Nutritional Anthropometry

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  • Monitoring the weight is helpful in diagnosing malnutrition at early stage
  • Nutritional Anthropometry

    1. 1. NUTRITIONAL ANTHROPOMETRY Presented by: Ekta Belwal HHM-2013-011 M.Sc (FN) I yr.
    2. 2. WHAT IS INSIDE !!!  What is Anthropometry  Anthropometric measurements  Indices  References used  Classification  Results of different National Surveys  Conclusion
    3. 3. INTRODUCTION • Anthropos - "man" and Metron "measurement” • A branch of anthropology that involves the quantitative measurement of the human body. Nutritional Anthropometry “Measurement of the variations of the physical Dimensions & the gross composition of the human body at different age levels and degrees of nutrition” - Jellife (1966) • It is used to evaluate both under & over nutrition. • The measured values reflects the current nutritional status & don’t differentiate between acute & chronic changes 3
    4. 4. USE OF ANTHROPOMETRY Individual Level SCREENING: ONE TIME ASSESSMENT to immediately decrease case fatality (emergency situations) in non-emergency situations GROWTH MONITORING: TREND ASSESSMENT Population Level ONE TIME ASSESSMENT under circumstances of food crisis for long-term planning NUTRITIONAL SURVEILLANCE: TREND ASSESSMENT for long-term planning for timely warning for programme management 4
    5. 5. SIGNIFICANCE OF ANTHROPOMETRY  Primary measures of past or current nutritional status in children.  Distinguish between stunting & wasting  Identify PEM & obesity  Monitor changes after nutrition intervention  In clinical settings- identify, hospital patients with CED or over nutrition. 5  Public Health screening
    6. 6. Advantages • Simple & Safe procedures • Inexpensive, portable, durable equipment • Little training • Precise & accurate methods • Info generated on past longtime nutritional history, not possible with other tech. with equal confidence. Disadvantages • Relatively insensitive method & can’t detect disturbances in nutritional status over short period of time or identify specific nutrient deficiency. • Unable to distinguish disturbances in growth or body composition induced by nutrient(Zn) def. from those caused by imbalances in P&E intake. 6
    7. 7. ANTHROPOMETRY   MEASUREMENTS - Using Anthropometric Instruments  Technique of measuring people REFERENCE VALUES / STANDARDS - National & International Measure Reference Index  INDICES - Computed Indicator Information -Age dependent/Independent  CLASSIFICATIONS - Grading of Nutritional Status 7
    8. 8. Nutritional Anthropometry Weight : - Total Body mass - Simple, widely used - Sensitive to small changes in nutrition Height : - Genetically Determined - Environmentally influenced - Stunting Reflects chronic undernutrition MUAC : - Reflects muscle/fat - Easy to measure, used for quick screening - Independent of age (1-5 years) FFT: - Measures body fat - Correlates well with total body fat 8
    9. 9. ANTHROPOMETRIC MEASUREMENTS ( For New Born & Young Children)  Weight  Recumbent length  Head Circumference  Chest Circumference  Mid Upper Arm Circumference (MUAC) 9
    10. 10. ANTHROPOMETRIC MEASUREMENTS ( For Adults )  Weight (in Kg)  Hip Circumference (in cm)  Height (in cm)  Fat fold thickness (in mm)    Mid Upper Arm Circumference (MUAC) (in cm)    Triceps Biceps Supra-Iliac Sub-scapular Waist Circumference (in cm) 10
    11. 11. REQUIREMENTS FOR NUTRITIONAL ANTHROPOMETRY Standard equipment: - Accuracy / Consistency, Appropriate techniques: - Training & Standardization Correct assessment of age: Reference values: - For comparison and computation of indices Classification: - For grading nutritional status 11
    12. 12. 1. WEIGHT OR BODY MASS  The measurement of weight is most reliable criteria of assessment of health and nutritional status of children.  The weight can be recorded using a :  Beam type weighing balance  Electronic weighing scales for infants and children  Bathroom type of mechanical scale (very unreliable)  Salter spring machine (in field conditions) 12
    13. 13. INDICATION  Sensitive indicator of current nutritional status.  Deficit in weight indicates short term under nutrition which can be easily reversed.  PEM is best indentified by weight deficiency in all groups 13
    14. 14. MEASURING CHILD’S WEIGHT USING THE SALTER SCALE. (SOURCE: UNICEF, 1986)        Adjust the pointer of the scale to zero level. Take off the child’s heavy clothes and shoes. Hold the child’s legs through the leg holes (arrow 1). Hold the child’s feet (arrow 2). Hang the child on the Salter Scale (arrow 3). Read the scale at eye level to the nearest 0.1 kg (arrow 5). Remove the child slowly and safely. 14
    15. 15. MEASURING WEIGHT OF ADULTS USING THE BEAM BALANCE SCALE .     Participants are asked to remove their heavy outer garments (jacket, coat, trousers, skirts, etc.) and shoes. If subjects refuse to remove trousers or skirt, at least make them empty their pockets and record the fact in the data collection form The participant stands in the centre of the platform, weight distributed evenly to both feet. Standing offcentre may affect measurement. The weights are moved until the beam balances (the arrows are aligned). The weight is recorded to the resolution of the scale (the nearest 0.1 kg or 0.2 kg). 15
    16. 16. CONTD.. USE OF SALTER SCALE 16
    17. 17. OTHER METHODS 17
    18. 18. WEIGHT  Sensitive to changes  Changes in two directions up and down  Fast change  Usually easy to collect  Standardisation of scales needed, calibration  Small changes are difficult to measure: food intake of the child, urine, dehydration, temp, etc: not very specific  community aversion: connotations  can be difficult: co-operation of children  to nearest 100 gr. 18
    19. 19. 2. HEIGHT OR LENGTH  Height vertical distance measured from crown of head to bottom of feet (heels) for children 2 yr of age or older.  Recumbent Length: distance measured from crown of head to bottom of feet (heels) while child(< 2 yr of age) is measured supine. Indication   Infantometer Gives a picture of past nutritional status Deficit inheight indicates chronic & prolonged under nutrition resulting often in permanently stunted physical staus 19 Stadiometer
    20. 20. TECHNIQUE OF LENGTH MEASUREMENT  The infant is placed supine on the infantometer.  Assistant or mother is asked to keep the vertex or top of the head snugly touching the fixed vertically plank.  The leg are fully extended by pressing over the knee, and feet are kept vertical at 90⁰ , the movable pedal plank of infantometer is snuggly apposed against 20 soles and length is read from scale.
    21. 21. 21
    22. 22. TECHNIQUE FOR HEIGHT MEASUREMENT • In older children who can stand , height can be measured by the rod attached to the lever type machine or by stadiometer. • Person should stand with bare feet on the flat floor against a wall with fit parallel and with heels buttocks, shoulders and occiput touching the wall. • • Head should be kept in Frankfurt plane. With the help of a wooden spatula or plastic ruler. The topmost point of the vertex is identified on the wall. 22
    23. 23. 23
    24. 24. HEIGHT  Difficult to measure, accuracy, large variations  Differences are small: 24 cm increment in the first year of life, 11 cm second year, 8 third  Low sensitivity  Large measurement errors  Measure to the nearest mm  Below 2 y recumbent, above standing 24
    25. 25. 3. WAIST-TO-HIP CIRCUMFERENCE RATIO MEASUREMENT TECHNIQUE Waist circumference  A good quality non-stretchable measuring tape should be used.  View the patient from the front.  Locate the narrowest point between ribs and iliac crests.  Ensure that the tape measure is at the same height around the waist.  Measure and state the measurement correctly to the nearest centimetre. ≥102cm (adult male) & ≥88 cm (adult female) considered having abdominal obesity 25
    26. 26. WAIST-TO-HIP CIRCUMFERENCE RATIO Hip circumference      View the person from the front. Hip measurement is taken at the widest lateral extension of the hips. Ensure that the tape measure is horizontal. Measure and state the measurement correctly to the nearest centimetre. Calculate Waist/Hip Ratio to 2 decimal places. 26
    27. 27. MEASURES OF BODY COMPOSITION  Weight loss, per se, does not provide the nutritionist with an indication of type of tissue lost (i.e. weight loss due to loss of adipose tissue or loss of muscle tissue).  Measurements of skin-folds, mid-arm circumference and mid-arm muscle circumference therefore provide a more comprehensive picture of body composition/ changes. 27
    28. 28. MID-ARM CIRCUMFERENCE (MAC) Locate the midpoint of the arm.  Non-dominant arm elbow flexed at 90deg with palm facing upwards  Measurer stands behind the subject & locates the lateral tip of the acromion and the most distal point on the olecranon process  Place a tape measure so that it passes between these 2 landmarks and mark the midpoint Measure the midarm circumference  The subject stands erect with arms hanging freely at the sides and the palms facing the thighs  Place the tape measure perpendicular to the long axis of the arm at the marked midpoint & measure the circumference to the nearest mm. (e.g. 18.1 cm)  Provide the actual MAC in cm. 28
    29. 29. 29 MUAC FOR CHILDREN
    30. 30. 30
    31. 31. 31
    32. 32. SKIN-FOLD MEASUREMENTS  Approximately half of the total amount of fat tissue in the human body is located below the surface of the skin. In general, when measuring skin-fold thickness,  This makes it possible to predict total body fat from skin-fold thicknesses with a relative high degree of accuracy using a simple two-compartmental method. This accuracy is confirmed by CT scan as well as ultrasonic and radiographic techniques used to measure subcut.fat. The assessor, using the forefinger and the thumb, grasps and lifts the subcut. tissue and skin from the underlying muscle.  Places the pincers of the skin-fold caliper, applying a constant pressure, 2cm below the fingers at a depth of 1cm.    Holds this position for 3-4seconds.  Takes three measurements for accuracy. 32  Provides the actual skin-fold thickness in mm.
    33. 33. DIFFERENT TYPES OF SKIN FOLD CALLIPERS Holtain Sanny Professional Skin fold Caliper Defender Body Fat Caliper Cescorf Body Caliper Lange Fat Caliper Warrior Digital Body Mass Calliper Accu-Measure 33 Personal Body Fat Tester Harpenden Caliper Lafayette
    34. 34. TRICEPS SKIN-FOLD (TSF) A measure of subcutaneous fat stores taken at the midpoint of the posterior aspect of the humerus.  Correlates closely with percentage of body fat and with total body fat.  Triceps skin-fold thickness varies between 6 -12mm in lean individuals and between 40 - 50mm in obese individuals.  34
    35. 35. TRICEPS SKIN-FOLD MEASUREMENT TECHNIQUE  Subject should be standing with arms hanging loosely at the sides.  Assessor to be positioned behind the subject.  To locate the triceps skin-fold site, locate the site previously marked for the midarm circumference measurement (MAC).  The triceps skin-fold site is on the posterior surface of the arm, midway between the shoulder and the elbow.  Using the forefinger and the thumb the assessor grasps and lifts the subcut. tissue and skin 2cm above TSF site.  Place the pincers of the skin-fold caliper at the TSF point at a depth of 1cm.  Hold this position for 3-4seconds.  Take three measurements for accuracy.  Provide the actual skin-fold thickness in mm. 35
    36. 36. BICEPS SKIN-FOLD MEASUREMENT Locate the biceps skin-fold site:  The assessor positioned in front of the subject.  Subject should be standing erect with arms hanging loosely at their sides.  To locate the biceps skin-fold site, locate the level previously marked for the mid-arm circumference measurement.  The biceps skin-fold site is on the anterior surface of the arm, midway between the shoulder and elbow. 36
    37. 37. SUBSCAPULAR SKIN-FOLD MEASUREMENT TECHNIQUE        The assessor is positioned behind the subject. The subscapular skin-fold site is located 1cm below the inferior angle of the scapula. The assessor grasps and lifts the subcut. tissue and skin at a downward angle of approximately 45 towards the lateral aspect of the body. Place the pincers of the skin-fold caliper at a depth of 1cm. Hold this position for 3 to 4 seconds. Take three measurements for accuracy (answer in mm). Provide the actual skin-fold thickness in mm. 37
    38. 38. SUPRA-ILIAC SKIN-FOLD MEASUREMENT TECHNIQUE        The assessor to be positioned in front of the subject. The supra-iliac site is located 5cm above the anterior superior iliac spine. The assessor grasps and lifts the subcut. tissue and skin at a downward angle of 45 towards the medial aspect of the body. Place the pincers of the skin-fold caliper at a depth of 1cm. Hold this position for 3 to 4 seconds. Take three measurements for accuracy (answer in mm). Provide the actual skin-fold thickness in mm. 38
    39. 39. HEAD CIRCUMFERENCE • Brain growth takes place 70% during fetal life, 15% during infancy and remaining 10% during pre-school years. • Head circumference are routinely recorded until 5 years of age. • If scalp edema or cranial moulding is present , measurement of scalp edema may be inaccurate until fourth or fifth day of life . •The head circumference is measured by placing the tape over the occipital protuberance at the back and just over the supraorbital ridge and the glabella in front. 39
    40. 40. EXPECTED HEAD CIRCUMFERENCE IN CHILDREN Age Head circumference (cm) At birth 41 6 months 42 - 43 1 year 45 - 46 2 years Adult head size is achieved between 5 to 6 years . 40 4 months  38 3 months During first year there is 12 cm increase in head circumference , while 1 – 5 year age , only 5 cm gain occur in head size. 34 – 35 2 months  47 - 48 40 5 years 50 - 51
    41. 41. The term Macrocephaly refers to OFC of more than 2SD above the mean while Microcephaly refers to OFC more than 3SD below the mean for age , sex , height and weight. 41
    42. 42. CHEST CIRCUMFERENCE It is usually measured at the level of nipples, preferably in mid inspiration.  Xiphisternum  In children ≤ 5years - lying down position > 5 years - standing position  42
    43. 43. RELATIONSHIP BETWEEN HEAD SIZE WITH CHEST CIRCUMFERENCE:  At birth: head circumference > chest circumference by up to 3 cm.  At around 9 months to 1 year of age: head circumference = chest circumference,  but thereafter chest grows more rapidly compared to the brain. 43
    44. 44. Summary Measurements Advantage Disadvantage Common in use Weight Age groups Difficult in field; Can’t tell body composition; need accurate age; Need proper scale Differs by day time: Other factors play a role all Height all Common in use Simple to do in field Head Circumference 0-4 yr simple Other factors play a role all Simple; age dependent; child need not to be denuded; suitable for rapid survey No limits for over nutrition & no standard for adults All Measure body composition; Detect obesity in adults Need expensive callipers; difficult with the child & in the field 44 1-2 yr Simple; age independent For limited age; no classification method MUAC Skin-fold thickness Chest –head ratio
    45. 45. AGE  Usually the most difficult and inaccurate measurement  Less of a problem if a trend in the same child is measured, the mistake is repeated every time and thus cancels out 45
    46. 46. INDICES  Relation between two measurements  weight for age W/A general appreciation of nutritional status  combined measurement  NO individual diagnosis but trend assessment  For growth monitoring  height for age H/A measure of linear growth deficit or STUNTING     not sensitive to change slow progress Community diagnosis weight for height/length W/H measure of weight deficit according to length WASTING    Individual diagnosis Community diagnosis Sensitive to change 46
    47. 47. THE REFERENCE  One reference for all?  Reference or standard?  International Standards used: Harvard standards  NCHS(U.S. National Centre for Health Sciences)  WHO standards  47
    48. 48. COMMON ERRORS  First year of life is up to 11.9 months of age and not O-12  Length and height; change technique at 24 mo  Lack of distinction between descriptive use and operational use  No use of statistics: Confidence intervals and tests to compare prevalence and averages  Undernutrition Wasting Stunting 48
    49. 49. CLASSIFICATION OF NUTRITIONAL STATUS   By SD By % deviation from the Median of Standard  e.g. Gomez classification  Using percentiles   Velocity of growth Distance Charts Birth weight( normal is ≥2.5Kg)  Weight for Age:  Gomez Classification  IAP Classification  Jelliffe Classification  Wellcome Classification   Height for Age 49
    50. 50. Weight/Height ratios  Relative weight/indices  Power type indices      Quetelet’s index = Wt(in Kg)/Ht(m2) pondreal index = Wt. / Ht. Weight/Height Ratio = Wt (in gm)/ Ht (cm2) Wt/Ht2 x 100 = > 0.15 indicates PEM Wt/Ht % classification = <80 Under Nutrition 80-120 Normal 120-130 over nutrition >130 obese 50
    51. 51. NUTRITIONAL GRADING / CLASSIFICATIONS Preschool Children: GOMEZ CLASSIFICATION WEIGHT FOR AGE (% of NCHS Standards) 90 NUTRITIONAL GRADE Normal 75 – 89.9 Grade I (Mild Undernutrition) 60 – 74.9 Grade II (Moderate Undernutrition) < 60 Grade III (Severe Undernutrition) 51
    52. 52. IAP CLASSIFICATION (INDIAN ACADEMY OF PAEDIATRICS) WEIGHT FOR AGE (% of Harvard Standard) 80 NUTRITIONAL GRADE Normal 70 – 89.9 Grade I (Mild Undernutrition) 60 – 69.9 Grade II (Moderate Undernutrition) 50 – 59.9 Grade III (Severe Undernutrition) < 50 Grade IV (Severe Undernutrition) 52
    53. 53. 53
    54. 54. STANDARD NORMAL DISTRIBUTION “Measuring Changes in Nutritional Status” (WHO, Geneva 1983). Normal 2% -3.0 -2.0 14% -1.0 34% 34% 0.0 1.0 SD Score ( 2SD = 96 %) 14% 2.0 2% 3.0 54
    55. 55. STANDARD DEVIATION (SD) CLASSIFICATION NUTRITIONAL GRADE CUT-OFF LEVEL Median – 2 SD WEIGHT FOR AGE HEIGHT FOR WEIGHT FOR AGE HEIGHT Normal Normal Normal Median – 3 SD to Median – 2 SD Moderate Underweight Moderate Stunting Moderate Wasting < Median – 3 SD Severe Underweight Severe Stunting Severe Wasting 55
    56. 56. Classification BMI(kg/m2) <18.50 <18.50 Severe thinness <16.00 <16.00 16.00 - 16.99 16.00 - 16.99 Mild thinness Body Mass Index (BMI) Additional cut-off points Moderate thinness Nutritional gradation based on BMI (adult) Principal cut-off points 17.00 - 18.49 17.00 - 18.49 Underweight Normal range Overweight = Weight in kg / height in meter sq. Pre-obese Obese 18.50 - 24.99 18.50 - 22.99 23.00 - 24.99 ≥25.00 25.00 - 29.99 ≥25.00 25.00 - 27.49 27.50 - 29.99 ≥30.00 Obese class I 30.00 - 34-99 Obese class II 35.00 - 39.99 Obese class III ≥30.00 30.00 - 32.49 ≥40.00 32.50 - 34.99 35.00 - 37.49 37.50 - 39.99 ≥40.00 56 Source: Adapted from WHO, 1995, WHO, 2000 and WHO 2004
    57. 57. 57
    58. 58. 58
    59. 59. 59
    60. 60. 60
    61. 61. BROKA’S INDEX Height (in cm) ─ 100 = IBW Persons with IBW Nutritional Status 10-20% more mildly Overweight 20-30% more Overweight 30-40% more Obese 40% + severly Obese 20-30% lower Underweight 30-40% lower Severly Underweight Between 80-120% normal 61
    62. 62. WHAT NATIONAL REPORTS SAYS…… 62
    63. 63. UNDERWEIGHT CHILDREN < 5 YEARS (PROFILE OF STATES/ UTS)  The 2011 census estimates the population of children below 6 years at 158.8 million.  Nearly 40 % undernourished ( >63 million)  The proportion of children <5years who are underweight was lowest in Sikkim (19.7%) followed by Mizoram (19.9%).  >50 % children <5years of age underweight are in M.P (60%), Jharkhand (56.5%) & Bihar (55.9%). Other states where more than 40 percent and upto 50% of children are underweight are Meghalaya, Chhattisgarh, Gujarat, Uttar Pradesh, and Orissa.     Although the prevalence of underweight is relatively low in Mizoram, Sikkim, and Manipur, even in those states more than 1/3 of children are stunted. Stunting was more prevalent in Uttar Pradesh (56.8%), Bihar (55.6%), and Meghalaya (55.1%). 63 Wasting is most common in Madhya Pradesh (35%), Jharkhand (32%), and Meghalaya (31%).
    64. 64. TRENDS IN CHILD NUTRITIONAL STATUS Percent of children age under 3 years NFHS-3 NFHS-2 51 43 20 Stunted (Low height for age) 40 23 Wasted (Low weight for height) Underweight (Low weight for age) NFHS-3, India, 2005-06 45
    65. 65. NFHS-3, India, 2005-06
    66. 66. Child nutrition: Status of achieving Millennium Development Goals The MDG1 is ‘Eradicate extreme poverty and Hunger’ Under Goal 1, target 2 states, ‘halve, between 1990 and 2015, the proportion of people who suffer from hunger’ with the indicator ‘Prevalence of underweight children<3 years of age’. India is therefore, committed to halving the prevalence of underweight children by 2015.. 66
    67. 67. (Each of these indices is expressed in standard deviation units SD, from the median of the 2006 WHO international reference population) Higher is the percentage of underweight female children (< 5 years) than male children, whereas females are in a slightly better position compared to male children (< 5 years) while considering stunting and wasting. 67
    68. 68. 68
    69. 69. 69
    70. 70. NUTRITIONAL STATUS OF ADULTS Percent of women and men age 15-49 36 Men 55 NFHS-3, India, 2005-06 Women 34 24 13 9 BMI below normal Overweight/ Obese Anaemic
    71. 71. MALNUTRITION OF WOMEN BY RESIDENCE AND EDUCATION Percent of women age 15-49 7 7 14 13 13 14 11 24 36 42 41 42 35 35 36 3535 36 25 25 Ru ra ed uc l at i <8 on ye 8- ars 9 ye 10 ars + ye ar s 25 No 25 21 Underweight Underweight to ta l 41 11 21 NF HS -2 24 13 To ta l Ur ba n 50 13 45 40 35 30 25 36 20 15 10 5 0 7 7 Overweight Overweight NFHS-3, India, 2005-06 50 45 40 35 30 25 20 15 10 5 0
    72. 72. MALNUTRITION OF MEN BY RESIDENCE AND EDUCATION Percent of men age 15-49 50 50 45 45 35 35 8 8 66 55 14 14 14 14 30 30 25 25 20 20 15 15 40 40 38 38 34 34 40 40 38 38 Overweight Overweight 27 27 25 25 10 10 5 5 N o s ar ye 10 + ye 9 8- ye <8 ar ar s s n io at ed uc R ur al 0 0 To ta l U rb an NFHS-3, India, 2005-06 40 40 33 55 Underweight Underweight
    73. 73. 75
    74. 74. 76 The increase in fat fold thickness over the last three decades begins in childhood and increases with age in both males and females. The increase is more in women.
    75. 75. DATA FROM NNMB SURVEYS IN URBAN SLUMS Data from NNMB surveys in urban slums on time trends in weight; mid-upper arm circumference and fat fold thickness at triceps are shown in Figure 7.2.10, 7.2.11, 7.2.12 and 7.2.13.  Mean body weight, mid upper arm circumference and fat fold thickness at triceps are higher in all age groups in 1993 - 94.  The increase in body weight is mainly due to increase fat as shown by rising fat fold thickness.  Data from NNMB reports shows that both in men and women over years, there have been an increase in body weight and fat fold thickness.  The increase in body weight and fat fold is greater in urban slum 77 dwellers. 
    76. 76. 78
    77. 77. 79
    78. 78. 80
    79. 79. 81
    80. 80. 82
    81. 81. REFERENCES  Yasoda Devi. P, Uma Maheshwari. K ; Manual on Nutritional Anthropometry; PG&RC, ANRAU  Rosalind S. Gibson ;1990, Principles of Nutritional Assessment; Oxford University Press  National Family Health Survey 3 (2005-2006)  CHILDREN IN INDIA 2012 - A Statistical Appraisal ; Ministry of statistics and Programme Implementation Government of India  NNMB surveys Report (1975 -2005) ; DIETARY INTAKES AND NUTRITIONAL STATUS http://wcd.nic.in/research/nti1947/7.2%20dietary%20intakes%20pr%204.2. 83 pdf www.pediatrics.about.com 

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