Nutritional assessment: anthropometric, biochemical, clinical and dietary

In short

Nutritional assessment is the systematic measurement of a person's or a community's nutritional status using four complementary approaches — Anthropometric, Biochemical, Clinical and Dietary (the "ABCD" of assessment), supported by vital and ecological statistics. It converts body measurements, laboratory values, physical signs and food intake data into a judgement of adequacy, deficiency or excess, and is the starting point of every diet prescription, nutrition programme and nutrition survey. It is examined in Foods and Nutrition, Community Nutrition and Dietetics papers of B.Sc Home Science / Community Science, and in entrance and recruitment tests for M.Sc, RD (Registered Dietitian) examinations of the Indian Dietetic Association, and for jobs with ICDS, NHM, hospitals, FSSAI-regulated food companies and NGOs. Indian practice uses ICMR-NIN RDA 2020, WHO Child Growth Standards (2006) with WHO 2007 references for 5–19 years, IAP growth charts, and national data from NFHS-5 (2019-21), CNNS (2016-18) and the NNMB surveys.

Explained

1. Concepts, purposes and the ABCD framework

• Nutritional status: the condition of the body resulting from the intake, absorption and utilisation of nutrients, and from disease that affects these.
• Nutritional assessment quantifies that condition; nutritional surveillance monitors it continuously in a population; nutritional screening is a quick first filter (e.g. MUAC tape at an Anganwadi) to identify who needs full assessment.
• Purposes: identify malnutrition type and degree; find at-risk groups; plan and target interventions; monitor and evaluate programmes; set RDAs and food policy; guide clinical diet therapy.
• Direct methods (on the individual) = ABCD: Anthropometry, Biochemical/biophysical tests, Clinical examination, Dietary survey.
• Indirect methods (on the community): vital and health statistics (infant mortality rate, under-5 mortality, maternal mortality ratio, cause-specific death rates), ecological factors (food balance sheets, crop and market data, sanitation, income, literacy, cultural food habits).
• Sequence of deficiency: dietary inadequacy → tissue depletion → biochemical change → functional change → clinical sign → anatomical lesion. Hence dietary and biochemical methods detect deficiency earliest; clinical signs appear last. No single method is sufficient — they are used together.

2. Anthropometric assessment

Measurements of body size, shape and composition; objective, cheap, non-invasive, needs little training, but reflects long-term status and cannot identify a specific nutrient.

Measurements and tools

• Weight: beam/digital scale; infant pan balance (accuracy 100 g), adults to 0.1 kg; minimal clothing, no footwear.
• Height (≥2 years, standing): stadiometer, Frankfurt plane, heels together, to 0.1 cm. Length (<2 years): infantometer, recumbent. Recumbent length exceeds standing height by about 0.7 cm.
• Alternatives when height cannot be taken: arm span, demi-span, knee height, sitting height (used in elderly, bed-ridden, spinal deformity).
• MUAC (mid-upper arm circumference): fibre-glass/Shakir tape at the midpoint of acromion–olecranon, left arm hanging free; reflects muscle + fat; age-independent between 1–5 years, so excellent for field screening.
• Head circumference: maximum occipito-frontal; useful to 2–3 years, reflects brain growth. Chest circumference at nipple level at mid-expiration.
• Skinfold thickness: Harpenden/Lange calliper, 10 g/mm² pressure, read after 2–3 s; sites — triceps, biceps, subscapular, suprailiac. Estimates subcutaneous fat.
• Circumferences for fat distribution: waist (midpoint of lowest rib and iliac crest, or at the narrowest point), hip (maximum gluteal), mid-arm; waist-hip ratio and waist circumference indicate abdominal obesity.
• Body composition methods (biophysical/advanced): BIA (bioelectrical impedance), DEXA, hydrodensitometry (underwater weighing), air-displacement plethysmography, total body water by isotope dilution, creatinine-height index, CT/MRI.

Indices and classifications (children)

• Weight-for-age → underweight (acute + chronic); height-for-age → stunting (chronic); weight-for-height → wasting (acute, current); BMI-for-age; MUAC-for-age.
• Reference and expression: WHO Child Growth Standards 2006 (0–5 y) and WHO 2007 reference (5–19 y); expressed as Z-score (SD score), percentile, or percent of median. Z-score is preferred — it is linear, comparable across indices and allows means and SDs.
• WHO cut-offs: < −2 SD = moderate; < −3 SD = severe; > +2 SD = overweight (BMI-for-age in 5–19 y: > +1 SD overweight, > +2 SD obese).
• Gomez (weight-for-age, % of reference median): 90–110% normal; 75–89% Grade I (mild); 60–74% Grade II (moderate); < 60% Grade III (severe).
• IAP classification (weight-for-age, % of median): > 80% normal; 71–80% Grade I; 61–70% Grade II; 51–60% Grade III; ≤ 50% Grade IV. Grades III and IV with oedema = kwashiorkor.
• Waterlow classification: combines stunting (height-for-age) and wasting (weight-for-height) into four cells — normal, wasted only (acute), stunted only (past/chronic), wasted + stunted (acute on chronic).
• Wellcome Trust classification of severe PEM: uses weight-for-age with/without oedema — underweight, kwashiorkor, marasmus, marasmic kwashiorkor.
• SAM (severe acute malnutrition), WHO/India NRC criteria, 6–59 months: weight-for-height < −3 SD, or MUAC < 11.5 cm, or bilateral pitting oedema. MAM: weight-for-height −3 to −2 SD or MUAC 11.5–12.5 cm. Children with SAM plus complications/no appetite are admitted to a Nutrition Rehabilitation Centre (NRC).
• Shakir's tape colour code (1–5 y): green ≥ 13.5 cm normal; yellow 12.5–13.5 cm moderate; red < 12.5 cm severe (programme thresholds for SAM use 11.5 cm).

Adults

• BMI (Quetelet's index) with Asian/Indian cut-offs: < 18.5 underweight (CED Grade III < 16.0, II 16.0–16.9, I 17.0–18.4); 18.5–22.9 normal; 23.0–24.9 overweight/at risk; ≥ 25.0 obese (25.0–29.9 obesity I, ≥ 30 obesity II). WHO international cut-offs are 25 overweight and 30 obese — state which set is being used.
• Abdominal obesity (Indian consensus/NCD guidelines): waist circumference ≥ 90 cm men, ≥ 80 cm women; WHR ≥ 0.90 men, ≥ 0.85 women.
• MUAC in adults: < 23 cm (men) / < 22 cm (women) suggests undernutrition; in pregnancy MUAC < 23 cm is a common risk marker.
• Advantages: simple, reproducible, cheap, quantitative, retrospective. Limitations: non-specific for nutrients; affected by oedema, dehydration, ethnicity, equipment error and age mis-statement (common in rural India).

3. Biochemical and biophysical assessment

Laboratory measurement in blood, urine, hair, nails or tissue; most sensitive and objective, detects subclinical deficiency, but invasive, costly, needs a lab, and values shift with infection, inflammation, hydration and recent intake.

• Protein status: serum total protein (6.0–8.0 g/dL) and albumin (3.5–5.0 g/dL; < 3.5 depletion, < 2.5 severe). Short-half-life (sensitive) proteins — prealbumin/transthyretin (2 d), retinol-binding protein (12 h), transferrin (8 d). Urinary creatinine-height index reflects muscle mass; the urea/creatinine ratio reflects recent protein intake and the hydroxyproline index collagen turnover/growth in children; nitrogen balance for protein turnover. Albumin falls in inflammation and liver/renal disease, so it is a poor stand-alone marker.
• Iron: haemoglobin (screening), serum ferritin (stores; < 15 µg/L deficient in adults, < 12 µg/L in children; raised by infection — read with CRP), serum iron, TIBC, transferrin saturation (< 16%), soluble transferrin receptor, peripheral smear (microcytic hypochromic). WHO/NFHS anaemia cut-offs: < 11.0 g/dL children 6–59 months and pregnant women, < 11.5 g/dL 5–11 y, < 12.0 g/dL 12–14 y and non-pregnant women, < 13.0 g/dL adult men. (WHO revised its haemoglobin guidance in 2024 with small changes; India's programme cut-offs under Anemia Mukt Bharat remain as above — ICMR has also debated lower Indian cut-offs, so quote the source being used.)
• Vitamin A: serum retinol < 20 µg/dL (0.70 µmol/L) deficient, < 10 µg/dL severe; RDR (relative dose response) test; conjunctival impression cytology.
• Iodine: urinary iodine excretion (median UIE 100–199 µg/L = adequate in school children; < 100 deficient), serum TSH (neonatal TSH > 5 mIU/L indicates population deficiency), T3/T4, goitre prevalence.
• Vitamin D: serum 25(OH)D — deficient < 20 ng/mL, insufficient 20–29, sufficient ≥ 30 ng/mL; with raised alkaline phosphatase and low calcium/phosphorus in rickets.
• B-vitamins: thiamine — erythrocyte transketolase activity and TPP effect; riboflavin — EGRAC (erythrocyte glutathione reductase activity coefficient); niacin — urinary N-methyl nicotinamide; B12 serum level and methylmalonic acid; folate serum and red-cell folate; homocysteine rises in B12/folate/B6 deficiency. Macrocytic picture on smear.
• Vitamin C: plasma/leucocyte ascorbic acid; zinc: serum zinc (hair zinc in chronic deficiency).
• Metabolic/NCD markers: fasting and post-prandial glucose, HbA1c, lipid profile, uric acid, urea and creatinine (renal diets), electrolytes.
• Functional/biophysical tests: dark adaptation and electroretinography (vitamin A), radiography of wrist/long bones (rickets, osteomalacia), bone densitometry, grip strength and muscle function, taste acuity (zinc), capillary fragility (vitamin C).

4. Clinical assessment

History plus head-to-toe physical examination for signs of deficiency or excess; cheap, needs no equipment, but subjective, non-specific and detects only late deficiency.

• History: dietary and feeding history, breastfeeding and weaning, socio-economic status, illness, surgery, drugs, appetite, weight loss (% of usual weight and over what period), GI symptoms, food allergy, physical activity, alcohol/tobacco.
• Hair: dyspigmented, sparse, easily pluckable, "flag sign" — protein-energy malnutrition.
• Face/skin: moon face, nasolabial dyssebacia (riboflavin); flaky-paint dermatosis and oedema (kwashiorkor); follicular hyperkeratosis/phrynoderma (vitamin A, essential fatty acids); pellagra — Casal's necklace, symmetrical dermatosis on sun-exposed skin, with diarrhoea and dementia (niacin); petechiae and perifollicular haemorrhage (vitamin C).
• Eyes: night blindness, conjunctival xerosis, Bitot's spots, corneal xerosis, keratomalacia (vitamin A, WHO XN–XS grading); angular palpebritis and circumcorneal vascularisation (riboflavin); pale conjunctiva (anaemia).
• Mouth: angular stomatitis and cheilosis (riboflavin, iron), glossitis (B12, folate, niacin, iron), magenta tongue (riboflavin), spongy bleeding gums (vitamin C), dental caries and mottling/fluorosis (fluoride excess).
• Neck: goitre (iodine deficiency; WHO grades 0, 1, 2).
• Bones/joints: rachitic rosary, wide wrists, bow legs, frontal bossing, craniotabes, pigeon chest (vitamin D); tender bones (vitamin C, osteomalacia).
• Nails: koilonychia (iron); oedema — bilateral pitting, kwashiorkor, also hypoproteinaemia of other causes.
• Neurological: calf tenderness, loss of ankle reflex, peripheral neuropathy, wrist/foot drop (thiamine — dry beriberi); oedema and cardiac failure (wet beriberi); dementia (niacin, B12).
• Composite clinical tools: SGA (Subjective Global Assessment) — history + physical, grades A well-nourished, B moderately/suspected malnourished, C severely malnourished; MUST, NRS-2002 and MNA (Mini Nutritional Assessment) for the elderly; GLIM criteria (phenotypic — weight loss, low BMI, reduced muscle mass; aetiologic — reduced intake, disease burden/inflammation) for diagnosing malnutrition in hospitals.

5. Dietary assessment

Measures the food and nutrient intake that causes the status; essential for finding the cause and for planning diets.

• 24-hour dietary recall: interview on all food and drink in the previous 24 h, with standardised cups/spoons and food models; quick, low respondent burden, literacy not needed; but relies on memory, misses day-to-day variation (a single recall cannot describe an individual's usual intake — multiple non-consecutive days or repeat recalls are needed), and under-reporting is common.
• Weighment/weighed inventory method: every raw/cooked item weighed before and after, with plate waste; most accurate for individuals and the method used in NNMB/ICMR-NIN surveys, but expensive, intrusive and may alter eating behaviour.
• Food frequency questionnaire (FFQ): how often (per day/week/month) each food group is eaten; semi-quantitative with portion size. Captures usual long-term intake and is used in epidemiological studies; weak for absolute nutrient amounts.
• Dietary history (Burke's method): usual pattern + 24-h recall + 3-day record + food frequency cross-check — good for clinical use and chronic disease.
• Food record/diary (3-, 5- or 7-day): respondent records intake as eaten, estimated or weighed; no memory error, but needs literacy, motivation and often changes intake.
• Household methods: food inventory/larder method, raw food expenditure/accounting, household consumption surveys (NSSO-type); need adult consumption units (CU) to convert household intake into per-person intake.
• Other: duplicate portion analysis (chemical analysis of a replica meal), diet–observation combinations, food balance sheets (national availability, not intake).
• Converting food to nutrients: use ICMR-NIN "Indian Food Composition Tables (IFCT) 2017" (which replaced the older *Nutritive Value of Indian Foods*); apply cooked/raw conversion factors, edible-portion factors and recipe yields. Compare with ICMR-NIN RDA 2020 — note the shift from RDA alone to EAR, RDA, AI (adequate intake), TUL and a Nutrient Adequacy Ratio approach. NAR per nutrient and MAR (mean adequacy ratio) summarise adequacy; dietary diversity scores (IDDS, WDDS, MDD-W; WHO/UNICEF IYCF indicators — MDD, MMF, MAD for 6–23 months) measure quality.
• Errors: recall bias, prestige/social-desirability bias, under-reporting by the obese, over-reporting by the undernourished, portion-size error, interviewer bias, seasonality, festival/fast days, intra-family food distribution.

6. Indian standards, surveys and practice

• ICMR-NIN RDA 2020 (Hyderabad) — reference Indian man 19–39 y, 65 kg; reference woman 55 kg, with activity levels sedentary/moderate/heavy expressed as PAL; pregnancy and lactation increments.
• IFCT 2017 for food composition; ICMR-NIN Dietary Guidelines for Indians (revised 2024) with My Plate for the Day.
• Surveys: NFHS-5 (2019-21) — children under 5: stunted 35.5%, wasted 19.3%, underweight 32.1%, overweight 3.4%; anaemia 67.1% in children 6–59 months, 57% in women 15–49 y, 25% in men; women BMI < 18.5 = 18.7%, overweight or obese (BMI ≥ 25) 24.0%. CNNS 2016-18 gave the first national biochemical micronutrient data for children and adolescents. NNMB/NNMS repeated diet and nutrition surveys. Figures are revised by each new round, so cite the round.
• Programme links: ICDS/Poshan Tracker growth monitoring (weight, height, MUAC entered monthly), VHSND days, Anemia Mukt Bharat testing by digital haemoglobinometer, NRCs for SAM, Rashtriya Bal Swasthya Karyakram screening, school health and mid-day meal weighing.
• Food labelling and claims rest on the same science: FSSAI's labelling and display regulations prescribe the nutrition panel and RDA-percentage declaration — relevant to dietitians who verify product claims.

Key points

• ABCD - Anthropometric, Biochemical, Clinical, Dietary; direct methods, supported by indirect vital and ecological statistics.
• Earliest detection - dietary inadequacy and biochemical change come first; clinical signs are the last and least sensitive stage.
• Z-score - (observed − reference median)/reference SD; < −2 SD moderate, < −3 SD severe deficit.
• Wasting - low weight-for-height, acute; stunting - low height-for-age, chronic; underweight - low weight-for-age, mixed.
• Waterlow - cross-classifies wasting and stunting; Gomez and IAP grade weight-for-age as % of median.
• SAM (6–59 m) - WHZ < −3 SD or MUAC < 11.5 cm or bilateral pitting oedema; refer to NRC if complicated.
• MUAC - age-independent in 1–5 years, best single field screening measure; Shakir's tape colour coding.
• BMI - weight (kg)/height (m)²; Indian cut-offs 18.5–22.9 normal, ≥ 23 overweight, ≥ 25 obese.
• WHR/waist - abdominal obesity at waist ≥ 90 cm (men) / ≥ 80 cm (women), WHR ≥ 0.90 / ≥ 0.85.
• Albumin - 3.5–5.0 g/dL, long half-life (~20 d) and falls with inflammation; prealbumin and RBP react fastest.
• Ferritin - best marker of iron stores but rises in infection; interpret with CRP.
• Vitamin A - serum retinol < 20 µg/dL deficient; Bitot's spots and night blindness are clinical markers.
• Iodine - median urinary iodine 100–199 µg/L adequate; goitre and neonatal TSH as population indicators.
• Skinfolds - triceps, biceps, subscapular, suprailiac measure subcutaneous fat; BIA/DEXA for body composition.
• 24-h recall - quick but memory-dependent; weighment most accurate; FFQ best for usual long-term intake.
• IFCT 2017 + RDA 2020 - convert foods to nutrients and judge adequacy (EAR, RDA, AI, TUL; NAR and MAR).
• SGA, MNA, MUST, NRS-2002, GLIM - standard hospital screening and diagnosis tools for malnutrition.
• NFHS-5 - the current national benchmark for stunting (35.5%), wasting (19.3%), underweight (32.1%) and anaemia.

Formulas and examples

Example 1 — BMI and grade of malnutrition (adult). A 34-year-old woman weighs 42.5 kg and is 1.55 m tall.

• Height² = 1.55 × 1.55 = 2.4025 m²
• BMI = 42.5 / 2.4025 = 17.7 kg/m²
• Indian cut-offs: 17.0–18.4 → Chronic Energy Deficiency Grade I (mild underweight). Action: energy-dense diet, assess dietary intake by 24-h recall, screen haemoglobin.

Example 2 — Z-score and classification (child). A boy aged 36 months weighs 10.8 kg and is 85.0 cm tall. Reference (WHO) weight-for-age median at 36 months = 14.3 kg, SD = 1.6 kg; height-for-age median = 96.1 cm, SD = 3.8 cm; weight-for-height median at 85 cm = 12.1 kg, SD = 1.0 kg.

• Weight-for-age Z = (10.8 − 14.3)/1.6 = −3.5/1.6 = −2.19 SD → moderately underweight.
• Height-for-age Z = (85.0 − 96.1)/3.8 = −11.1/3.8 = −2.92 SD → moderately (nearly severely) stunted.
• Weight-for-height Z = (10.8 − 12.1)/1.0 = −1.30 SD → not wasted.
• Waterlow: stunted but not wasted = past/chronic malnutrition (nutritional dwarfing). Long-term feeding and infection control, not emergency therapeutic feeding.

Example 3 — Gomez and IAP grading. Same child: weight 10.8 kg, reference median weight-for-age 14.3 kg.

• % of median = (10.8/14.3) × 100 = 75.5%
• Gomez: 75–89% → Grade I (mild) malnutrition; IAP: 71–80% → Grade I. Both agree here; note that Gomez and IAP band boundaries differ, so always name the classification used.

Example 4 — WHR, waist and MAMC. A 46-year-old man: waist 102 cm, hip 98 cm, MUAC 27.0 cm, triceps skinfold 14 mm.

• WHR = 102/98 = 1.04 → ≥ 0.90, abdominal obesity.
• Waist 102 cm ≥ 90 cm → high risk of type 2 diabetes and cardiovascular disease (Indian cut-off).
• MAMC = 27.0 − (0.314 × 14) = 27.0 − 4.40 = 22.6 cm → muscle mass adequate; the excess is fat, not muscle. Assessment: central obesity with preserved lean mass → weight management, fasting glucose/HbA1c and lipid profile.

Example 5 — Dietary adequacy by NAR and MAR. A 19-year-old sedentary woman's weighed intake: energy 1,540 kcal, protein 38 g, iron 11 mg, vitamin A 400 µg RAE. Taking ICMR-NIN RDA 2020 values for a sedentary adult woman as energy 1,660 kcal, protein 45.7 g, iron 29 mg, vitamin A 840 µg RAE:

• NAR energy = 1,540/1,660 = 0.928; protein = 38/45.7 = 0.832; iron = 11/29 = 0.379; vitamin A = 400/840 = 0.476
• MAR = (0.928 + 0.832 + 0.379 + 0.476)/4 = 2.615/4 = 0.654 ≈ 65%
• Interpretation: energy and protein near-adequate, iron (38% of RDA) and vitamin A (48%) grossly deficient — the classic Indian pattern. Confirm with haemoglobin/ferritin and serum retinol; add green leafy vegetables, vitamin C with meals, and check for IFA supplementation under Anemia Mukt Bharat.

Where it is used

• Hospital dietetics (AIIMS, PGIMER, Apollo, Fortis, Manipal): dietitians screen every admission with SGA/MUST/GLIM, compute BMI and ideal body weight, track albumin, prealbumin and nitrogen balance, and set enteral/parenteral prescriptions — the core skill tested in RD examinations of the Indian Dietetic Association.
• ICDS and Poshan Abhiyaan: Anganwadi workers and supervisors weigh and measure children monthly, plot growth charts and enter data on the Poshan Tracker; MUAC tapes screen for SAM and refer to Nutrition Rehabilitation Centres.
• Public health and surveys: NFHS, CNNS, NNMB and district nutrition surveys employ graduates as field investigators and anthropometrists; NHM, UNICEF, WFP, and NGOs (Akshaya Patra, Pratham, SNEHA) use the same protocols for baseline and impact evaluation.
• Food industry and R&D: product development, clinical/efficacy trials of fortified foods and nutraceuticals, and nutrition labelling under FSSAI regulations need dietary intake data and biomarker endpoints.
• Sports, fitness and corporate wellness: body composition (BIA, skinfolds, DEXA), diet recalls and biochemical panels for athletes at SAI/NIS centres, gyms and employee health programmes.
• Academia and clinical research: ethics-approved nutrition surveys, ICMR-funded projects, M.Sc and PhD dissertations; also school health programmes and geriatric care (MNA) in old-age homes.

Interview questions

• Q: What does the "ABCD" of nutritional assessment stand for, and why are all four needed? A: Anthropometric, Biochemical, Clinical and Dietary. Each detects a different stage of deficiency — dietary and biochemical early, clinical late, anthropometric cumulative — so only together do they give a complete and valid picture.
• Q: Differentiate wasting, stunting and underweight. A: Wasting is low weight-for-height (acute, recent), stunting is low height-for-age (chronic, past deprivation), and underweight is low weight-for-age, reflecting both.
• Q: Why is MUAC preferred for screening children in the field? A: Between 1 and 5 years arm circumference changes little with age, so a single cut-off works without knowing the exact age; the tape is cheap, portable and the measurement predicts mortality risk well.
• Q: State the criteria for severe acute malnutrition in a 2-year-old. A: Weight-for-height below −3 SD of the WHO standard, or MUAC under 11.5 cm, or bilateral pitting oedema — any one is sufficient.
• Q: Why is serum albumin a poor single indicator of protein status? A: Its half-life is about 20 days so it changes slowly, and it falls with inflammation, infection, liver and renal disease and fluid shifts independently of protein intake; prealbumin or RBP respond faster.
• Q: How is a Z-score better than percent of median? A: The Z-score is expressed in SD units, so it is comparable across indices and ages, allows values beyond the reference range to be quantified, and means and standard deviations can be computed for a population.
• Q: A patient has normal BMI but a waist of 95 cm. What is your assessment? A: Normal-weight central obesity — visceral fat raises the risk of diabetes and cardiovascular disease even at a normal BMI, which is common in Indians; investigate glucose, HbA1c and lipids and advise waist reduction.
• Q: Which dietary survey method would you use for a large epidemiological study of diet and cancer, and why? A: A validated semi-quantitative food frequency questionnaire, because it captures usual long-term intake cheaply in thousands of subjects — accepting lower accuracy for absolute nutrient amounts.
• Q: Why can one 24-hour recall not describe an individual's usual diet? A: Intake varies greatly from day to day; a single day captures that day only, so multiple non-consecutive days (or a diet history/FFQ) are needed for usual intake, though one recall per person is adequate for a group mean.
• Q: Ferritin is 80 µg/L but haemoglobin is 9 g/dL and CRP is high. Interpret. A: Ferritin is an acute-phase reactant raised by inflammation, so it may mask iron deficiency; interpret with CRP and use transferrin saturation, soluble transferrin receptor or repeat testing after the infection settles.
• Q: Name the Indian reference sources you would use to convert a diet recall into nutrient intake and judge adequacy. A: ICMR-NIN Indian Food Composition Tables 2017 for composition and the ICMR-NIN RDA 2020 (EAR, RDA, AI, TUL) for comparison, with the Dietary Guidelines for Indians for qualitative advice.
• Q: Which clinical signs point to vitamin A, riboflavin and vitamin C deficiency respectively? A: Night blindness, conjunctival xerosis and Bitot's spots for vitamin A; angular stomatitis, cheilosis and magenta tongue for riboflavin; spongy bleeding gums and perifollicular haemorrhages for vitamin C.

Common mistakes

• Using WHO's international BMI cut-offs (25/30) when the question or the patient calls for Asian-Indian cut-offs (23/25), or quoting only one set without naming it.
• Squaring height in centimetres instead of metres in BMI, or mixing kg with pounds and cm with inches.
• Confusing wasting with stunting, or treating a chronically stunted child as an emergency acute case.
• Mixing up classification bands — Gomez, IAP, Waterlow and Wellcome have different cut-offs and different base indices; naming the system is part of the answer.
• Getting the sign of a Z-score wrong, or calling −2.19 SD "severe" (severe needs < −3 SD).
• Interpreting a single biochemical value without the inflammation context (ferritin, albumin, serum zinc, retinol all shift with infection), or without the lab's own reference range.
• Taking anthropometry carelessly — shoes on, unfasted, scale uncalibrated, head not in the Frankfurt plane, MUAC tape over a flexed or clothed arm, callipers read too late.
• Accepting a dietary recall at face value: no portion aids, no cooked-to-raw conversion, no probing for snacks, oils, sugars and beverages — then calling the intake "adequate".

Related topics

Nutrition and dietetics · Meal planning for the life cycle · Public health nutrition: ICDS, POSHAN Abhiyaan and mid-day meals · Therapeutic diets: diabetes, cardiac, renal and obesity · Nutritional biochemistry · Protein-energy malnutrition and micronutrient deficiency disorders