellcome
Trust Party (1970)

: Clinical + anthropometric
(W/A)

Waterlow (1973)

: W/H

WHO (1999)

: Clinical+anthropometric
(Z-score)

Standard Growth Chart

The CDC (2000) standards
have been recommended for
worldwide use by the WHO
regardless of racial or ethnic
origin:
CDC-NCHS 2000

IBW is used as a clinical weight goal in

the nutrition rehabilitation
Classification of Percent of IBW
120%
obesity
110 -120%
90-110%
80-90%
70-80%
<70%

overweight
normal
mild malnutrition
moderate malnutrition
severe malnutrition.

Percent of Ideal Body Weight

(Olsen et al, 2003)
Percent of IBW the best index & reflect nutritional
status better
IBW is determined from the CDC growth chart 2000
_ Plotting the childs height for age
Extending the line horizontally to the 50th percentile
height-for-age line
Extending the vertical line from the 50th percentile
height for age to the corresponding 50th percentile
weight, noting this as IBW
Percent IBW is calculated as (actual weight divided
by IBW) X 100%

A , 8 y old boy
Wt :15 kg (< P3)
Ht : 105 cm (< P3)
short stature
IBW : 16.5 kg
Nutritional status
Wt/IBW : 15/16.5
(90.9%)

well-nourished

Body mass index for age percentiles

{Weight(kg)/Height(m)2}

Assessment anthropometrics
BMI for Age-CDC 2000
(in children)
<5th percentile underweight
5th - <85th percentile normal
85th - <95th percentile overweight
95th percentile obese

Assessment anthropometrics
BMI in adult
Underweight : < 18,5 kg/m2
Normal
: 18,5 24,9 kg/m2
Overweight
: > 25,0 kg/m2
Pre-obese
: 25,0 29,9 kg/m2
Obese I : 30 34,5 kg/m2
Obese II : 35 39,9 kg/m2
Obese III : > 40 kg/m2

WHO 2006 charts

for children under 5 years
Z Score :
> (+3 SD)
: Obesity
(+2 SD) (+ 3 SD): Over weight
(- 2 SD) (+ 2 SD): Well nourished
(- 3 SD) (- 2 SD): under nourished
< (-3 SD)
: severe malnutrition

Indikator Pertumbuhan

Z-score
TB/U

BB/U

BB/TB

BMI/U

Di atas +3

Obese
(kegemukan)

Obese
(kegemukan)

Di atas +2

Overweight
(BB lebih)

Overweight
(BB lebih)

Possible risk of
overweight
(Berisiko
BB lebih)

Possible risk of
overweight
(Berisiko
BB lebih)

+
Di atas +12

Perawakan, Berat, Gizi Baik

Median (nol)
Di bawah -12

Di bawah -2

Perawakan pendek

BB kurang

Gizi kurang

Gizi kurang

Di bawah -3

Perawakan sangat
pendek

BB sangat
kurang

Gizi buruk

Gizi buruk

Infants with a history of premature

birth should have their chronological
age corrected by gestational age
until age 24 months for weight
measurements,
40 months for length
18 months for head circumference

Mid-upper arm circumference

MUAC can showed nutritional status
Left arm, middle between acromion-olecranon
Useful if :
- No data of BW & Height
- BW & Height can not be measured precisely
Examples patients with:
organomegaly; edema; hydrocephalus

NUTR.STATUS = SPECTRUM
WHT
/HT
undernutrition
70

-3SD

80

90
-2SD

PEM severe moderate mild

-Kwashiorkor
-Marasmus
-M-K

normal

overnutrition

110

120 %

+2SD

+3SD

overweight obese
mild
moderate
severe
super

UNDER NUTRITION

POTEIN-ENERGI
MALNUTRITION

PROTEIN-ENERGY
MALNUTRITION
DISEASE / CLINICAL CONDITIONS CAUSED
BY ENERGY & PROTEIN DEFICIENCY, USUALLY
ACCOMPANIED BY DEFICIENCY OF OTHER
NUTRIENTS.
PRIMARY
- NUTR.INTAKE <<
- QUALITY / QUANTITY OF NUTR. <<
SECONDARY
- NUTR. NEEDS/OUTPUT >>

ENERGY BALANCE: NEGATIVE

INPUT:
Infection
Poverty
Organic dis.
etc.

OUTPUT:
Infection
Chronic diarrhea/
Malabsorption
Hypermetabolism
etc.

The problems of PEM

THE MAIN HEALTH PROBLEM
PRIMADONNA OF NUTRITIONAL DISEASES
INFLUENCING MORBIDITY & MORTALITY AMONG
UNDERFIVES
EARLY DETECTION AND PROPER MANAGEMENT
ARE VERY IMPORTANT
SEVERE MALNUTRITION POOR QUALITY OF LIFE
SHOULD BE HOSPITALIZED

CLINICAL MANIFESTASION
Weight, Length/Height <<
Old man face, oedema, baggy pant, hair,
dermatosis, muscle atrofi, hepatomegali
Signs of circulatory collapse : cold hands &
feet, weak pulse, consciousness <<
Temperature : hypothermic / fever
Respiratory rate and type of respiration :
signs of pneumonia or heart failure.
Severe pallor

anaemia gravis

Eyes : - corneal lesion (vit.A deficiency)

Severe PEM : Marasmus

face

hair

Ribs

Muscles atrophy
SC fat <<

Severe PEM : Kwashiorkor

hair

face
Puffy

Oedema

Severe PEM : Kwashiorkor

Hepatomegaly
Crazy pavement
dermatosis

oedema

Clinically Anemic

Mc Laren Classification for Malnutrition

Clinical Sign and Laboratory

Score

Edema
3
Dermatosis
2
Edema and dermatosis
6
Hair changes
1
Hepatomegali
1
Albumin serum or protein total serum (g %)
< 1.00
< 3.25
1.00 - 1.49
3.25 - 3.99
1.50 - 1.99
4.00 - 4.75
2.00 - 2.49
4.75 - 5.49
2.50 - 2.99
5.50 - 6.24
3.00 - 3.49
6.25 - 6.99
3.50 - 3.99
> 4.00

7.00 - 7.74
> 7.75

score 0 3 : marasmic
score 4 8 : kwashiorkor marasmic
score 9 15 : kwashiorkor

7
6
5
4
3
2
1
0

5 ASPECTS in the MANAGEMENT of

MALNUTRITION
A. 10 main steps
B. Treatment of underlying diseases
C. Failure to respond to treatment
D. Discharge before recover
E. Emergency

10 main steps
No

Interven-

tion

Stabilization Transition Rehabilitation Follow-up

d.1-2 d.3-7

1. Treat/prevent
hypoglycaemia
2. Treat/prevent
hypothermia
3. Treat/prevent
dehydration
4. Correct electr.
imbalance
5. Treat infection
6. Correct micronutrients defic.
7. Begin feeding
8. Increase feeding
9. Stimulation
10. Prepare for
discharge

wk-2

without Fe

wk 3-6

+ Fe

wk 7-26

On admission :
Sh, girl, 2 yrs,
W : 3.875 g
H : 67 cm
W/H : < -4SD

2 weeks later :
W : 4.750 g
H : 67.4 cm
W/H : < -3 SD

4 weeks later :
W : 5.310 g
H : 67.7 cm
W/H : + -3 SD

5 weeks later :
W : 6.280 g
H : 67.8 cm
W/H : - 2 SD

7 yrs,
10 kg
Recovery : 16 kg

Over nutrition

OBESITY

Definitions
Obesity

Excessive deposition of adipose tissue

Overweight

Weight in excess of the average for

height
lean body mass or adipose tissue or
both (relatively large skeletal frame or
amount of muscular tissue)

Obesity a problem ?
Obesity is a global epidemy
the risk of mortality at any given age
the risk of morbidity
type 2 diabetes, coronary heart disease,
stroke, congestive heart failure, hypertension,
dyslipidemia, gall-bladder disease,
osteoarthritis, sleep apnea, and certain cancers
(ovary, breast, colon)

total health care cost

Childhood obesity

a problem ?

Persistence of childhood obesity to adult

obesity

15% of infant
25% of preschool children (6 mos-5yrs)
>50% of > 6yrs of age children
80% of 10-14yrs of age children & one obese parent

Significant impact on psychosocial well-being

negative self-image & low self-esteem
Difficult to lose weight and to sustain weight loss
long term

Epidemiology
Prevalence of overweight and obese
youth (6-18 years) globally:
USSR
China
UK
USA

: overweight 6% and obese 8%

: overweight 3.6% and obese 3,4%
: overweight 22-31% and obese 10-17%
: obese 12-14 %

Etiology
Positive energy
balance = idiopathic
( 90%)
Excessive caloric
intake
Decreased physical
activity
Decreased resting
metabolic rate

Medical causes =
endogenous (<10%)
Endocrinology

Cushing syndrome
Growth hormone
deficiency, etc

Syndromal

Prader-Willi, etc

Genetics

Leptin deficiency,
etc

Energy intake & Food composition

(254 obese elementary school children who choosed
randomly from 3 private schools, Jakarta 2002)

Energy intake (% RDA based on Widya Karya Nasional Pangan dan

Gizi, 1998)
120% :
64 %
90-119%
:
24 %
<90%
:
12 %
Fat intake
30%
:
28%
>30%
:
72%

School Canteen & westernized

food

Increased food avalability, food

advertising, pricing strategy

Physical activity

(254 obese elementary school children who choosed

randomly from 3 private schools, Jakarta 2002)

Routine exercise (3x/week)

Routine exercise (1x/week)
Not routinely exercise

: 10,6%
: 39.4%
: 50%

Anthropometric Measurements
BMI 95th percentile
% Ideal Body Weight (IBW) 120%
Triceps Skinfold 85th percentile
Visceral Adiposity Tissues
Waist circumference
Waist circumference to height ratio
Waist circumference to hip ratio

Clinical Manifestations
Heavier, taller & advanced bone age
Gynaecomastia
Pendulous abdomen & white or purple
striae
Peripheral or truncal obesity
Burried penis (embedded in the pubic fat)
Early puberty & advanced menarche
Genu valgum

Clinical Manifestations
Pendulous abdomen
gynecomastia

Buried penis
Genu valgum

INSULIN RESISTANCE SYNDROME

Pseudoacanthosis Nigricans

Obesity co-morbidities

Management
Determine the goal of treatment
Appropriate for the childs age and developmental
status
Significant weight reduction to within 20% of the
IBW
Long-term appropriate eating and physical
activity weight maintenance but do not hinder
growth & development
Principles of treatment
Dietary management
Physical activity (exercise)
Behaviour modification
Family involvement
Alternative therapy

Recommendations for Weight Goals

2 years
Usually no need to
restrict an infants diet
Advice appropriate
feeding practice
React appropriately
to infants crying
(bored, tired)
Avoid any additions
to infants bottle
(sugar, cereals)
Correct feed
dilution & volume
appropriate for age

Weaning solids
low energy density
(vegetables &
fruits) & greater
variety to
decrease milk
intake
Introduced to a cup
from about 7-8
months, omit bottle
by one year
Drinks of water
with and in between
meals

Recommendations for Weight Goals

2 - 7 years

Principle of exercise
Frequency 3-5x/week
Intensity 50-60% maximal ability
Duration 15 min initially, building to 30-40 min
Mode : use large muscles walking, jogging,
swimming, bicycling
Interest : patient dependent tennis, dancing,
martial arts, skating
Enjoyment : important factor
Incorporation into functional activities walking
to school, taking stairs vs elevator, bicycles vs
cars
Reducing passive activities tv watching,
videogames

Activity Pyramid for children

Family Involvement
Parents are the most important role models
for children.
Some ways that parents can establish a
lifetime of healthy habits for their family:
Create a Healthy Eating Environment
Create an Active Environment

Alternative (aggressive) therapy

(for morbid obesity)
BMI 95th percentile

Very Low Caloric Diet (Protein Sparing

Modified Fast Diet = PSMF)

Pharmacotherapy

at this time no drugs approved for use in

children

BMI 97th percentile (rarely used)

Bariatric surgery (reduced caloric & nutrient

absorption)
jejunoileal bypass
Roux-en-Y gastric bypass

Bariatric surgery

Early intervention is
better
Overweight children are more likely
to be overweight as adults
Obese parents increase risk of child
being obese
Treating obesity in adults is very
difficult

Thank you