Measuring malnutrition at individual level

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Measuring malnutrition at individual level
Module 6
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Learning objectives

• Be familiar with the standard methods used to
  measure weight, height, mid-upper arm
  circumference (MUAC) and oedema.
• Understand the classifications of undernutrition
  in children and adults using different
  anthropometric indices.
• Be able to identify Z-score ranges for
  weight-for-height for children 6-59 months using
  the 2006 WHO Growth Standards simplified field
  tables for boys and girls
• Be aware of the uses of anthropometric
  measurements in both emergency and non-emergency
  contexts.
• Be aware of the limitations of anthropometry.

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How do we assess the nutritional status of an
individual?
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Measurements for undernutrition

• Anthropometry or body measurements
• Clinical assessment
• Dietary intake
• Biochemical assessment

All of them are suitable in emergencies?
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Body measurements and clinical assessment for
acute malnutrition

• Age and sex
• Anthropometry
• Weight
• Height (or length)
• Middle-upper Arm Circumference (MUAC)
• Clinical signs
• Presence of bilateral pitting oedema
• Presence of medical complications
• Absence of appetite

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Use of MUAC for children 6-59 months

• MUAC (Mid upper arm circumference) is measured in
  the middle of the left arm of children and is a
  proxy for measures of reserves of fat and muscle
  in the body.

• It is an effective predictor of death in children
  6 to 59 months, but it tends to select more
  younger children

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Clinical assessment and acute malnutrition

• Presence of bilateral pitting oedema
• Assessment for medical complications and appetite

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Checking for oedema
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Anthropometrical or nutritional indices

• Combination of two measurements
• Weight and age WFA
• Height (or length) and age HFA
• Weight and height (or length) WFH (or BMI)

Why do we need them?
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Use of anthropometrical indices at individual
level

• To determine the condition of an individual by
  comparing to expected anthropometric values for
  an individual of the same sex and age, e.g. a
  growth standard or growth reference. Then
• Classify the nutritional status of individuals,
  e.g. whether they present or not malnutrition,
  according to specific cut-off points, and
• Decide whether the individual needs to be treated
  or not
• Some indices dont need to be compared with
  references, thresholds are used instead (BMI).

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Which standards / references do we use?

• For children, for each height standards of weight
  are expected
• The 2006 WHO Growth Standards are universal
  standards of growth for children and also provide
  a classification for malnutrition lt-3 SD for
  severe malnutrition, lt-2 SD for moderate
  malnutrition
• WHO and UNICEF also endorsed the use of MUAC lt115
  mm as a criteria for severe malnutrition for
  children 6 to 59 months.

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Normal distribution of weight for an specified
height (Growth standards)
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Anthropometry and acute malnutrition

• Wasting
• low weight-for-height (WFH) or
• and/or low mid upper arm circumference (MUAC) or
• low BMI (for adults)
• MUAC and BMI are interpreted directly with
  cut-off points, without comparison to a reference
  (index)

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Acute malnutrition in children 6-59 months

• The basic information and body measurements
  needed to assess acute malnutrition in children
  6-59 months are
• Age and sex,
• Anthropometrical measurements weight,
  height/length and MUAC,
• Clinical signs of visible wasting, bilateral
  edema, medical complications and lack of appetite
  
• The nutritional index is WFH

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For children aged 6-59 months

• Classification of acute malnutrition

    Moderate acute malnutrition (MAM)     Severe acute malnutrition (SAM)  
WFH (wasting) -3 SD lt -2 SD  lt -3 SD 
MUAC 115mm lt 125mm lt 115mm
Bilateral Oedema No Yes
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Classification of acute malnutrition
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For infants less than 6 months

• Criteria for malnutrition are based on clinical
  signs (e.g. oedema, visible wasting, too weak to
  suckle, not gaining weight despite feeding) and
  risk factors (e.g. insufficient breast milk,
  absence of mother
• Birth weight (lt 2,500gr) is a recognized measure,
  but does not account as malnutrition criteria.
  LBW is used as indicator of issues during
  pregnancy (like IUGR) and represents a risk
  factor for subsequent malnutrition

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For older children and adolescents (5-19 years
of age)
  BMI-for-age Z-score
Severe thinness lt-3SD 
Thinness -3 SD lt -2 SD 
BMI-for-age calculations are based on the use of
the WHO growth references
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For adults (20 59.9 years)
    Well-nourished  Mild acute malnutrition Moderate acute malnutrition Severe acute malnutrition
BMI (WHO 1995)   18.5kg/m2 lt18 to 17kg/m2 lt17 to 16kg/m2 lt 16kg/m2

• For pregnant and lactating women MUAC is
  recommended
• MUAC lt210 mm indicates a nutritional risk
  requiring intervention. Normality is defined at
  gt230 mm.

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For elderly (over 60 years old)

• Very difficult to measure age for being
  considered old differs between settings or
  possibility to take accurate measures is limited.
• Same cut-offs as BMI for adults should be used
  for identifying older people suffering from
  malnutrition.

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Anthropometry and chronic malnutrition

• Stunting is indicated by low height-for-age (HFA)
• Underweight is indicated by low weight-for-age
  (WFA)

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Stunting and underweight in children 6-60 months

• The three nutritional indices of WFH, HFA, and
  WFA each assess different aspects of growth
  failure.
• Tables exist in the WHO growth reference for
  measure of each of them

Moderate stunting  Severe stunting
HFA (stunting) lt-2 SD to -3 SD  lt -3 SD 
  Moderate underweight Severe underweight
WFA (underweight) lt-2 SD to -3 SD  lt -3 SD 
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Growth Monitoring charts (WFA index)
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Measuring the different forms of undernutrition
 Acute malnutrition Acute malnutrition is indicated by wasting and/or bilateral oedema. Wasting is measured by the nutritional index of WFH or mid upper arm circumference (MUAC). Bilateral oedema, found in cases of kwashiorkor and marasmic-kwashiorkor, is an abnormal infiltration and excess accumulation of serous fluid in connective tissue or in a serous cavity. Other clinical signs are presence of medical complications and anorexia
Chronic undernutrition (stunting) Stunted children are short for their age (low height-for-age (HFA). Stunting is measured by the nutritional index of HFA.
Underweight (acute and/or chronic) Underweight children weigh less than the average weight for children of the same age and sex. Underweight is measured by the nutritional index of weight-for-age (WFA)
Micronutrients deficiencies Direct assessment measurement of actual clinical or sub-clinical deficiency in individuals Indirect assessment estimation of nutrient intakes at a population level and from this the risk of deficiency and the likely prevalence

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Key messages Module 6

• Anthropometry is the use of body measurements to
  assess and classify nutritional status in an
  individual.  
• Other measurements include clinical, biochemical
  and dietary intake assessment
• Body measurements include age, sex, weight,
  height / length and mid-upper arm circumference
   
• Clinical signs of acute malnutrition include
  visible wasting, bilateral oedema and lack of
  appetite
• Acute malnutrition among children 6-60 months is
  assessed using the nutritional indices of
  weight-for-height or weight-for-length (WFH),
  MUAC, and signs of bilateral oedema. 
• Acute malnutrition for other age-groups
• Infants less than 6 months of age is assessed
  using visible signs of wasting and bilateral
  oedema. Social criteria such as an absent mother
  or inadequacy of breastfeeding can indicate
  nutritional risk.  
• Undernutrition among children and adolescents
  5-19 years is assessed using the nutritional
  index of body mass index for age (BMI-for-age)
  and clinical signs.  
• Adult undernutrition is assessed through Body
  Mass Index (BMI) (either adjusted or unadjusted
  by Cormic index) or MUAC in addition to clinical
  signs. MUAC is the preferred nutritional index
  during pregnancy and up to 6 months postpartum.  
• There are numerous issues related to the
  assessment of undernutrition in the elderly,
  however BMI is recommended in addition to
  clinical signs. 
• The use of the 2006 WHO Growth Standards is now
  recommended over the use of the 1978 National
  Center for Health Statistics growth reference
  (NCHS GR) in the definition of acute malnutrition
  in children 6-60 months. The 2007 WHO Growth
  References is recommended for use in assessment
  of children and adolescents 5-19 years. 
• Nutrition indices should be presented as Z-scores
  as opposed to percentage of the median.
  Percentage of the median is no longer recommended
  for use in classification of individual nutrition
  status.