This document provides information on nutritional assessment using anthropometric measurements. It begins by defining nutritional assessment and describing direct and indirect assessment methods. The direct methods include anthropometry (A), biochemical tests (B), clinical exams (C), and dietary assessments (D). The document focuses on anthropometric assessments (A) which involve direct body measurements. It describes several anthropometric measurements used to assess growth in children, such as weight, height/length, mid-upper arm circumference, and head circumference. The document also discusses deriving indices from these measurements, such as weight-for-age, height-for-age, and weight-for-height, which are used to evaluate nutritional status. Finally, it provides classifications systems

1. Nutritional Assessment
For
MPH Student
By:- Fitsum Z. (BSc, MPH)

2. Learning Objectives
At the end of this session, the learners will
be able to
■ Identify anthropometric measurements of
growth and body composition
■ Differentiate from index an indicator
■ Determine nutritional status based on various
indices
■ Conduct an anthropometric survey
■ Be able to analyze anthropometric and data

3. Measurement
OR
Assessment ?

4. Definition
 Nutritional assessment is an interpretation of
anthropometric, biochemical (laboratory),
clinical and dietary survey data to tell whether a
person/ group of people are well nourished or
malnourished (Over nourished or under
nourished).
 There are direct and indirect methods of
assessing Nutritional status.

5. DIRECT METHODS
The direct involve the direct measurement of body
dimensions and proportions, determination of
tissue or body fluid concentrations of nutrients,
dietary intake, appearance of the clinical
symptoms and signs related to a specific
nutrient dependent functional impairment
abbreviated as the ABCDs
 A=Anthropometry
 B= biochemical/Biophysical,
 C= Clinical,
 D= Dietary

6. The indirect methods #1
Indirect methods include assessment of
indicators of the food and nutrition situations
in the area/ region of interest by looking at
malnutrition or which are aggravated
certain data that are closely related to
by
malnutrition. These include:
■ Cause specific mortality rates
■ Age specific mortality rates
■ Health service statistics
■ Rate of nutritionally relevant infections

7. The indirect methods #2
■Meteorological data (rainfall data )
■Production pattern and distribution
pattern
■Income levels
■Market price of foods
■Predominance of cash crops

8. A. ANTHROPOMETRIC
ASSESSMENTS

9. ANTHROPOMETRIC
ASSESSMENTS #1
Anthropometry comes from two Greek
words: Anthropo = Human, and
Metry/metron = measurement.
Definition: - Anthropometry refers to
measurement of variations of physical
dimension and gross composition of
human body at different levels and
degrees of nutrition (Jelliff, 1966).

10. ANTHROPOMETRIC ASSESSMENTS #2
Anthropometric measurements could be used
both in the clinical and field set-ups. In the
clinical set-ups they are used to assess the
nutritional status of:
 post-operative patient,
 post traumatic patient (after acute trauma or
surgery),
 chronically sick medical patient,
 patient preparing for operation,
 severely malnourished patient to assess the
impact of nutritional intervention.

11. Purposes of Anthropometric
measurements
Anthropometric measurements are
performed with two major purposes in
mind:
IN CHILDREN: to assess physical growth
IN ADULTS: to assess changes in body
composition or weight

12. Anthropometric
Measurement of growth

13. ANTHROPOMETRIC
MEASUREMENTS OF GROWTH
Growth performance of children is an
excellent reflection of their underlying
nutritional status.
Children adapt to the chronic
nutritional insult by either reducing
their rate of growth or by totally failing
to grow.

14. Measurement of Child
Growth
■Growing child is healthy child.
■Optimal growth occurs only with a
adequate food, absence of illness,
caring and nurturing, social
environment
■most rapid in first year of life.

15. How to measure growth ?
■ Common anthropometric measurements are
weight, height/length, MUAC, head
circumference
■ Most accurate and sensitive method of
measuring growth is weight gain
■ Weight gain can be measured by regularly
weighing

16. ANTHROPOMETRIC MEASUREMENTS
OF GROWTH
■ Therefore, assessment
performance of children
of growth
is one very
important purpose of anthropometric
measurements.
■ The following body measurements are
good indicators of growth performance of
children at different ages when combined
with the cut-off points.

17. HEAD CIRCUMFERENCE (HC):
 Measured using flexible measuring tape
around 0.6cm wide to the nearest 1mm.
 It is the circumference of the head along the
supra orbital ridge anteriorly and occipital
prominence posteriorly.
 HC is useful in assessing chronic nutritional
problems in under two children.
 But after 2 years as the growth of the brain is
sluggish it is not useful.

18. LENGTH
A wooden measuring board (also called
sliding board) is used for measuring
length.
It is measured in recumbent position in
children ≤2 yrs old to the nearest 1mm.
It is always > height by 1-2cm.
One assistant is needed in taking the
measurement
Measurement is read to the nearest mm

19. Length…

20. HEIGHT
 Is measured in children > 2 yrs and a adults in
standing position to the nearest 0.1 cm.
 The head should be in the Frankfurt plane during
measurement, knees should be straight and the
heels buttocks and the shoulders blades, should
touch the vertical surface of the stadiometer (
anthropometer) or wall.
 Stadiometer or portable anthropometer can be
used for measuring.
 There is also a plastic instrument called acustat
Stadiometer that is cheaper than the
conventional Stadiometer.

21. Height…
Stadiometer

22. WEIGHT
 Weighing sling (spring balance) also called
salter scale is used for measurement of weight
in children < 2 years.
 In children the measurement is performed to
the nearest 10g.
 In adults and children ≥2 years, beam balance
is used and the measurement is performed to
the nearest 0.1 kg.
 For both digital (electronic) scales can be used
and are very acurate.

23. Weight…
Salter
Scale

24. Improvising Weight
measurement…

25. INDICES DERIVED FROM THESE
MEASUREMENTS
What is an index? It is a combination of
two measurements or a measurement plus
age. The following are few of them: -
 Head circumference-for age
Weight -for-age
Height-for age
Weight for height

26. MEANINGS OF THE INDICES DERIVED FROM
GROWTH MEASUREMENTS
W eight for A ge = x 100
Weight of the child
Weight the normal child of
the same age
Weigh for height = Weight of the child x 100
Weight of the normal child of
the same height
Height for age X 100
= H eight of the child .
Height of the normal child of
the same age

27.  Both weigh for age and weight for height are
indices sensitive to acute changes to nutritional
status
 Height for age of children in a given population
indicates their nutritional status in the long run.
 The best example is change in the average
height of children in the industrialized countries
towards higher values following improvements
in nutrition, control of infectious problems etc.
 This is called Secular change (trend) in Height

28. Indicator
An indicator is an index + a cut-off point.
E.g.
W F A < 60% = is indicator of severe
malnutrition
HFA < 85%= indicator of severe stunting
W F H < 70% = is indicator of severe
wasting

29. EXPRESSING ANTHROPOMETRIC
MEASUREMENTS
A. Z- score which is expressed as,
Z = median of the reference population---subject’s value X100
Standard deviation of the reference
-2 Z is a cut-off point for under nutrition
B. Standard deviation score which could be expressed as,
SD =(subject’s value -- the mean of the group)2
Number of subjects—1
- 2 SD if a cut-off point for under nutrition

30. EXPRESSING ANTHROPOMETRIC
MEASUREMENTS
Percent of the median expressed as,
P = Weight or height Value of the subject X 100
(Median height or weight value of the reference of the same age)
80 % of the median is a cut-off point for under nutrition
. Centiles, Expressed according to the value of the subject in reference to
NCHS’s 3rd
,
5tyh, 10th
and 90th
centiles
Usually the 3rd
centiles is taken as a cut off point for labeling
malnourished
subject.

31. Various indices and cut-off points for defining
malnutrition:
Indices Indicators
for malnutrition
Z or SD
from ref-
rerence
median #
Wt-for-ht Wasting < - 2
Ht-for-age Stunting
Cut-off points for defining
malnutrition
Percentile of ref- % of refer-
erence median ence median
< 3rd < 80%
< 3rd < 90% < - 2
Wt-for-age Underweight < 3rd < 80% < -2
“Moderate” malnutrition classified as the percent falling between – 2 to – 3

32. Relationship of conventional cut-off points
for diagnosing moderate malnutrition
Type of
standard
Height for
age
Weight for
height
Weight for
age
Z-score -2 -2 -2
Standard
deviation
-2 -2 -2
Centile 3rd
3rd
3rd
Percent of the
median
90% 80% 80%

33. Interpretation of different
indicators
Indicator Acute
Malnutrition
Chronic
Malnutrition
Wt-for-age < -2 SD
Ht-for-Age < -2 SD Normal
Wt-for-Ht< -2 SD Normal

34. What is a Percentile?
95th
5th
Major Percentile Divisions
85th
50th

36. Using appropriate methods for
different setups
■ Percentiles are not recommended for
evaluating anthropometric measurements from
less developed countries when reference data
from industrialized countries such as NCHS
are used
■ Because many of the study population may
have indices below the extreme percentiles of
the reference population making it difficult for
accurately classifying large number of
individuals

37. Using appropriate methods
for different setups
■ Standard deviation score is recommended by
waterlow et al(1977) for evaluating
anthropometric data from less industrialized
countries.
■ This is because the deviations scores can be
defined beyond the limits of original reference
data.
■ This allows accurate classification of
individuals below the extreme percentiles of
the reference data.

38. Comparison of the characteristic of
three measures of scale
Characteristic Z score Percentile Percent of
median
Adherence to reference
population
Yes Yes No
Summary statistics
Possible
Yes No Yes
Uniform Criteria across
indices
Yes Yes No
Useful for detecting
changes at extreme of
distribution
Yes No Yes

39. Comparison between Z- score and Percentile

40. We use SD in Ethiopia

41. CLASSIFICATION OF
NUTRITIONAL STATUS
BASED ANTHROPOMETRIC
INDICES

42. I. Gomez classification (weight-for-age)
(Gomez et al, 1956)
Percentage (%) of NCHS
reference
Level of malnutrition
90-109 Normal
75-89 Mild(grade I)
60-74 Moderate(Grade II)
< 60 Severe (grade III)

43. Disadvantages of Gomez
classification
 The cut off point 90% may be too high as many
well-nourished children are below this value,
 edema is ignored and yet it contributes to
weight and
 It does not indicate the duration of malnutrition
 age is difficult to know in developing countries
(agrarian society).
 It does not also differentiate between

44. Well-come classification (weight-for-age)
(Welcome trust working party 1970)
Percentage (%) of
NCHS
Level of malnutrition
Reference Edema No edema
60
-80
% Kwashiorkor
Undernou
rishe
< 60% Marasmic-kwashiorkor Marasmus

45. Disadvantages
This method does not differentiate :
Acute malnutrition (for emergency
planning)
Chronic malnutrition( for food security
planning)
Depends on knowledge of the child’s
age
Does not take height differences in to
account

46. Waterlow Classification
( Waterlow JC,1972)

47. Anthropometric
Measurements of Body
composition

48. ASSESSMENT BODY COMPOSITION #1
Linear growth ceases at around the age
of 25-30 years.
Therefore, the main purpose of
nutritional assessment of adults using
Anthropometry is determination of the
changes of body weight and body
composition.

49. Five levels of body composition
Assessment
1. Atomic level(C, H, N, P, Ca, O)
2. Molecular level(fat, Water, protein)
3. Cellular level(body cell mass, intra/extra
cellular water, intracellular solids)
4. Tissue level(adipose tissue, muscle, bone)
5. Whole body level (Weight, height, skin
folds)

50. Some of the main components at the first four body
composition levels

51. ASSESSMENT BODY COMPOSITION
Using Anthropometry
Whole body level assessment is used
In assessing body composition we consider
the body to made up of two compartments:
 The fat mass and the fat free mass. Total
body mass= Fat mass + fat free Mass.
Therefore different measurements are
used to assess these two compartments:

52. Measurements used for assessing
fat free mass:
Mid upper arm circumference***
Mid upper arm Muscle area
Mid thigh circumference
Mid thigh muscle area
Mid calf circumference
Mid calf muscle area

53. Mid upper arm circumference
(MUAC)
 Is used for screening purposes especially in
emergency situations where there shortage of human
resource, time and other resources as it is less
sensitive as compared to the other indices.
 It is measured half way between the olecranon
process and acromion process using non stretchable
tap
 In children the cut-off points are:
 Normal > 13.5 cm
 Mild to moderate malnutrition 12.5-13.5 cm
 Severe malnutrition < 12.5 cm
***These cut-offs could be arbitrarily
modified based on available resources

54. 5/2/2017 1:22 54
Model
Unstandardized Coefficients
Sig.
95.0% Confidence Interval
for β
β Std. Error Lower Bound Upper Bound
(Constant) 0.707 0.273 0.0100 0.17 1.243
RUAC 0.961 0.009 <0.0001 0.944 0.978
SEX -0.063 0.042 0.1340 -0.145 0.019
AGE 0.031 0.015 0.0400 0.001 0.060
Table 3 . Multivariable linear regression model predicting Mid upper arm
Circumference (MUAC) using Random arm circumference (RUAC)

55. The following cut-offs are used In community Based
Nutrition (CBN) programs of Ethiopia
Target
Groups
MUAC
Malnutrition
Under
five years
old
children
11-11.9 cm
11.5-12.5(Now)
Moderate
acute
malnutrition
(MAM)
<11 cm
<11.5(now)
Severe acute
malnutrition
(SAM)
Pregnant
women/
Adults
17 to <21cm
Moderate
malnutrition
18 to < 21 cm with
recent weight loss
< 17 cm
Severe
<18 cm with recent

56. Philip et al

57. MUAC…
It is a sensitive indicator of risk of
mortality
Useful for screening of children for
community based nutrition
interventions
Useful for the assessment of
nutritional status of pregnant women

59. MUAC stays the same during the first 5 years

60. MUAC..

61. Measurements Used to Assess
Fat Mass :
Weight & Height(Body mass index )
 Waist to Hip circumference ratio
Skin fold thickness

62. Indices derived from height
and weight measurements
Different indices could be derived by
measuring the weight and height of
an adult
Body mass index (Quetelet’s index) =
Wt/(Height in meters)2
Weight/height ratio (Benn’s index)P
Ponderal index = Wt/ (ht) 3

63. Correlation between BMI and weight and height
measurements from selected studiesLocation Categories
Number Correlation with
Weight Height
1
UK males 5,000 0.83 to 0.86 (*) -0.1 to 0.08
2
Polynesians males 432 0.88 to 0.92 0.02 to 0.05
1 Khosla & Lowe, 196
2 Evans & Prior, 1969
females 378 0.92 to 0.95 (*) -0.01 to -0.12
3 Florey, 1970.
3
USA males 1,723 0.83 -0.08 4 Smalley et al., 1990.
females 2,202 0.90 -0.20
4
USA females 213 0.94 -0.15
5
Hawaii males 17,657 0.81 to 0.90 (*) -0.01 to -0.12
females 17,866 0.85 to 0.92 (*) -0.23 to -0.09
6
Israel males 9,475 0.83 -0.03
7
New Zealand males 477 0.80 -0.20
females 301 0.93 -0.17

64. Body mass Index(BMI)
Body mass index the best method for
assessing adult nutritional status as
the index is not affected by the height
of the person
Therefore, it is most frequently used
for assessing adult nutritional status

65. Cut-off points for BMI
 > 40 kg/m2 = very obese
 30-40 kg/m2 = obese
 26-30 kg/m2 = overweight
 18.5-25kg/m2 = Normal
 17-18.4 kg/m2 = mild chronic energy deficiency
 16-16.9kg/m2 = Moderate chronic energy
deficiency
 < 16 kg/m2 = severe chronic energy deficiency

66. ■What BMI cut‐offs are used in children and
adolescents?
■WHO suggest a set of thresholds based on
single standard deviation spacing.
■• Thinness: <‐2SD
■• Overweight: between +1SD and <+2SD
■• Obese: >+2SD

67. This cut-offs are based on the mortalities
and morbidities associated with extreme
values
The
Safe zone
Chronic diseases
(hypertension,
diabetes, cancer,
coronary heart
disease
Malnutrition
related
infections and
deficiency
diseases
Mortality
And
Morbidity
In %
1
6
18.
5
2
5
3
0
4
0
Body mass index KG/M2

68. THANK YOU