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
OUTLINE OF PRESENTATION
 Introduction
 Nutrition Indicators
 Nutritional Assessment
 Anthropometric Measurement
 Stunting, Wasting, Underweight and Classification
 BMI & MUAC and Classification
 Biochemical Assessment of Micronutrient Malnutrition
 Health Indicators
 Summary
INTRODUCTION
The nutritional status of an
individual is often the result of many
inter-related factors.
It is influenced by food intake,
quantity & quality, & physical health.
The spectrum of nutritional status
spreads from severe malnutrition to
obesity
National sources of anthropometric data and
nutrition status information

Bangladesh Demographic and Health Surveys
(BDHS) : every 3 years
 Multiple Indicators Cluster Surveys (MICS) : 5 years
 Food Security and Nutrition Surveillance :
(3 rounds/year)
 Other surveys : need/issue specific (IYCF, VAD)
Nutritional Assessment - Why?
The purpose of nutritional assessment is
to:
Identify individuals or population groups
at risk of becoming malnourished
Identify individuals or population groups
who are malnourished
Nutritional Assessment –Why?
To develop nutrition and health care
programs that meet the community needs
which are defined by the assessment
To measure the effectiveness of the
nutritional programs & intervention once
initiated
Indicators to assess and analyse nutrition
In the Triple-A Cycle model:
ASSESSMENT
of the nutritional
situation in target
population
ACTION
based on the
analysis &
available
resources
ANALYSIS
of the causes
of the problem
The ASSESSMENT stage aims to
define the nutritional problem in
terms of magnitude and
distribution.
The ANALYSIS stage aims to
analyse the causes of malnutrition
Nutrition and health indicators
Different indicators are used for assessment and analysis purposes.
Indicators used to define the
nutritional problem
Indicators used to analyze the
causes of the problem
They address the following questions:
• Who suffers from malnutrition?
• What is the type of malnutrition?
• When?
• Where?
They address the following question:
• Why are people malnourished or at risk of
malnutrition?
ANTHROPOMETRIC AND MICRONUTRIENT
DEFICIENCY INDICATORS
FOOD, HEALTH AND CARE PRACTICE
INDICATORS
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.
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.
2. Childhood Malnutrition
The consequences of malnutrition are most severe if it happens
very early in life.
Malnutrition from this time in life onward has long lasting effects
on subsequent growth, morbidity, cognitive development,
educational attainment and productivity in adulthood.
For these reasons, nutrition status of young children, particularly
those aged below 5 years, has been shown to be one of the most
sensitive indicators of food security, vulnerability and overall socioeconomic development of a country.
Nutritional assessment - ABCD
 Anthropometry: height, weight, BMI, MUAC
 Biochemical: analysis of blood, urine, and other
body tissues
 Clinical: complete physical examination, and a
medical and psychosocial history
 Dietary: foods and quantities eaten, eating habits,
accessibility of food, and cultural and socioeconomic
factors that affect selection of food.
Measuring Nutritional Status

Infant and Young Child Feeding
Practice
 Measurement of growth and body
composition (anthropometric
indicators)
 Biochemical content of blood and
urine (biochemical indicators)
 Clinical examination of external
physical signs of nutrient
deficiencies (clinical indicators)
Nutritional indicators
 Nutritional indicators are the quantitative threshold or
cut-off values by which the nutritional status of the
population can be assessed.
 Since malnutrition is seen among the population
throughout the life cycle, different indicators have been
developed to assess nutritional status of population of
different age and gender groups.
Potential key indicators to be mapped at national & subnational levels by sector
FOOD AND NUTRITION
Nutritional status indicators

Underweight (children under five)

Stunting (children under five)

Wasting (children under five)

Body-Mass-Index (<18.5 adults)

Low birth weight (LBW)

Vitamin A deficiency-night blindness (Children under five)

Total goitre rate (TGR)

Percentage of households consuming iodized salt
ADVANTAGES OF NUTRITIONAL ANTHROPOMETRY

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



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Methods are precise and accurate, provided standardized techniques are
used
Procedures use simple, safe and non-invasive techniques
Equipment required is inexpensive, portable and durable, and can be made
or purchased locally
Relatively unskilled personnel can perform measurement procedures
Information is generated on past nutritional history
Methods can be used to quantify the degree of under-nutrition (or overnutrition) and provide a continuum of assessment
Methods are suitable for large sample sizes such as representative
population samples
Methods can be used to monitor and evaluate changes in nutritional status
over time, seasons, generations, etc.
Methods can be adapted to develop screening tests to identify those at high
risk.
Source: Gibson (1990).
LIMITATIONS OF NUTRITIONAL ANTRHOPOMETRY
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The relative insensitivity to detect changes in nutritional
status following inadequacy of food over short periods of
time
The inability to distinguish the effect of specific nutrient
deficiencies (e.g. zinc deficiency) that affect growth in
children from that due to inadequacy of food in general
The inability to pinpoint the principal causality of undernutrition, as the poor nutritional status may be the result
of factors such as repeated insults owing to infections
and poor care in children
The relative higher costs and organization required to
obtain representative and quality data for the purpose of
estimating numbers of undernourished
Nutritional status can be assessed through:
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 weightfor-height and Underweight - low
weight-for-age.
The Z-score classification of these
indicators is most widely used.
A. Stunting (low height-for-age)
Under-nutrition for a long time retards the growth of a child by
height. The child is shorter than for its age. This is called
“Stunting”. For this, both height and age are to be known.
It reflects a process of failure to reach linear growth potential
due to sub-optimal food and/or health conditions in early
childhood (<2 year). The condition needs remedy in early
childhood, otherwise the process is irreversible.
The child is said to be of normal height, if its height-for-age is
within 2 standard deviations (-2SD) of the median height-for-age
of a reference population.
If the height falls below 2SD (<-2SD) but within 3 SD
below the reference median (-3SD), then the child is
classified to moderately stunted.
If the height falls below 3 SD of the reference median
(<-3SD), then the child is classified as severely stunted.
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
B. Wasting (low weight–for-height)
 Wasting is a measure of underweight relative to height and
indicates a weight deficit associated with acute starvation
and/or severe disease.
Acute, short-term malnutrition does not affect the height, but
the body weight.
This is seen as “Wasting” of the body, i.e. loss of body mass
compared to the body size.
Weight-for-height is therefore a useful indicator for assessing
body wasting.
For this, age does not need to be known.
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.
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
C. Underweight (low weight-for-age)
This is a composite indicator of long-term and acute shortterm malnutrition. The body weight may be lost from
malnutrition for a long time. The child is then low weightfor-age. Weight may also be lost from acute, short-term
malnutrition. In this case also, the child is low weight-forage.
For this, both weight and age are to be known.
The child is said to be of normal, if its weight-for-age is
within 2 standard deviations (-2SD) of the median weightfor-age of a reference population.
If the weight-for-age falls below 2SD (<-2SD) but within 3
SD below the reference median (-3SD), then the child is
classified as moderately underweight.
If the weight-for-age falls below 3SD of the reference
median (<-3SD), then the child is classified as severely
underweight.
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
GROWTH MONITORING AND PROMOTION - GMP
Growth monitoring is the continuous
monitoring of growth in children.
It can be performed at the individual level, or at a
group level. It can also be:
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 )
Mothers Waiting for Growth Monitoring and Promotion
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
12.5 – 14.0
cm = Normal
cm = Mild/moderate wasting
<12.5 cm = Severe wasting
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).
A. Height <145cm is indicative of chronic CED.
BMI is derived by dividing weight (in kg) by height
squared (in meters).
Weight (kg)
BMI = ---------------------Height2 (meter)
= (kg/m2)
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
C. Mid-upper arm circumference (MUAC)
MUAC is a better indicator of mortality risk associated with
malnutrition than Weight-for-Height. It is therefore a better measure
to identify children most in need of treatment.
MUAC is simple, cheap, more sensitive and less prone to mistakes.
 Appropriate cut-off points of MUAC for children between 6 to 59
months are given below:
>13.5 cm
Normal
12.5 to13.5 cm
At risk of acute malnutrition
11.0 to 12.5 cm
Moderate acute malnutrition
<11.0 cm
Severe acute malnutrition
Children
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
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)
4. Micronutrient malnutrition
The most widely prevalent micronutrient
malnutrition problems are:
 Vitamin A deficiency,
 Iodine deficiency, and
 Iron deficiency.
A. Vitamin A deficiency
Chronic dietary vitamin A deficiency first leads to night
blindness and then, in untreated cases, to total blindness.
Sub-clinical vitamin A deficiency is present in a much
larger population than clinical blindness.
Serum retinol (vitamin A) level is a dependable indicator
for sub-clinical vitamin A deficiency.
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
B. Iodine deficiency
Chronic dietary iodine deficiency first leads to
enlargement of the thyroid gland such that it is not yet
visible. This goiter is called Grade 1 goitre.
In untreated cases, Grade 1 goiter develops into Grade
2 goitre, which now becomes visible.
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.
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
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
When the iron store falls below such level that it
cannot support haemoglobin synthesis, haemoglobin
level begins to fall.
If haemoglobin falls below a critical level, then it is
anaemia.
The severity of anaemia depends on how low is
haemoglobin level. This can be measured by
determining haemoglobin concentration in whole
blood. The biochemical indicators of iron deficiency
and anaemia are as follows:
The critical levels of haemoglobin (g/L) vary according to different
age and sex groups and also various physiological conditions.
Group
Children
(6 - 59 Mo)
Children
(5 - 11 Yr)
Children
(12 - 14 Yr)
Male
15+ Yr
Female
15+ Yr
Pregnant
women
Lactating
mothers
Normal
Mild
anaemia
Moderate
anaemia
Severe
anaemia
≥110
100 – 109
70 - 99
<70
≥115
100 - 114
70 - 99
<70
≥120
100 - 119
70 - 99
<70
≥130
100 - 129
70 - 99
<70
≥120
100 - 119
70 - 99
<70
≥110
100 - 109
70 - 99
<70
≥120
100 - 119
70 - 99
<70
Basic health indicators
 Immunization rate for measles, tuberculosis, diphtheria,
poliomyelitis and tetanus (one-year-olds)
 Prevalence of infectious diseases and epidemics (malaria,
cholera, AIDS and other)
 Access to safe water (rural and urban)
 Rural access to safe water
 Urban access to safe water
Basic health indicators …….
Access to adequate sanitation
 Infant mortality rate
 Under five mortality rate
 Maternal mortality rate
 Percentage of all cases of diarrhea in children under five yr of
age treated with ORS and/or recommended home fluids
 Infants 0-6 months exclusively breastfed
 Infants 6-9 months breastfed with minimum acceptable diet
 Infants at 20-23 months with minimum acceptable diet and
continued breast feeding
Summary
 Nutritional status assessments enable to determine whether a population group is wellnourished or undernourished by using anthropometric measurements, biochemical testing or
by identifying physiological signs.
 The main data collection methodologies that provide anthropometric information are:
population-based surveys, growth monitoring, and sentinel site and school census data.
 Additional information on factors such as food security, livelihoods, and health and care
practices is usually necessary to interpret nutritional status data and determine the likely
causes of malnutrition.
 Information on nutritional status, combined with the analysis of underlying causes, will
provide the understanding needed to select the appropriate intervention. Combination of
dietary, anthropometric and biochemical indicators can strengthen nutrition assessment and
its quality.
 Experience shows that multi-sectoral interventions have a better chance of improving the
nutritional status of the population.
If you want to know more...
Online resources
•Nutrition Assessment: Background Papers. World Bank/UNICEF. http://www.tulane.edu/~internut/Trial/RSRC.htm
•Sphere handbook. http://www.sphereproject.org/handbook/
•Practical anthropometry 101 and 102, International Food Policy and Research Institute.
http://www.ifad.org/gender/tools/hfs/anthropometry/ant_toc.htm
•Anthropometric indicators measurement guide, 2003. http://www.fantaproject.org/publications/anthropom.shtml
•Field Exchange on Emergency Nutrition Network digital archives 2005. www.ennonline.net
•Improving the analysis of food insecurity. Food Insecurity Measurement, Livelihoods Approaches and Policy: Applications in
FIVIMS. S. Devereux et al. 2004. http://www.fivims.net/documents/Final%20Paper5.pdf
•State of Food Insecurity (SOFI) 2001. Food and Agriculture Organization.
http://www.fao.org/DOCREP/003/Y1500E/y1500e04.htm
•"Nutrition indicators for development - Reference Guide." B. Maire and F. Delpeuch. Institut de Recherche pour le Développement
(IRD), Montpellier, France. FAO, 2005. http://www.fao.org/docrep/008/y5773e/y5773e00.htm
•"Guidelines for Participatory Nutrition Projects" FAO Reprinted,
1994,1995, http://www.fao.org/documents/show_cdr.asp?url_file=/docrep/V1490E/V1490E00.htm
•"Participatory Appraisal of Nutrition and Household Food Security Situations and Planning of Interventions from a Livelihoods
Perspective - Methodological Guide." Karel Callens and Bernd Seiffert. FAO 2003.
http://www.fao.org/documents/show_cdr.asp?url_file=/docrep/006/ad694e/ad694e04.htm
Thank You for Your Kind Attention !