Advanced Nutrition Assessment - with Details

Advanced Nutrition Assessmentالغذائية تقييم الحالة

المجتمع ولألفراد Physician - Epidemiologist / Khaled M. Almaz

Assistant lecturer, Community Medicine Department,Aswan University hospital, Aswan, Egypt

Master Degree in Public Health , October 2011Master Degree in Internal Medicine , April 2015

Basics of Nutritional Assessment

Nutritional status of a community is a sum of Nutritional status of Individual.

Sum = Summation مجموع

What is meaning by : MalMal-Nutrition diseases. ( This Presentation / PPT ).

Mal-Distribution of People in the Country in Socio-Demography.People in Egypt focused in along with Nile Valley & the Delta Region.

Mal-Distribution of the Lipid in Human Body. as Obesity ( Fatty Person ).

Mal-Absorption Syndrome ( Group of GIT diseases ).

Mal-Nutrition diseases are 2 Types:

1- Over Weight. 2- Under Weight.Obesity (common over weight):

common in Adult ,,,, i.e.: older than (above) 18 yrs old.Nutrition Assessment by : BMI (Body Mass Index).---------------------------------------------------PEM (Protein Energy Mal-Nutrition) is common Under-Nutrition:Common in Children : Marasmus – Kwashiorkor.Children ,,,, i.e.: below 18 yrs old.Nutrition Assessment by : 1. Gomez Formula: Weight for Age.2. Waterlow`s Formula.3. Growth Chart (one of its types is BMI).-----------------------------------Maternal Depletion Syndrome ( MD$ ). Affect in Demography Science in Egypt.

1- Over Weight.1. Excess energy intake ( and sedentary life ) : Obesity.

2. Excess Fat ( = Lipid ) : Atherosclerosis ( in Artery ) . شرايين تصلب

3. Excess Na ( Sodium ) : HTN ( high blood pressure ).

4. Excess Fluorine / Fluoride intake : Dental Fluorosis ( not Dental Caries تسوس ). Note : Dental Fluorosis >> Dental Mottled (color is Brown or Black).

Standards of potable water:• Water samples are submitted to through physical, chemical and

bacteriological examination.

Standards of potable water:1. I- Physical

2. II- Chemical

3. III- Bacteriologic Tests

Composition of Water ElementsII- Chemical

Metals: M.P.F.

Arsenic 0.05 ppm

Lead 0.1 ppm

Iron 0.3 ppm

Manganese 0.3 ppm

Cu 3.0 ppm

Zinc 15 ppm

Fluorides :

Safe limits in water 0.1 - 1.5 p.p.m.

II- Chemical

Organic matter• It is derived from animal or plant sources, found as compound matter or decomposition products (ammonia,

nitrites and nitrates) though harmless by it self, it may be associated with contamination, may give

objectionable tastes and odors supplies pathogens with food. M.P.F. (maximum permissible fig).•  

• Compound organic matter should not exceed 0.1 p.p.m.

Decomposition product:

• i. Ammonia 0.05 p.p.m.

• ii. Nitrites Nil

• iii. Nitrate 1.0 p.p.m. The presence of nitrites indicates recent and still going on pollution with animal organic matters.

Summary of Risk Factors of Obesity

Modifiable factors ( Behavioral ) : majority of simple obesity:Continued consumption of food that have high calories.Sedentary lifestyle.

Non-modifiable factors ( Non-Behavioral ) : majority of secondary obesity:Genetics.Hormonal.Fat and carbohydrate metabolisms disorders.Hypothalamus diseases.

Special Groups liable for obesity

1- Children ( over-feeding ).2- Elderly ( as in associated chronic disease as DM \ Heart disease).3- Patients ( Myxedema – Cushing Syndrome).4- Adolescents ( specially for fast foods >>> Bad eating habits : (cocacolism and Magdonalism \ ماكدونالز .(ماك6- Familial susceptibility (genetics & hormonal) who interested in food.7- Middle-age women (as they exposed to traditional communities).8- Psychological disturbed cases (whether due to psychic drugs or behavioral).

Irritable bowel syndrome (IBS)Psychological patients (specially females)

1. IBS (irritable bowel syndrome) ( in Intestine ).

2. Anorexia Nervosa ( in stomach)

3. Depression.

4. Anxiety

5. Psychic Chest Pain ( considered in diagnosis with other causes in Heart / Chest )

• TTT of IBS :

•  Coloverin A for anxiety

• Coloverin D for gases and bloating

• Anti-psychiatric drugs.

IBD (Inflammatory Bowel Diseases) (IBD)

Medical history : usually bloody diarrhea.1. Ulcerative Colitis.

2. Crohn's disease.

TTT of IBD usually : Cortisone (steroid) >> leads to >> Increase glucose level.

Cortisone side-effects >> obesity (moon face & other signs).

High glucose level (CHO accumulation) : Obesity ( or abnormal fatty distribution).

The 2 goals of therapy are the achievement of remission (induction) and the prevention of disease flares (maintenance).

Cortisone (Hormone)

1. Cushing Disease / Cushing Syndrome.

2. TTT of IBD usually : Cortisone (steroid) drug (treatment).

specially for fast foods

2- Under Weight.1. PEM (Protein Energy Mal-Nutrition) : Marasmus – Kwashiorkor.

2. Fluorine Deficiency: Dental Caries تسوس

3. Vitamin C deficiency : Scurvy (bleeding disease)

4. Iron ( Fe ) & Vitamin B12 & B9 deficiency : Nutritional Anemia , (Vit B9 : Folic Acid).

5. Vitamin D & Ca (Calcium) deficiency: Rickets هشاشة , OsteoMalacia هشاشة (M=Minerals deficiency ) , OsteoProsis عظام .( P=Proteins deficiency) لين

6. Vitamin B1 deficiency : Beri Beri.

Nutrition Assessment

Is a dynamic process of evaluation of the nutritional status of

1- individuals, 2- groups or 3- the community,

>>>>> to identify the major malnutrition problem's

>>>> so as to set plans for prevention and control of malnutrition.

Objectives of Nutritional Assessment

Determine the Magnitude & Geographical Distribution of

malnutrition.

Determine Ecological factors of malnutrition.

Plan for Control & Prevention of malnutrition.

Ecology of Malnutrition• Malnutrition is a health problem with multiple facets.

Ecological triad :

Host – Agent – Environment

Ecological TriadHost

Agent Environment

Methods of Nutrition Assessment

2. National Level (indirect) : 1- Individual or group level (direct) :

1. National food consumption.2. Food Balance Sheet.

1.1 Anthropometric Measurements

2. Vital statistics. 1.2 Biochemical Assessment

3. Assessment of Ecological factors.( not specified : not direct nor indirect)

1.3 Clinical Assessment

1.4 Dietary Assessment

Methods of Nutritional Assessment

They are complementary to each other

Direct methods Indirect methodsClinical methods Assessment of dietary Intake (Diet Survey)

Anthropometry Vital statistics

Biochemical methods Ecological studies

Functional assessment

Biophysical and radiological examination

1- Individual or group level (direct)

1.1 Anthropometric Measurements

(direct)

• Weight for Age Measurements ( Gomez Classification ).• Height for Age for children.• Weight for Height for children.• Weight for Height : Relative Weight (RW).• Growth Charts (in Children only ; Pediatrics).• Body Mass index (BMI).• Waist Circumference (WC) & (WH Ratio >> Waist Hip Ratio) : Apple & Pear.• Mid Upper Arm Circumference (MAC).• Triceps Skin Fold Thickness (TSF).• Bio-electrical impedance (BEI).• Measurement of body water and body potassium.• Hydrostatic weighting.• Air displacement plethysmography.• Dual Energy X-ray Absorptiometry (DXA).

Weight Measurement

Triceps skin fold thickness

1- Waist Circumference (WC) & 2- (WH Ratio >> Waist Hip Ratio) : Apple & Pear

WC & BMI

Distribution of adiposity: Android obesity --- around the waist

According to fat distribution:1) Android (Apple)تفاحة : Musculine (male like)– visceral - البنطلون حزام مستوي فوق ترهلWaist Hip ratio : >0.9 in male - >0.8 in female.Risk factors and indication of Apple shaped :IHD – type II DM.

2) Gynoid (Pear) كمثري: Feminine (female like): حزام تحت ترهلالبنطلونWaist Hip ratio : <0.9 in male - <0.8 in female.Risk factors : gynecological & obstetric complication.

No. 1Pediatrics

< 18 yrs oldIn case of

PEM ( Protein Energy Mal-Nutrition )

Malnutrition &

the children’s Growth &

the children’s development

PEM ( Protein Energy Mal-Nutrition )

Types : 1. Kwashiorkor2. Marasmus'3. Mixed >> Kwashiorkor - Marasmus

The Nutritional Assessment are by :

1. Gomez Formula: Weight for Age2. Waterlow`s FormulaHeight for Age for children.Weight for Height for children.Weight for Height : Relative Weight (RW).

Body weight in Kg X 100 Gomez Formula: Weight for Age = _________________ Standard weight in Kg at same Age

Gomez, classification:Weight of the child

• Weight for age (%) = ---------------------------- x 100

Weight of a normal child of same age

• Between 90 and 110% : normal nutritional status.

• Between 75 and 89 % : 1st degree, mild malnutrition.

• Between 60 and 74% : 2nd degree, moderate malnutrition.

• Under 60% : 3rd degree, severe malnutrition.

Waterlow`s Formula

Mean / X` : a measure of Central Tendency.SD : a measure of Dispersion / Scatter التشتت.

(s) : Stunting >> short in the Length(w) : Wasting >> under weight / weight below the normal

Waterlow's classification:

< m – 2 SD > m – 2 SD W/HH/A

Wasted Normal > m - 2 SD

Wasted and stunted Stunted < m - 2 SD

M = mean, SD = standard deviation

Waterlow's classification defines two groups for protein energy

malnutrition:• Malnutrition with retarded

growth, in which a drop in the height/age ratio points to a chronic condition– shortness, or stunting:

• Malnutrition with a low weight for a normal height, in which the weight for height ratio is indicative of an acute condition of rapid weight loss, or wasting.

Interpretation of indicators:

Weight of the childWeight/Height (%) = ---------------------------------- x

100Weight of a normal child at same

height

Height of the childHeight/Age (%) = ----------------------------------- x

100Height of a normal child at same

age

Wasting(% of

weight/height)

Stunting(% of height/age) Nutritional status

> 90 > 95 Normal

80-90 87.5 – 95 Mildly impaired

70-80 80 – 87.5 Moderately impaired

< 70 < 80 Severely impaired

Classification of the nutritional status

• The normal range for the children growth corresponds to the range between two lines presenting -2 SD and +2 SD from the median reference value for the child’s age.

RW ( Relative Weight )Weight for Height : RW ( Relative Weight )The weight & height : measured to calculate RWRW : is deviation from standard weight for heighti.e. : displayed in special tables for the desirable weight for a given height.

International Classification of adult overweight & obesity

, according to BMI & RW Index ( Relative Weight )RW (relative weight) BMI Classification

<90 <18.50 Underweight

90 - 109 18.50 – 24.99 Normal range

110 - 119 25.00≤ Over weight

120 ≤ 30.00≤ Obese

120 - 139 30.00 – 34.99 Obese class I

140 - 200 35.00 – 39.99 Obese class II

>200 40.00 ≤ Obese class III

No. 2Pediatrics

< 18 yrs oldBy

Growth Chart(most common method)

Growth Chart by percentile Nutritional

Assessment

ILOs

Definition.

Plotting on growth charts.

Interpretation of growth curves.

Definitions

Growth: Increase in cell size and number with a resultant increase in height or girth or both.

Growth monitoring: Following the growth rate of a child in comparison to a standard by frequent periodic anthropometric measurements in order to assess growth adequacy.

Anthropometry: Measurement of a person’s physical parameters and comparing them with a standard.

Percentile : one of Measures of Position. Some Resources said it is one of measures of Dispersion.

Measures of Position : used for quantitative variables ( not qualitative ).

Measures of Position , Central Tendency , Dispersion : for Descriptive study & data (mainly).

Measures of Position

53

Measures of position are different techniques that divide a set of data into equal groups.

To determine the measurement of position, the data must be sorted from lowest to highest.

The different measures of position are: QuartilesThe quartiles divide the data set into four equal parts.DecilesThe deciles divide the data set into ten equal parts.PercentilesPercentiles divide the data set into one hundred equal parts.

Introduction of Growth Chart.

Introduction of Pediatric physical body assessments.

Introduction of Pediatric physical body assessments

Pediatric physical body assessments : 1st day old – 17 years old.17 years old : it means : less than 18 yrs old For example : an age of a child is 17 years old and 8 months.

Regarding height & weight.1. Height : same height , not need equation ( calculation).2. Weight : different according to the age groups: (next slide)

1st day - < 1 years old.1 years – 5 or 6 years old.5 or 6 years – 12 years old.12 years – 17 years old ( and above 30 Kg) : you have to check growth curve.

For Infants < 12 months: Weight (kg) = (age in months + 9)/2 For Children aged 1-5 years: Weight (kg) = 2 x (age in years + 5). For Children aged 5-14 years: Weight (kg) = 4 x age in years.

Medical importance to know weight & height :- Assessment of health status.- Calculate drug dosage.

Introduction of Growth Chart

What are these growth charts?

Growth charts are visible display of child’s physical growth and development.

Also called as “road-to-health" chart.

It was first designed by David Morley and was later modified by WHO.

Population aged targets in Growth Chart Assessment

( In Egypt ) regarding to the monitoring and assessment by Growth Chart. : 1st day after birth up to 20 years old.

1st day after birth – 17 years old : Pediatric age.

> 17 years - ≤ 20 years old : young Adult.

Cases in 5 % percentile – 95 % percentile

3 cases diagnosed from Growth Chart :1. Canalization / Road to health. Generally >>> not less than 5 % &

not more than 95 %... Also >> ( in one canal in growth chart as for example the line of measurement of child is between 25 % & 50 % ).

2. Over Weight : 85 % – 95 %.3. Failure to thrive / Under nutrition. (below / less than 5 %).4. Obese (over weight) / Over nutrition. (more than 95 %).Note : Correction time ( = Catch-up Growth ) ; ( when check growth chart of a child by ttt

/ treatment from failure to thrive then the line be in normal range > Road of the health ).

Cases in 3 % percentile – 97 % percentile

4 cases diagnosed from Growth Chart :1. Canalization / Road to health. Generally >>> not less than 5 % & not

more than 95 %... Also >> ( in one canal in growth chart as for example the line of measurement of child is between 25 % & 50 % ).

2. Over Weight : 90 % – 97 %.

3. Border line . (below / less than 5 %).

4. Failure to thrive / Under nutrition. (below / less than 3 %).

5. Obese (over weight) / Over nutrition. (more than 97 % or 95 %).Note : Correction time ( = Catch-up Growth ) ; ( when check growth chart of a child by ttt /

treatment from failure to thrive then the line be in normal range > Road of the health ).

Example of Failure to thrive / Under nutrition

• If child in first 12 months of his life : the line in growth chart was between : 50 % and 75 %.

• Then in 16th months of child age fall in growth chart to be between : 10 % and 25 %.

• This case is : Failure to thrive / Under nutrition.• As this line in Growth chart give significant alarm for under

nutrition to this child.• Note : although this case is not below / or not less than 5 %.

Under Weight1. PEM (Protein Energy Mal-Nutrition) : Marasmus – Kwashiorkor.

2. Fluorine Deficiency: Dental Caries تسوس

3. Vitamin C deficiency : Scurvy (bleeding disease)

4. Iron ( Fe ) & Vitamin B12 & B9 deficiency : Nutritional Anemia , (Vit B9 : Folic Acid).

5. Vitamin D & Ca (Calcium) deficiency: Rickets , OsteoMalacia (M=Minerals deficiency )

, OsteoProsis (P=Proteins deficiency ).

6. Vitamin B1 deficiency : Beri Beri.

Difference bet. Supplementation and Fortification

Supplementation food = therapeutic food ( Curative ) for ttt of mal-nutrition

it is a food substance which rich in a certain nutrient element that deficient in the patient.

Iron supplementation Food : treatment of Iron Deficiency Anemia

Because there are other types of Anemia not caused by Iron Deficiency

===================

Fortification food ( Preventive ) For prevention of mal-nutrition to a certain food substance

It is a nutrient element that added to be responsible for prevention of mal-nutrition to a certain food substance ,, that commonly consumed by all population.

Iodine Fortification Food : preventive for Goiter in regions that lack from Iodine

Example of Obese (over weight) / Over nutrition

• If child in first 12 months of his life : the line in growth chart was between : 50 % and 75 %.

• Then in 16th months of child age raise above in growth chart to be between : 90 % and 95 %.

• This case is : Risky for Obese / or Over nutrition.

Over Weight1. Excess energy intake ( and sedentary life ) : Obesity.

2. Excess Fat ( = Lipid ) : Atherosclerosis ( in Artery ) . شرايين تصلب

3. Excess Na ( Sodium ) : HTN ( high blood pressure ).

4. Excess Fluorine : Dental Fluorosis ( not Dental Caries تسوس ).

How to read growth chart ( for the beginners) :1 or 2 small squares above or below the normal range : Just under 3 % - 5 % percentile. or Just above 95 % - 97 % percentile.

More than 4 small squares above or below the normal range :Marked (severe) degree under 3 % - 5 % percentile. or Marked (severe) degree above 95 % - 97 % percentile.

2 types of percentile in growth charts :

1. Common : 5 % percentile – 95 % percentile.

2. Also : 3 % percentile – 97 % percentile.

Common :

5 % percentile – 95 % percentile

7 lines in this Type: 5 % – 10 – 25 – 50 – 75 – 90 – 95 %

3 % percentile – 97 % percentile

9 lines in this Type: 3 % -5 % – 10 – 25 – 50 – 75 – 90 – 95 % - 97 %

Types of Growth Charts :

Weight for Age.

Height for Age.

Weight for Height (Waterlow`s Formula).

BMI for Age.

Weight for Age

Age (days)

Age (Weeks)

Age (months)

Age (years)

Height for Age

Height (cm ; centimetre)

Height (meter)

Height (inches) ; 1 inch = 2.5 cm

Length : (on bed) Infant less than one year.Height : (on standing) older than one year.** Length also used in Adult ( but not in Growth Charts).

g

Weight for Height (Waterlow`s Formula)

Waterlow`s Formula >> weight for height part 1

Waterlow`s Formula

Mean / X` : a measure of Central Tendency.SD : a measure of Dispersion / Scatter التشتت.

Waterlow`s Formula >> weight for height part 2

BMI for Age

Growth Chart in Community Medicine

The assessment of growth may be longitudinal or cross sectional.

Longitudinal assessment of growth entails measuring the same child at regular intervals.

Cross sectional comparisons involve large number of children of same age.

Basic growth assessment involves measuring a child’s weight and length or height , comparing these measurements to growth standards.

Assessment of Growth

An upward curve in the road to health is ideal.

A flat and downward curves are not desirable.

WHO charts – blue for boys and pink

for girls.

Uses of Growth ChartsGrowth monitoring.Diagnostic tool-To identify high risk children.Planning and policy making. Education tool for educating mothers.Tool for action helps in type of intervention that is needed ( ttt of overweight &

underweight , and both according to their differential diagnosis).Evaluation of effectiveness of corrective measure and impact of a programme of

special interventions for improving Childs growth and development. Tool for teaching.Calculate drug dosage.

Purpose of growth assessment

• The purpose is to determine whether

a child is growing “normally” or growing “ abnormally” i.e. :Has a growth problem.

INTERPRETATION OF GROWTH CURVES

• This is determining whether the child is growing appropriately or not.

Normal growth curve: a healthy child’s growth curve is parallel to the printed curves on the chart.

• Important consideration on premature infants where growth failure can be over diagnosed, this can be avoided by subtracting the weeks of prematurity from postnatal age when plotting the growth measurements.

• The direction of the growth curve is more important than the position of the curve on the chart.

A horizontal growth curve (static) : This indicates danger, this means the child is not growing. A sign of disease, especially malnutrition. This makes them prone to recurrent infection as they can not resist disease, Medical history should be taken to establish the cause of growth failure, then

intervene; practical guidance to the mother to ensure continuation of normal growth. Thereafter growth monitoring helps to determine the adequacy of catch-up growth

(successful nutritional rehabilitation associated with growth spurt).

Downward growth curve: • Indicates a very dangerous situation where the child is losing the weight. • This requires extra care immediately. Indications :-• Malnutrition, Tuberculosis, AIDS or other medical conditions. • Investigations and treatment necessary.

Any infant who does not gain weight for a month or a child in 2 months should receive urgent attention, an indicator of the child being malnourished.

Advantages of CDC 2000 Growth Charts

Most importantly the 2000 charts were representative, of all (non-very low birth weight) infants.

Extent of breastfeeding project.

Disadvantage of CDC 2000 Growth Charts

Pooling of multiple datasets to construct the curves.

Though great care to ensure the comparability of the datasets being pooled, we cannot rule out, the possibility that the shape of the curves was affected by using different datasets at different ages.

Application

&

Examples

طفل محمودوزنه .... ٤السن  : • كان الوزن ٬كيلو ٦شهورعمر  • كان ٦وفي وزنه ٬كيلو ۷شهورعمر  • كان ۱۲وفي وزنه كيلو ۸شهر

------------------------- : السؤالComment

-----------------------: االجابة في األولي الخطوة : في أوال  الطفل بوزن الخاصة نقاط الثالثة الخط growth chartتحديد او المنحني هنرسم :  الخطوط ) (ثانيا او المنحنيات لمعرفة النقاط توصيل

 ============== : االجابة في الثانية التعليق Commentالخطوةبين  ) ( • الفترة في طبيعي الوزن النمو معدل شهور ٦و ٤كانبين  • الفترة عمل ۱۲و ٦وفي الخط التغذية crossingشهر نقص اتجاه في لخطينالنمو  : • خريطة في Failure to thriveالتشخيص

Interpretation – A boy Aged 3 years and 11 months. He weighs 19.5 kg and is 109.6 cm tall. His weight-for-age is above the 1 z-score line, and his height-for-age is above

the 1 z-score line. His weight-for-height, shown on the chart , is in the normal range.

Advanced Growth chart for Degree of Under Weight

Interpret trends on growth charts

When interpreting growth charts, be alert for the following situations, which may indicate a problem or suggest risk:

1. A child’s growth line crosses a z-score line.

2. There is a sharp incline or decline in the child’s growth line.

3. The child’s growth line remains flat (stagnant); i.e. there is no gain in weight or length/height.

Growth chart used in India

• India has adopted the new WHO Child Growth Standards (2006) in February 2009

• These standards are available for both boys and girls below 5 years of age .

• A joint "Mother and Child Protection Card" has been developed which provides space for recording :

o family identification and registration.o Birth record.o Pregnancy record.o Institutional identification.o Care during pregnancy.o Preparation for delivery.o Details about immunization procedures.o Breast-feeding and introduction of supplementary food.o Milestones of the baby.

Advanced Growth chart for degree of under weight

Management

Weight b/w curves 1 & 3-undernourished,require supplementary feeding at home.

Weight below curve 3-consult the doctor and follow his advice.

Weight below curve 4-hospitalized for treatment.

Limitations in growth charts

• Don`t reflect current feeding practices.

• The rapid weight gain demonstrated in the breastfed infants first six months may not be appropriate for all breastfed babies May inadvertently discourage exclusive breastfeeding.

• Slower than expected growth rates may be interpreted as neglect especially in aboriginal communities.

CDC recommendationsThe WHO growth standard charts should be used for children

younger than 2.

The CDC 2000 growth reference charts should be used for children aged 2 through 19 years, because these charts can be used continuously up to age 20

• Growth assessments that are not supported by appropriate response programmes are not effective in improving child health.

Implications for diagnosing over or underweight children

The CDC 2000 charts and the WHO 2006 charts produce slightly different curves for children at different age points

• More children could be assessed as underweight prior to six months of age and less after six months of age by using the WHO 2006 charts compared to the CDC 2000 charts.

• Breast fed infants may track well against the CDC reference for the first four to six months of life but poorly after the first four to six months.

• Mothers of breast fed babies who do not show the rapid growth rates in the WHO 2006 model in the first two to four months may also be at greater risk of introducing complimentary feeding at an early age.

Implications for diagnosing ,, cont,

• Healthy children.• Living under conditions likely to favor the achievement of their full genetic

growth potential.• Mothers engaged in fundamental health-promoting practices, namely

breastfeeding and not smoking.• The new standards show that growth can be achieved with recommended

feeding and health care (e.g. immunizations, care during illness).• The standards can be used anywhere in the world.• study also showed that children everywhere grow in similar patterns when their

nutrition, health, and care needs are met.

Additional benefits of the new growth standards include the following

• The new standards establish breastfed infants as the model for normal growth and development. As a result, health policies and public support for breastfeeding will be strengthened.

• The new standards will help better identify stunted and overweight/obese children.

• New standards such as BMI (body mass index) are useful for measuring the increasing worldwide epidemic of obesity.

• Charts that show standard patterns of the expected growth rate over time enable health care providers to identify children at risk of becoming undernourished or overweight early, rather than waiting until a problem level is reached.

Additional benefits of the new growth standards ,, cont,,

• For the assessment WHO has provided charts for both boys and girls.

• Growth indicators are used to assess growth considering a child’s age and measurements together.

length/height-for-age.

weight-for-age.

weight-for-length/height.

BMI (body mass index)-for-age.

Considerations

Effectiveness of growth charts:

• To what extent does growth monitoring results in positive health out comes for children.

• Growth is an individual process. Individual do not grow according to statistical distributions of size and age.

• The wide range with in normal growth patterns is not always well understood by health professionals or parents leading to unnecessary anxiety for parents and the possibility of ceasing breastfeeding too soon, or of overfeeding.

Conclusion No existing Growth chart is a perfect match in

Indian context.

The CDC 2000 and WHO 2006 growth charts both have their benefits and Limitations.

For Adult > 18 yrs oldBMI : Body Mass

Index

(most common method)

BMI : Body Mass Indexfor Individual ( adult & child )

• Body mass index (BMI) is a simple index of weight-for-height that is commonly used to classify overweight and obesity in adults.

• It is defined as a person's weight in kilograms divided by the square of his height in meters (kg/m2).

The WHO definition is:• a BMI greater than or equal to 25 is overweight.• a BMI greater than or equal to 30 is obesity.

Note : The most applicable for physicians is :BMI : Body Mass Index

BMI = Wt / (Ht)2

Wt : WeightHt : HeightDifference between Height and Length :-- Height - Length

Classification of Obesity:1- Under weight : less than 18.52- Normal : 18.5 – 24.93- Over weight : 25 – 29.94- Obese : “ Grades “ : 30 – 39.9 Class I : Mild Obesity 1: 30 – 34.9 Class II : Moderate Obesity 2 : 35 – 39.9 Class III : Severe Obesity 3 : more than 40

5- Morbid obesity “Fatal “ : BMI: > 50 kg/m2 class IV (extreme)

International Classification of adult overweight & obesity

according to BMI & RW Index ( Relative Weight )RW (relative weight) BMI Classification

<90 <18.50 Underweight

90 - 109 18.50 – 24.99 Normal range

110 - 119 25.00≤ Over weight

120 ≤ 30.00≤ Obese

120 - 139 30.00 – 34.99 Obese class I

140 - 200 35.00 – 39.99 Obese class II

>200 40.00 ≤ Obese class III

WC & BMI

Anthropometric Measurements (direct) continue..

Measurement of body water and body potassium :

Total body fat = total weight – ( total body water – 0.72). الجسم في الدهون نسبة االنسان= معادلة جسم الوزن– وزن

. الدهون بدون

Note : ( total body water – 0.72 ) is = free fat mass ( FFM ).

1.2 Biochemical (Investigation) Assessment

(direct)

1.2 Biochemical (Investigation) Assessment (direct)

1. Serum or plasma :Total proteins or amino acidsVitamin A & carotene , Vit. C , Vit. B12Iron , transferrin1. RBCs , Hb (Haemoglobin) : for Vit. B22. Urine : Cr ( creatinine ) , B1 , B23. Immunological tests : Lymphocytes ( one of WBCs) : (( note : WBCs : 4000 – 11000 cells ))1200 : normal800 – 1200 : moderate< 800 : severe nutritional deficiencySkin test : type 4 hypersensitivity ( delayed cell mediated immunity )Humoral immunity : decreased or absent response

Biochemical (Investigation) Assessment : Laboratory and radiological assessment:

-Blood hemoglobin, hematocrite value and red blood cell count.-Serum level of different nutrients: carotenes, vitamin C, D and B12.-Plasma proteins and transferritin.-Lipoproteins (especially LDL) and triglycerides (TGs) in serum.-Stool analysis for intestinal parasites.-X-ray examination of bones and teeth.

1.3 Clinical Assessment & Observations

(direct)

Note:Taking Medical History as :1. Personal history , 2. History of Present illness , 3. Family history , 4. Past ( old ) history 5. Therapeutic history.

1.3 Clinical Assessment & Observations (direct)

Depends on signs manifested on epithelial tissues: Skin , eyes , hair , buccal mucosa.Thyroid gland : goitre ( gland enlargement)Other physical data may include vital signs as pulse rate, respiration and blood pressure.

Disadvantages of this method:Non specific as these signs may be affected by environmental factors as : DrynessWeatherWindy areas

I- Head and neck (Face, lips, gums, teeth, tongue

eyes):

Examples:• 1. Pale color of face in iron deficiency anemia• 2. Mottled enamel (brown or black) in case of Excess

Fluorine / Fluoride intake : Dental Fluorosis ( not Dental Caries )تسوس.• 3. Neck: enlarged thyroid in iodine deficiency.

II- Musculoskeletal

• Muscle wasting in PEM• Epiphyseal enlargement as in rickets.• Thorax (Pigeon Chest ) and head deformities in complicated

rickets.

** PEM : Protein Energy Malnutrition :• Marasmus.• Kwashiorkor.• Mixed : Marasmus & Kwashiorkor.

OsteoMalacia ( in Adult ) : Minerals Deficiency.

العظام هشاشةIn Children ( < 18 yrs old ) : Rickets. الكساح و العظام هشاشة

OsteoProsis : Protein Deficiency.

العظام لين

• III-Skin, Hairs, Nails• As follicular hyperkeratosis in vitamin A deficiency • Dermatitis in pellagra B3 & B6 deficiency.

• IV- Nervous Manifestation• Polyneuritis and sensory loss: B1 deficiency.• Psychoneurosis dementia in niacin B3 deficiency. • Neurologic changes: B 12 deficiency.

1.4 Dietary Assessment &

Evaluation (direct)

1.4 Dietary Assessment & Evaluation (direct)

Objectives :

Identify pattern of food intake.

Assess amount of energy , nutrient intake.

Comparison with recommended dietary reference intake.

Identify pattern of food intake

Direct Methods for Nutrition Assessment

A- Household food Survey

The tools are Surveys that need national statistics on food & agriculture.

It shows distribution of national food supply among different groups of population.Disadvantages : not very specific , long time between initial poor nutrition and first clinical evidence of problem.

Types of Surveys :1. Community level ( Food Balance Sheet) : (( National Level > Indirect Methods)).

2. Family level.3. Specific groups.4. Individuals.====================Note: Community level ( Food Balance Sheet) : (( National Level > Indirect Methods)). National Food Consumption and Food Balance Sheet. Nutrition Assessment at the National Level.

1. Family surveys : recording according to age , sex , occupation.

Food consumption measures : over week or month.Disadvantages : Failure of house wives to recall or record.

Exaggeration of recalling the food intake of the family.

2. Individual surveys : Measures : quantitative (over 24 hours) , qualitative (types of food eaten).Disadvantages : data not collected.

3. Specific surveys : The feeding state of vulnerable groups : pregnant , lactating , infants , children , elderly.

للغذاء ا العائلي الستهالكHousehold consumption of food = Family food consumption (group)

المباشرة الطرق الصغيره من المجموعاتالغذاء المستهلكة إجمالي كميات لتقديرتستخدم هذه الطريقة•

محدده فترة زمنية مثل:أفراد العائلة,طلبه المعاهد,وغيرها خالل اجتماعياالمتجانسة.يوم30-15مابين تتراوح

المنزل متكرره الصحاب على فترات دورية التغذية عمل زياراتاخصائيأي يتطلب على بينهما والفرق, المستهلكة وغير المستهلكة الطعام لتسجيل كميات الدراسةأثناء فترة

. االسرة خالل تلك الفترةاستهلكتهايمثل كمية الغذاء التي :مميزات هذه الطريقه

. الصغيرةللمجموعة عن الحالة الغذائية جيدةتعطي فكره- 1.االقتصادي او االسرة المجموعهتوضح مستوى- 2. في االسواقالمتوفره عن أنواع االغذية تكشف-3

:العيوب الفرد مايستهلكه لذلك فان تقديرالغذائية االسرة في االحتاجات افرادتفترض تساوي- 1

.غير دقيقةمن غذاء في االسرة تكون . وغير دقيقه واقعيهالنتائج غير-2

B- Dietary History:

Dietary history is obtained by interview with individuals and record data in a questionnaire form.

The questionnaire includes questions related to dietary history, related living situation and other, personal psychosocial and economic data as well as drugs being used.

الغذائي التاريخ = Food historyالمباشرة الطرق

السائده بين أفراد الغذائية للتعرف على العادات مفيدهتعد هذه الطريقه•.المجتمع:مميزاتها

الفرد يستهلكها المختلفه التي االغذيه عن مجموعات واضحهتعطي فكره - 1.في اليوم

. وعدد الوجباتاليوم المجموعات في هذه مدى تكرار توضح- 2.الغذائيه الوجبه كفاءهم مدىيناجحه لتقي- 3

:عيوبها. نسبيامكلفه- 1 . وقتا أطولتستغرق-2.الباحثين كبير من عددتحتاج الى - 3 اعلى من المتحصل الفردالغذاء التي يستهلكها لكميات تعطي تقديرات- 4

.الوزن عن طريق سجالت عليها

C- 24 Hour Recall:

The 24-hours recall approach ( by Telephone ) is a simple but cannot be used for elderly persons whose memory may be limited and less costly method than dietary history.

Advantages :Low burden , suitable for large surveys , administrated by telephone.Disadvantages :Single observation is a poor measure, bias in recording , memory dependent.

ساعة وعشرين اربعه الغذاء خاللتذكر Remember food during the twenty-four hours = 24 hours Recall

المباشرة الطرق.ساعه24 خالل الفرد من غذاء معرفة كميه مايتناولهوتعتم§د على وأكثرها انتشارا الطرقتعد من اسهل •

:مميزاتها.ا الفرد يتناوله الغذاء التي كميهتحدد بدقه-1. للفرد سجال كامال عن الحالة الغذائيةتعطي-2

.عاداته الغذائيةالتعطي فرصه للفرد لتغير . التقرأ والتكتباالمية التي في المجتمعات مناسبه خاصهتعتبر -3 . بدال من االستماراتتسجيل استخدام آالت بالمقابلهيستطيع القائم - 4

:عيوبها المعتاد تناوله بسبب§ حضور حفله او ليس بطعامه في اليوم االخيرالفرد الذي يتناوله الطعامقد يكون -1

.الى مطعمالذهاب . والفسيولوجيةوالحاله النفسية ونوعه باختالف فصول السنة كميه الغذاءالتأخذ في االعتبار اختالف-2 صوره كامله عن الحالة الغذائيةالتعطي تعتبر مده محدوده جدا قد ساعه24الغذاء خالل تقدير كميه - 3

.للشخص. ماليا وجسديامكلفه-4.بمفرده تقدير كميات الطعام التي يتناولها قد اليستطيعالشخص العادي-5. بمفرده التى تناولها يوميا أنواع االطعمةقد اليتذكر الشخص-6

الطرق المباشرة() ساعه24خالل تناول الغذاء سجل• Food intake record within 24 hours

الغذائية لتقييم الحالة على نطاق واسع جداالطريقهتستخدم هذه • ساعة فيما عدا24 طريقة تذكر الغذاء خالل تشابهللسكان وهي

الفارغة بملء االستمارةأن الشخص يقوم بنفسه

...... . ساعة24خالل التي يتناولها

==================.... .اخصائي التغذيه ساعه حيث يقوم بملئها 24بعكس تذكر

24-hours recall approach by Telephone

D- Food Records:

When full dietary analysis of all nutrient and energy values is needed a 3-7 day food record supplies the detailed information.

Give information about food habits & amounts , frequency of intake of certain nutrients.

تناول الغذاء سجل الغذائيه أوالمفكرهFood records = FOOD Diary or Log of food intake

المباشرة الطرقلمده بسجل أو مفكره الشخص احتفاظ تتطلب هذه الطريقه•

ومعياد التي يتناولها وكميتها االغذيهيسجل فيها جميع زمنيه محدده كما يسجل مايفعل أثناء تناول , والمكان الذي يتناولها فيه تناولها

التي االعمال ام يقرأ الصحف وغيرها من يشاهد التلفاز مثل هلالطعام صوره كامله عن جميع هذه المعلوماتويمكن أن تعطي, تناول الطعاميفعلها أثناء

.الغذائيهالعادات :مميزاتها

يتناولها االغذيه التي كامله ودقيقه عن كميهمعلومات للحصول على الطرقمن أ§فضل - 1.المريض

. المزاجيه وغيرهاوالحاله الطعام مثل مكان تناول§ الطعام المصاحبه لتناولتوض§يح ا§لظروف- 2.للفرد عن العادات الغذائية وصحيحه ص§وره حقيقه تعطي -3

E- Food Frequency Questionnaire Form (FFQ).

Suitable for large surveys , self completed , low burden.

Disadvantages :over reporting of healthy foods as fruits & vegetables.

الطعامتناول تكراراستماره Food Frequency Questionnaire

المباشرة الطرق حيث ساعه 24 تذكر الغذاء مكمله لطريقهتعد هذه الطريقه •

على تناولها يداوم من تذكر االغذية التي التمكن الفردانها . ساعه24 خالل تذكر الغذاءوالتي لم يذكرها في استماره

المرات أسئله تتعلق بعدد تناول الغذاءوتتضمن استماره تكرار في اليوم من االغذية أصنافا محدده الشخصالتي يتناول فيها

.أو االسبوع أو الشهر الموجوده بكثرة في المجموعات الغذائيةوتفيد في تحديد

الوجبه الغذائية أو الناقصة,المتحصل عليها صحه المعلومات وتساعد على التأكد من مدى•

. ساعه24 الغذاء خالل من تذكر

2 Approach complementary for each otherIdentify pattern of food intake

Direct Methods for Nutrition Assessment 1 -

المباشرة) ( ساعة وعشرين اربعه الغذاء خاللتذكر الطرقRemember food during the twenty-four hours = 24 hours Recall

-------------- 1او

الطرق المباشرة( ) ساعه 24خالل سجل تناول الغذاء  Food intake record within 24 hours

=================2 -

( الطرق المباشرة ) تناول الطعامتكراراستماره Food Frequency Questionnaire

F- Food records Weighted = Weighed food recordsThis involves weighing each & every item of food & drink before its consumption.Weighed food records can be kept for : 3 , 4 , 5 , 7 days.The 7 day Weighed food records taken as : Gold Standard against

which less detailed & demanding methods can be compared.Advantages :1- Widely used method. ,,, 2- Precision of portion sizes.Disadvantages :1. High respondent burden.2. Mis-reporting.3. Expensive.4. Food composition data limited.

الموزون الغذاء سجالتFood records Weighted = Weighed food records

المباشرة الطرق باستخدامالمقدمه الى الشخص الغذاء تتلخص هذه الطريقه بوزن كميات •

موازين خاصة ,و يطرح منها :----- المتبقية في الطبق كميه الغذاء 1. المخلفات كميه الغذاء 2.

.بالضبطلتحديد الكمية المتناولة الهدف من سجالت الغذاء الموزون :- ---

المعلوماتدقه :مميزاتها مما يحد من وقت طويلتحتاج - 3,,, تحتاج مجهود كبير- 2,,, مكلفه- 1 :عيوبها

.استخدامها

Difference between Screening Test & Gold Standard

• Screening: is testing for disease in population or in individuals who are not seeking health care.

Example: premarital screening for syphilis Testing for AIDS in blood donors• Case finding: Use tests to detect disease in individuals seeking health

care for other reasonExample: use of. VDRL test to detect syphilis in pregnant women• Diagnostic tests: Use of clinical or laboratory procedures to confirm the

existence of disease in patients with signs and symptoms of diseaseExample: VDRL testing of patients with lesions suggestive of secondary

syphilis.

Screening Test and Diagnostic TestsGold Standard = Diagnostic tests

Diagnostic test Screening testDone for sick individuals Applied on apparently healthy people

Applied to single patient Applied on groups

More accurate Less accurateMore expensive Less expensiveUsed as basis of treatment Not a basis of treatment

The initiative comes from a patient with a complaint

The initiative come from the investigator or agency providing care

When to screen?

Screening Test:

• There should be a suitable test or examination.

• The test should be acceptable to the population.

2. National Level (indirect)

Identify pattern of food intake

Indirect Methods for Nutrition Assessment

Nutrition Assessment at the National Level

2.1 National Food Consumption & Food Balance Sheet.

2.2 Assessment of the Ecological factors.

2.3 Vital statistics.

2.1 A- National Food Consumption Per Capita per Day

At the Societal level ( National )- Make regular physical activity and healthier dietary choices available,

affordable and easily accessible to all - especially the poorest individuals.The food industry can play a significant role in promoting healthy diets by:Reducing the fat, sugar and salt content of processed foods;Ensuring that healthy and nutritious choices are available and affordable

to all consumers; Practicing responsible marketing especially those aimed at children and

teenagers;Ensuring the availability of healthy food choices and supporting regular

physical activity practice in the workplace.

2.1 A- National Food Consumption Per Capita per

Day• The total food consumption of the whole country in a given year can be determined by

the following formula:Total food consumption = (food produced locally +food imported) – food exported• The average food consumed per capita per day can be calculated by dividing the food

consumed by the number of population and the number of days in the year.Average food consumed per capita per day:- = Total food consumed Mid year population x 365

** 365 : 365 days >> a given one year.

** Capita : one person.

B- Food balance sheet• It is the sheet prepared to show the average daily per capita

intake from the different food items in a given year (e.g. meat, milk, fish).

• The foods are analyzed into their component nutrients and energy supply using a special food composition table.

• The sheet illustrates the overall national food supply and the pattern of food consumption, but it does not demonstrate the nutritional status of individuals or groups.

B- The characteristic Food Balance Sheet for Egypt

At the Societal level (National )1- Cereals (bread) form a good bulk of diet and provide the greater part of

Energy, proteins, iron and B-vitamins.

2- Energy Expenditure exceeds energy Intake.

3- Animal food (meat, poultry, milk and eggs) is relatively low.

4- Protein content is largely from plant source (animal protein forms a small

percent of total protein).

5- Iron intake is largely obtained from cereals which is characterized by low

absorbability.

الغذاء توازن Food Balance = استمارةSheet

الطرق غير المباشرة عن كمية الغذاء المتوافرةمبدئيهيمكن أن تعطي فكرة •

. السكانيةلالفراد والمجموعات:مميزاتها

.للفرد المتوافرة الغذاءتحديد كمية -1 التغذيه بين حالة سوء مدى انتشاراعطاء تنبوء عن -2

. السكانيةاالفراد والمجموعات البالد وماتحتاجه الزراعي والصناعي االنتاجمعرفه كفاية -3

.االستيرادمن لالنتاج الدولة المستقبلية على وضع سياسهالمساعدة- 4

. التى تحتاجها البالدوالصناعاتالزراعي :عيوبها أساس للفرد على كمية الغذاء المتوفرهمتوسطتقدر

للغذاء دون االخذ في االعتباراحتياجات االفرادتساوي أو الحالة الصحية أو درجة النشاط أو الدخل العمر أو الجنس

.وغيرها

2.2 Assessment of the Ecological factors

Ecology of Malnutrition• Malnutrition is a health problem with multiple facets.

Ecological triad :

Host – Agent – Environment

Ecological TriadHost

Agent Environment

2.3 Assessment of the Ecological factors1. Cultural factors: national food habits, attitude towards infants’ feeding, and traditions in food preparation. 2. Food production, cultivated crops, food storage and importation , food price.3. Socioeconomic condition: Family size, Income, Occupation, Education.4. Prevalence of infectious and parasitic diseases which lead to malnutrition.5. Health and educational services, availability of health facilities, distribution of health personnel , quality of health care centers.

Please ,, Don`t mixed withDescriptive Triad ( 3 P`s )

in Descriptive Study (Methodology)Person

Period ( Time )Place

2.3 Vital statisticsIndirect indicators : for the nutritional status of the community :1. Mortality rate : - Infant mortality, neonatal mortality, still birth, per-natal mortality rates. - Child ( = under five mortality rates ).2. Morbidity statistics : Life expectancy (Survival Rate) (Disease

Burden).3. Morbidity statistics : Incidence rate - Prevalence rate.

الحيويه = Vital statistics االحصاءاتالمباشرة غير الطرق

بعض االحصاءات الدولتوجد لدى بعض • التي تستعمل كمؤشر عن الكفاية الحيويه

التغذوية..:-وهي تشمل •

االعمار, الوفيات وسجالت1.

واالصابة باالمراض,2.

.االمراضوأسباب 3.

2.3 Vital statisticsIndirect indicators : for the nutritional status of the community :1. Mortality rate : - Infant mortality, neonatal mortality, still birth, per-natal mortality rates. - Child ( = under five mortality rates ).2. Morbidity statistics : Life expectancy (Survival Rate) (Disease

Burden).3. Morbidity statistics : Incidence rate - Prevalence rate.

Classification for estimating Mortality & Disability

Deaths were classified using a tree structure, in which the first level of disaggregation comprises three broad cause categories of diseases :-1. Group I: communicable diseases, perinatal,

and nutritional conditions;2. Group II: non-communicable diseases;3. Group III: injuries.

Morbidity statistics to assess the frequency of the disease

Incidence rate.

Prevalence rate.

Disease burden.

Morbidity statistics : Incidence rate - Prevalence rate

Incidence rate : new cases of Nutritional Diseases ( Over Nutrition / or / Under-Nutrition = Deficiency ).

Prevalence rate : new + old : all cases of Nutritional Diseases ( Over Nutrition / or / Under-Nutrition = Deficiency ).

(service statistics derived from hospitals) e.g. 1. protein energy malnutrition among (marasmus- kwashiorkor), 2. Rickets among hospital attendants.3. iron deficiency anemia among hospital attendants.4. keratomalacia among hospital attendants.

Life expectancy (Survival Rate)

---------------Morbidity statistics :

To assess the frequency of the diseaseDisease Burden

( years of potential life lost )DALYs : Disability-adjusted life year QALYs : Quality-adjusted life years

Disability ( Health Burden )

االصابات و االعاقة

( Measure of Morbidity = Disease Burden)

Types of Disease Burden

DALYsQALYsHALE

Indicators of Health

Disability Indicators: Sullivan's index , HALE (Health Adjusted Life Expectancy) , DALY (Disability Adjusted Life Year).

===============Sullivan's index is a expectation of life free from disability.HALE is the equivalent number of years in full health that a newborn can

expected to live based on the current rates of ill health and mortality. DALY expresses the years of life lost to premature death and years lived

with disability adjusted for the severity of disability.

Health ExpectanciesHealth expectancies measure years of life gained or years of improved quality of life. In this group of measures, among others, Following Measures are classified:1. Active life expectancy (ALE),2. Disability-free life expectancy (DFLE),3. Disability-adjusted life expectancy (DALE),4. Healthy adjusted life expectancy (HALE),5. Quality adjusted life expectancy (QALE).

Health GapsHealth gaps measure lost years of full health in comparison with some ‘ideal’ health status or accepted standard. In this group of measures among others,Following Measures (indicators) are classified:1. Potential years of life lost (PYLL),2. Healthy years of life lost (HYLL),3. Quality adjusted life years (QALY),4. Disability adjusted life years (DALY).

Both approaches use Time and multiply number of years lived (or, not lived in case of premature death) by the “quality” of those years. The process of adjustment of the years of healthy life lived is called “quality adjustment” (expressed as QALYs)… The process of adjustment of the years of healthy life lost is called “disability adjustment” (expressed as DALYs)…

It means that QALYs represent a gain which should be maximized,

DALYs represent a loss which should be minimized. In the QALY approach the quality is weighted (sometimes called

“utility”, as it is the case of cost-utility analyses) on a Scale

from 1 indicating perfect health and the highest quality of life, to 0 indicating no quality of life and is synonymous to death.

In the DALY approach the Scale goes in opposite way: a Disability weighted zero indicates perfect health (no disability), and weighted 1 indicates death.

The Disability weighting is the most difficult and controversial part of the DALY approach .

DALYs

DALYs

Calculation of DALYsDisability-Adjusted Life Year

(DALY) conceptThe DALY measure is the sum of both dimensions / components just described :-

The Sum of the YLLs and the YLDs (4,10,11,15-19) :

DALY = YLL + YLDDALY = disability adjusted life yearsYLL = years of life lost due to premature deathYLD = years lost due to disability

Calculating DALYs.At the end the YLLs and the YLDs are summed up according to Equation 4.

The sum of the YLLs and the YLDs (4,10,11,15-19) :

DALY = YLL + YLDFor the woman from Example 8 the DALYs are calculated as follows:DALY = 33.99 + 10.50 = 44.49The burden of disease in this case in terms of DALYs is 44.49 years.

QALYs

QALYs

QALYs

Measuring Disability

A. Instruments used to measure functional ability

The Index of Activities of Daily Living (ADL), and Instrumental Activities of

Daily Living (IADL)

• If the person could do the 6 basic activities of ADL without difficulty or help

from another person, he was considered non disabled in ADL activities.

• If the person could do one or more of the 6 activities of ADL with difficulty,

he was considered having mild-moderate disability.

• If the person could not do one or more of the 6 activities of ADL except with

help from another person, he was considered having severe ADL disability.

B. Techniques used to measure functional ability

• 1- Direct observation is rarely used because it is so time consuming.

• 2- Direct tests of functioning, such as range of limb movement, walking time or standards such as joint pain scores and erythrocyte sedimentation rate, while objective may not necessarily give an accurate indication of ability or performance.

• 3- Interview with the person concerned Most measures of functional disability are self-report methods.

Respondents are asked to report limitations on their activities.

The main criticism of this type of measure is subjectivity.

C . Methods for Quantifying Disability

1- Direct Methods

2- Indirect Methods

1- Direct methods Cross sectional study

•Cross sectional census and surveys which measure prevalence in a given period, this may be relevant

for defining the extent and demographic pattern of disabilities in a population and thus indicating the need

for rehabilitative services.

Longitudinal / Cohort study

•To measure the incidence rates or trend of disability in a given population longitudinal

studies are needed.

Disability in Community ..

Cross-sectional studies have demonstrated that with an increasing number of chronic diseases there is a stepwise increase in disability in ADLs, IADLs and mobility.

2. Indirect methods:Indirect methods is used for ranked the disease as a cause of disability. So, it used to apply primary preventive measures against diseases accused to have higher score in doing disability.

Disability-Adjusted Life Years (DALYs): The DALYs for a given disease

condition are the sum of years of life lost due to premature mortality and the number of years of

life lived with disability- adjusted to the severity of disability.

Healthy Life Years (Heal Y): Healthy life years (Heal Y) lost as a result of premature

mortality and disability is a composite indicator that incorporates mortality and morbidity into a

single number.

Both DALYs and Heal Y are measuring disease burden on disability.

Quality Administration

Quality Assurance of Medical Practice

QUALITY OF HEALTH CARE

What is Quality?

“The quality of technical care consists in the application of medical

science and technology in a manner that maximizes its benefit to

health without correspondingly increasing risks. The most

comprehensive and perhaps the simplest definition of quality is that

used by advocates of Total Quality Management: “Do the right thing,

right, the first time.”

Components of Quality

1. Effectiveness

2. Efficiency

3. Technical ~2ornpeence

4. Safety

S. Accessibility

6. Interpersonal Relations

7. Continuity

8. Amenities

Effectiveness: doing "right" things, i.e. setting right

targets to achieve an overall goal

Efficiency: doing things in the most economical

way (good input to output ratio)

Cost EffectivenessCost-effectiveness analysis (CEA) is a form of Economic Analysis that compares the Relative Costs and Outcomes (Effects) of different courses of action. Cost-effectiveness analysis is distinct from cost–benefit analysis, which assigns a monetary value to the Measure of Effect.

The most commonly used Outcome Measure is Quality-Adjusted Life Years (QALY).A special case of CEA is Cost–Utility Analysis , where the

Measure of Effect in terms of years of full health lived, using a measure :

1. Quality-Adjusted Life Years. 2. Disability-Adjusted Life Years.

Cost-Effectiveness is typically expressed as an incremental cost-effectiveness ratio (ICER), the ratio of change in costs to the change in effects.

A complete compilation of Cost-Utility Analyses in the peer reviewed medical literature is available from the Cost-Effectiveness Analysis Registry website.

التكلفة فعالية CEAتحليل التكاليف بين المقارنة أساس على يقوم والذي االقتصادي، التحليل أشكال من

. ) العمل ) خطط من أكثر أو باثنتين الخاصة الصلة ذات التأثيرات النتائج وبين يعين والذي والفائدة، التكلفة تحليل عن التكلفة فعالية تحليل مفهوم ويختلف

. المتّبع التأثير مقياس على النقدية القيمة ما الحاالت وعادةً في الصحية، الخدمات مجال في التكلفة فعالية تحليل يُستخدم

. يتم عام، وبشكل الصحي الوضع على التأثيرات معرفة فيها يصعب عن التي التعبيرالمكاسب إلى المقام فيها يرمز الناتجة النسبة إن حيث من التكلفة فعالية تحليل

سنوات ) المبكرة، الوالدة حاالت تفادي الحياة، سنوات القياس عن الناتجة الصحية) بالرؤية الصحية التمتع بالمكاسب المرتبطة التكلفة البسط .ويمثل

الجودة ويعد حيث من الحياة سنوات النتيجة.. QALYمقياس مقياس هو. اإلطار هذا في شيوعًا أكثر بشكل المستخدم

القول يمكن الوقت، نفس لتحليل وفي مماثل التكلفة فائدة تحليل إن . التكلفة فعالية

Cost Efficiency (Cost Optimality)In the context of Parallel Computer Algorithms, refers to a

Measure of how Effectively Parallel Computing can be used to solve a particular problem.

A Parallel Algorithm is considered Cost Efficient if its Asymptotic Running Time multiplied by the number of processing units involved in the computation is comparable to the Running Time of the best sequential Algorithm.

For example, an Algorithm that can be solved in time using the best known sequential Algorithm and in a Parallel Computer with processors will be considered Cost Efficient.

) المثالية ) التكلفة أو الكفاءة أو الفعالية كلفةالمتوازية • الحو±اسيب خوارزميات مجال± فيمدى • قياس إلى المتوازية فعاليةيشير مشكلة الحوسبة حل أجل من

معينة. الوقت • كان إذا التكلفة حيث من فعالة أنها متوازية خو±ارزمية تعتبر

المشاركة المعالجة وحدات من عدد في مض±روبا للتشغيل المقارب. تسلسلية خو±ارزمية أفضل تشغيل مدة تعادل الحساب في

،المثال سبيل المدة على في حلها يمكن التي للخوارزمية سينظرO(n) معروفة متسلسلة خوارزمية أفضل كمبيوتر و باستخدام في

معالجات مع التكلفة O(p) mبالتوازي حيث من ...كفعالة

Cost–Benefit Analysis (CBA) = Benefit–Cost Analysis (BCA)

1. It is a systematic approach to estimating the strengths and weaknesses of alternatives (for example in transactions, activities, functional business requirements);

2. It is used to determine options that provide the best approach to achieve benefits while preserving savings.

3. The CBA is also defined as a systematic process for calculating and comparing benefits and costs of a decision, policy (with particular regard to government policy) or (in general) project.

والفائدة التكلفة CBA / BCAتحليلسياسة • أو قرار أو مشروع وتكاليف فوائد حساب خاللها من يمكن منهجية عملية عن عبارة

. )" بينها )" والمقارنة ما المشروع حكومية: والفائدة التكلفة لتحليل غرضان وهناك

1.) / ( / ، الجدوى التبرير سليًما اتخاذه تم الذي القرار االستثمار كان إذا ما تحديد

2. . هذه وتُبنى المشروعات بين المقارنة في عليه االعتماد يمكن أساس توفيرفي خيار لكل المتوقعة اإلجمالية التكلفة بين المقارنة أساس على العملية

تفوق الفوائد كانت إذا ما لمعرفة المتوقعة، اإلجمالية الفوائد مقابل. كمية وبأي التكاليف،

Study Designs

used in

Outcomes Research

in

Quality Assurance of Medical Practice

1. Randomized control trials

2. Cross-sectional studies

3. cohort studies

4. Meta-analysis

5. Systematic reviews

SPSS Program

Minitab Program

( used Mainly in Quality Administration )

Statistics1. Survival Analysis Statistical Tests2. Hospital Statistics

1- Survival Analysis Statistical Tests

Survival analysis & Survival Time in Statistical Tests

Usually asked from Medical Physicians in Oncological department whatever chemotherapeutic medical oncology or surgical oncology or radiothrapeutic medical oncology.

Oncology is a medical department in faculty of medicine concerned with (tumour specially Malignancy not benign ) diseases.

Survival Analysis is widely used in the bio-sciences to quantify survivorship in a population under study. The statistical programs includes three widely used tests :- 1. Kaplan-Meier (product-limit) Estimator 2. Cox Proportional Hazards Model 3. Weibull Fit.

Regression & Survival Analysis• Kaplan Meier Regression : if deal with one factor i.e.: one

predictor>>> Called : Simple Regression

• Cox regression : if deal with more than one factors i.e. more than one predictors

>> Factors called in SPSS program : Covariate/s.Covariate/s : Quantitative or Qualitative Variable/s.

2– Hospital Statisticsالخدمات مراكز في الطبي االحصاء

الصحية

Used in :-

1. Health Care Administration (Hospital Administration)

2. Medical Statistics

Types of Hospital Statistics Vital statistics :

Births & Deaths Patients statistics

Demographic dataAdministrative data : Stay , mode of Treatment , Discharge Utilization statistics

Bed use & Patient Movement StreamNumber of patients , Visits , lab & radiology InvestigationsBed use : Occupancy , Turnover , Stay

Rates in Hospital Statistics

Average inpatient census = No. of patients / total duration in days

Bed occupancy rate : Total No. of inpatients days in a given period * 100

= -------------------------------------------------- No. of available staffed beds * No. of days in this period

Bed overload rate : = No. of days when the bed occupancy is 100 %

Bed underloading rate : = No. of days when the bed occupancy is 60 % or less in a duration (days)

Bed turnover rate : No. of In-patients in a specific period = ---------------------------------------------- No. of beds in the same period

In-patients : Patients treated in Health Care are services ( Hospital Stay = with Admission ) until improvement of health status.Out-patients : 1. Patients treated in Health Care are services ( Hospital ) = but without admission2. Patients treated in Clinic Office

Bed Vacancy Rate : Vacancy Rate in a specific duration = 100 % - Occupancy Rate in this duration

Net Bed Vacancy Rate = 100 – Highest Occupancy Rate

Length of Hospital Stay :

Calculated for each patient after discharge from hospital

Refers to the No. of calendar days from the day of patient

admission to the day of discharge

Length of stay : = date of discharge – date of admission

Total length stay :

is the sum of all stay days

Refers to No. of days of care provided to patients

1. Discharged

2. Died

3. The discharge days.

Average length of stay :

Total Length of Stay for a given period = -------------------------------------------------- Total No. of discharge (including deaths)

,,,, for the same period

To calculate the average length of stay for the hospital or for every departments :

Step 1 : length of stay (for every department) = date of discharge – date of admissionStep 2 : Total length stay = summation of all length of stayStep 3 : Average length of stay = Total length stay / total No. of discharge (including deaths)

Hospital Death Rates

( Hospital Mortality Rates )

Hospital death rates :1. Gross death rate2. Net death rate3. Neonatal death rate4. Maternal mortality rate5. Fetal death rate6. Still – Birth rate7. Postoperative death rate8. Post anaesthetic death rate

Gross death rate : Total No. of Inpatients deaths for a given period * 100

= -------------------------------------------------------

Total No. of discharges ;

including : adult , child , new-born deaths

(for the same period)

Net death rate :Exclude < 48 hoursTo not count deaths to the hospital ( infection control diseased

inpatient : got infection after hospital admission by 48 hours) Is a debatable issue

Hospital acquired infection :

Total No. of infections for a given period * 100

= --------------------------------------------------------

Total No. of discharges (including deaths)

for the same period

Specific : Postoperative Infection Rate

( Infection Control Administration )

Consultation rate :

Refers to the No. of all consultations for patients

It is a Measure of Hospital Use and Quality of Care

Epidemiological Science of

Disability ( Health Burden )

Working Definitions &

Operational Definitions of

Impairment , Disability , Handicap

Definitions1. Working definitions of Impairment , Disability , Handicap

The WHO ; World Health Organization’s International Classification of Impairments, Disabilities and Handicaps provide a consistent terminology and a classification system.

These concepts lead to the concept of dependency on other people or service providers.

Impairment :

“in the context of health experience, impairment is any loss or

abnormality of psychological, physiological or anatomical

structure or function”. It represents deviation from some

norms in the individual’s biomedical status. While impairment

is concerned with biological function, disability is concerned

with activities expected of the person or the body.

Disability :

‘in the context of health experience, a disability is any

restriction or lack in ability (resulting from an

impairment) to perform an activity in the manner or

within range considered normal for a human being’.

Functional Handicap :

It represents the social consequences of Impairments or Disabilities.

It is thus a social phenomenon and a relative concept.

‘In the context of health experience, a Handicap is a

disadvantage for a given individual resulting from an

Impairment or a Disability that limits or prevents the fulfillment

of a role that is normal- depending on age, sex and social and

cultural factors- for that individual’.

Dependency :

is defined as “a state in which an individual is

reliant upon other(s) for assistance in meeting a

recognized need”.

2. Operational definitions of Disability

Operational definitions of Disability, on the whole, concentrate upon 1. Activities of daily living (ADL), 2. Instrumental activities of daily living (IADL)

1-Activities of daily living (ADL):

The term ‘activities of daily living' includes

activities that are basic to daily life, such as

bathing, dressing, feeding, continence, transfer

from bed and chair and toileting.

2- Instrumental activities of daily living (IADL)

The scope was broadened with IADL concept, which

incorporates measures of more complex adaptive or

self-maintaining functions such as housekeeping and

grocery shopping, i.e. doing heavy housework, light

housework, cooking, transportation and marketing.

The emerging concept of ‘preclinical disability’ focuses on identifying stages in the natural history of functional loss that precede the onset of overt ADL or IADL dependencies.

This phenomenon has been measured in terms of adaptive modification in the performance of common tasks such as doing heavy housework and walking up and down stairs.

In addition to screening and care planning for individual patients.

Conceptual Framework for Disability

The following map demonstrates the current understanding of interactions between the dimensions of ICIDH-2.

Health condition

•Function and disability are seen as an interaction or complex relationship

between the health and the contextual factors (i.e., environmental and personal

factors).

•There is a dynamic interaction among these factors.

•Interventions at one element level have the potential to modify other

related elements.

•The interaction works in two directions; even the presence of a disability

may modify the health condition itself.

3- Models of Functioning and Disability

Models of Functioning

Models of Disability

A- Medical models

The medical model views disability as a personal problem, directly caused

by disease, trauma or other health condition, which requires medical care

provided in the form of individual treatment by professionals.

Medical care is viewed as the main issue, and at the end, the principal

response of the political level is that of modifying or reforming health care

policy.

B- Social modelsThe social model of disability, on the other hand, sees the issue mainly as socially

created, as a matter of the full integration of individuals into society.

Disability is not an attribute of an individual, but rather a complex collection of

conditions, many of which are created by the social environment.

Hence, the management of the problem requires social action, and it is a collective

responsibility of society at large to make the environmental modifications necessary

for the full participation of people with disabilities in all areas of social life and at

political level it becomes a question of human rights.

Exposure &

Causes&

Risk Factors

Factors that may affect the future proportion of the Disabled Persons in

the world

I- Change in the age composition of the general population.

II- Change in the pattern of morbidity and mortality.

III- Change in the extent of health services.

IV-Increase in the urbanization and industrialization.

Underlying causes of Disability

A number of chronic conditions have been found to be strongly

related to disability, these include heart disease (especially

myocardial infarction, angina, congestive heart failure),

osteoarthritis (especially arthritis of the keens), hip fracture, stroke,

chronic obstructive pulmonary disease, visual impairment, hearing

impairment, depression.

The co-occurrence of multiple chronic conditions,

or comorbidity is common in older population.

Cross-sectional studies have demonstrated that with an

increasing number of chronic diseases there is a stepwise

increase in disability in ADLs, IADLs and mobility.

Risk factors and Disability1. Age2. Sex3. Socio-Economic Status (SES)4. Lifestyle factor as a predictor of Disability5. Body Mass Index (BMI)6. Skeletal Muscle Mass cut points7. Foot pain and Disability8. Drug Abuse (illicit drugs)9. Race

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