9 min readConcept sheetOften a 10-mark answer; single signs come in Section A

Clinical, biochemical, biophysical and functional assessment

Clinical examination looks for visible signs of deficiency; biochemical tests measure nutrients in blood and urine; biophysical and functional tests show how tissues work.

WHO grouping of clinical signsSigns of value in surveys; signs needing further study; signs not related to nutrition

Most used field biochemical testHaemoglobin (for anaemia)

Clinical method: strengthQuick, cheap, needs no equipment

Clinical method: weaknessSigns appear late and are often non-specific

Clinical signs and what they point to

Body part	Sign	Possible deficiency
Hair	Thin, sparse, easily pulled, discoloured; flag sign	Protein (kwashiorkor)
Face	Moon face (oedema)	Protein
Eyes	Night blindness, conjunctival xerosis, Bitot's spots, keratomalacia	Vitamin A
Eyes	Pale conjunctiva	Iron (anaemia)
Lips	Angular stomatitis, cheilosis	Riboflavin; also iron
Tongue	Magenta tongue; smooth, red, sore tongue (glossitis)	Riboflavin; niacin, folate, B12
Gums	Spongy, bleeding gums	Vitamin C
Teeth	Mottled enamel	Excess fluoride
Neck	Goitre	Iodine
Skin	Follicular hyperkeratosis; dermatitis on sun-exposed skin; flaky-paint skin; small bleeding spots (petechiae)	Vitamin A; niacin (pellagra); protein; vitamin C
Nails	Koilonychia (spoon nails)	Iron
Bones	Bow legs, knock-knees, rickety rosary, frontal bossing	Vitamin D and calcium
Nervous system	Calf tenderness, loss of knee and ankle jerks, pins and needles	Thiamine (beriberi)
General	Pitting oedema; severe wasting	Protein; energy

Activity: identifying clinical signs, with a hospital or PHC visit

1
Prepare a clinical examination schedule: a form listing each body part and the signs to look for, with tick boxes.
2
Take permission from the medical officer and from the patient or mother; explain why you are examining.
3★
Examine in good daylight, head to toe: hair, face, eyes, lips, tongue, gums, teeth, neck, skin, nails, legs and bones. Press the shin for pitting oedema.
4
Record each sign and grade it where possible, e.g. goitre grade 0, 1 or 2.
5
Confirm with a simple test where you can: haemoglobin for pallor; ask the mother about night blindness.
6
At the PHC or hospital, observe and record cases of PEM, anaemia, vitamin A deficiency, goitre and fluorosis, with each patient's age, diet and history.
7
Write a report: signs seen, likely deficiency, and the treatment or programme the patient is linked to.

★ one-way, controls the pace

Biochemical tests

Nutrient	Test	Suggests deficiency when
Iron	Haemoglobin; serum ferritin (iron stores)	Hb below the WHO cut-off; ferritin low
Protein	Serum albumin	Low (below about 3.5 g/dL); very low in kwashiorkor
Vitamin A	Serum retinol	Below 20 µg/dL; below 10 µg/dL is severe
Iodine	Urinary iodine	Population median below 100 µg/L
Vitamin D	Serum 25-hydroxy vitamin D; alkaline phosphatase	Low vitamin D; alkaline phosphatase raised in rickets
Folate and B12	Serum folate and B12; blood smear	Low levels; large red cells (macrocytes)
Riboflavin	Erythrocyte glutathione reductase activity coefficient	Raised coefficient

Biophysical, radiological and functional tests

Type	Test	What it shows
Biophysical	Dark adaptation test	Vitamin A status (vision in dim light)
Radiological	X-ray of the wrist and long bones	Rickets (cupping and fraying of bone ends), scurvy, bone age, skeletal fluorosis
Biophysical	Bone density scan; bioelectrical impedance	Bone mineral; body fat and lean mass
Functional	Hand-grip strength (dynamometer)	Muscle function; falls in PEM
Functional	Work capacity and fitness tests	Lowered in anaemia
Functional	Immune response; attention and memory tests	Lowered in PEM; affected by iron and iodine deficiency

Clinical vs biochemical methods

Clinical examinationQuick and cheap, needs no equipment, suits large surveys. But signs appear late, many are non-specific (angular stomatitis can come from riboflavin or iron lack), and results depend on the examiner.

Biochemical testsObjective and early: they pick up deficiency before signs appear and confirm the cause. But they need blood or urine samples, a laboratory, trained staff and money; levels can change with a recent meal or infection.

In the community

On a PHC visit, students see that a pale, tired mother and a child with Bitot's spots are linked to Anemia Mukt Bharat and vitamin A prophylaxis. A point-of-care haemoglobin test at the anganwadi turns a guess about pallor into a number.

Exam angle

2 marks: “Name two clinical signs of riboflavin deficiency.” Angular stomatitis and cheilosis; magenta tongue is a third.

5 marks: “Write a note on biochemical methods of assessing nutritional status.” Define; table of nutrient, test and cut-off (Hb, ferritin, albumin, serum retinol, urinary iodine, vitamin D); advantages and limitations.

10 marks: “Describe the clinical and biochemical methods of nutritional assessment, with their merits and demerits.” Clinical: head-to-toe table of signs and the WHO grouping of signs; biochemical: table of tests; biophysical and functional tests in brief; compare merits and demerits.

Remember it

Clinical sees late, biochemical sees early. Examine head to toe: hair, eyes, mouth, neck, skin, nails, bones.