The distinction between the well and poorly nourished might appear to present no difficulty. A well nourished person is strong and active with firm muscles, bright eyes and a smooth elastic skin. The poorly fed person is weak and lethargic, with feeble muscles and perhaps, a rough dry skin. Accurate recording of the incidence of major nutritional diseases and also the lesser stigmata of malnutrition is a valuable part of a nutritional survey. Whenever possible and particularly in the less developed countries where under and malnutrition are common the incidence of nutritional diseases should be determined by examining a satisfactory sample of the population by economic class, occupation, age and sex.
    Pre-school children, their mothers and elderly people living alone are particularly liable to deficiency diseases and are overlooked by surveys of functional groups such as school children, factory workers, farmers or businessmen. The latter types of survey are easier to conduct.
    A real difficulty arises in recognizing minimal signs of nutritional disorders. In examining the eyes and skin and observing and recording minor changes that are not pathological, care should be taken and the surveyor must be properly trained and should strictly follow the guidelines indicated for the purpose.
    Record card
    No: Date of birth or age:
    Name: Sex:
    Father’s name: Anthropometric measurements:
    Mother’s name: Weight:
    Special conditions:
    Arm circumference

    Hair Mouth
    Depigmentation Angular stomatitis, glossites
    Pluckability Hypertrophic gums
    Texture: Silky, Coarse, Rough Pallor of buccal mucus membranes
    Eyes Tooth
    Bitot’s spots Total no. of teeth present
    Watering eyes No. of caries teeth

    Thyroid Skin
    Gr:I- Palpable-not visible
    Gr:II- Palpable- visible small size
    Gr:III- Palpable-visible-large size nodules
    Follicular hyperkeratosis (symmetrical)
    Posterior aspect of forearms
    Pigmented areas, neck, chest, forearms, hand, feet etc

    Blood Deformed lower limbs
    Haemoglobin level (specify method) Bandy legs, knock knees

    Skeleton Other signs
    Rickety rosary, widening of epiphyses of wrists Name of observer

    Signs of protein energy malnutrition
    Hair may become thin, fine and silky in texture and sparse, that is covering the scalp incompletely and with wider gaps between.
    The hair shows a distinct lightening of its normal colour. Various changes of colour may be found. In subjects with normally black hair the changes usually seen are dark brown, coppery reddish and blonde. Allowance should be made in some communities like washermen, because of their practices, depigmentation may be present. It is suggested that it would be noted only when the complete scalp is affected.
    Easy pluckability
    In this sign a small clump or tuft of hair can be easily pulled out with a moderate force and without pain. It is usually accompanied by the other hair changes such as depigmentation, thinness and sparseness occurs in kwashiorkor.
    Moon face
    This is a peculiarly round prominence of the cheeks which protrude over the general level of the nasolabial folds. The mouth presents a parched appearance. The condition is encountered mostly in the pre-school child with protein calorie malnutrition of the kwashiorkor type. Pitting or pressure does not occur.
    Skin changes
    Flaky point dermatosis / crazy pavement dermatosis, extensive, often bilateral hyper-pigmented patches of skin or superficial ulceration often resembling a second degree burn. It can occur anywhere but characteristically on the buttocks and the back of the thighs.
    First apparent over the wrinkles and feet, it may extend to other areas of the extremities. In early stages it can be detected by firm pressure for 3 seconds with one digit on the nodal surface of the tibia. The sign is taken as positive if there is a visible and palpable pit that persists after the pressure is removed. It is recorded only if present bilaterally.

    Clinical signs as means of judging nutritional status
    The nutritional status of a child may be judged by a physician either (a) on his estimate of the child’s general nutritive intake or (b) on specific evidence of nutritional deficiency symptoms. The physician’s estimate of a child’s nutritional status is usually based mainly on the overall appearance and bearing of the child, on the amount of his subcutaneous tissue and on his growth record. A well nourished happily adjusted child has the general appearance of vitality and well being that is a characteristic of all healthy young animals whose bodies are functioning normally and efficiently. His eyes are clear and bright with no dark circles beneath them; his hair is smooth and glossy. His skeleton is well grown and sturdy with strong straight arms and legs, well shaped head and chest. His teeth are sound and well formed and are set in well shaped jaws with room enough to prevent any crowding or overlapping. The tissues around the teeth are firm and faint and cling to the teeth closely. There are no signs of easy bleeding.
    Biochemical Estimation
    Data accumulated on human response to diet under controlled conditions, that is, metabolic studies, have been used to establish standards for evaluation of the nutritional status of nutrients. Just as biochemical analysis are limited primarily to blood in human metabolic studies, so are analysis for surveys limited to blood and urine. Collection of urine samples obviously presents more problems than blood. Most often a single blood sample is analyzed and may be a fasting sample, collected in the morning before any food is eaten or a random sample taken at any time during the day. The techniques most commonly used in surveys are measurement of thiamine, riboflavin, and u-methyl nicotine amide in urine and haemoglobin, vitamin A, carotene and ascorbic acid in blood. Serum proteins are often determined than some other measurements. The determination of plasma amino acids appears to be useful.

    Diet Survey
    It is an indirect method of understanding the quantity and quality of foods consumed by and individual. Different methods of diet survey are indicated below;
    Methods of Diet survey
    Oral questionnaire method
    Oral questionnaire or interview is the most commonly used method of diet survey. This method is also called as 24hrs recall method. The investigator has to formulate a diet survey questionnaire depending upon the purpose. After conducting a pilot study with the questionnaire changes can be made on the pattern of the questions. Then the investigator goes from door to door and collects information regarding the types and qualities of foods consumed. The data is not very perfect, only approximate amounts can be collected through this method. Therefore, this method is suitable only to collect information on the general dietary patterns or an approximate picture of dietary habits of a large section of population, general ideas like choice of foods, foods avoided in certain conditions, foods included in special conditions or in festivals, food fads and fallacies, are to be collected. The advantages of the questionnaire method are that it is not a time consuming method, therefore a large number of families can be covered within a specific time.
    Food inventory or log book method
    This method can be used only with a literate group because a book with question is entrusted to the head of the family or to the housewife. The person entrusted must enter all purchases in the book. Full cooperation from the householder is essential because reliability of the data depends upon the entry. Therefore at times the data may not be authentic.
    Weighment of raw and cooked foods
    This method is the most reliable one. But it is time-consuming and therefore it is not used for a large sample. As the investigator cannot leave the questionnaire with the householder she has to stay near and record the amount of various foods before and after cooking. The amount of food used can be recorded by weighing the leftovers after consumption. Often the housewife shows more raw foods to give a wrong impression about their food intake. Therefore the investigator must have some practical knowledge about the quantities of cooked foods of various sources.
    Study of vital statistics
    Most countries keep at least some vital statistics and from them it is usually possible to draw certain inferences about the nutrition of people. The most used statistics for this purpose has been the infant mortality rate. It has been suggested that the neo-natal mortality and the still birth rate may give a more precise index of nutrition. The manifestations and effects of malnutrition are well known to be severe in toddlers (1-4years). Death rate from infectious diseases has been used in the past as indications of nutritional status of a population. They are, however, of little practical value in most countries at the present time because of the use of specific remedies either against the diseases or their complications. In times of food scarcity, daily, weekly and monthly crude death rates may give valuable information about changes from conditions of hardship to conditions of famine.

    Nutritionally relevant disorders
    The manifestation of nutritionally relevant disorders namely anemia, goiter and blindness due to vitamin A deficiency gives an indication of the nutritional status by pointing out the particular nutrients absent in the diet.

Last modified: Saturday, 2 June 2012, 4:46 AM