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Measuring malnutrition at individual level


Involves assessing the physical presentation of signs and symptoms of acute malnutrition, such as . visible wasting. and . bilateral oedema – PowerPoint PPT presentation

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Title: Measuring malnutrition at individual level

Measuring malnutrition at individual level
Module 6
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
  • Be aware of the limitations of anthropometry.

How do we assess the nutritional status of an
Measurements for undernutrition
  • Anthropometry or body measurements
  • Clinical assessment
  • Dietary intake
  • Biochemical assessment

All of them are suitable in emergencies?
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

Checking for oedema
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?
Use of anthropometrical indices at individual
  • 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).

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
  • WHO and UNICEF also endorsed the use of MUAC lt115
    mm as a criteria for severe malnutrition for
    children 6 to 59 months.

Normal distribution of weight for an specified
height (Growth standards)
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

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

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
Classification of acute malnutrition
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

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
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
  • MUAC lt210 mm indicates a nutritional risk
    requiring intervention. Normality is defined at
    gt230 mm.

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

Anthropometry and chronic malnutrition
  • Stunting is indicated by low height-for-age (HFA)
  • Underweight is indicated by low weight-for-age

Stunting and underweight in children 6-60 months
  • The three nutritional indices of WFH, HFA, and
    WFA each assess different aspects of growth
  • 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 
Growth Monitoring charts (WFA index)
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

Key messages Module 6
  • Anthropometry is the use of body measurements to
    assess and classify nutritional status in an
  • 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
  • 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
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