Chapter 1: Conduct nutrition assessment

Malnutrition remains a major public health challenge in Kenya, affecting vulnerable groups such as children under five, pregnant and lactating women, and the elderly. Nutrition and Dietetics professionals play a critical role in identifying, assessing, and managing malnutrition cases to improve health outcomes. A thorough understanding of malnutrition, including its definitions, types, causes, and the necessary personal protective equipment (PPE) for assessment, is essential for effective intervention in clinical and community settings.

1.1 Overview of malnutrition

Malnutrition means that the body does not receive the right balance of energy and nutrients, either too little or too much, or the wrong proportions. It affects children, adolescents, women and men, and it shows in different ways: a thin child with swollen feet, a short child who has been ill often, a woman with pale lips from iron deficiency and a man with a large waistline and high blood pressure are all malnourished. A dietitian cannot manage a case well without first being able to name the type of malnutrition, understand what caused it and protect both the client and the worker during the assessment. This topic defines the key terms, describes the types and causes of malnutrition and sets out the protective equipment that a dietitian wears during assessment. The measurements, laboratory tests and clinical signs used to detect malnutrition are taught in the later topics Anthropometric data, Biochemical markers, Clinical signs and symptoms and Dietary assessment.

1.1.1 Definition of terms

Everyone on the care team must use the same words in the same way, so that a record written in one place is understood in another. The terms below are used throughout the unit.

1.1.1.1 Malnutrition

Malnutrition is a condition caused by deficiencies, excesses or imbalances in a person's intake of energy and nutrients. It covers three broad groups. Undernutrition includes wasting (low weight for height), stunting (low height for age) and underweight (low weight for age). Micronutrient-related malnutrition includes deficiencies, and sometimes excesses, of vitamins and minerals. Overweight, obesity and diet-related noncommunicable diseases form the third group. A child may be malnourished even when the child is eating, if the food is poor in quality or the body cannot use it because of infection. Malnutrition weakens the immune system, slows growth and learning, and increases the risk of illness and death.

1.1.1.2 Malnutrition management

Malnutrition management is the whole set of actions taken to find, treat and follow up people who are malnourished and to prevent the condition from coming back. It follows a cycle: identify the client and assess nutritional status, decide whether the client needs inpatient or outpatient care and enrol the client, carry out nutrition interventions such as therapeutic or supplementary feeding, counselling and referral for treatment of infections, monitor progress, and discharge the client when the discharge conditions are met. A child with severe malnutrition and medical complications is treated in a ward, while a child who is alert, has an appetite and has no complications is usually treated at home with regular visits to an outpatient clinic. Management also includes education of caregivers and links to community health workers who follow the client at home. The later chapters of this unit teach enrolment, interventions and evaluation in detail.

1.1.1.3 Nutrition

Nutrition is the process by which the body takes in food, digests it, absorbs the nutrients, transports them and uses them for energy, growth, repair and the regulation of body processes. The nutrients are carbohydrates, fats and proteins (needed in large amounts and called macronutrients), vitamins and minerals (needed in small amounts and called micronutrients), and water. Fibre is also needed for a healthy gut. Good nutrition is a balanced intake of these nutrients in the amounts that match the person's age, sex, activity, health and stage of life such as pregnancy or lactation. Nutrition is also a field of study, and a dietitian applies it to plan diets for healthy and sick people.

1.1.1.4 Nutrition Status

Nutrition status is the condition of a person's body that results from the food eaten, the way the body uses it and the effect of disease. A person's nutrition status may be good, with healthy weight and growth and no signs of deficiency, or poor because of undernutrition or overnutrition. Four groups of measurements are used to judge it. They are anthropometric measurements of the body (weight, height and others), biochemical (laboratory) tests, clinical signs seen on examination, and dietary assessment of what the person eats. Information on the home, income and environment adds to this picture. A single measurement is rarely enough, so the dietitian combines several of these to reach a conclusion.

1.1.1.5 Therapeutic feeds

Therapeutic feeds are special energy-dense and nutrient-dense foods made to treat severe acute malnutrition. They are used under a treatment protocol, they are given to the sick child and are not shared with the rest of the family. Two main types are used:

• Therapeutic milks (F-75 and F-100): these are prepared by mixing a powder with water. F-75 provides 75 kcal and 0.9 g of protein per 100 ml and is given in the first, stabilising phase of inpatient care. F-100 provides 100 kcal and 2.9 g of protein per 100 ml and is given in the rehabilitation phase to rebuild lost tissue.
• Ready-to-use therapeutic food (RUTF): a soft, energy-dense paste or biscuit that supplies about 520 to 550 kcal per 100 g and is made with fat, sugar, milk powder and added vitamins and minerals. It has little free water, so it does not spoil easily and bacteria do not grow in it, and it can be eaten at home without cooking. It is given to children who have an appetite and are free of complications.

Therapeutic feeds must be stored in a cool, dry place, prepared with clean water and clean equipment (for milks) and given in the amounts prescribed for the child's weight.

1.1.1.6 Supplementary feeds

Supplementary feeds are extra foods that supply additional energy and nutrients to people who have moderate acute malnutrition or who are at risk of becoming malnourished. They are given in addition to the normal diet and not as a replacement for it. The target groups are children under five years with moderate acute malnutrition, and pregnant and breastfeeding women who are undernourished. Examples are fortified blended flours made from cereal and pulse, which are cooked into a porridge, and ready-to-use supplementary foods in the form of pastes or biscuits. Supplementary feeds are given as a take-home ration or on-site at a feeding centre, together with advice to the caregiver on how to prepare and share the food. They are less energy-dense than therapeutic feeds, and they do not replace therapeutic feeds in severe malnutrition.

1.1.2 Types of malnutrition

Malnutrition can be described by how quickly it developed (acute or chronic), and by the direction of the imbalance (undernutrition or overnutrition). A client may have more than one type at the same time. For example, a stunted child may also have anaemia, and one family may include an underweight child and an overweight mother.

1.1.2.1 Acute

Acute malnutrition develops over a short period, as a result of recent weight loss or a failure to gain weight, often after illness, diarrhoea or a period of severe food shortage. It shows as wasting: the child has a low weight for height, or a thin upper arm, and may have bilateral pitting oedema, which is swelling of both feet that holds a dent when pressed. A weight-for-height below minus 2 standard deviations (z-score) of the WHO growth standard indicates wasting, and below minus 3 indicates severe wasting.

Acute malnutrition is classified as moderate or severe, and it needs treatment promptly because the risk of death rises sharply. Two clinical forms of severe acute malnutrition are:

• Marasmus: severe wasting without oedema. The child is very thin, with loose skin and little fat or muscle, and looks old.
• Kwashiorkor: bilateral pitting oedema, often with thin, changed hair, skin changes and an apathetic child. The child may not look thin because the oedema hides weight loss.

Some children show both signs, which is called marasmic kwashiorkor. A child with acute malnutrition can recover completely when treated in time. The measurements used to classify it are taught in the topic Anthropometric data.

1.1.2.2 Chronic

Chronic malnutrition develops over a long period as a result of poor diet, repeated infections and poor care. It shows as stunting, which means a low height for age, below minus 2 standard deviations of the WHO growth standard. The child is short but may not look thin, so stunting is easily missed unless height is measured. The harm is especially severe during the first 1,000 days of life, from conception to the child's second birthday, when the brain and body grow rapidly. Stunting that begins in this period is largely irreversible, and it is linked with poor learning, lower adult earnings and a higher risk of illness in later life. In adults, chronic energy deficiency is recognised by a body mass index below 18.5 kg/m².

1.1.2.3 Undernutrition

Undernutrition is a condition caused by too little energy, protein or micronutrients to meet the body's needs. It includes wasting, stunting and underweight, and it also includes micronutrient deficiencies, which can be present even when the person eats enough energy (sometimes called hidden hunger). Important examples are iron deficiency, which causes anaemia, vitamin A deficiency, which causes night blindness and increases the risk of infection, iodine deficiency, which causes goitre and impaired mental development, and zinc deficiency, which slows growth and healing. Undernutrition also includes underweight, which is a low weight for age.

1.1.2.4 Overnutrition

Overnutrition is a condition caused by a long-term intake of more energy or nutrients than the body needs. It shows as overweight and obesity, and sometimes as an excess of a particular micronutrient, such as too much vitamin A from high-dose supplements. It raises the risk of type 2 diabetes, high blood pressure, heart disease, some cancers and joint problems. In adults, body mass index (BMI) is calculated as weight in kilograms divided by height in metres squared. A BMI of 25 to 29.9 kg/m² indicates overweight and 30 kg/m² or above indicates obesity. For example, a woman who weighs 70 kg and is 1.60 m tall has:

BMI = weight ÷ height² = 70 ÷ (1.60 × 1.60) = 70 ÷ 2.56 = 27.3 kg/m²

This falls in the overweight range. Overnutrition can exist in the same community, and even in the same household, as undernutrition, which is called the double burden of malnutrition.

1.1.3 Causes of Malnutrition

Malnutrition has many causes that interact. They are grouped into three levels in a causal framework: basic causes in society, underlying causes in households and communities, and immediate causes in the individual. A dietitian looks for causes at all three levels, because treating the immediate cause without addressing the others often means that the problem comes back.

1.1.3.1 Basic

Basic causes are the wide social, economic and political conditions that decide how resources are shared in a country or community. They are the root of the problem. Examples are poverty, unemployment, low levels of education, unequal access to land and income, weak services, climate shocks such as drought and floods, and cultural and social beliefs that affect who eats what. A household that depends on rain-fed farming may lose its income when the rains fail, and it can no longer buy enough food. These causes are tackled through policy and community action, and a dietitian contributes by reporting patterns and advising on programmes.

1.1.3.2 Underlying

Underlying causes operate at household and community level. There are three groups:

• Household food insecurity: the household cannot produce or buy enough safe, varied food all year, for example because of low income, poor storage and seasonal shortage.
• Inadequate care for mothers and children: poor feeding practices such as late start of breastfeeding, early or late introduction of complementary foods, food taboos that deny nutritious foods to pregnant women or children, and a mother who has no time or support.
• Poor health environment and services: unsafe water, poor sanitation and hygiene, which cause diarrhoea and worms, and poor access to health services.

A dietitian addresses these causes through nutrition education, counselling and links with community health workers.

1.1.3.3 Immediate

Immediate causes act directly on the individual and are two in number. The first is inadequate dietary intake: the person does not eat enough food, or the food lacks energy, protein or micronutrients. The second is disease. Infections such as diarrhoea, pneumonia, measles, malaria, tuberculosis and HIV reduce appetite, interfere with the absorption of nutrients and increase the body's need for energy and nutrients. Infection and poor intake feed each other: a malnourished child gets sick more easily, and illness makes the malnutrition worse. During assessment, the dietitian asks about what the client has eaten, any recent illness and any other condition that affects eating, digestion or absorption.

1.1.4 PPEs

Personal protective equipment (PPE) is clothing and equipment worn to protect the worker and the client from the spread of infection and from injury. A dietitian touches clients, handles skin that may be broken or swollen, may stand close to clients who cough and may be near blood or body fluids during measurement and sampling. Malnourished clients have weak immunity, so they are easily infected by the worker, and the worker may in turn be exposed to infections such as tuberculosis and diarrhoeal disease. PPE is one part of standard precautions, together with hand hygiene, safe disposal of waste and cleaning of equipment.

Personal protective equipment (PPE) (Source: 5f700936fcc590f8)

1.1.4.1 Mask

A mask covers the nose and mouth and reduces the spread of germs carried in droplets from coughing, sneezing and talking. A surgical mask protects the client from the worker's droplets and protects the worker from the splashes and large droplets of a coughing client. Where airborne infection such as tuberculosis is suspected, the facility's infection-control rules may require a respirator-type mask, such as an N95, fitted tightly to the face. The mask must cover the nose, mouth and chin, and the metal strip should be shaped over the nose. It should not be pulled down to the chin, touched while worn, or reused once it is damp or dirty. Handle it only by the straps when removing it, and discard it as waste.

1.1.4.2 Dust coat or gown

A dust coat (laboratory coat) or gown protects the worker's clothes and skin from dirt and from contact with clients or contaminated surfaces. A clean, long-sleeved, washable coat is worn over normal clothing in the nutrition clinic or ward and is fastened in front. A fluid-resistant gown is used when splashes of blood, vomit or diarrhoea are likely, and a waterproof apron may be worn over the coat for such tasks. The coat is changed when it is visibly soiled and is washed regularly. A coat worn in the clinic must be taken off before the worker goes to a canteen, an office or home, otherwise germs are carried away from the clinic.

1.1.4.3 Closed shoes

Closed shoes cover the whole foot and protect it from spilled fluids, sharp objects and dropped equipment. Wards and clinic floors are often wet or have waste, so shoes should have non-slip soles and a flat or low heel. Open sandals expose the skin to splashes and sharps and increase the risk of slips. Shoes are kept clean and are wiped or washed when they are contaminated.

1.1.4.4 Gloves

Gloves protect the hands from contact with blood, body fluids, broken skin and contaminated surfaces. They are worn when a dietitian is likely to touch these, for example when examining a client with open sores or when helping with a procedure that involves blood. They are not needed for every client contact, for instance when only talking to a client or recording a weight on a dry, intact surface. Gloves are single use. A fresh pair is put on for each client and each task, they are never washed or reused, and they are removed and discarded as soon as the task is complete. Hands must be cleaned after gloves are removed, because hands can still be contaminated.

Hand hygiene and the order of using PPE

Hand hygiene comes before and after PPE. Hands are washed with soap and running water for 40 to 60 seconds, or cleaned with an alcohol-based hand rub for 20 to 30 seconds when they are not visibly dirty or when water is not available, as during outreach visits in the community. The order in which PPE is put on and taken off prevents the worker from contaminating himself or herself. The steps are:

1. Clean the hands.
2. Put on the dust coat or gown and fasten it.
3. Put on the mask and fit it over the nose, mouth and chin.
4. Put on the gloves, pulling the cuffs over the sleeves of the coat or gown.
5. After the task, remove the gloves first by peeling them off inside out, and discard them in the waste container.
6. Clean the hands.
7. Remove the gown or coat by untying it and rolling or folding it with the outer surface inside, and place it in the laundry or waste.
8. Remove the mask by the straps only, and discard it.
9. Clean the hands again.

Chapter Summary

This chapter provides a comprehensive understanding of malnutrition and its management by first defining key terms such as malnutrition, nutrition status, therapeutic feeds, and supplementary feeds. It distinguishes between various types of malnutrition including acute, chronic, under nutrition, and over nutrition, while exploring the basic, underlying, and immediate causes that contribute to its development. The importance of personal protective equipment such as masks, gowns, closed shoes, and gloves in managing malnutrition cases is emphasized to ensure safety. Anthropometric measurements like weight, height, mid-upper arm circumference, head circumference, hip and waist circumference, and skinfold thickness are detailed as essential tools for assessing nutritional status. Biochemical markers including mean cell volume, haemoglobin, blood sugar levels, urea, and key electrolytes are discussed for their role in evaluating patient health. Clinical signs such as pallor, changes in hair texture and colour, sunken eyes, edema, mobility, and bleeding gums provide visible indicators of nutritional deficiencies. The chapter also covers dietary assessment methods like 24-hour recall, food frequency questionnaires, food records, and dietary diversity scores to capture eating patterns. Finally, socioeconomic and environmental factors are recognized as critical influences on nutrition, shaping both risk and recovery in malnutrition cases.