1. Project GCP/BGD/037/MUL National Food Policy Capacity Strengthening Programme (NFPCSP) Training Workshop on FOOD SECURITY CONCEPTS, BASIC FACTS & MEASUREMENT ISSUES 25 June – 07 July, 2011 Topic: Measurement and empirical evidence Sub-topic 6b : Concepts and Measurement in Nutrition I Lecture : Anthropometric Measurement and Nutritional Status By Mohammad Abdul Mannan, PhD Nutrition Advisor, NFPCSP-FAO

7. In the Triple-A Cycle model: Indicators to assess and analyse nutrition The ANALYSIS stage aims to analyse the causes of malnutrition The ASSESSMENT stage aims to define the nutritional problem in terms of magnitude and distribution. ASSESSMENT of the nutritional situation in target population ACTION based on the analysis & available resources ANALYSIS of the causes of the problem

9. 1. Intra-uterine Undernutrition: Low Birth Weight (LBW) Malnutrition can begin from intra-uterine life, mainly due to maternal malnutrition. Maternal malnutrition during pregnancy retards the growth and development of the foetus. The foetus, therefore, is born with birth weight lower than normal. When the birth weight of a full-term foetus is below a cut-off level, the newborn is termed as a LBW baby. According to WHO, the cut-off value for birth weight is 2.5 kg. Therefore, babies born with birth weight <2.5 kg are LBW babies.

10. In Bangladesh, the prevalence of LBW was found 43% [BDHS 2004]. LBW babies make a bad start in life. Their chance of survival is poor; they have less ability to resist diseases, therefore, suffer from frequent infection, and soon become severely malnourished. Many do not live up to their first birthday.

18. Anthropometric measurements : Several anthropometric indicators have been identified for assessment of nutrition status of U-5 children. These are Stunting - refers to low height-for-age, Wasting - low weight-for-height and Underweight - low weight-for-age. The Z-score classification of these indicators is most widely used. Nutritional status can be assessed through:

21. The classification can be summarized as follows: Stunting: Height-for-age up to –2SD = Normal Height-for-age <-2SD to –3SD = Moderate Height-for-age <-3SD = Severe

23. The child is said to be of normal weight-for-height , if its weight-for-height is within 2 standard deviations (-2SD) of the median weight-for-height of a reference population. If the weight-for-height falls below 2SD (<-2SD) but within 3 SD below the reference median (-3SD), then the child is classified as moderately wasted . If the weight-for-height falls below 3SD of the reference median (<-3SD), then the child is classified as severely wasted.

24. The classification can be summarized as follows: Wasting: Weight-for-height up to –2SD = Normal Weight-for-height <-2SD to –3SD = Moderate Weight-for-height <-3SD = Severe

25. C. Underweight (low weight-for-age) This is a composite indicator of long-term and acute short-term malnutrition. The body weight may be lost from malnutrition for a long time. The child is then low weight-for-age. Weight may also be lost from acute, short-term malnutrition. In this case also, the child is low weight-for-age. For this, both weight and age are to be known.

27. The classification can be summarized as follows: Underweight : Weight-for-age up to –2SD = Normal Weight-for-age <-2SD to –3SD = Moderate Weight-for-age <-3SD = Severe

28. GROWTH MONITORING AND PROMOTION - GMP It can be performed at the individual level, or at a group level. It c an also be: Growth monitoring is the continuous monitoring of growth in children. Clinic-based growth monitoring (conducted by health professionals at Maternal and Child Health clinics), OR Community -based growth monitoring (conducted by trained members of the community in villages )

29. Mothers Waiting for Growth Monitoring and Promotion

30. D. Mid-upper-arm Circumference (MUAC) Between the ages of 1 and 5 years , there is very little change in a normal child’s arm circumference. Thus, this measurement gives a simple anthropometric measure of wasting which is almost age-independent. The degree of severity of malnutrition in children on the basis of MUAC is given below. MUAC >14 cm = Normal 12.5 – 14.0 cm = Mild/moderate wasting <12.5 cm = Severe wasting

31. 3. Maternal malnutrition The most common nutritional problem in women, especially the poor, is chronic energy deficiency (CED). CED is measured by height as well as by Body Mass Index (BMI).

32. A. Height <145cm is indicative of chronic CED. BMI is derived by dividing weight (in kg) by height squared (in meters). Weight (kg) BMI = ---------------------- = (kg/m 2 ) Height 2 (meter)

33. B. BMI is widely used to assess nutritional status of children above 10 years of age and the adults as follows: BMI >30 = Obese 25.1 – 30.0 = Overweight 18.5 - 25.0 = Normal <18.5 = Malnourished <16.5 = Severely malnourished

35. Mid-upper arm circumference (MUAC) for Adults As with children, MUAC can be used to grade the degree of body wasting in adults. Appropriate cut-off points of MUAC for adults are given below: Male ≥ 23 cm <23 cm Normal Malnourished Female ≥ 22 cm <22 cm Normal Malnourished

36. Nutrition indicators for monitoring and impact assessment Intervention Most relevant nutritional indicators Improved availability of food (dietary energy) at the household level, in areas where dietary energy intake is initially constrained BMI (adults) Weight-for-height Z-score (2-5 year olds) Weight-for-age Z-score (2-5 year olds) Height-for-age Z-score (long-term evaluations only; 2-5year olds) Improved availability of food at the individual level, plus improvements in other basic needs, especially health Height-for-age Z-score (under 5s) Weight-for-age Z-score (under 5s) Weight-for-height Z-score (under 5s) Increased intake of animal products Anemia (Hemoglobin) Serum Vitamin A (retinol) Increased intake of fruits and leaves Serum Vitamin A (retinol)

39. The cut-off value for serum retinol is given below: Serum retinol ≥ 20 µg/100 ml = Normal Serum retinol <20 µg/100 ml = Vitamin A deficiency Serum retinol <10 µg/100 ml = Severe vitamin A deficiency

41. As with vitamin A deficiency, sub-clinical (also called biochemical) iodine deficiency is present in a larger population than goiter. Urinary iodine level is an internationally accepted and widely used indicator of iodine deficiency .

42. The cut-off value for urinary iodine is given below: Urinary iodine excretion (UIE) <20 micrograms/litre = Severe iodine deficiency Urinary iodine excretion (UIE) <100 micrograms/litre = Iodine deficiency Urinary iodine excretion (UIE) ≥100 micrograms/litre = Normal

43. C. Iron deficiency and iron deficiency anaemia Chronic dietary iron deficiency first leads to depletion of iron stores of the body (in the form of ferritin in liver). This is called iron deficiency . Serum ferritin <12 mg/100ml = Iron deficiency

45. The critical levels of haemoglobin (g/L) vary according to different age and sex groups and also various physiological conditions. Group Normal Mild anaemia Moderate anaemia Severe anaemia Children (6 - 59 Mo) ≥ 110 100 – 109 70 - 99 <70 Children (5 - 11 Yr) ≥ 115 100 - 114 70 - 99 <70 Children (12 - 14 Yr) ≥ 120 100 - 119 70 - 99 <70 Male 15+ Yr ≥ 130 100 - 129 70 - 99 <70 Female 15+ Yr ≥ 120 100 - 119 70 - 99 <70 Pregnant women ≥ 110 100 - 109 70 - 99 <70 Lactating mothers ≥ 120 100 - 119 70 - 99 <70