Pauline Emmett
1
and interpret this type of assessment; otherwise, a clinician who is an expert in these procedures should be used.
Assessment of Barriers
The main dietary problem may be a barrier to in- take or absorption which has led to the dietary deficiency. It is important, therefore, to ask some straightforward questions about the possible bar- riers. The most likely barriers to intake are listed in table 1 , and an affirmative answer to any of these should lead to a tailored course of action
with a view to improving intake. This may involve other professionals with particular expertise to deal with the problem, such as speech therapists, psychiatrists, child feeding behaviour specialists, social workers, etc. These barriers may not be easy to resolve, but dietary intake is unlikely to im- prove if they are ignored.
Dealing with the barriers to absorption may also lead to referral to other professionals; how- ever, if the barrier is due to the combinations of foods consumed, this will need to be assessed during the taking of the dietary history. During this process, it should be possible to formulate the advice necessary to correct the problem.
Table 1. Dietary assessment of an individual child Assess barriers to obtaining an adequate dietary intake
Physical problems – chewing, swallowing, use of utensils, consistency of food, etc.
Psychological problems – will only eat certain foods, in particular places, using particular plates, etc.
Parental or socio-economic problems – not enough/too much food available, parents not able to provide correct food for a particular reason (financial, illness), conflict between child and parent over food
Assess barriers to absorption of nutrients
Physical – diarrhoea, vomiting, regurgitation, use of purgatives, etc.
Dietary – types of foods eaten in combination (this will be assessed after the diet history has been taken – see below)
Physical activity – is the child very inactive compared to peers, does the child exercise excessively or compulsively Assess foods and drinks consumed
Talk through and record (as the interview proceeds) a normal day’s meals with the child/parent; use prompt questions and follow-up questions about foods mentioned. The examples given at breakfast below need to be tailored to the foods/drinks taken at each meal as the day progresses. Expand to cover a week for complex meals
What do you have for breakfast usually?
Bread – type? – how many slices? – Is anything normally spread on the bread, etc.
Breakfast cereal – type? – milk added? Etc.
What do you usually have to drink?
Do you usually have anything else at this time of the day?
Do you usually have anything before breakfast?
Do you usually have anything in mid-morning?
Do you usually have anything at mid-day?
Do you usually have anything in mid-afternoon?
Do you usually have anything in late afternoon?
Do you usually have anything in early evening?
Do you usually have anything in late evening?
Do you usually take any food or drink to bed?
Do you usually get up in the night to eat or drink anything?
Do you take any vitamins or other food supplements? How often do you take these?
16 Emmett
Dietary History Method
The diet history method aims to find out what is being eaten or drunk by the subject over the course of a usual day [2] . For some eating occa- sions and meals, this is a relatively simple task, because some basic foods are eaten at similar times almost every day. For the more complex meals, the usual day needs to be expanded: for the purposes of this type of assessment, covering a usual week will provide enough information in the first instance. The questioning should be sys- tematic with standard prompts and follow-up questions, as listed in table 1 ; however, some re- sponses may be unexpected and should be probed with further questions at the time. Always return to the basic plan of the interview after a diversion in order to cover the whole day. A record should be kept during the interview of what is being said;
this could be a voice or video recording if the child/parent is happy to allow it.
It is important to keep in mind the length of the interview because if the interview is very long, the child/parent may become bored or stressed and give less accurate answers. It may be possible to split the interview into sections car- ried out at different times. A simple diet history would typically take 45 min to complete, but if the usual foods consumed are complex, it may take much longer.
It is imperative not to show surprise or to comment on what is being consumed during the assessment, because it is important not to influ- ence the answers given by the child/parent. The aim is to obtain as accurate a picture as possible of the child’s normal diet. This should give a reasonable understanding of the type of foods usually eaten and should allow a basic assess- ment of whether there is likely to be a dietary problem. This information will also help to tai- lor any dietary advice needed to the individual situation.
Diet Records
As a helpful adjunct to the main method, the par- ent/child could be asked to keep a record of all the foods and drinks consumed by the child over a period of time [3] . Typically, this would be for at least 24 h but may be between 3 and 7 days. In some circumstances, it could be helpful to request that diet records are kept for a few days prior to the initial interview; they could then be used to speed up the gaining of the detailed diet history.
Another area where they could be extremely help- ful is in monitoring the child’s diet over time, ei- ther to understand further the dietary problem that has presented or to assess the degree to which advice is being followed. In the latter case, asking the child/parent to record the child’s food and drink intake once or twice a week over the period between consultations may be more helpful than asking for more continuous recording. When the diet records are received, they should be used as a basis for follow-up questions to clarify any parts that are not explicit. They can then be used to re- inforce and adapt the dietary advice that has been prescribed. If the parent/child is unable to keep a record, then asking them at the follow-up consul- tation about foods/drinks consumed by the child over the previous 24 h could be helpful in inform- ing the next stage of the consultation.
Interpretation and Advice
Table 2 lists some of the key aspects to consider in interpreting a dietary assessment of a particular child. As suggested, the interpretation is driven by the problems with which the child has present- ed, and examples are given for the most common diseases related to diet. The type of health profes- sional most likely to be of help in each situation is also suggested.
The main usefulness of the dietary informa- tion collected is to get an understanding of the balance of the foods consumed, of any obvious
Koletzko B, et al. (eds): Pediatric Nutrition in Practice. World Rev Nutr Diet. Basel, Karger, 2015, vol 113, pp 14–18 DOI: 10.1159/000367877
1
nutrient deficiencies or excesses and of any barri- ers to intake or to following the advice given. Ad- vice should then be tailored accordingly. It is es- sential to involve both the child and the parent(s) (and any significant other carers) in understand- ing any dietary advice prescribed. Nutrient anal- ysis of the diet history or food records collected can be used as a summary of the diet, but the fig- ures obtained are not accurate at the level of the individual and thus should only be used as a rough indicator of dietary adequacy.
After the initial dietary history, if the child is thought to have an inadequate diet, advice may be given about incorporating dietary sources of the relevant nutrients into the child’s diet or about the addition of suitable supplements. Wherever pos- sible, dietary solutions should be encouraged, since, once established, they tend to be more sus- tainable than supplement use. Furthermore, foods tend to provide a mixture of nutrients, fibre and different textures, and it is not always under- stood which is providing the beneficial effect; in- deed, it may be that it is the combination that is important rather than one constituent alone.
If, during the monitoring phase of working with the child, more than 7 days of reasonably complete food records have been accumulated, then nutrient analysis may be informative. This requires a suitable dietary analysis programme which can accommodate all the foods eaten and provide up-to-date nutrient contents for all the nutrients of interest [4] . Obtaining this type of analysis package needs careful thought, since foods change over time and off-the-shelf versions of packages do not always cover culturally spe- cific foods, new foods on the market or some spe- cific nutrients. Again, it is best to involve an ex- pert dietician in this process.
Conclusions
• Assessment of diet in a clinical setting with an individual child requires a different set of con- siderations than assessing diet in groups of chil- dren. The aim should be to diagnose the par- ticular dietary problem and provide suitable treatment or advice to alleviate the problem
Table 2. Key aspects to consider in interpreting a dietary assessment This will depend on the problem that the individual child presents with:
Slow weight gain/weight loss/eating behaviour problems
Barriers to intake or absorption are likely to be the main problem
Diet history is likely to show a limited food intake either in amount or range of foods consumed Consider involving a child feeding behaviour specialist
Anaemia or low blood concentrations of other key nutrients Barriers less likely to be the main problem
Diet history is likely to show a poor balance of foods consumed
e.g. for anaemia – check enhancers: meat, fruit, vegetables, vitamin C [5]
inhibitors: cow’s milk, tea, calcium [5]
Consider involving a dietician Overweight, obesity and diabetes
Barriers less likely to be the main problem Inactivity may be a factor
Diet history is likely to show a poor balance of foods consumed
e.g. for all three morbidities – check promotors: snack foods, sweet foods, soft drinks [6]
inhibitors: fruits, vegetables, wholegrain cereals [6]
Consider involving a dietician
18 Emmett
• Individualised assessment of diet and barriers to dietary intake or absorption is required be- fore diagnosis, followed by the formulation of tailored treatment and advice and the moni- toring of how that advice is being worked out over time
• Dietary assessment requires particular exper- tise in understanding how a balanced diet is
likely to work and how to obtain and interpret information about foods and drinks con- sumed. An experienced dietician or clinician should preferably carry out the dietary assess- ment
• It is important to involve the child and the parents or caregivers at all stages of the pro- cess
5 Cowin I, Emond A, Emmett P; ALSPAC Study Team: Association between com- position of the diet and haemoglobin and ferritin levels in 18-month-old chil- dren. Eur J Clin Nutr 2001; 55: 278–286.
6 Ambrosini G, Emmett P, Northstone K, Howe L, Tilling K, Jebb S: Identification of a dietary pattern prospectively associ- ated with increased adiposity during childhood and adolescence. Int J Obes (Lond) 2012; 36: 1299–1305.
References
1 Livingstone MBE, Robson PJ, Wallace JMW: Issues in dietary intake assess- ment of children and adolescents. Br J Nutr 2004; 92(suppl 2):S213–S222.
2 Livingstone MBE, Prentice AM, Coward WA, Strain JJ, Black AE, Davies PSW, Stewart CM, McKenna PG, Whitehead RG: Validation of estimates of energy intake by weighed dietary record and diet history in children and adolescents.
Am J Clin Nutr 1992; 56: 29–35.
3 Bingham SA, Cassidy A, Cole TJ, Welch A, Runswick SA, Black AE, et al: Valida- tion of weighed records and other meth- ods of dietary assessment using the 24 h urine nitrogen technique and other bio- logical markers. Br J Nutr 1995; 73: 531–
550.
4 Price GM, Paul AA, Key FB, Harter AC, Cole TJ, Day KC, et al: Measurement of diet in a large national survey: compari- son of computerized and manual coding of records in household measures. J Hum Nutr Diet 1995; 8: 417–428.
Koletzko B, et al. (eds): Pediatric Nutrition in Practice. World Rev Nutr Diet. Basel, Karger, 2015, vol 113, pp 14–18 DOI: 10.1159/000367877
1 Specific Aspects of Childhood Nutrition
Key Words
Resting energy expenditure ã Dual-energy X-ray absorptiometry ã Indirect calorimetry ã Body composition
Key Messages
• Accurate nutritional assessment should be an inte- gral part of pediatric care and may require technical measurements
• The measurement of resting energy expenditure using indirect calorimetry is the best available method to accurately estimate a child’s caloric needs to promote weight gain or maintenance • In addition to anthropometry, the most commonly
used clinical method of body composition assess- ment is dual-energy X-ray absorptiometry (DXA).
DXA-based bone density measurements are in- creasingly being used to assess bone health in chil- dren with chronic diseases © 2015 S. Karger AG, Basel
Introduction
Accurate nutritional assessment should be an in- tegral part of pediatric care. Children at risk of malnutrition or who are chronically ill should undergo a detailed nutritional assessment, which
sometimes requires technical measurements. An important aspect of nutritional assessment is es- timating daily energy needs for optimal growth and development. This is especially important in children with health conditions causing under- nutrition or obesity. However, the energy needs of such children can be difficult to estimate [1] . Resting energy expenditure (REE) represents a large portion of the energy needed each day. The measurement of REE using indirect calorimetry is the best available method to accurately estimate an individual child’s caloric needs to promote weight gain or maintenance.
Growth evaluation by measuring length or stature and weight is the first step in nutritional assessment, but measurement of body composi- tion provides more detailed information about nutritional status than anthropometry alone.
The relative and absolute amounts of muscle, fat and bone change during growth [2] . In addition to anthropometry, the most commonly used clin- ical method of body composition assessment is dual-energy X-ray absorptiometry (DXA). Al- though mainly used to assess bone health, whole- body DXA scans also provide measurements of three compartments: bone, fat and lean body mass. DXA-based bone density measurements
Koletzko B, et al. (eds): Pediatric Nutrition in Practice. World Rev Nutr Diet. Basel, Karger, 2015, vol 113, pp 19–22 DOI: 10.1159/000367867
1.2 Nutritional Assessment