Measuring malnutrition at individual level

1. Measuring malnutrition at individual level Module 6

2. 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.

3. How do we assess the nutritional status of an individual?

4. Measurements for undernutrition • Anthropometry or body measurements • Clinical assessment • Dietary intake • Biochemical assessment All of them are suitable in emergencies?

5. 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

8. ?

11. 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

13. Clinical assessment and acute malnutrition • Presence of bilateral pitting oedema: • Assessment for medical complications and appetite

14. Checking for oedema

15. 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?

16. 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 don’t need to be compared with references, thresholds are used instead (BMI).

17. 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: <-3 SD for severe malnutrition, <-2 SD for moderate malnutrition • WHO and UNICEF also endorsed the use of MUAC <115 mm as a criteria for severe malnutrition for children 6 to 59 months.

18. Median weight for 80 cm tall boys Standard deviation = 1.05 Normal distribution of weight for an specified height (Growth standards)

19. 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)

20. 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

21. For children aged 6-59 months Classification of acute malnutrition

22. Classification of acute malnutrition Acute malnutrition Moderate acute malnutrition Weight for height ≥-3 ZS and <-2 ZS Or MUAC ≥11.5 and <12.5 cm Severe acute malnutrition Without medical complications Weight for height <-3 ZS Or MUAC <11.5 cm Or Bilateral pitting edema and no medical complications Severe acute malnutrition With medical complications Weight for height <-3 ZS Or MUAC <11.5 cm Or Bilateral pitting edema and medical complications

23. 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 (< 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

24. For older children and adolescents (5-19 years of age) BMI-for-age calculations are based on the use of the WHO growth references

25. For adults (20 – 59.9 years) • For pregnant and lactating women MUAC is recommended: • MUAC <210 mm indicates a nutritional risk requiring intervention. Normality is defined at >230 mm.

26. 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.

27. Anthropometry and chronic malnutrition • Stuntingis indicated by low height-for-age (HFA) • Underweightis indicated by low weight-for-age (WFA)

28. 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:

29. Growth Monitoring charts (WFA index)

30. Measuring the different forms of undernutrition

31. 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 oedemaand 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 undernutritionis 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.