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  • 1. NUTRITIONAL ASSESSMENT BY USING ANTHROPOMETRY AND BMI Md. Moksed Ali Pramanik Principal Research Associate INFS University of Dhaka Nutritional Assessment: Nutritional Assessment is the evaluation of individual nutritional status. Types or Methods of Assessment Direct Indirect Clinical Biochemical Biophysical Anthropometry Food Consumption / Dietary Survey Nutritional Epidemiology 1
  • 2. Anthropometric Assessment: For Anthropometric Assessment, information is needed on each individual’s sex, age, weight, height, Mid Upper Arm Circumference etc. Anthropometric Data Analysis: The anthropometric data were calculated and analyzed as standard deviation scores (Z-scores) of NCHS (The US National Center for Health Statistics) reference height-for-age, weight-for-age and weight-for-height and as percentage of reference median of these indicators. The Anthro software package and Epi Info were used in this regard. Z-score (Standard Score): Z-score is simple a position score in terms of standard vdeviation with reference to the mean. Individual’s value ─ Mean value x = ∑ x I ÷ n Z score = ------------------------------------------------------------------ SD = ∑ √ ( xi ―x)2 ÷ (n ― 1) Standard deviation = √ 1 [ ∑ xi 2 ―(∑xi)2 ] There are three categories of z-score for Anthropometric Data Analysis. They are as follows • HAZ (Height for age z-score) – Measures Stunting Low HA is considered an indicator of stunting (i.e. shortness) which is frequently associated with poor overall economic condition and/or repeated exposure to adverse condition. (past chronic under nutrition) • WAZ (Weight for age z-score) – Measures Underweight WA is primarily a composite of WH and HA, and fails to distinguish tall, thin. Children from short, well proportioned children (stunting wasting / current acute and chronic under nutrition). • WHZ (Weight for height z-score) – Measures Wasting Low WH is considered an indicator of wasting (i.e. thinness) and is associated with failure to gain weight or a loss of weight. 2
  • 3. (Individual’s height) ─ (Mean or median height of reference for given age and sex) HAZ = --------------------------------------------------------------------------------------- Standard deviation of reference Cut-off point of HAZ – HAZ < − 3 SD : Severely stunted HAZ < − 2 SD to − 3 SD : Moderately stunted HAZ ≥ − 2 SD : Not stunted (Individual’s weight) ─ (Mean or median weight of reference for given age and sex) WAZ = --------------------------------------------------------------------------------------- Standard deviation of reference Cut-off point of WAZ WAZ < − 3 SD :Severely underweight WAZ < − 2 SD to − 3 SD : Moderately underweight WAZ ≥ − 2 SD : Not underweight (Individual’s weight) ─ (Mean or median weight of reference for given sex and height) WHZ = --------------------------------------------------------------------------------------- Standard deviation of reference Cut-off point of WHZ WHZ < − 3 SD : Severely wasted WHZ < − 2 SD to − 3 SD : Moderately wasted WHZ − 2 SD & WHZ < + 2 SD : Normal WHZ + 2 SD to + 3 SD : Over-weight WHZ > + 3 SD : Obese Epi info software G 18 eQi eqm ch©š— †Q‡j ‡g‡q‡`i HAZ Ges WAZ calculate Kiv hvq| WHZ Gi †¶‡Î †Q‡j‡`i eqm 11.5 eQi Ges D”PZv 145 †m.wg Gi Kg Ges †g‡q‡`i Rb¨ 10 eQi Ges D”PZv 137 †m.wg. Gi Kg| D”PZv 49 †m.wg. Gi Kg n‡j WHZ calculate Kiv hvq bv| (HAZ and WAZ of children aged up to 18 years can be calculated by using Epi Info software. WHZ of boys aged 11.5 years and height less than 145 cm. and for girls aged 10 years and height less than 137 cm can be calculated. When height less than 49 cm. WHZ can not be calculated. 3
  • 4. Weight for-age percent of median (WAM) (PEM or Gomez Classification): Percent Expected weight for age Classification Category of Nutritional status Weight for-age percent of median (WAM) > 90 % Normal Normal Weight for-age percent of median (WAM) 76-90 % Mild malnutrition 1st degree malnutrition Weight for-age percent of median (WAM) 61-75 % Moderate malnutrition 2nd degree malnutrition Weight for-age percent of median (WAM) ≤ 60 % Severe malnutrition 3rd degree malnutrition Wellcome Classification Percent Expected weight for age Edema present Edema absent WAM 60-80 % Kwashiorkor Underweight WAM < 60 % Marasmic-Kwashiorkor Marasmus In Waterlow classification children are categorized into four groups on the basis of percentage deviation from the reference median height-for-age and weight-for-height. The following cut-off points were used to categories normal, stunted, wasted and stunted & wasted: Normal : Height-for-age ≥ 90 % of reference median Weight-for-height ≥ 80 % of reference median Stunted : Height-for-age < 90 % of reference median Weight-for-height ≥ 80 % of reference median Wasted : Height-for-age ≥ 90 % of reference median Weight-for-height < 80 % of reference median Stunted : Height-for-age < 90 % of reference median and wasted Weight-for-height < 80 % of reference median 4
  • 5. Degree of Stunting Height for age percent of median (HAM) Category of nutritional status HAM > 95% Grade ‘0’ or normal HAM 90 – 95% Grade 1 stunting HAM 85 – 89.99% Grade 2 stunting HAM < 85% Grade 3 stunting WAM = (hs ÷ hp) × 100 Where hs = height of the sample hp = height of the reference population. Equivalents of percentile and Z-score in normal distribution Below Mean Above Mean percentile Z-score percentile Z-score 0.0 to 4.9 - 3.090 to – 1.650 50.0 to 54.9 0.000 to 0.120 5.0 to 9.9 - 1.645 to – 1.290 55.0 to 59.9 0.126 to 0.250 10.0 to 14.9 - 1.282 to – 1.040 60.0 to 64.9 0.253 to 0.380 15.0 to 19.9 - 1.036 to – 0.850 65.0 to 69.9 0.3855 to 0.520 20.0 to 24.9 - 0.842 to – 0.680 70.0 to 74.9 0.524 to 0.670 25.0 to 29.9 - 0.675 to – 0.530 75.0 to 79.9 0.675 to 0.840 30.0 to 34.9 - 0.524 to – 0.390 80.0 to 84.9 0.842 to 1.030 35.0 to 39.9 - 0.385 to – 0.260 85.0 to 89.9 1.036 to 1.280 40.0 to 44.9 - 0.253 to – 0.130 90.0 to 94.9 1.282 to 1.640 45.0 to 50.0 - 0.126 to – 0.000 95.0 to 99.9 1.645 to 3.090 Anthropometric classification for the evaluation of growth and nutritional status Category Percentile Z –score Growth status Weight status Muscle status Category I 0.0 to 5.0 Z<-1.650 Short Low Weight Low Muscle Wasted Category II 5.1 to 15.0 -1.645<Z <-1.040 Below Average Below Average Below Average Category III 15.1 to 85.0 -1.036<Z <+1.030 Average Average Average Category IV 85.1 to 95.0 +1.036<Z <+1.640 Above Average Above Average Above Average Category V 95.1 to 100.0 Z>+1.645 Tall Heavy Weight High muscle: Good Nutrition 5
  • 6. Table AP9.1: Weight-for-age for young children (birth to 60 months;sexes combined) in kg. (in standard deviations above and below reference (NCHS/WHO data) Age (months) As standard deviations + 4SD + 2SD Reference ─ 2SD ─ 4SD 0 5.0 4.1 3.2 2.3 1.4 1 6.7 5.4 4.1 2.9 1.7 2 7.9 6.4 4.9 3.4 1.9 3 8.9 7.3 5.7 4.0 2.3 4 9.8 8.1 6.4 4.6 2.8 5 10.6 8.8 7.0 5.2 3.4 6 11.3 9.4 7.5 5.7 3.9 7 12.0 10.0 8.0 6.2 4.4 8 12.5 10.5 8.5 6.6 4.7 9 12.9 10.9 8.9 6.9 5.0 10 13.4 11.3 9.2 7.1 5.3 11 13.8 11.7 9.6 7.5 5.6 12 14.2 12.0 9.8 7.8 5.8 13 14.5 12.3 10.1 8.0 5.9 14 14.9 12.6 10.3 8.2 6.1 15 15.1 12.8 10.6 8.4 6.2 16 15.4 13.1 10.8 8.5 6.3 17 15.6 13.3 11.0 8.7 6.4 18 15.8 13.5 11.2 8.8 6.5 19 16.0 13.7 11.4 8.9 6.6 20 16.3 13.9 11.5 9.1 6.7 21 16.7 14.2 11.7 9.2 6.8 22 17.0 14.4 11.8 9.4 7.0 23 17.3 14.6 12.0 9.5 7.1 24 17.8 15.0 12.1 9.7 7.2 25 18.3 15.4 12.3 9.9 7.3 26 18.8 15.7 12.5 10.0 7.4 27 19.2 15.9 12.7 10.2 7.5 28 19.5 16.2 12.9 10.3 7.6 29 19.8 16.5 13.1 10.4 7.7 30 20.1 16.7 13.3 10.5 7.8 Table AP9.1 continued 6
  • 7. Age (months) As standard deviations + 4SD + 2SD Reference ─ 2SD ─ 4SD 31 20.1 17.0 13.5 10.7 7.9 32 20.8 12.2 13.6 10.8 8.0 33 21.1 17.4 13.8 10.9 8.1 34 21.4 17.7 14.4 11.0 8.1 35 21.6 17.9 14.2 11.2 8.2 36 21.9 18.1 14.4 11.3 8.2 37 22.2 18.4 14.5 11.4 8.3 38 22.5 18.6 14.7 11.5 8.4 39 22.7 18.8 14.9 11.7 8.4 40 23.0 19.0 15.0 11.8 8.5 41 23.3 19.2 15.2 11.9 8.6 42 23.6 19.5 15.4 12.0 8.6 43 23.9 19.7 15.5 12.1 8.7 44 24.1 19.9 15.7 12.3 8.8 45 24.3 20.1 15.9 12.4 8.8 46 24.6 20.3 16.0 12.5 8.9 47 24.8 20.5 16.2 12.6 9.0 48 25.1 20.7 16.3 12.7 9.0 49 25.4 21.0 16.5 12.8 9.1 50 25.7 21.2 16.6 13.0 9.2 51 26.0 21.4 16.8 13.1 9.3 52 26.3 21.6 16.9 13.2 9.4 53 26.5 21.8 17.1 13.3 9.5 54 26.8 22.0 17.2 13.4 9.6 55 27.1 22.2 17.4 13.5 9.7 56 27.4 22.5 17.6 13.7 9.8 57 27.7 22.7 17.7 13.8 9.9 58 28.0 22.9 17.8 13.9 10.0 59 28.3 23.1 18.0 14.0 10.0 60 28.6 23.4 18.2 14.1 10.1 Table AP9.5: Weight-for-age (kg) for children aged 5-9.5 years (sexes combined) as standard deviations from reference population (NCHS/WHO data) 7
  • 8. Age (years) As standard deviations + 2SD Reference ─ 2SD 5.0 23.4 18.2 14.1 5.5 24.8 19.1 14.8 6.0 26.4 20.1 15.5 6.5 28.2 21.2 16.2 7.0 30.2 22.3 17.0 7.5 32.5 23.6 17.7 8.0 35.1 25.1 18.5 8.5 37.9 26.6 19.3 9.0 41.0 28.3 20.1 9.5 44.2 30.1 21.0 Table AP9.6: Height-for-age (cm) for children aged 5-9.5 years (sexes combined) as standard deviations from reference population (NCHS/WHO data) Age (years) As standard deviations + 2SD Reference ─ 2SD 5.0 118.2 109.2 100.1 5.5 121.7 112.3 102.9 6.0 125.1 115.4 105.6 6.5 128.5 118.3 108.1 7.0 131.7 121.1 110.6 7.5 134.9 123.9 112.9 8.0 138.1 126.7 115.3 8.5 141.2 129.4 117.6 9.0 144.4 132.2 120.0 9.5 147.6 133.0 122.5 Table AP9.8: Weight-for-age (kg) of children aged 10-18 years (sexes seperate) as standard deviations from reference (NCHS/WHO data) 8
  • 9. Age (years) Weight (kg) of Boys Weight (kg) of Girls + 2SD Mean ─ 2SD + 2SD Mean ─ 2SD 10.0 46.0 31.4 22.1 49.2 32.5 21.9 10.5 49.3 33.3 23.1 52.8 34.7 23.1 11.0 52.7 35.3 24.1 56.4 37.0 24.5 11.5 56.3 37.5 25.4 60.0 39.2 25.9 12.0 59.9 39.8 26.8 63.3 41.5 27.4 12.5 63.5 42.3 28.4 66.5 43.8 29.1 13.0 67.2 45.0 30.4 69.4 46.1 30.8 13.5 70.9 47.8 32.5 72.1 48.3 32.5 14.0 74.6 50.8 34.9 74.5 50.3 34.2 14.5 78.2 53.8 37.4 76.5 52.1 35.9 15.0 81.6 56.7 39.9 78.3 53.7 37.4 15.5 84.9 59.5 42.4 79.6 55.0 38.7 16.0 87.9 62.1 44.7 80.6 55.9 39.8 16.5 90.7 64.4 46.8 81.2 56.4 40.7 17.0 93.2 66.3 48.6 81.5 56.7 41.3 17.5 95.3 67.8 49.9 81.5 56.7 41.8 18.0 97.0 68.9 50.9 81.3 56.6 42.1 Table AP9.8: Height-for-age (cm) of children aged 10-18 years (sexes separate) as standard deviations from reference (NCHS/WHO data) Age (years) Height (cm) of Boys Height (cm) of Girls + 2SD Reference ─ 2SD + 2SD Reference ─ 2SD 10.0 149.7 137.5 125.3 152.0 138.3 124.6 10.5 153.1 140.3 127.6 155.3 141.5 127.6 11.0 156.7 143.3 129.9 158.7 144.8 130.9 11.5 160.5 146.4 132.2 162.0 148.2 134.4 12.0 164.7 149.7 134.6 165.2 151.5 137.9 12.5 168.9 153.0 137.2 168.0 154.6 141.1 13.0 173.0 156.5 139.9 170.5 157.1 143.8 13.5 176.9 159.9 142.8 172.4 159.0 145.7 14.0 180.2 163.1 146.0 173.7 160.4 147.0 14.5 183.0 166.2 149.4 174.7 161.2 147.8 15.0 185.1 169.0 152.9 175.3 161.8 148.3 15.5 186.7 171.5 156.2 175.6 162.1 148.7 16.0 187.9 173.5 159.2 175.7 162.4 149.1 16.5 188.8 175.2 161.5 175.8 162.7 149.7 17.0 189.4 176.2 163.1 175.7 163.1 150.4 17.5 189.8 176.7 163.7 175.7 163.4 151.1 18.0 190.0 176.8 163.6 175.6 163.7 151.8 Table AP9.12: Weight-for-height (in kg and cm) for children (49-120 cm; sexes combined) in as standard deviations above and below reference (NCHS/WHO data) 9
  • 10. Weight (kg) Height (cm) + 2SD + 1SD Reference ─ 1SD ─ 2SD ─ 3SD 49 4.1 3.7 3.2 2.9 2.5 2.2 50 4.3 3.9 3.4 3.0 2.6 2.3 51 4.5 4.0 3.5 3.1 2.7 2.3 52 4.7 4.2 3.7 3.3 2.8 2.4 53 5.0 4.5 3.9 3.4 2.9 2.4 54 5.2 4.7 4.1 3.6 3.1 2.6 55 5.5 4.9 4.3 3.8 3.3 2.8 56 5.8 5.2 4.6 4.1 3.5 3.0 57 6.1 5.5 4.8 4.3 3.7 3.2 58 6.4 5.8 5.1 4.5 3.9 3.3 59 6.7 6.0 5.3 4.7 4.1 3.5 60 7.0 6.3 5.6 5.0 4.3 3.7 61 7.3 6.6 5.9 5.3 4.6 3.9 62 7.6 6.9 6.2 5.5 4.8 4.1 63 7.9 7.2 6.5 5.8 5.1 4.4 64 8.2 7.5 6.7 6.1 5.4 4.7 65 8.5 7.8 7.0 6.3 5.6 4.9 66 8.9 8.1 7.3 6.6 5.9 5.2 67 9.2 8.4 7.6 6.9 6.1 5.4 68 9.5 8.7 7.9 7.2 6.4 5.7 69 9.8 9.0 8.2 7.5 6.7 6.0 70 10.1 9.3 8.5 7.7 6.9 6.2 71 10.4 9.6 8.7 8.0 7.2 6.4 72 10.6 9.8 9.0 8.2 7.4 6.6 73 10.9 10.1 9.2 8.4 7.6 6.8 74 11.2 10.4 9.5 8.7 7.8 7.0 75 11.4 10.6 9.7 8.9 8.1 7.2 76 11.7 10.8 9.9 9.1 8.3 7.4 77 11.9 11.0 10.1 9.3 8.5 7.6 78 12.1 11.3 10.4 9.5 8.6 7.7 79 12.4 11.5 10.6 9.7 8.8 7.9 80 12.6 11.7 10.8 9.9 9.0 8.1 81 12.8 11.9 11.0 10.1 9.2 8.3 82 13.0 12.1 11.2 10.3 9.4 8.5 83 13.3 12.4 11.4 10.5 9.6 8.7 84 13.5 12.5 11.5 10.6 9.7 8.8 85 13.7 12.7 11.7 10.8 9.9 9.0 86 13.9 12.9 11.9 11.0 10.1 9.2 87 14.1 15.1 12.1 11.2 10.3 9.4 88 14.4 13.4 12.4 11.5 10.5 9.6 Table AP9.12 continued 10
  • 11. Weight (kg) Height (cm) + 2SD + 1SD Reference ─ 1SD ─ 2SD ─ 3SD 89 14.6 13.6 12.6 11.7 10.7 9.8 90 14.8 13.8 12.8 11.8 10.8 9.9 91 15.1 14.1 13.0 12.1 11.1 10.2 92 15.3 14.3 13.2 12.3 11.3 10.4 93 15.6 14.6 13.5 12.5 11.5 10.5 94 15.8 14.8 13.7 12.7 11.7 10.7 95 16.1 15.1 14.0 13.0 11.9 10.9 96 16.4 15.3 14.2 13.2 12.2 11.2 97 16.6 15.6 14.5 13.5 12.4 11.4 98 16.9 15.9 14.8 13.7 12.6 11.6 99 17.2 16.1 15.0 14.0 12.9 11.9 100 17.6 16.5 15.3 14.3 13.2 12.2 101 19.0 17.4 15.8 14.4 13.0 11.6 102 19.3 17.7 16.1 14.7 13.3 11.9 103 19.7 18.1 16.4 15.0 13.5 12.1 104 20.0 18.4 16.7 15.2 13.7 12.2 105 20.3 18.6 16.9 15.5 14.0 12.6 106 20.7 19.0 17.2 15.7 14.2 12.7 107 21.1 19.3 17.5 16.0 14.5 13.0 108 21.4 19.6 17.8 16.3 14.7 13.2 109 21.8 20.0 18.1 16.6 15.0 13.5 110 22.2 20.3 18.4 16.8 15.2 13.6 111 22.6 20.7 18.8 17.2 15.5 13.9 112 23.0 21.1 19.1 17.5 15.8 14.2 113 23.4 21.4 19.4 17.8 16.1 14.5 114 23.9 21.9 19.8 18.1 16.4 14.7 115 24.4 22.3 20.1 18.4 16.7 15.0 116 24.8 22.7 20.5 18.8 17.0 15.3 117 25.4 23.1 20.8 19.1 17.3 15.6 118 25.9 23.6 21.2 19.4 17.6 15.8 119 26.4 24.0 21.6 19.8 18.0 16.2 120 27.0 24.5 22.0 20.2 18.3 16.5 Source : Community nutrition Assessment; Jelliffe Anthropometric reference data. Example: Age of a male person =40 yrs, weight = 50 kg. Evaluate the nutritional status by using WAZ classification. Solution: Age 40 yrs, average weight = 81 kg and SD 13.5 (from the reference value). Calculated WAZ = (50 ― 81.4) ÷ 13.5 = ― 2.325 Comment : Calculated WAZ value is ― 2.325 which is lies between ― 2SD and ― 3SD. This implies that the sample moderately underweight. Body Mass Index (BMI): 11
  • 12. Weight in kg. BMI = ----------------------------- (Height in metre)2 The following cut-off points were used to categories the nutrition status by BMI: Grade 3 Chronic energy deficiency (CED) ( Severely thinness) :BMI < 16 Grade 2 Chronic energy deficiency (CED) (Moderate thinness) :BMI 16-16.99 Grade 1 Chronic energy deficiency (CED) :17- 18.49 (Mild thinness) BMI 18.5-24.99 : Normal Grade 1 Over weight :BMI 25-29.99 Grade 2 Overweight :BMI 30.00-39.99 Grade 3 Over weight :BMI ≥40 (Source: WHO 1995) Three category of BMI Body Mass Index were usually classified into three categories. The following cut-off points were used to categories chronic energy deficiency (CED), normal and obese: CED = BMI < 18.5 Normal = BMI 18.5-24.99 Obese = BMI equal or greater than 25 Classification of malnutrition in children aged 1-5 years by Mid Upper Arm Circumference (MUAC) Circumference (cm) Level of nutrition MUAC > 14 Normal MUAC 12.5 – 14.0 Mild / moderate malnutrition MUAC < 12.5 Severe malnutrition For Bangladeshi children 11 cm. is the cut-off point. Classification of adult malnutrition by MUAC Sex Circumference (cm) Level of nutrition Male MUAC ≥ 23 MUAC < 23 Normal Malnourished Female MUAC ≥ 22 MUAC < 22 Normal Malnourished 12