Bmi Chart Children

					              Food and Nutrition Security
              Community
              Health

              Maternal and Child Health Community

The Food and Nutrition Security Community
The Maternal and Child Health Community
Consolidated Reply
Query: Indices for measuring nutritional status in children, from NFI
New Delhi, (Advice).
Compiled by Gopi N Ghosh and Meghendra Banerjee, Resource Persons; additional research
provided by Shavika Gupta and Bidisha Pillai, Research Associates
8 January 2006
_______________________________________________________________________________

Original Query: Prema Ramachandran, New Delhi
Posted: 5 December 2005

I am Prema Ramachandran, Director of the Nutrition Foundation of India, New Delhi.

Children are vulnerable segment for under-nutrition and their nutritional status has been considered as
an important indicator for progress in efforts to combat under nutrition and associated ill health. Weight
for age is the most widely used index for assessment of under-nutrition in children. By this criterion about
45% of Indian children are under nourished (underweight). Height for age is also used for assessment of
nutritional status. By this criterion about 50% of the children are under nourished (stunted). However if
the criterion of weight /height (wasting) is used only about 15 % of the Indian children are
undernourished. The high under nutrition rate and relatively low mortality rates in Indian children had
long been recognized as the South Asian Enigma.

Given the multigenerational factors that affect height, it will not be possible to achieve significant
increase in height within a short time through nutritional and health interventions, though wasting can be
corrected. There has been a debate among nutritionists whether in India where many of the young
children are short and weigh less as compared to NCHS norms but have appropriate weight for their
height; weight/ (height)2 (BMI – Body Mass Index) for age is the more appropriate indicator for
assessment of nutritional status. Difficulties in accurate measurement of height in children, the
complexity in computing the BMI for age (because unlike the situation in adults, BMI varies with age in
children) have come in the way of wider use of BMI for age as indicator for assessment of nutritional
status in children in India.

Currently India is undergoing developmental, demographic, nutrition and health transition. While under
nutrition remains a major concern, over-nutrition is also emerging as a public health problem. Over-
nutrition in India begins in early childhood. The International Obesity Task Force has recommended that
BMI for age is the most appropriate index for assessment of over-nutrition in children.



                                                                                                          1
I would like to draw the experience of the community members about use of different indicators (weight
for age, height for age, weight for height and BMI for age) for assessment of both under and over-
nutrition of Indian children and relative merits of use of each of these indices as criterion for identification
of under- or over-nutrition in children for intervention - either in community or hospital settings.
_______________________________________________________________________________

Responses were received, with thanks, from:
1.                Sarala Gopalan, New Delhi
2.                Marine Mukherjee, CINI – RRC, Kolkata
3.                Alok Chaurasia, Population Resource Centre, Bhopal
4.                Umesh Kapil, AIIMS, New Delhi
5.                Rukhsana Haider, WHO, South-East Asia Regional Office, New Delhi
6.                Prakash V Kotecha, Government Medical College, Vadodara
7.                Daksha, SIFPSA, Lucknow
8.                Piyali Mustaphi, UNICEF, Republic of Maldives
9.                H P S Sachdev, Maulana Azad Medical College, New Delhi
10.               GNV Brahmam, NIN, Hyderabad
11.               Kamala Krishnaswamy, NIN, Hyderabad

Further Contributions are welcome!
_______________________________________________________________________________

Summary of Responses
Related Resources
Responses in Full
_______________________________________________________________________________

Summary of Responses
Four indices are being used to assess nutritional status (under- and over-nutrition) in children. Height for
age, weight for age, BMI for age and wasting (age independent). Members advised that ample data now
indicate that it is inappropriate to compute wasting as an age-independent index for under-nutrition
because values for BMI for age vary with age, and that it should be replaced with BMI for age. The
discussion explored some other methods like MUAC (Mid Upper Arm Circumference), (BMR) Basal
Metabolic Rate, Chest Circumference, and an Index through a combination of weight, height and chest
circumference of child. It was agreed that the different indices had their merits and demerits in their own
context and these are complementary to each other; and can be used in combinations according to the
need and settings.

Members described the relative merits of using the remaining three indices as criterion for identification
of under- or over-nutrition in children for nutritional intervention - in community or hospital settings, as
given below:

Weight for age has been the most widely used index for assessment of nutritional status.

Advantages
•     Norms for assessment of under-nutrition have been in vogue for the last three decades;
•     Balances are available in most areas, up to village level;
•     Weighing is a simple operation; almost all persons involved in assessment of nutritional status have
      been trained in weighing children and classifying them according to the weight- for-age charts;
•     With nutrition and health interventions, deficit in weight for age can be readily reversed; so weight
      for age can be used to assess improvement following interventions.



                                                                                                              2
Disadvantages
•   Indian children are shorter as compared to US and European children of comparable age. Many
    weigh less than US and European children of comparable age, and get classified as undernourished,
    even though they have appropriate weight for their height. This mis-classification might be the
    reason for South Asian Enigma (of high under-nutrition rate and relatively low mortality rates).
•   Over-nutrition in India begins in early childhood. Some short children who are over weight for their
    height, get missed, if weight for age is used as the criterion.

Role in assessment of nutritional status
Weight for age is likely to remain the most widely used index for assessment of nutritional status in
the community settings where under-nutrition is the major problem, and trained skilled workers and
equipment are not available. In such settings, it may, therefore be appropriate to use this index. For
instance, in the ICDS programme, weight for age will continue to be the index used for assessment of
nutritional status.

Height for age is an important parameter for assessment of nutritional status.

Advantages
Linear growth measurement is important especially considering that the Indian children are short as
compared to US and European children.

Disadvantages
•   It is not easy to measure length/height accurately in infants/young children.
•   Majority of the field functionaries are not well trained in height measurement.
•   Instruments for measuring length/height are not readily available in community settings.
•   Height measurement cannot be used as a single index for assessment of nutritional status.
•   Linear growth is influenced by birth length, linear growth in childhood.
•   Majority of short children will continue to grow at a lower trajectory as compared to their taller
    counterparts.
•   Unlike weight, linear growth faltering does not get reversed with supplementary feeding, and so it
    cannot be used as an index to assess adequacy of ongoing intervention programmes.

Role in assessment of nutritional status
Height for age cannot be used as a single index for assessment of nutritional status; however, when used
along with weight for age, or used to derive indices, such as BMI for age or wasting, it can be of help in
detection of both under- and over-nutrition

BMI for age is the most appropriate index for assessment of nutritional status in situations of dual
nutrition burden.

Advantages
•   BMI-for-age takes into account current height, and correctly identifies children with low BMI for the
    age - requiring health and nutritional interventions to achieve optimal weight for current heights.
•   It can be used to assess adequacy of nutrition intervention measure (achievement of optimal weight
    for height for age).
•   If under-nutrition, as indicated by low BMI for age is identified early and corrected through
    appropriate health and nutrition intervention, it is likely that these children will grow along the
    trajectory appropriate for their height.

Disadvantages
•   BMI for age norms applicable to the developing country populations are at the moment not available.




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•     WHO is likely to release these norms by April 2006. Personnel trained in deriving BMI for age for
      children and comparing it with the norm to assess under-nutrition are few and far between;
      computation of the BMI for age and assessing nutritional status using it, is considered cumbersome
      by most.

Role in assessment of nutritional status
•  In population groups, who are currently at risk of dual nutrition burden, this is the most appropriate
   index.
• It can be introduced in clinic settings as soon as the norms become available. Over time, the clinic
   staff will learn the advantages of the index.
• BMI for age should be used in R&D efforts to assess the adverse health consequences of under-
   /over-nutrition, and the sensitivity and specificity of this index vis-a-vis weight for age index - for
   detection of under-/over-nutrition, and association with health hazards needs to be documented.
_______________________________________________________________________________

Related Resources

Recommended Documentation

An index for the measurement of growth in children (from Alok Chaurasia, Population Resource
Centre, Bhopal)
by Alok Chaursia and J Pattankar. Indian Journal of Paediatrics, 46. 1979
    An index developed with a combination of weight, height and chest circumference; however has not
    been validated empirically

Development of normalized curves for the international growth reference: historical and
technical considerations (from Umesh Kapil, AIIMS, New Delhi)
by Dibley, M.J., Goldsby, J.B., Staehling, N.W., Trowbridge, F.L. American Journal of Clinical Nutrition, 46,
pp749-762. 1987
    This is one of the earliest work on development and use of growth curves

Anthropometric field methods: Criteria for selection (from Umesh Kapil, AIIMS, New Delhi)
by Habicht, J-P., Yarborough, C., Martorell, R., (1979). In: Jelliffe, D.B., Jelliffe, E.F.P. (eds), Human
Nutrition, Vol.2, Nutrition and Growth, Plenum Press, New York.
    The paper reviews use of anthropometric indicators in field situations.

2000 CDC Growth Charts: United States (from Prakash V Kotecha, Government Medical College,
Vadodara)
by National Centre for Health Statistics
http://www.cdc.gov/growthcharts/
    The growth charts represent the revised version of the 1977 NCHS growth charts with additional two
    body mass index-for-age charts for boys and for girls, ages 2 to 20 years.

Identified by Shavika Gupta, Research Associate

Physical status: the use and interpretation of anthropometry, World Health Organization
Report of a WHO expert committee. Technical Report Series No. 854. Geneva: WHO, 1995.
http://www.unu.edu/unupress/food/V182e/ch12.htm#TopOfPage
    The book provides information on anthropometric indices that can be used in all the countries.




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Appropriate Uses of Anthropometric Indices in Children
by G. Beaton, A. Kelly, J. Kevany, R. Martorell, and J. Mason, Nutrition Policy Discussion Paper No. 7,
ACC/SCN Workshop, United Nations, Geneva, 1990
http://www.unsystem.org/scn/archives/npp07/begin.htm#Contents
 It provides a view of the current "State-of-the-Art" of appropriate uses of child anthropometry

Poverty, child undernutrition and morbidity: new evidence from India
by Shailen Nandy; Michelle Irving; David Gordon; S.V. Subramanian; George Davey Smith
http://www.scielosp.org/scielo.php?pid=S0042-96862005000300014&script=sci_arttext&tlng=en
 Alternative composite index of anthropometric failure (CIAF) for children was constructed and
 examined the relationship between subgroups of anthropometric failure, poverty and morbidity.

Anthropometric indices of failure to thrive
by Pauline Raynor, Mary C J Rudolf, Arch Dis Child. May 2000; 82:364-365
http://adc.bmjjournals.com/cgi/content/full/82/5/364#F1
 The study compared five anthropometric methods of classifying failure to thrive in order to ascertain
 their relative merits in predicting developmental, dietary, and eating problems

Weight-for-stature compared with body mass index–for-age growth charts for the United
States from the Centers for Disease Control and Prevention
by Katherine M Flegal, Rong Wei and Cynthia Ogden, American Journal of Clinical Nutrition, Vol. 75, No.
4, 761-766, April 2002
http://www.ajcn.org/cgi/content-nw/full/75/4/761/
 The study compared BMI-for-age with weight-for-stature using 2000 Centers for Disease Control and
 Prevention growth charts for the United States

Anthropometric, health and demographic indicators in assessing nutritional status and food
consumption
by Simon Chevassus-Agnès, FAO Food and Nutrition Division, 1999, Rome
http://www.fao.org/sd/WPdirect/WPre0125.htm
 The article reviews the various anthropometric indicators and their relation with food consumption and
 nutritional status.

Recommended Organizations

SAHAY - Children International (from Marine Mukherjee, CINI – RRC, Kolkata)
734 Block P, New Alipur, Calcutta 53. Email : sahayci@cal.vsnl.net.in
http://www.children.org/
  An organization supporting holistic child development including their nutritional status.

Identified by Bidisha Pillai, Research Associate

WHO
http://www.who.int/nut/
 WHO includes nutrition promotion, and the prevention and reduction of malnutrition, among its key
 health-promotion instruments.

UNICEF, India
http://www.unicef.org/india/health_170.htm
 UNICEF supports the national RCH programme in its aim to reduce maternal, neonatal and child
 mortality by improving the nutrition status and healthcare services for communities.

National Institute of Nutrition, Hyderabad



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http://icmr.nic.in/000229/nin.htm
 NIN monitors the diet and nutrition situation of the country as well as evolves effective methods of
 management and prevention of nutritional problems.

Nutrition Foundation of India, Delhi
http://nutritionfoundationofindia.res.in/
 The Nutrition Foundation of India (NFI) is a non-governmental voluntary agency dedicated to improving
 the nutrition status of Indians.

CCRC, Kolkata
http://www.cini-india.org/ccrc.asp
 CINI Chetana Resource Center is the training wing of CINI focusing on Reproductive and Child Health
 including nutrition.

Recommended Websites

WHO (From Meghendra Banerjee, Resource Person)
http://www.who.int/childgrowth/publications/en/
 The website provides publications and peer reviewed articles on child growth standards.
_______________________________________________________________________________

Responses in Full

Sarala Gopalan, New Delhi

This is excellent information, which should be given to Self Help Groups to monitor child development.
The information could percolate to households through the Self Help Groups, and there can be massive
monitoring of nutrition intake and corrections.
_______________________________________________________________________________

Marine Mukherjee, CINI – RRC, Kolkata

As we know weight-for-age is the most universal of all nutritional indicators in the sense that it is used to
measure the nutritional status of children in community settings by ICDS in India. For all practical
purposes weight-for-age (to measure under or over weight) should be the indicator to manage and
evaluate the situation in the field settings.

Apart from other factors height of an individual principally depends on the genetic factors which cannot
be influenced within a very short period. And as such height-for-age, weight-for-height and BMI are
indicators that should differ from region to region throughout the world. Unless we have an Indian
standard protocol developed for this country, specific, I don't think the measurement would yield much as
much of the data generated would not be comparable. Also the answer to the South Asian Enigma might
lie here where low nutrition might not be that low (as to kill) as conceived on the face value.

Moreover BMI is an indicator more appropriate for laboratory/research settings. I have heard of
anthropological studies and PhD thesis on various tribes and aborigines of India that have used BMI and
BMR (basal metabolic rate) as nutritional indicators. In some of the studies on adolescent population they
have also used height-for-age and weight-for-height as measuring indicators. The last method has also
been found to be in use in some of the action research programmes on adolescents (like the SAHAY
programme supported by Children International). But again the cumbersome procedure of availing a
height measurement scale and reaching to the community has rendered the process somewhat
infrequent in use.




                                                                                                           6
Mid-Upper-Arm-Circumference and chest girth as indicators for measuring under-nutrition are also
subject to human error. In fact it is this human error that renders these measurements somewhat
unsuitable in the community settings (In most of the cases MUAC, chest girth and height is measured
through tapes whose usage is subject to these human errors. And a standing height measurement
scale/rod is difficult to carry in the field.). Juxtaposed to these, seeing a weight and recording and asking
for the age render least hazards and hence subject to least mistakes. Moreover concept wise Weight-for-
age is the most easily conceivable indicator (as compared to MUAC or BMI etc.) and hence easy to train
the field level workers employed to record the happenings. Calculating BMI for children is also difficult as
been rightly pointed out due to variation of BMI with age in children.

But there is a general word of caution for the community as a whole - that I am not an expert in this field
or a researcher. This mail comes as a general reaction to the query, some familiar indicators and some
field experiences.
_______________________________________________________________________________

Alok Chaurasia, Population Resource Centre, Bhopal

I am Alok Chaurasia working as Professor and CEO, Population Resource Centre Madhya Pradesh, Bhopal.
Long ago I developed an age independent index for measuring the nutritional status of children. It takes
into account three variables weight, height and chest circumference of the child. The required reference
is
Alok Chaursia and J Pattankar (1979) An index for the measurement of growth in children. Indian Journal
of Paediatrics, 46.

This index has however not been comprehensively tested empirically.
_______________________________________________________________________________

Umesh Kapil, AIIMS, New Delhi

Nutritional Status is a major determinant of the health and well-being of children. Inadequate or
unbalanced diets and chronic illness are associated with poor nutrition among children.
To assess their nutritional status, measurements of weight and height/length are obtained for children.
Children under two years of age are measured in lying down and older children are measured standing
up. Data on weight and height/length are used to calculate the following three summary indices of
nutritional status.
·       weight-for-age
·       height-for-age
·       weight-for-height

The nutritional status of children is calculated according to these three measures is compared with the
nutritional status of an international reference population recommended by the World Health
Organization (Dibley et al).

The use of this reference population is based on the empirical finding that well-nourished children in all
population groups for which data exist follow very similar growth patterns (Martorell and Habicht, 1986).

The three indices of nutritional status are at times expressed in standard deviation units (z-scores) from
the median for the international reference population. Children who are more than two standard
deviations below the reference median on any of the indices are considered to be undernourished, and
children who fall more than three standard deviations below the reference median are considered to be
severely undernourished.




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Each of these indices provides somewhat different information about the nutritional status of children.
Weight-for-age is a composite measure that takes into account both chronic and acute undernutrition.

Children who are more than two standard deviations below the reference median on this index are
considered to be underweight. The height-for-age index measures linear growth retardation. Children
who are more than two standard deviations below the median of the reference population in terms of
height-for-age are considered short for their age of stunted. The percentage in this category indicates the
prevalence of chronic undernutrition, which often results from a failure to receive adequate nutrition over
a long period of time or from chronic or recurrent diarrhoea.

Height-for-age, therefore, does not vary appreciably by the season in which data are collected. The
weight-for-height index examines body mass in relation to body length. Children who are more than two
standard deviations below the median of the reference population in terms of weight-for-height are
considered too thin or wasted. The percentage in this category indicates the prevalence of acute
undernutrition. Wasting is associated with a failure to receive adequate nutrition in the period
immediately before the survey and may be the result of seasonal variations in food supply or recent
episodes of illness.

In community settings it is operationally difficult to measure height. Measurement of height is difficult
and requires complicated calculations for it's interpretation of nutritional status

For Growth monitoring, serial weighing body weight is still the best indicator.

For research purpose any indicator can be used
_______________________________________________________________________________

Rukhsana Haider, WHO, South-East Asia Regional Office, New Delhi

You have raised a very important question. Our HQ counterparts and I agree with your comments. The
new WHO child growth standards will be launched in April 2006. They will provide charts and table for
the use of the four indicators, and hopefully a universal set of standards for use by all the countries.
_______________________________________________________________________________

Prakash V Kotecha, Government Medical College, Vadodara

Weight for Height or wasting seen less as compared to underweight or stunting is quite expected when
we have both height and weight less. Standards do need re-look and new standards of NCHS (2000) are
being used now.

However because 'Indian data show higher prevalence' is not good enough reason to look for alternative
classification. One direct question for action is "What is the purpose to look for these Indicators?" and
most logical answer is "To take corrective or preventive and promotive actions on the basis of magnitude
of Problem". If higher prevalence (and if it is not right) should be challenged but if it is debatable (and
not out right wrong) but likely to initiate actions for prevention and promotion, there is no reason to
debate to derive lesser magnitude of the problem and take less effective actions based on the revised
classification.

We use WAZ and HAZ for our evaluation and speak of 50% malnutrition in children broadly when we talk
of NFHS but using IAP criteria in ICDS show grade III and IV is 2% and grade II, III and IV also much
less. This is the reason why in ICDS we are hardly seriously discussing high magnitude of problem with
AWW and focusing on grade III and IV hardly helps in reducing malnutrition...




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While fully endorsing importance of classification, any classification that is likely to generate positive
action and keep us away from false sense of security needs to be adopted... is a right approach to me.
_______________________________________________________________________________

Daksha, SIFPSA, Lucknow (Additional reply)

The issue of using appropriate indices for assessment of NH status of children has been raging for years
among various groups working in our country.

In our country where prevalence of under nutrition is very high compared to over nutrition, the lack of or
rather poor MIS has shadowed the real picture. Even in the year of 2005, we continue to quote NFHS -II
data. There are many prestigious institutions who are working in this area but there is no consensus on
their reports.

Based on my limited observation and experiences in the area of program management, I am of opinion
that there is an imperative need to look at the capacity of grass root worker i.e. AWW and system
machinery. Here I would like to share some information which I came across in some meeting. In West
Bengal, UNICEF has been working with ICDS to develop nutrition surveillance system. It took them about
five years to get AWW to correctly report the data. The details may be obtained from Ms Piyali Mustafi,
PO, Unicef, West Bengal and Dr K Vijayaraghavan, NIN.

I am of opinion that while talking about using appropriate indicators to combat under nutrition among
children, at programme level, considering the capacities - skills of grass root worker and priorities of the
health issues/problems - WA is better indicator over HA mentioned by Dr Ramachadran that correcting
height is difficult owing to generational factor.
_______________________________________________________________________________

Piyali Mustaphi, UNICEF, Republic of Maldives

In continuation to Daksha's mail I have few words here:

We are caught between the doable and the desirable in this debate. BMI for age may have to be
assessed regularly and periodically through standardized surveys and the information circulated in SRS
bulletin. Its consistency over the years will lend it credibility and use for policy. I agree with Daksha that
quoting NFHS II even in 2005 is rather discomforting. The state must spend allocate some funds for
periodical surveys conducted by professional bodies. These surveys should not however try to measure
everything but confine themselves to nutritional status i.e. BMI for age.

But at the field level we need to continue with the weight for age measure and focus on getting the best
out of it in terms of sensitizing the field workers and mobilize the community. Fairly encouraging results
CAN be obtained in a relatively short span. This is very briefly described below.

The Nutrition Surveillance Project in West Bengal aimed at implementing an evidence based action plan
for ICDS to reduce and prevent malnutrition among children in the 0-3 years age group. This was done
by putting in place a system of data analysis at different levels i.e Anganwadi centre, project, district and
the state, with the help of simple indicators and their geographical mapping. The analysis in turn
improved the quality of data on one hand and also paved the way for focused interventions for reduction
of malnutrition in pockets of high malnutrition identified through mapping. The project promoted the use
of simple IT packages for analysis of the data from Monthly Progress Report (MPR) of ICDS and to ensure
data transmission electronically. A major capacity building programme for the ICDS functionaries was
therefore an important component of the project. Another important component was sensitization of the
community about the problem of malnutrition and tackling it through an innovative approach called the




                                                                                                            9
Positive Deviance (PD) involving capacity building of functionaries and mothers / caregivers of young
children.

The response from ICDS functionaries as well as community to the two initiatives has been very
heartening. The system of e-transmission of the data has taken roots in all the districts. The weighing of
children has gone up significantly both in quality and in numbers. The analysis of data is regularly done
at different levels paving way for a two way communication between the field and the policy level. The
community based intervention for reduction and prevention of malnutrition i.e. the PD approach has
yielded highly significant results, paving the way for its scaling up for rapid reduction of malnutrition.
These interventions are being replicated in some other states. Within the State too, the project
methodology has been adopted in other sectors notably in Panchayat and Rural Development for
decentralized monitoring of development outcomes.

Daksha’s observation about West Bengal taking 'five years' to get the AWWs to report the data correctly
are partly misplaced. Five years was the time taken for scaling up the efforts for improving weighing of
children in terms of coverage, accuracy and regularity THROUGH OUT THE STATE. In individual districts
the change can be brought about in relatively shorter time e.g. one to two year as seen in the later phase
of the 'five years'. In two other states, Maharashtra and Orissa too district level scale up took place in
shorter time.

More important is the fact that the field workers were able to relate to the task of data collection as they
became part of the process of analysis. Details of this simple analysis that can be carried out at the field
level can be obtained from (kamalpal@vsnl.com).

To sum up we need not look at the measures in the either or mode. Both of these will have its utility.
Sophisticated measures determined on annual basis through professional surveys are useful for more
macro purposes. The more humble measures like weight for age at the field level can be used for both
micro and macro purposes.
_______________________________________________________________________________

H P S Sachdev, Maulana Azad Medical College, New Delhi

I do not think that there are simple evidence based answers for this enigma at the moment. What is most
important to understand is that anthropometry is to be used for what purpose and for performing which
intervention? If we want to predict adult disease BMI is the best; similarly for deciding hospitalization of
malnourished children and for famine relief BMI for age is best; likewise BMI reflects better the adiposity
or obesity issue. With a personal bias I would tend to consider BMI as one of the better alternatives.
_______________________________________________________________________________

G.N.V.Brahmam, NIN, Hyderabad

This has reference to your e-mail dated 9th December 2005 seeking clarifications to the queries on
anthropometric indices currently being used. The following are my comments:

•       The expression in para 1 “criterion of weight /(height)2 (wasting) …..” is not correct, since
    weight/(height)2 gives BMI, while children with weight for height less than median -2SD of NCHS
    values are considered as wasted.

•       ‘Underweight’ (Weight for age < median-2SD of NCHS standards) reflects the overall
    undernutrition of <5 year children, and does not however indicate its nature, in terms of duration of
    undernutrition. It is the simplest indicator that can be used efficiently by the grass root level workers
    such as AWWs in monitoring the changes in the nutritional status of children even in periods of
    shorter duration.



                                                                                                          10
•       The growth chart being used currently under ICDS is based on IAP classification using unisex
    Harvard standards. A few people opine that the growth charts could be developed based on
    internationally accepted SD classification, by suitably dividing < median – 2 SD class in to 3 or 4 sub-
    groups to make them suitable for use in growth monitoring. But till then, one has no option, but to
    use existing growth charts.

•        ‘Stunting’ (height for age < median-2SD of NCHS standards), on the other hand is an indicator of
    long duration undernutrition, which is used to study the changes in the nutritional status of the
    community over longer period. However, measurement of correct height requires special skills as well
    as instruments and cannot be carried out by grass root level workers.

•       ‘Weight for height’ reflects the current nutritional status. This, unlike the other two indicators is
    independent of age. However, a child with normal weight for height, who is other wise stunted, is
    also considered as normal.

•        Age/gender specific centiles of Body Mass Index are used to assess the nutritional status of
    children of 9 to 17 years of age, in terms of undernutrition as well as overweight/obesity.

•       If the main objective is to identify undernourished children of <5 years age group for nutrition
    intervention and monitoring, the weight for age can be considered as the simple, yet good indicator.

•      On the other hand, if the objective is to assess the nature and magnitude of the undernutrition, a
    combination of the indices may be used, depending on the resources available.

I, therefore, believe that these indices are complementary to each other and none of them can be totally
dispensed with.
_______________________________________________________________________________

Kamala Krishnaswamy, NIN, Hyderabad

NNMB uses following indices to assess the nutritional status of the children:

Weight for Age: used to assess acute malnutrition in children widely used to assess PEM and over
nutrition. As a result, children with a very low weight for age who are not necessarily malnourished are
classified as malnourished if they are of shorter ‘stature’.

Height for age : It is particularly valuable as an index of ‘stunting’ of a child’s full growth potential.

Weight for Height: Is a sensitive index of current nutritional status. It is relatively independent of age
between 1 to 10 years. In contrast to weight for age, weight for height differentiates between nutritional
stunting (when weight may be appropriate for height) and wasting (when weight is very low for height as
result of deficits in both tissue and fat mass).

Always combination of two indices is considered as the good indicator for assessing nutritional status.

Waterlow classification uses both height for age and weight for height.


%Expected
Height for age       % Expected weight for height degrees of wasting
(degrees    of
stunting)



                                                                                                             11
Percent             >90%                  80-90%               70-80%               <70%
>95 %
                                    Normal                                    Wasting
90-95%
85-90%
                                   Stunting                           Stunting and Wasting
<85%

*The authors suggest that the children who are wasted or both stunted and wasted should receive the
highest priority for nutrition intervention.
_______________________________________________________________________________

                        Many thanks to all who contributed to this query!

If you have further information to share on this topic, please send it to Solution Exchange for the Food
and Nutrition Security Community in India at se-food@solutionexchange-un.net.in or se-
mch@solutionexchange-un.net.in with the subject reading ‘Re: [se-mch][se-food] Query: Indices for
measuring nutritional status in children, from NFI New Delhi, (Advice).

Disclaimer: In posting messages or incorporating these messages into synthesized responses, the UN
accepts no responsibility for its veracity or authenticity. Members intending to use or transmit the
information contained in these messages should be aware that they are relying on their own judgment.

                 Solution Exchange is a UN initiative for development practitioners in India. For
                         more information please visit www.solutionexchange-un.net.in
_______________________________________________________________________________




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