Methodological issues in the use of anthropometry for evaluation of nutritional status

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1 Methodological issues in the use of anthropometry for evaluation of nutritional status Mercedes de Onis WHO Department of Nutrition

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6 Time schedule child anthropometry Measurement Time frame Frequency No. of visits Weight, length, head circumference Birth Once 1 Weeks 2-8 Bi-weekly months Monthly months Bi-monthly 6 Arm circumference 3-12 months Monthly 10 Skinfold thicknesses months Bi-monthly 6 WHO Multicentre Growth Reference Study

7 Assessing nutritional status of lactating mothers WHO Multicentre Growth Reference Study

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9 Variation of height-for-age according to maternal education 8 Height-for-age standard deviations Educational level No education Primary Secondary Higher Country - 8 Source: Programme of Nutrition, W HO, Nepal Pakistan Bolivia Peru Source: de Onis M. Socioeconomic status and child growth. Int J Epidemiol 2003 (In press)

10 Methods in anthropometry Anthropometric indicators Reference population Cut-off points Applications of anthropometry

11 WHO Global Database on Child Growth and Malnutrition Department of Nutrition World Health Organization Geneva, Switzerland

12 Background Child growth internationally recognized as an important public health indicator Numerous surveys but not comparable WHO s systematic standardization of data initiated in 1986 WHO Global Database on Child Growth and Malnutrition

13 General objectives To establish a global nutritional surveillance system To compile, standardize and disseminate results of anthropometric surveys performed worldwide WHO Global Database on Child Growth and Malnutrition

14 Specific objectives Characterize nutritional status Enable international comparison Identify populations in need Evaluate interventions Monitor secular trends Raise political awareness WHO Global Database on Child Growth and Malnutrition

15 Methods: Data standardization Use of the NCHS/WHO international reference Prevalence of wasting, stunting, underweight and overweight Cut-off points in Z-scores: Z <-2, < <-3 < 3 and >+2 SD Stratification by age, sex, region, urban/rural Summary statistics: means & SDs of Z-scoresZ WHO Global Database on Child Growth and Malnutrition

16 Anthropometric indicators Attained growth Length/height-for for-age Weight-for for-age BMI-for for-age MUAC-for for-age Head circumference-for for-age Subscapular skinfold-for for-age Triceps skinfold-for for-age Weight-for for-height/length MUAC-for for-height/length WHO Multicentre Growth Reference Study

17 Database Indicators Wasting or low weight-for for-height (cut-offs <-3 < 3 and <-2 < 2 SD) Stunting or low height-for for-age (cut- offs <-3 < 3 and <-2 < 2 SD) Underweight or low weight-for for-age (cut-offs <-3 < 3 and <-2 < 2 SD) Overweight or high weight-for for-height (cut-off >+2 SD) WHO Global Database on Child Growth and Malnutrition

18 Percent below -11 and -22 SD WA current <-1 sd new <-1 sd current <-2 sd new <-2 sd Age (months) Source: de Onis M, Onyango A. The CDC reference and the growth of breast-fed infants. Acta Paediatrica, 2003 (In press)

19 Percent above +1 and +2 SD WA current >1 sd new >1 sd current >2 sd new >2 sd Age (months) Source: de Onis M, Onyango A. The CDC reference and the growth of breast-fed infants. Acta Paediatrica, 2003 (In press)

20 Mean BMI-for for-age of the Calcutta boys compared with the French, Dutch, British, and NCHS reference medians 22 BMI ( k g /m 2 ) NCHS reference Calcutta Growth Study French reference Dutch reference UK reference Age (years) Source: de Onis M, Dasgupta P, Saha S, Sengupta D, Blössner M. The National Centre for Health Statistics reference and the growth of Indian adolescent Boys. American Journal of Clinical Nutrition 2001; 74:

21 Mean weight-for for-age z-scorez CDC NCHS Age (months) Source: de Onis M, Onyango A. The CDC reference and the growth of breast-fed infants. Acta Paediatrica, 2003 (In press)

22 Source: de Onis M, Onyango A. The CDC reference and the growth of breast-fed infants. Acta Paediatrica, 2003 (In press) Mean length-for for-age z-scorez 0.4 CDC NCHS Age (months)

23 Percent above +1 and +2 SD LA current >1 sd new >1 sd current >2 sd new >2 sd Age (months) Source: de Onis M, Onyango A. The CDC reference and the growth of breast-fed infants. Acta Paediatrica, 2003 (In press)

24 Percent below -11 and -22 SD LA current <-1 sd new <-1 sd current <-2 sd new <-2 sd Age (months) Source: de Onis M, Onyango A. The CDC reference and the growth of breast-fed infants. Acta Paediatrica, 2003 (In press)

25 A Growth Curve for the 21st Century The WHO Multicentre Growth Reference Study Nutrition for Health and Development World Health Organization Geneva, Switzerland

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27 Main features of the new International Growth Reference Prescriptive (versus descriptive) reference International sample Breastfed infants Healthy populations with unconstrained growth WHO Multicentre Growth Reference Study

28 Anthropometric protocols Anthropometric equipment Training of field workers Standardization sessions Measurement techniques Quality control during data collection (data verification, validation, completeness, etc) WHO Multicentre Growth Reference Study

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35 0.45 Technical error of measurement Arm circumference - Follow up centimeters BRAZIL GHANA INDIA NORWAY OMAN USA 0 Bimonthly standardization sessions

36 Database work-flow Data search, review of methods and data extraction Check for completeness and consistencies across indicators and summary statistics Get back to data holders: Clarification Further analysis Raw data Assist analysis Run standard analysis Enter data into WHO Global Database Archive background documents and raw data WHO Global Database on Child Growth and Malnutrition

37 Coverage (May 2002) 400 national surveys from 139 countries 433 sub-national surveys 155 countries 99% children <5 yr in developing countries 65% children <5 yr in developed countries 2332 references WHO Global Database on Child Growth and Malnutrition

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39 Global and regional estimates of stunted children in 2000 Stunted children Region (%) (millions) Africa Asia Latin America & Caribbean 13 7 All developing countries Source: de Onis, Frongillo, Blössner. WHO Bull 2000;78: WHO Global Database on Child Growth and Malnutrition

40 Trends in estimated numbers of stunted children <5 years millions Year-2000 Goal Asia Developing countries Africa Latin America & the Caribbean 0 Source: de Onis, Frongillo, Blössner. WHO Bull 2000;78: WHO Global Database on Child Growth and Malnutrition

41 Trends of stunting in preschool children of Latin America & the Caribbean Million 14 Latin America & Caribbean Caribbean % South America Central America Source: de Onis, Frongillo, Blössner. WHO Bull 2000;78: WHO Global Database on Child Growth and Malnutrition

42 Overweight in preschool children Overweight in preschool children % Overweight Zambia Pakistan Trinidad and Tobago Venezuela Cameroon Turkey United Kingdom Haiti Uganda Nicaragua Dominican Rep. Senegal Togo Guyana Romania El Salvador Rwanda Bhutan India Ghana Hungary Burkina Faso Papua New Guinea Cote Japand'Ivoire Honduras Dominican Republic Maldives Benin Fiji Thailand Bangladesh Niger Solomon Islands Madagascar Burundi Oman Central Philippines African Republic Viet Nam Nepal Singapore Sri Lanka Italy Yemen China Kazakhstan Zimbabwe Czech Republic Afghanistan Mauritius Indonesia Guatemala Barbados Mongolia Paraguay Comoros Panama Mexico Azerbaijan Kenya Tunisia Seychelles Nigeria Iran Namibia (Islamic Republic of) Colombia United Republic of Tanzania Saint Lucia Argentina Chile Morocco Qatar Malawi South Africa Bolivia Peru Armenia Costa Rica Uruguay Jamaica Croatia Jordan Kuwait Canada Australia Yugoslavia Brazil Bahrain United States of America Algeria Egypt Kiribati Uzbekistan Source: de Onis and Blössner. Am J Clin Nutr 2000;72:

43 Wasting Overweight Wasting and overweight Wasting and overweight in preschool children in preschool children Source: de Onis and Blössner. Am J Clin Nutr 2000;72:

44 Overweight estimates in preschool children Overweight children Region (%) (millions) Africa Asia Latin America & Caribbean All developing countries Source: de Onis and Blössner. Am J Clin Nutr 2000;72: WHO Global Database on Child Growth and Malnutrition

45 Trends of overweight in children Mexico % >+2 SD Nigeria Tunisia India Mali Source: de Onis and Blössner. Am J Clin Nutr 2000;72: WHO Global Database on Child Growth and Malnutrition

46 Timing of growth faltering Height-for for-age by region Z-score (NCHS) Africa Asia Latin America and Caribbean Age (months) Source: Shrimpton et al. Pediatrics 2001;107(5).

47 Relationship between child malnutrition & LBW in selected Asian countries % underweight Myanmar Indonesia Thailand Laos Vietnam Philippines India Sri Lanka Pakistan Bangladesh 10 0 China % low birth weight

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51 Underweight prevalence by WHO Mortality Region Region Prevalence of Underweight (% below 2 SD) Afr D 32.2 Afr E 31.0 Amr A 2.3 Amr B 5.0 Amr D 12.4 Emr B 8.1 Emr D 25.1 Eur A 2.3 Eur B 7.6 Eur C 2.6 Sear B 25.8 Sear D 45.9 Wpr A 3.8 Wpr B 16.0 Source: Fishman S, Caulfield LE, de Onis M, et al. In: Comparative Quantification of Health Risks: The Global and Regional Burden of Disease due to 25 Selected Major Risk Factors. WHO/Harvard University Press, Cambridge, 2003 (in press).

52 Mean Z-scores and prevalence by WA category according to WHO mortality Region Region Mean Percent of Children in WA Category (%) Z-score < -3 SD > -3,< -2 SD > -2,< -1 SD > -1 SD,< 0 Afr D Afr E Amr A Amr B Amr D Emr B Emr D Eur A Eur B Eur C Sear B Sear D Wpr A Wpr B Source: Fishman S, Caulfield LE, de Onis M, et al. In: Comparative Quantification of Health Risks: The Global and Regional Burden of Disease due to 25 Selected Major Risk Factors. WHO/Harvard University Press, Cambridge, 2003 (in press).

53 Underweight and all-cause mortality: (a) deaths per 1000 Deaths per Sudan 500 Senegal Ghana 400 Gbissau 300 Pakistan Bangladesh 200 India Nepal 100 Indones ia P h ilipp in es w eight-for-a ge z-score Source: Fishman S, Caulfield LE, de Onis M, et al. In: Comparative Quantification of Health Risks: The Global and Regional Burden of Disease due to 25 Selected Major Risk Factors. WHO/Harvard University Press, Cambridge, 2003 (in press).

54 RR of mortality overall and by cause associated with low weight-for for-age Cause of Death < -3 SD < -2 to -3 SD -1 to 2 SD >-1 SD Diarrhea Pneumonia Malaria Measles All-cause Source: Fishman S, Caulfield LE, de Onis M, et al. In: Comparative Quantification of Health Risks: The Global and Regional Burden of Disease due to 25 Selected Major Risk Factors. WHO/Harvard University Press, Cambridge, 2003 (in press).

55 Disease Total Burden of underweight status among children year Attributable Fraction (%) Mortality (WA < -1 SD) Attributable Attributable Burden Mortality (x 1000) (DALYs, x 1000) Protein-Energy Malnutrition ,885.2 Perinatal Conditions* ,610.7 Pneumonia/ALRI , ,135.0 Diarrhea ,500.1 Malaria ,572.7 Measles ,102.1 Other ,355.8 TOTAL** , ,161.6 * Perinatal conditions estimates reflect deaths due to low birth weight only. ** 57.3% of all early childhood deaths beyond the perinatal period Source: Fishman S, Caulfield LE, de Onis M, et al. In: Comparative Quantification of Health Risks: The Global and Regional Burden of Disease due to 25 Selected Major Risk Factors. WHO/Harvard University Press, Cambridge, 2003 (in press).

56 Comparative Risk Assessment Rank Risk Factor DALYs (000) % total global DALYs 1 Underweight 204, % 2 Unsafe sex 93, % 3 Blood pressure 60, % 4 Tobacco 57, % 5 Alcohol 56, % 6 Unsafe water, sanitation, and hygiene 54, % 7 Non-breastfeeding 49, % 8 Iron deficiency 49, % 9 Indoor smoke from solid fuels 36, % 10 Cholesterol 34, % 11 Inadequate fruit and vegetable intake 27, % 12 Body mass 27, % 13 Zinc deficiency 23, % Source: World Health Report 2002

57 Comparative Risk Assessment Rank Risk Factor DALYs (000) % total global DALYs 14 Physical inactivity 21, % 15 Physical hazards causing injury 13, % 16 Illicit drugs 10, % 17 Vitamin A deficiency 9, % 18 Childhood sexual abuse 7, % 19 Ambient air pollution 7, % 20 Unplanned pregnancies 5, % 21 Lead 3, % 22 Unsafe health care injections 3, % 23 Climate change 3, % 24 Chemical or physical agents 1, % causing cancer 25 Chemical agents causing nonmalignant % respiratory disease 26 Noise levels % Source: World Health Report 2002

58 Dissemination via internet Bimonthly updates accessible at: registrations (May May 2002) WHO Global Database on Child Growth and Malnutrition

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