Assessment of Nutritional Status in Emergency-Affected Populations

ASSESSMENT OF
NUTRITIONAL STATUS IN
EMERGENCY-AFFECTED
POPULATIONS
July 2000
Bradley A. Woodruff & Arabella Duffield
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Br adley A . Br adley A . Woodr uf f , Woodr uf f , I nt er nat ional Emer gency and Ref ugee Healt h Br anch, U . S.
Cent er f or Disease Cont r ol and Pr event ion
A r abella A r abella Duf f i el d Duf f i el d, A CC/ SCN Secr et ar iat
We ar e gr at ef ul t o t he f ollowing r eviewer s f or t heir comment s:
M onika Blsnner ( WHO ) , Tim Cole ( I nst it ut e of Child Healt h) , M ar y Cor bet t ( Concer n) ,
M er cedes de O nis ( WHO ) , M ike Golden ( Univer sit y of A ber deen) , Saskia van der Kam ( M decins
Sans Fr ont ir es) , Car los N avarro-Colorado ( A ct ion Cont re La Faim) , N ick N or gan ( U niver sit y of
Loughborough) , Claudine Pr udhon ( A ct ion Cont re La Faim) , Simon St rickland ( London School of
Hygiene and Tr opical M edicine) , St anley U lijaszek ( O xf or d U niver sit y) .
Funding suppor t is gr at ef ully acknowledged f r om CI DA , DFA ( I r eland) , N O RA D, Funding suppor t is gr at ef ully acknowledged f r om CI DA , DFA ( I r eland) , N O RA D,
DFI D ( U K) , U N HCR, U N I CEF and WFP. DFI D ( U K) , U N HCR, U N I CEF and WFP.
This r epor t was made possible t hr ough t he suppor t pr ovided by t he Food and N ut r it ion A ssist ance This r epor t was made possible t hr ough t he suppor t pr ovided by t he Food and N ut r it ion A ssist ance
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SU M M A RY SU M M A RY
The World Health Organization (WHO) currently recommends using the BMI (Body Mass Index) of
individual adolescents compared to a reference population made up of adolescents in the United States and
using the 5th centile of this reference as the cut-off point to define undernutrition. These recommendations
may not be appropriate; surveys using these recommendations have found unrealistically high levels of
adolescent undernutrition.
PRO BLEM S WI TH A N THRO PO M ETRY I N A DO LESCEN TS PRO BLEM S WI TH A N THRO PO M ETRY I N A DO LESCEN TS
Anthropometry may be more difficult in adolescents than other age groups because of many complicating
factors.
q Body proportions, including indices using weight and height measurements, change with age, making
it necessary to compare an individual to adolescents in a reference population who are of the same
age. As a result, age must be collected on persons screened for admission to feeding programs or
measured as survey subjects. Adolescents in many emergency affected populations do not accurately
know their ages.
q Body proportions change with sexual development. The age at which sexual development occurs
differs in different populations and complicates the comparison of subjects from one population to
adolescents in a reference population.
q Body proportions may differ between the reference and survey populations. It may not be valid to
expect all populations of adolescents, even if well nourished, to achieve the same body proportions as
a single, universal reference.
PO SSI BLE SO LU TI O N S PO SSI BLE SO LU TI O N S
These problems affect all anthropometric indices including weight-for-height, BMI, Rohrer Index
(weight/height
3
), and MUAC (mid-upper arm circumference). Regardless of the anthropometric index used,
the following adjustments may allow better estimates:
q Better methods of assessing the age of attainment of key pubertal landmarks may allow adjustment
for differences in maturation age between survey and reference populations.
q Cormic Index (sitting height/standing height ratio) may, to some extent, be used to adjust for ethnic
differences in body proportions; however, this technique has not been studied in adolescents.
q A new international reference consisting of adolescents from 6 countries and a new method of
determining cut-off points may alleviate some of the biases from using a reference population from a
single country.
CU RREN T RECO M M EN DA TI O N S CU RREN T RECO M M EN DA TI O N S
Additional research is necessary before a single, valid methodology can be widely recommended for
anthropometric assessment of adolescents. Only tentative and preliminary recommendations can be given
at this time.
q Screening for severe undernutrition
Until better methods can be developed and validated, screening for severe undernutrition in order to
determine the need for therapeutic feeding should use clinical criteria.
q Corrections for different ages of sexual maturation
In surveys, some correction for different ages of sexual maturation should be carried out if the age of
sexual maturation differs substantially between the survey and reference population:
For pre-pubertal adolescents, weight-for-height could be used as the anthropometric index and
compared to revised weight-for-height tables currently in use.
For post-pubertal adolescents, BMI could be used as the anthropometric index and compared to a
new international reference population. Appropriate cut-off points could be used to identify
malnourished individuals.
q Corrections for effect of age on anthropmetric measurements
Regardless of which index is used, cut-off points are age-specifc; as a result, age should be collected
as accurately as possible on all adolescents measured during screening or survey activities.
q Reference populations
The reference population of American adolescents, currently recommended by WHO for use with BMI,
should not be used.
q Additional data
Adolescents should not undergo nutritional assessment in isolation. Young children, women of child-
bearing age, adults, elderly, or other population subgroups should also be assessed. A large
discrepancy between the estimated level of undernutrition in adolescents and other population
subgroups should stimulate investigation of the validity of the methods and results of the adolescent
assessment. Estimates of the levels of morbidity and mortality, and information on diet, food security,
and food sources should also be collected
q Comparison of surveys
In order to assess the methods and comparability of surveys, all survey reports should describe in
detail the anthropometric index used, how measurements were taken, which reference population was
used, how individuals were compared to this reference, the cut-off points used to define various
degrees of undernutrition, and any other ancillary data collected on the population of interest.
CONTENTS
Introduction 1
Background on anthropometry ...................................................................................................................................... 2
Current WHO recommendations .................................................................................................................................... 3
Description of recommendations .................................................................................................................. 3
Application of recommendations................................................................................................................... 4
Complications of adolescent anthropometry.................................................................................................................. 6
Changes in body proportions with age......................................................................................................... 6
Pubertal development.................................................................................................................................... 7
Interethnic differences in genetic growth potential....................................................................................... 9
Which anthropometric index?......................................................................................................................................... 9
Weight-for-height measures.......................................................................................................................... 9
Theoretical problems with indices using weight and height ................................................................ 10
Practical problems with indices using weight and height .................................................................... 10
MUAC 11 ....................................................................................................................................................
Theoretical problems with the use of MUAC........................................................................................ 11
Practical problems with the use of MUAC............................................................................................ 11
Possible solutions for the future ................................................................................................................................... 12
Changes in body proportions with age....................................................................................................... 12
Pubertal development.................................................................................................................................. 12
Interethnic differences in genetic growth potential..................................................................................... 12
Use of other data ......................................................................................................................................... 13
Future research needs.................................................................................................................................................. 14
Conclusions and recommendations ............................................................................................................................. 14
References .................................................................................................................................................... 16
Annex I: Median and 70% of median weight for various heights, for males and
female adolescents..................................................................................................................................... 19
List of Boxes, Tables and Figures
Box 1: An explanation of cut-off points for anthropometric indices in child and adults .............................................. 3
Box 2: Example of adjustment of BMI for maturational age for girls .......................................................................... 4
Table 1: Summary of the results of surveys which used WHO recommendations to assess
adolescent nutritional status.............................................................................................................. 5
Figure 1: Weight-for-height, BMI, and Rohrer Index as a function of age during childhood
and adolescence................................................................................................................................ 7
Figure 2: Example of drawing used in self-assessment............................................................................................... 8
Figure 3: BMI as a function of Cormic Index................................................................................................................. 9
Signalling t he need f or nor ms and st andar ds Signalling t he need f or nor ms and st andar ds.
The SCN will ident if y f or t he at t ent ion of t echnical agencies or
ot her bodies cr it ical ar eas wher e nor ms and st andar ds ar e missing
or out -of -dat e and holding pr ogr ammes back. This includes
( especi al l y) i dent i f yi ng knowl edge gaps and si gni f i cant ar eas i n
disput e or cont r over sy; as well as ident if ying ar eas r equir ing
oper at ional r esear ch, and f acilit at ing t his wor k.
Ext r act f r om t he A CC/ SCN ' s St r at egic Plan, A pr il 2 0 0 0
UNITED NATIONS Administrative Committee on Coordination
SUB-COMMITTEE ON NUTRITION
THE UN SYSTEM'S FORUM FOR NUTRITION
V I SI O N A N D M A N DA TE V I SI O N A N D M A N DA TE
Our long-run vision is of a world in which malnutrition is no longer a human development constraint. This is
possible, but to achieve it will require decisive action at country level, supported by a coherent and co-
ordinated international strategy, founded on human rights and providing a framework for action throughout
the UN and international development finance system, implemented in close partnership with NGOs,
bilaterals and governments. Nutrition needs to be made a key development priority, recognized as vital to
the achievement of other social and economic goals. Good nutrition under normal conditions contributes to
the prevention and mitigation of death and malnutrition in emergency situations. Good nutrition facilitates
the prompt return to conditions favouring development following disasters.
The mandate of the ACC/SCN is to raise awareness of nutrition problems and mobilize commitment to
solve them -- at global, regional and national levels; to refine the direction, increase the scale and
strengthen the coherence and impact of actions against malnutrition world wide; and to promote co-
operation amongst UN agencies and partner organizations in support of national efforts to end malnutrition
in this generation.
Three main areas for action have been identified: (i) Promote of harmonized approaches among the UN
agencies, and between the UN agencies and governmental and non-governmental partners, for greater
overall impact on malnutrition. (ii) Review the UN system response to malnutrition overall, monitor resource
allocation and collate information on trends and achievements reported to specific UN bodies. (iii) Advocate
and mobilize to raise awareness of nutrition issues at global, regional and country levels and mobilize
accelerated action against malnutrition. These three functions are all vital and of equal importance and can
be seen as a triangle, one dependent on the other.
The UN members of the ACC/SCN are the FAO, IAEA, IFAD, ILO, UN, UNAIDS, UNDP, UNEP, UNESCO,
UNFPA, UNHCHR, UNHCR, UNICEF, UNRISD, UNU, WFP, WHO and the World Bank. The ADB and
IFPRI are also part of this group. From the outset, representatives of bilateral donor agencies and NGOs
have participated actively in SCN activities. The Secretariat is hosted by WHO in Geneva.
The SCN undertakes a range of activities to meet its mandate. Annual meetings have representation from
those mentioned above as well as academia -- a one-day Symposium is held during the annual meeting,
focussing on a subject of current importance for policy. The SCN convenes working groups on specialized
areas of nutrition; currently there are nine working groups in areas ranging from foetal and infant
malnutrition, nutrition of the school aged child, and household food security to capacity building .
The SCNs reports on the world nutrition situation, published every two to three years, are authoritative
sources of information to guide the international community in its nutrition work. Nutrition Policy Papers and
the SCN News summarise current knowledge on selected topics. Quarterly bulletins on the nutritional status
of refugees and displaced persons are also published in collaboration with a large network of NGOs.
Assessment of Nut rit ional St at us of Adolescent s in Emergency-Af f ect ed Populat ions Assessment of Nut rit ional St at us of Adolescent s in Emergency-Af f ect ed Populat ions
1
I N TRO DU CTI O N I N TRO DU CTI O N
This RNIS supplement discusses the assessment
of undernutrition in adolescents in emergency
situations. The World Health Organization (WHO)
defines adolescents as persons aged 10-19 years
old. Because of the focus on humanitarian
emergencies, the discussion will include only an
evaluation of acute undernutrition. This paper will
not address many other important nutritional
problems in adolescents, such as anaemia and
other micronutrient deficiencies, poor nutritional
habits, eating disorders, and obesity
1
.
The report will also not directly address chronic
undernutrition. In children and young adolescents,
chronic undernutrition leads to stunting (low height-
for-age). In adolescents, chronic undernutrition also
delays normal maturation
2-8
. Although chronic
undernutrition is an important and widespread
problem
9
with multiple adverse health outcomes, it
is not usually the highest nutritional priority in
emergency situations. In such situations, acute
undernutrition is often common and, at least in
young children, may account for a substantial
proportion of overall mortality
10
. Moreover, the
distinction between acute and chronic
undernutrition among adolescents and adults is not
nearly as clear as it is among young children. Since
adults and older adolescents no longer increase
their height, they cannot become stunted, and
thinness may result from either a sudden or long-
standing food deficit.
This discussion emphasizes practical issues of
anthropometric assessment of nutritional status
rather than general knowledge of adolescent
growth and development. Nonetheless, this
supplement does include some information on
these topics so that the reader can understand the
difficulties associated with anthropometric
assessment in this age group.
This paper also points out some of the deficiencies
of the current recommendations regarding the
nutritional assessment of adolescents, including
those published by WHO. Examples of
assessments that have used the recommended
procedures are included. Many of these
assessments have produced misleading results,
and at least one has resulted in the implementation
of potentially unneeded interventions.
In displaced and emergency-affected populations,
the most common method of assessing the overall
nutritional status in a population is to weigh and
measure children 6-59 months of age
11-14
.
However, emergencies in Europe, Central Asia,
and Africa have highlighted the nutritional
vulnerability of other population subgroups, such as
elderly adults
1, 15-19
. Adolescents have not
traditionally been considered at disproportionately
elevated nutritional risk in emergency situations.
Nonetheless, because of rapid growth in stature,
muscle mass, and fat mass during the peak of the
adolescent growth spurt, the requirements for
some nutrients is as high or higher in adolescents
than in other age groups
13
. Between 10 and 19
years of age, the requirement for many
micronutrients, including vitamin A, thiamine,
riboflavin, niacin, folic acid, vitamin B12, vitamin C,
and iodine, reaches levels required by non-
pregnant adults. Moreover, rapid growth produces
a higher requirement among adolescents 10-14
years of age for calcium than any other population
age group except pregnant women. The 2,420 kcal
required per day by adolescents 15-19 years of
age is the highest energy requirement of any age
group. The recommended general ration of 2100
kcal per person per day for populations wholly
dependent on relief food is based on a distribution
of age and sex which assumes that 20% of the
population are adolescents 10-19 years of age and
56% are adults. In populations with a higher
proportion of adolescents or adults, this ration may
provide insufficient energy
13
.
Adolescence may also present a nutritional
opportunity, although little is known about the short
and long-term effects of acute undernutrition during
adolescence. In many cultures, a large proportion
of girls have their first pregnancy during
adolescence. Improvement in nutritional status can
improve pregnancy outcomes, including maternal
death, foetal death, and preterm delivery,
experienced by pregnant adolescents
9
.
RNIS Supplement -- July 2 0 0 0 RNIS Supplement -- July 2 0 0 0
2
BA CKGRO U N D O N BA CKGRO U N D O N
A N THRO PO M ETRY A N THRO PO M ETRY
Anthropometry is the measurement of certain
parameters of the human body. It is frequently
used to assess nutritional status in young children
and adults
12, 20, 21
. Anthropometry has also been
used to study the growth and development of
school-aged children and adolescents. Only
recently has an attempt been made to use
anthropometric methods to assess acute
undernutrition in adolescents
12
.
Use of anthropometry requires two essential items:
an anthropometric indicator and a cut-off point. The
indicator, often called an anthropometric index, is a
measurement or a combination of measurements
made in the field, such as weight and height, or the
combination of measurements with additional data,
such as age. Different indices reflect different
components of nutritional status. The index weight-
for-height indicates thinness, and because acutely
undernourished persons generally lose body
weight but not height, weight-for-height decreases
with acute undernutrition. On the other hand, young
children with chronic undernutrition may not be
thinner than normal children, but may have
retarded growth in height. Chronic undernutrition
may not be severe enough to cause weight loss,
but does interfere with normal linear growth. As a
result, height-for-age is decreased, and children
become stunted. Weight-for-age reflects both acute
and chronic undernutrition because both thin
children and stunted children are underweight. In
many emergency-affected populations, acute
undernutrition may be superimposed over a high
level of background chronic undernutrition. As a
result, both thinness and stunting may be common.
Mid-upper arm circumference (MUAC) is an
indicator of the amount of fat and muscle in the
upper arm. Skinfold thickness measurements,
taken at various places on the body, provide an
estimate of the thickness of subcutaneous fat.
Acutely undernourished persons metabolise fat and
muscle to compensate for decreased nutrient
intake, resulting in a decline in skinfold thickness
and MUAC.
Anthropometry can be used to evaluate either
individuals or populations. To identify those in need
of nutritional rehabilitation, a cut-off point is
established below which persons are offered
nutritional therapy. Young children 6-59 months of
age with severe acute undernutrition are usually
treated in inpatient therapeutic feeding centres.
The recommended admission criteria are weight-
for-height <-3 z-scores or <70% of median (see
Box 1 for explanation of cut-off points) or the
presence of oedema
14, 22
. Anthropometric
measurements are taken frequently during
nutritional therapy and, in combination with clinical
observations, are used to determine when children
can be discharged. The application of universal
cut-off points has the dual advantage of allowing
comparisons of the level of undernutrition between
populations and also helping to prevent bias on the
part of feeding-centre staff when performing initial
assessment or follow-up of patients.
Anthropometry is also used to determine the
prevalence of undernutrition in a population.
Anthropometric measurements for each child
selected as part of a representative sample are
compared to a reference population to determine
each childs nutritional status. The proportion of
sampled children who are undernourished provides
an estimate of the prevalence of undernutrition in
the entire population of children. Such surveys are
most commonly performed in children 6-59 months
of age, but can be undertaken in any population
subgroup, such as older adults, adolescents, or
pregnant women. Estimates of the prevalence of
undernutrition, along with other data on food and
health, are used to plan programmes of food aid
and nutritional therapy, or to evaluate the effect of
such programs.
Anthropometry, however, cannot provide the
complete picture of the nutrition and food situation
needed for problem solving and programme
planning. Anthropometry can provide an estimate
of the prevalence of undernutrition, but evaluations
of food security, food distribution, nutrient content,
morbidity and mortality, and other elements are
needed to understand the causal factors resulting
in undernutrition
23
. Nonetheless, anthropometric
measurements are relatively easy to obtain in the
field and anthropometric surveys can often be
carried out in displaced populations, even during
the acute phase of a humanitarian emergency.
3
CU RREN T WHO CU RREN T WHO
RECO M M EN DA TI O N S FO R RECO M M EN DA TI O N S FO R
A DO LESCEN T A DO LESCEN T
D DESCRI PTI O N O F ESCRI PTI O N O F WHO WHO RECO M M EN DA TI O N S RECO M M EN DA TI O N S
( SU M M A RI SED FRO M : PHYSI CA L STA TU S: THE USE A N D
I N TERPRETA TI O N O F A N THRO PO M ETRY, REPO RT O F A
WHO EXPERT CO M M I TTEE
12
)
(1) To screen adolescents for severe undernutrition
to determine the need for admission to
therapeutic feeding:
q Use clinical criteria. Visual evidence of
extreme emaciation can identify those
requiring immediate feeding. The ability to
walk or work may also be important in
identifying those in greatest need.
Pregnant and lactating adolescents may
need additional nutritional support.
(2) To screen adolescents in less extreme need of
nutritional interventions:
q Use BMI-for-age to assess acute
undernutrition. Each measured
adolescent's BMI is compared to
members of the same age and sex in the
National Center for Health Statistics
(NCHS) reference population consisting of
Box 1 . A n explanat ion of cut -of f point s f or ant hr opomet r ic indices in childr en and Box 1 . A n explanat ion of cut -of f point s f or ant hr opomet r ic indices in childr en and
adul t s adul t s
For each anthropometric index, a specific level must be determined as the cut-off point which distinguishes the normal
nutritional state from undernourished. Cut-off points are also used to distinguish different levels of undernutrition. Cut-off
points for anthropometric indices can be determined statistically. For example, the most commonly used index of acute
undernutrition in young children is weight-for-height. Each measured child is compared to the reference population to
determine how far that child is from the average child in the reference population. This discrepancy between an individual
child and the reference can be expressed in a number of ways. One frequently used method when assessing individual
children is the percent of median. A weight of a measured child is compared to the median weight of all children in the
reference population of the same sex and height. We will use as an example a 17 month-old girl who weighs 8 kg and is 80
cm long. The median weight of girls in the reference population who are 80 cm long is 10.6 kg (note that age is not
necessary). Therefore, the measured child has a weight-for-height which is 75% of median.
An alternate method, now somewhat outdated, is to express weight-for-height in centiles. That is, upon looking up in a centile
table, we find that our 8 kg, 80 cm girl weighs less than 84% of girls in the reference population who are 80 cm long.
Therefore, this child falls on the 16th centile of weight-for-height. In population surveys, the preferred method for expressing
the comparison between a specific child and the reference is by using z-scores. The distribution of weights for all reference
children of the same sex and height is described by the median and standard deviation, given in kg. One standard deviation
is one z-score. Using the example girl referred to above, the standard deviation of the weight for reference girls who are 80
cm long is approximately 0.88 kg. The median weight of these reference girls is 10.6 kg. Because the weight of our example
child is 2.6 kg lower, she falls 2.95 standard deviations below the median. Therefore, her weight-for-height z-score is -2.95.
The z-score cut-offs for moderate and severe undernutrition (<-2 and <-3, respectively) were determined from the distribution
of weight-for-height values in a sample of American children.
It must be remembered that reference populations are used only to develop statistical cut-off points and may not necessarily
represent targets for, or examples of, optimum nutritional status. Indeed, by definition, 2.3% of the children in the American
reference population will fall below -2 z-score weight-for-height and be defined as acutely undernourished. Regardless of
whether percent of median, centile, or z-score is used, if anthropometry is being used to determine who needs nutritional
intervention, children falling below the selected cut-off point will be included in such an intervention and those falling above
this cut-off point will not be included. In a population survey, the prevalence of undernutrition is calculated by dividing the
number of children falling below the selected cut-off point by the total number of children measured.
The cut-off point defining undernutrition is sometimes determined using health outcome data. For example, adult
undernutrition is frequently assessed using the body mass index (BMI), which is also called the Quetelet Index. It is
calculated as the weight in kilograms divided by the square of the height in meters (Wt/Ht
2
). Although very little data are
available relating a specific cut-off point to the consequences of acute undernutrition, there are many studies of the health
outcomes of chronic undernutrition. These studies have shown that adults with a BMI less than 18 or 18.5 have more
frequent illness, less capacity for physical labour, and, in women, poorer birth outcomes
21.
4
adolescents in the United States who
were measured as a part of the first
National Health and Nutrition Examination
Survey (NHANES I) in 1971-1974
24, 25
.
[Note that CDC has recently published
new growth charts based on children from
the US, see www.cdc.gov/nchs.]
q Adolescents falling below the 5th centile
of the NCHS reference population may
need intervention, although local cut-offs
can also be developed which take into
account the availability of resources to
manage the patient load.
q Because of major differences between
boys and girls in the timing of maturational
events (including the growth spurt)
separate references must be used for
each sex.
(3) To estimate the prevalence of acute
undernutrition in a population of adolescents:
q Use BMI-for-age as described above.
Calculate the proportion of adolescents
falling below the 5th centile or a locally-
defined cut-off point.
(4) To estimate the prevalence of chronic
undernutrition in a population of adolescents:
q Compare the height of each adolescent to
the height of adolescents of the same sex
and age in the NCHS reference
population. Adolescents falling below the
3rd centile of the NCHS reference
population are defined as stunted
26
.
(5) In addition, WHO recommendations describe a
method to adjust, at least in part, for potential
differences in the ages of maturation between
survey populations and the reference
population. This adjustment can be
undertaken when assessing either acute or
chronic undernutrition.
q Along with weight, height, and age, survey
workers should collect data on specific
landmarks of sexual maturation. For each
female adolescent, the Tanner breast
stage and the age of menarche (if
postmenarcheal) should be collected. For
male adolescents, the Tanner genitalia
stage and the age of attainment of adult
voice should be collected. For female
adolescents, investigators then calculate
the median age of reaching the Tanner
breast stage 2 and the median age of
menarche. For male adolescents
investigators calculate the median age of
attaining the Tanner genitalia stage 3 and
median age of attaining adult voice.
q The difference is calculated between the
survey population and the reference
population in the median ages of attaining
these landmarks. For each sex, the
differences for the two landmarks are
averaged.
q For each sex separately, the average
difference between the survey and
reference populations in these median
ages is then used to adjust the age of
each survey subject. (See Box 2 for
example of adjustment for maturational
age in females.)
A A PPLI CA TI O N O F THE PPLI CA TI O N O F THE WHO WHO
RECO M M EN DA TI O N S RECO M M EN DA TI O N S
Since their publication, the WHO recommendations
have been used to analyse the results of several
surveys undertaken in both stable and displaced
populations in developing countries. The survey
population characteristics and the estimated
prevalence rates of thinness and stunting are
summarised in Table 1.
Box 2 . Example of adjust ment of Box 2 . Example of adjust ment of
BM I f or mat ur at ional age BM I f or mat ur at ional age f or f or
gi r l s gi r l s
The median ages of attaining breast stage 2
and menarche is calculated by plotting the
cumulative percentage of girls who have
attained these landmarks by age. The age at
which 50% of girls have attained these
landmarks is the median age. In a hypothetical
survey population, if the median ages for girls
of attainment of breast stage 2 and menarche
is 12.2 years and 14.2 years, respectively;
these are subtracted from the median ages in
the NCHS reference population (10.6 and 12.8
years, respectively). The average of these two
differences is approximately 1.5 years, which
is then subtracted from the age of each of the
girls in the survey population. This adjustment
allows survey girls to be compared to girls in
the reference population who are at the same
level of sexual maturation
5
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Based on the data contained in Table 1 and in
reports from these surveys, certain considerations
cast doubt on the validity of some of these
estimates of thinness and the methods employed
to produce the estimates.
q Although no data were specifically collected
on health outcomes, four of the surveys
chose samples from among children who
were well enough to attend school during
survey activities. Nonetheless, three of these
surveys estimated that the prevalence of
thinness (indicating undernutrition) was
greater than 50%. In the three refugee camp
surveys that collected additional health data,
there was no evidence of elevated morbidity
or mortality in these populations
30-32
.
q Two of the surveys included adolescents
from families with relatively high
socioeconomic status and yet still found
substantial acute undernutrition among
adolescents.
q In three surveys undertaken in refugee
camps, monitoring showed that the amount
of food contained in the general distribution
was generally adequate
30-32
. One would
have to hypothesize extraordinarily
inequitable intra-household food distribution
to explain the high prevalence of acute
undernutrition among adolescents if the
survey results are valid.
q In the refugee camp surveys there were no
indications, other than the results of the
adolescent surveys, that substantial
undernutrition existed in any segment of the
population. In all these populations, recent
surveys of children less than 5 years of age
had estimated a low prevalence of acute
undernutrition
29-32
.
q Eight surveys estimate the prevalence of
both thinness and stunting. In five of these
surveys, the estimated prevalence of
thinness exceeded that of stunting by a factor
of 1.6 - 6.3. Although little is known about the
usual ratio of the prevalence rates of thinness
and stunting among nutritionally
compromised adolescents, these results
would be highly unusual in children up to 5
years of age. An analysis of the results of
175 nutrition surveys throughout the world
demonstrated that among children 12-23
months of age, stunting was 2.5-12.5 times
more common that thinness, depending on
the region where the survey was done
33
. In
addition, in the WHO Global Database on
Child Growth and Malnutrition, only Fiji has a
higher prevalence of thinness than of stunting
34
. Although the applicability of these data to
adolescents is not precisely known, one
might expect that in adolescents - as for
young children - the prevalence of stunting
would exceed the prevalence of thinness
because stunting is cumulative, while
thinness is due to relatively recent
undernutrition.
Uncritical use of the WHO recommendations may
yield misleading results, which may, in turn, lead to
inappropriate interventions. For example, as a
consequence of one survey of adolescents, relief
food was diverted from the general ration
distribution to a supplementary feeding programme
targeted to school attendees. Given the questions
about the validity of the procedures recommended
by WHO, this intervention may have been
unnecessary and may have diverted food from
population subgroups which needed this food more
than adolescents who were sufficiently healthy to
attend school.
CO M PLI CA TI O N S O F CO M PLI CA TI O N S O F
A DO LESCEN T A DO LESCEN T
The anthropometric assessment of undernutrition
among adolescents presents several problems that
are not relevant to the assessment of young
children. This section will outline some of these
complications, including:
q Changes in body proportions with age
q Pubertal development
q Inter-ethnic differences in genetic growth
potential
C CHA N GES I N BO DY PRO PO RTI O N S WI TH A GE HA N GES I N BO DY PRO PO RTI O N S WI TH A GE
Thinness, as measured by weight-for-height and
BMI, changes with age in healthy, well-nourished
children, adolescents, and adults. In populations in
industrialised countries, BMI reaches a nadir at
about 6 years of age, then rises steadily until
7
middle-age
35-37
. (see figure 1) The Cormic Index
(sitting height divided by standing height) measures
the ratio of leg-length to trunk length, and is
sometimes called the sitting height to standing
height ratio. The Cormic Index declines throughout
childhood because leg length increases faster than
trunk length during prepubertal growth
38
. However,
the adolescent growth spurt is made up
disproportionately of growth in the trunk, leading to
a rise in Cormic Index in later adolescence
38-40
. At
least one study shows a sharp change in the index
with onset of adolescent growth
40
. Other
anthropometric measurements also change with
age in adolescence. MUAC rises progressively
throughout adolescence at a rate greater than that
in early childhood
41
.
Populations of many developing countries do not
know their own ages. In young children age can be
approximated by asking a mother about significant
events on a local calendar which coincided with the
child's birth. Such a technique may be much more
difficult when asking about local events which
occurred 10-19 years before. In any case, using
such techniques to ascertain age takes substantial
time, both in preparation of a local calendar and in
posing extra questions during data collection.
P PUBERTA L DEV ELO PM EN T UBERTA L DEV ELO PM EN T
Superimposed on the more gradual age-related
changes, more rapid changes in anthropometric
measurements occur during sexual development.
For example, during the adolescent growth spurt,
the highest rate of weight gain follows the highest
rate of height gain
42
. This leads to an acceleration
in the rise of BMI shortly after reaching the peak
height velocity, and this rise is more related to
pubertal development than chronologic age
42, 43
.
Moreover, sexual development occurs at different
ages in different populations
44
. As a result,
differences between study populations and
reference populations in sexual
maturation can confound
comparisons. Therefore, the
comparison of a pre-pubertal
child in a study population to
post-pubertal individuals of the
same age in a reference
population would be invalid
because the normal BMI for
these two persons would be quite
different. Chronic undernutrition
can also delay sexual maturity
and the adolescent growth spurt
4, 5, 44
. This delay can exaggerate
differences in age of sexual
maturation and the growth spurt
between undernourished survey
populations and well-nourished
reference populations
45
.
Associations are also found
between sexual development
and skinfold thicknesses and
MUAC. The onset of puberty
changes the rate of
subcutaneous fat deposition and
fat distribution, as measured by
skinfold thickness,
46-49
and these changes occur
independently of chronologic age
50
. Similarly,
MUAC changes with onset of puberty
47, 49
.
Adjustment for differences between the survey and
reference populations, as recommended by WHO,
requires the collection of data on the age at which
certain landmarks of sexual maturation occur in the
survey population. Each subject must be assessed
Figur e 1 Weight -f or -height ( Figur e 1 Weight -f or -height ( W/S) , BM I ( ) , BM I ( W/S2) , and ) , and Rohr er Rohr er
I ndex ( I ndex ( W/S3) as a f unct ion of age dur ing childhood and ) as a f unct ion of age dur ing childhood and
adolescence, const r uct ed f r om medians of N CHS r ef er ence adolescence, const r uct ed f r om medians of N CHS r ef er ence
populat ion populat ion ( f rom Cole, 1 9 9 1
37
)
8
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9
for pubertal changes; however, in practice, judging
Tanner breast or genital stages during field surveys
is very difficult. Health workers require extensive
training and, in most field situations, exposing
breasts and genitals of adolescents is not culturally
acceptable. The single maturational landmark
which might easily be collected in the field is age of
menarche. In all populations where adolescents
know their ages, age at menarche can be recalled
by girls and women, and has been measured
successfully in many surveys
2, 4, 43, 49, 51-53
.
However, the situation is very different for boys, for
whom no such easily obtained landmark exists.
Self-assessment of genital and breast stage, using
photographs or line drawings, has been validated
in some countries, but has not been evaluated in
developing countries or in a variety of cultures
54-56
.
(See figure 2 for an example of drawings used in
self-assessment.)
I I N TER N TER- -ETHN I C DI FFEREN CES I N BO DY SI ZE ETHN I C DI FFEREN CES I N BO DY SI ZE
A N D SHA PE A N D SHA PE
Although well-nourished, healthy children younger
than 5 years of age are of similar size and shape
worldwide,
57
school-age children and adolescents
may not be similar. Older adolescents who have
completed their growth spurt and have essentially
become adults may reflect adult differences in body
shape. Adults display differences in Cormic Index,
which is one measure of body shape
58
. Figure 3
demonstrates the substantial effect which
differences in Cormic Index have on BMI. As a
result, it may be inappropriate to compare older
adolescents, who may manifest ethnic differences
in anthropometric indices, to a single universal
reference population. (See accompanying report on
assessment of adult nutritional status for further
details
59
.)
WHI CH A N THRO PO M ETRI C WHI CH A N THRO PO M ETRI C
I N DEX? I N DEX?
There are several body measurements and
combinations of body measurements that may be
useful in assessing the nutritional status of
adolescents. Measurements for use in
humanitarian emergencies must use inexpensive
equipment, be simple to teach to health workers,
and be easy to interpret in the field. In addition, the
ideal index used to assess adolescent nutritional
status in emergencies would allow compensation
for differences between the survey and reference
populations in age, sexual development, and
ethnicity. The measurements most commonly
considered for use in emergencies include weight,
height and MUAC. Skinfold thickness may also be
a useful measure of body protein and fat stores,
but is not considered useful in emergencies as it is
difficult to obtain accurate measurements,
particularly in emergencies.
W WEI GHT EI GHT- -FO R FO R- -HEI GHT M EA SU RES HEI GHT M EA SU RES
Indices which use weight and height are currently
the most frequently used tools to assess
adolescent undernutrition. As described above,
WHO recommends the use of BMI. To screen
adolescents for admission to nutrition programs,
other organizations, including Mdecins Sans
Frontires (MSF) and Action Contre la Faim (ACF),
use weight-for-height reference tables extended to
older children and adolescents (Michael Golden,
personal communication). This method uses
existing reference tables of weight-for-age and
height-for-age to calculate the median weight and
70% of median weight for adolescents of each sex
and height category. These height-specific cut-off
points are shown in Annex 1. Although
demonstrated to be effective in screening
adolescents for admission to therapeutic feeding
programs, this table has not been evaluated for use
in defining less severe degrees of undernutrition in
order to estimate the prevalence of undernutrition
Figur e 3 BM I as a f unct ion of Figur e 3 BM I as a f unct ion of
Cor mic I ndex in a hypot het ical 7 0 Cor mic I ndex in a hypot het ical 7 0
kg, 1 7 5 cm man. kg, 1 7 5 cm man. ( f rom Norgan, 1 9 9 4
58
)
1 0
in a population of adolescents. Moreover, many of
the same drawbacks listed below apply to this use
of weight-for-height.
Theor et ical pr oblems wit h indices using Theor et ical pr oblems wit h indices using
weight and height weight and height
Lack of dat a direct ly correlat ing
measurement s t o healt h out comes - there are
no data directly correlating weight-for-height, BMI,
or the Rohrer Index with functional or health
outcomes in adolescents. Hence, as yet there are
no validated cut-offs for these indices to define
undernutrition in adolescents.
Age - indices using weight and height are
correlated with age. In young children, it is
assumed that the index weight-for-height is
constant regardless of a childs age. That is, a well-
nourished three year-old child is assumed to have
the same ideal weight as a stunted five year-old
child of the same height. Although this assumption
may not be entirely true, it does not grossly
interfere with the use of weight-for-height in
children less than five years of age. In contrast,
because adolescents add substantial muscle and
fat, especially during sexual development, the
normal weight for adolescents of a given height
changes substantially depending on their age and
pubertal development (figure 1). As a result, when
using weight-for-height, it is necessary to collect
and record accurate ages. Moreover, use of
weight-for-height may also require adjustment for
the difference in the age of sexual maturation
between the survey population and reference
population.
As with weight-for-height, BMI also changes with
age
37
(figure 1). Although this association with age
is not so strong as with weight-for-height, the use
of BMI still requires the collection of accurate ages,
and also ages of maturational landmarks from
individual subjects.
The Rohrer Index is calculated as the weight in
kilograms divided by the height in meters cubed
(wt/ht
3
). As seen in figure 1, the Rohrer Index may
be less age-dependent during adolescence than
other indices combining weight and height.
Correlat ions wit h height - some studies have
found that the Rohrer Index is correlated with
height, especially among older adolescents
60-62
.
Moreover, there has been very little research on
the correlation of the Rohrer Index with other
measurements of body protein and fat stores, such
as percent body fat. And finally, there is no widely
available reference population or established cut-
off points for this index.
Pr act ical pr oblems wit h indices using weight Pr act ical pr oblems wit h indices using weight
and height and height
Dif f icult ies in obt aining t he component
measures during f amine - the height and weight
measurements required to assess weight-for-
height, BMI, and Rohrer Index may be difficult to
obtain during an emergency. During severe
famines where adolescents are affected, many of
the most severely undernourished requiring
admission to therapeutic feeding centres cannot
stand, making measurement of height impossible.
Many studies have reported that gross weakness
and flexor contractions prevented measurements of
weight or height in a substantial proportion of
severely undernourished adults. (See
accompanying report on assessment of adult
nutritional status for further details
59
.) Moreover,
the necessary equipment, including scales and
height boards, may not be available.
Dif f icult ies in t he calculat ion of t he indices -
the calculation of BMI and Rohrer Index may be
unfamiliar to field workers and therefore more
difficult to use than other anthropometric indices.
Famine oedema - regardless of the specific index
used, evaluation of nutritional status must take into
account the presence or absence of oedema. Many
adolescents and adults develop oedema when
severely undernourished
1, 63
. This leakage of fluid
into tissues artificially increases an individuals
weight, which may result in a weight-for-height,
BMI, or Rohrer Index which appears more normal
than would be expected given the degree of
emaciation. In addition, because adolescents and
adults with oedema have a poorer prognosis than
those who are equally undernourished but do not
have oedema, adolescents with oedema should be
identified and admitted to appropriate therapy.
Although oedema in both feet or legs may be due
to other causes, in a situation with a high
prevalence of undernutrition, adolescents with
bilateral oedema may be severely undernourished
and should be referred to a clinician for further
diagnosis. They should then be admitted for
1 1
therapeutic feeding if famine oedema is diagnosed
59, 63
.
Pregnancy - indices comparing weight and height
cannot be used to assess pregnant adolescents.
Because of the extra weight of the foetus, other
products of conception, and added maternal tissue,
indices using weight and height may not accurately
indicate the nutritional status of pregnant
adolescents. During pregnancy, other measures,
such as weight gain during pregnancy or MUAC,
must be used to judge nutritional status.
M U A C M U A C
MUAC is relatively simple and easy to measure
and has recently been recommended for use in
rapid screening of adults for undernutrition to
determine the need for admission to a feeding
programme
19, 59, 64, 65
. In many well-nourished
populations, a reasonable correlation exists
between MUAC and BMI in adults. A scheme using
a combination of MUAC and BMI has been
proposed to categorise the degree of undernutrition
in adults
65
. No MUAC cut-offs have been
established for the diagnosis of adolescent
undernutrition yet. The published results of several
nutrition assessment surveys of adolescents in
developing countries include MUAC data; however,
because of the lack of a reference population and
cut-off points, no estimate of the prevalence of
undernutrition could be made
4, 7, 51, 53, 66-71
.
Theor et ical pr oblems wit h t he use of Theor et ical pr oblems wit h t he use of
M U A C M U A C
Lack of dat a direct ly correlat ing
measurement s t o measurement s of body f at
and prot ein st ores - there are no data directly
correlating MUAC with other measures of body fat
and undernutrition, such as BMI, in adolescents. In
addition, there are no data relating MUAC cut-off
points with functional or health outcomes in
adolescents. Hence, as yet there are no validated
cut-off points to define undernutrition with MUAC
measurements in adolescents.
Age - MUAC changes substantially with age during
adolescence, as shown in several reference
populations from industrialised countries
41, 72
. As
a result, a different cut-off point must be used for
adolescents of different ages. This requires an
accurate age for each survey subject in order to
judge whether they fall above or below an age-
specific cut-off point.
Sexual development - MUAC changes with
sexual development. The rapid addition of soft
tissue, predominantly muscle tissue in males and
subcutaneous fat in females, which occurs with
puberty results in a more rapid rise in MUAC at this
time than prior to or following puberty. One study
clearly demonstrates a greater MUAC in
postmenarcheal female adolescents than
premenarcheal female adolescents of the same
age
53
.
Et hnicit y - ethnic differences in MUAC have not
been sufficiently studied to determine if a single
cut-off point for MUAC could be used for
adolescents in all ethnic groups.
Pr act ical pr oblems wit h t he use of M U A C Pr act ical pr oblems wit h t he use of M U A C
Measurement error - in spite of the convenience
and ease of measurement, MUAC measurement
requires careful training and supervision in order to
prevent wrapping the measuring tape too tightly or
too loosely, which results in an erroneous estimate.
One study estimated that the smallest change over
time detectable in MUAC was 8-10%, when
measurements were taken by different observers
73
.
A second study demonstrated that MUAC
measurements show more inter-observer variability
than weight and height measurements
74
.
MUAC should be measured at the mid-point of the
upper arm between the shoulder (lateral end of the
clavicle) and elbow (inferior tip of the olecranon).
Although this not critical in young children who
often have little muscle contour in the upper arm, it
becomes increasingly important in post-pubertal
adolescents who have developed adult
musculature. Therefore workers will have to be
carefully trained to measure adolescent MUACs.
1 2
PO SSI BLE SO LU TI O N S FO R PO SSI BLE SO LU TI O N S FO R
THE FU TU RE THE FU TU RE
No single method has proved adequate for
assessment of undernutrition in adolescents in
emergency situations. Below are listed some
possible strategies for overcoming the major
difficulties.
C CHA N GES I N BO DY PRO PO RTI O N S WI TH A GE HA N GES I N BO DY PRO PO RTI O N S WI TH A GE
An anthropometric index that is unrelated to age is
required if adolescents do not know their ages. The
Rohrer Index may offer such advantages over
weight-for-height, BMI, or MUAC. Further research
is required in this area.
PUBERTA L DEV ELO PM EN T PUBERTA L DEV ELO PM EN T
Simpler methods of determining pubertal stage
may, in the future, allow adjustment for this
complicating factor. Such methods could include
appropriate line drawings or photographs of
different Tanner stages. In contrast, it may be
easier and more accurate when assessing
adolescents to consider pre-pubertal and post-
pubertal adolescents separately. Ideally, this would
require the assessment of the presence or absence
of only one landmark of sexual development, rather
than the determination of different levels of a
development indicator, such as Tanner breast or
genital stages. Such separation may make it
possible to include pre-pubertal adolescents with
school age children and post-pubertal adolescents
with adults when choosing which anthropometric
indicator or cut-off point to use.
I I N TER N TER- -ETHN I C DI FFEREN CES I N GEN ETI C ETHN I C DI FFEREN CES I N GEN ETI C
GRO WTH PO TEN TI A L GRO WTH PO TEN TI A L
A method has been proposed to account for at
least part of the difference in body shape in adults
by calculating a BMI which is adjusted for the
Cormic Index
75-77
. However, this procedure
remains untested in adolescents (Nicholas Norgan,
personal communication). Theoretically, such an
adjustment could also be applied to other
anthropometric indices calculated from weight and
height, such as weight-for-height or the Rohrer
Index. The application of this technique to
adolescents may be complicated by the normal
changes in Cormic Index throughout adolescence.
Moreover, some data indicate that chronic
undernutrition changes the Cormic Index
78
.
Stunted children may have a greater Cormic Index
than comparable children without stunting.
An additional method of compensating for ethnic
differences would be to choose different, more
appropriate cut-off points (either % of median or z-
scores) to define undernutrition when using a
reference population whose ethnicity differs from
that of the survey population. Some populations
may be genetically thinner than the reference
population, requiring a lower cut-off to define
undernutrition. WHO recommends such a
procedure when using anthropometry to screen
persons for admission to nutritional rehabilitation
12
.
Nonetheless, the procedure of determining
appropriate cut-off points is not simple. Such a
process would require either data on health
outcomes in order to estimate a functional cut-off or
data on a well-nourished population of similar
ethnicity in order to derive a statistically-defined
cut-off point. Collection of such data for multiple
ethnic groups would be expensive and time-
consuming.
Using a local reference would permit comparison of
a survey population to well-nourished adolescents
of the same ethnicity. Although this has been used
in published surveys
79
, creation of a reference
population is a difficult task requiring substantial
resources. Separate reference populations cannot
be created for each nationality or ethnicity. An
alternate possibility would be to create a few
reference populations for use with major ethnic
categories. Investigators could then choose a
reference which most closely matches the survey
population. For example, if a survey population is
known to have an average Cormic Index of 0.50,
the investigators would use a reference population
with a similar average Cormic Index. Of course,
such a strategy would make comparison of the
results of different surveys very difficult if they used
different reference populations to calculate the
prevalence of undernutrition. In addition, it would
require measuring sitting height as well as standing
height in all surveys of adolescents.
A single, international reference population
consisting of adolescents from multiple countries
could be used, similar to that currently under
1 3
development for children less than 5 years of age.
A reference population described in recently
published work includes children and adolescents
from national surveys done in six countries
80
. In
this proposal, cut-off points for BMI to define
overweight and obesity were identified by
determining the centile among 18 year-old
adolescents in each national survey population
which matched the adult BMI cut-off points of 25
and 30. That centile was then applied separately
for males and females to each one-half year age
group from 2-17.5 years to determine the cut-off
BMI value at for each age and sex group. The cut-
off points for each national population were then
averaged to produce age- and sex-specific cut-off
points for the combined international reference.
The same procedure could be used to determine
cut-off points which correspond to the adult cut-off
points for various degrees of undernutrition, i.e.,
BMI of 16, 17, and 18.5 kg m
-2
. This proposed
reference and the method of determining cut-off
points for BMI eliminates the bias which may result
from using as a reference a sample from a
relatively obese population, such as American
adolescents. However, its use still requires
accurate ages because the BMI cut-offs change
substantially with age, and it does not correct for
differing ages of sexual maturation. In addition, the
reference proposed may not be appropriate for
populations with different body shape, such as
Nilotic Africans and Australian aborigines.
U U SE O F O THER DA TA SE O F O THER DA TA
When assessing adolescents, additional data from
the same population should be collected. Such
data could include the prevalence of undernutrition
in young children, the prevalence of undernutrition
in adults, rates of morbidity and mortality, and
information on food security, food distribution, and
alternate sources of food. If a survey of
adolescents indicates substantial undernutrition,
but data on young children, adults, and other
population groups do not demonstrate
undernutrition or elevated morbidity or mortality, it
is very important to look critically at the adolescent
data. It is unlikely that adolescents are the only
population group with substantial undernutrition.
Unless anthropometric measures are valid, i.e.,
they truly measure nutrition and health, they may
not be useful at all. Other measures, such as
strength or other functional outcomes, may better
reflect an individual's risk of nutrition-related
morbidity or mortality. Experience in screening
adults for admission to therapeutic feeding
programmes has demonstrated that three clinical
signs (apparent dehydration, oedema, and inability
to stand) predict mortality better than BMI
59, 63
.
Such an approach, although as yet untested in
adolescents, may be able to distinguish
adolescents in need of therapeutic feeding from
those who could benefit from a less intensive
feeding program. However, clinical signs may not
be useful for measuring the overall prevalence of
lesser degrees of undernutrition in a population
because persons with less severe undernutrition
may not be so markedly impaired nor exhibit such
a distinctive clinical picture.
Measures of muscle function, such as grip
strength, shuttle run, or maximum jump height, may
be able to detect moderate degrees of wasting.
One author proposes that muscle performance
may actually be affected earlier in the course of
undernutrition than body composition
81
. In one
study among surgical patients, hand grip was
associated with MUAC, and those patients with
hand grip less than 85% of normal did much poorer
postoperatively
82
. In a second study, muscle
strength, as measured by grip strength, endurance
run, shuttle run, distance throw, and standing long
jump, was greater in normally-nourished children 4-
6.5 years of age than undernourished children
83
.
However, in this study, muscle strength was
correlated with stature, and after removing the
effect of this variable, well-nourished and poorly-
nourished children no longer differed in muscle
strength. A third study that directly stimulated the
ulnar nerve and measured isometric muscle
contractions did not find a difference between
undernourished and normally nourished adults
84
.
Clearly, such measures are not ready to be used in
the field. Much more work needs to be done to
determine whether appropriate measures of
muscle function exist, to describe a reference
population and cut-off points, and to determine the
sensitivity and specificity of proposed methods to
detect moderate and severe undernutrition.
1 4
FU TU RE RESEA RCH N EEDS FU TU RE RESEA RCH N EEDS
Certain questions need to be answered before
definite recommendations can be made regarding
the best method of assessing nutritional status in
adolescents.
Ant hropomet ric index - the association of
various indices, such as weight-for-height, BMI,
and Rohrer Index, with age and height should be
further explored in adolescents. Such exploration
should include analysis of existing data from past
surveys that measured weight, height, MUAC, and
age of adolescents. Re-analyses using data from
populations with a variety of health conditions and
various degrees of undernutrition could be
undertaken. In addition to investigating the
association between anthropometric indices and
age and height, future analyses of survey data
could include estimates of the error induced in the
estimated prevalence of undernutrition by various
degrees of uncertainty about age. The index
chosen should be the least dependent on age in
order to minimize the effect of using inaccurate
ages.
Def ining f unct ional cut -of f s - longitudinal
studies are required to determine whether
adolescents falling below specific cut-off points for
weight-for-height, BMI, and Rohrer Index have
elevated morbidity or mortality, poor pregnancy
outcome, suppressed growth, or decreased work
ability or physical performance measures. These
studies should be conducted in a variety of
situations among adolescents with different levels
of undernutrition.
Pract icalit y of measurement s and calculat ions -
the practicality of obtaining various measures
should be explored in field situations. Survey
organizers should assess the ease of training
survey workers in measuring MUAC, weight, and
height, as well as assessing inter-observer
variability when measuring adolescents.
Markers of pubert al development - the accuracy of
self-reported Tanner stage for breast and genital
development among female and male adolescents
needs to be tested in a variety of populations. For
example, adolescents' self-assessment upon
viewing drawings or photographs of different
Tanner stages could be compared to findings of
physical examinations. Studies could also explore
the use of other markers of sexual development,
such as the extent of axillary hair. Moreover, the
ages at which various landmarks of sexual
development are achieved should be described in
many different populations, both normally-
nourished and undernourished, in order to
determine which markers can be used for adjusting
for different developmental ages between survey
and reference populations.
Adj ust ing f or dif f erences in body shape -
surveys should explore the utility of adjusting
anthropometric indices for differences in body
shape by using the Cormic Index or other
indicators of body shape in distinct populations.
Vulnerabilit y - more nutrition surveys should
include assessments of the nutritional status of
different age groups to determine the relative
vulnerability of young children, adolescents,
women of child-bearing age, elderly, and other
population subgroups in different types of
humanitarian emergencies.
Use of ant hropomet ry at all - other measures,
such as strength or other functional outcomes, may
better reflect an individual's risk of nutrition-related
morbidity or mortality and should be explored as
indicators of adolescent nutritional status.
CO N CLU SI O N S A N D CO N CLU SI O N S A N D
RECO M M EN DA TI O N S RECO M M EN DA TI O N S
A fundamental dilemma exists in trying to measure
adolescent undernutrition: a system simple enough
for a non-expert is required for use in emergencies,
but the reality of adolescent undernutrition is very
complex. Until better tools for nutritional
assessment of adolescents are developed, current
recommendations regarding the use of
anthropometry in adolescents must be critically
examined. Their use may yield misleading results
that stimulate inappropriate interventions. Given
the lack of validated anthropometric procedures,
anthropometric measurement of adolescents
should not currently be used as the sole technique
for the nutritional assessment of adolescents. Such
assessments should include evaluation of the
1 5
nutritional status of other population subgroups,
clinical evaluation of adolescents, evaluation of
food uses and access, and measurement of the
levels of morbidity and mortality among
adolescents and adults.
No standard method of anthropometric assessment
of the nutritional status of adolescents can be
recommended at this time. However, recent
developments have suggested potential methods
that may be used until the results of the research
described above are available and a method can
be recommended. The following components
should be included in any anthropometric
assessment of adolescents:
q Screening f or severe undernut rit ion.
Until better methods can be developed and
validated, screening for severe undernutrition
in order to determine the need for therapeutic
feeding should use clinical criteria as
recommended for adults
59
.
q Correct ion f or dif f erences in age of
sexual mat urat ion. Some measure of the
age of specific pubertal landmarks should be
measured during nutrition surveys of
adolescents. Measures that may be useful
include age of menarche in females.
Unfortunately, validated markers that are
practical for field use do not exist for males.
Correction for differences between the survey
population and the reference population
should be undertaken if the necessary data
are available for the reference population
used.
q Prepubert al adolescent s. Because young
adolescents may be more similar to children,
the most appropriate index for use in
measuring undernutrition prevalence among
prepubertal adolescents may be weight-for-
height, at least until other indices are more
fully investigated. Individuals can be
compared to an existing reference using the
preliminary weight-for-height tables in Annex
1. Data from this original reference
population should be recalculated to provide
direct weight-for-height cut-off points.
q Post pubert al adolescent s. Because older
adolescents may be more similar to adults,
BMI should be used until other indices have
been more fully investigated. Nonetheless,
some linear growth continues and BMI
continues to change with age after attaining
sexual maturity. As a result, cut-off points
should be age-specific. Although several
reference populations exist for which BMI
centiles and/or z-scores have been
calculated, the international reference
population described by Cole
80
may be the
best reference currently available for use in
the developing world. The method for
creating age-specific cut-off points described
by Cole should be used to determine cut-off
points, in both percent of median and z-
scores, corresponding to the adult BMI cut-off
points of 16, 17, and 18.5 kg m
-2
.
q Ref erence populat ions. The reference
population of American adolescents,
currently recommended by WHO for use with
BMI, should not be used.
q Age. Both weight-for-height and BMI are
age-dependent. Therefore, when these
indices are used, age must be collected as
accurately as possible for each survey
subject or individual screened. It may be
necessary to construct a local calendar to
determine ages, although this may be difficult
with adolescents because of the many years
since birth. It may also be necessary to
investigate the existence of systematically
biased reporting of age which could lead to
substantial under- or over- estimation of the
prevalence of undernutrition when using
weight-for-height or BMI.
q Addit ional dat a. Adolescents should not
undergo nutritional assessment in isolation.
Young children, women of child-bearing age,
adults, elderly, or other population subgroups
should also be assessed. A large
discrepancy between the estimated level of
undernutrition in adolescents and other
population subgroups should stimulate
investigation of the validity of the methods
and results of the adolescent assessment.
q Comparison of surveys. In order to assess
the methods and comparability of surveys, all
survey reports should describe in detail the
anthropometric index used, how
measurements were taken, which reference
population was used, how individuals were
compared to this reference, the cut-off points
used to define various degrees of
undernutrition, and any other ancillary data
collected on the population of interest.
1 6
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1 9
ANNEX 1 ANNEX 1
M edi an and 7 0 % of medi an wei ght s f or var i ous hei ght s, f or mal es and M edi an and 7 0 % of medi an wei ght s f or var i ous hei ght s, f or mal es and
f emal e adol escent s. Dat a f r om M i chael Gol den. f emal e adol escent s. Dat a f r om M i chael Gol den.
Weight ( Weight ( kgs) kgs)
Males Males Females Females
Height ( cm) Height ( cm) Median Median 7 0 % of median 7 0 % of median Median Median 7 0 % of median 7 0 % of median
100.0 15.916 11.141 15.565 10.896
100.5 16.046 11.232 15.686 10.980
101.0 16.177 11.324 15.807 11.065
101.5 16.308 11.416 15.928 11.150
102.0 16.440 11.508 16.050 11.235
102.5 16.574 11.601 16.172 11.320
103.0 16.707 11.695 16.294 11.406
103.5 16.842 11.789 16.418 11.492
104.0 16.978 11.884 16.541 11.579
104.5 17.114 11.980 16.666 11.666
105.0 17.252 12.076 16.791 11.754
105.5 17.391 12.173 16.917 11.842
106.0 17.530 12.271 17.044 11.931
106.5 17.671 12.370 17.172 12.021
107.0 17.813 12.469 17.301 12.111
107.5 17.957 12.570 17.432 12.202
108.0 18.101 12.671 17.564 12.295
108.5 18.247 12.773 17.697 12.388
109.0 18.395 12.876 17.833 12.483
109.5 18.544 12.981 17.970 12.579
110.0 18.694 13.086 18.109 12.676
110.5 18.846 13.192 18.250 12.775
111.0 19.000 13.300 18.394 12.876
111.5 19.156 13.409 18.540 12.978
112.0 19.313 13.519 18.689 13.083
112.5 19.473 13.631 18.841 13.189
113.0 19.634 13.744 18.996 13.297
113.5 19.797 13.858 19.154 13.408
114.0 19.963 13.974 19.316 13.521
114.5 20.131 14.092 19.481 13.637
115.0 20.301 14.211 19.650 13.755
115.5 20.474 14.331 19.823 13.876
116.0 20.649 14.454 20.000 14.000
116.5 20.826 14.578 20.181 14.127
117.0 21.006 14.705 20.367 14.257
117.5 21.189 14.833 20.558 14.390
118.0 21.375 14.963 20.753 14.527
118.5 21.564 15.095 20.954 14.668
119.0 21.756 15.229 21.160 14.812
119.5 21.951 15.366 21.371 14.960
120.0 22.149 15.504 21.588 15.112
120.5 22.350 15.645 21.811 15.267
121.0 22.555 15.789 22.036 15.425
121.5 22.763 15.934 22.270 15.589
122.0 22.975 16.083 22.510 15.757
122.5 23.190 16.233 22.756 15.929
123.0 23.409 16.387 23.008 16.105
123.5 23.632 16.542 23.265 16.285
124.0 23.859 16.701 23.527 16.469
124.5 24.089 16.862 23.794 16.656
125.0 24.323 17.026 24.066 16.846
125.5 24.561 17.193 24.344 17.040
126.0 24.803 17.362 24.625 17.238
2 0
126.5 25.050 17.535 24.912 17.438
127.0 25.308 17.716 25.202 17.642
127.5 25.563 17.894 25.497 17.848
128.0 25.822 18.075 25.796 18.057
128.5 26.084 18.259 26.098 18.269
129.0 26.351 18.446 26.404 18.483
129.5 26.622 18.635 26.714 18.700
130.0 26.896 18.828 27.027 18.919
130.5 27.175 19.022 27.343 19.140
131.0 27.457 19.220 27.662 19.363
131.5 27.743 19.420 27.984 19.589
132.0 28.032 19.622 28.308 19.816
132.5 28.325 19.827 28.635 20.044
133.0 28.621 20.035 28.963 20.274
133.5 28.921 20.244 29.294 20.506
134.0 29.223 20.456 29.627 20.739
134.5 29.529 20.670 29.961 20.973
135.0 29.838 20.887 30.297 21.208
135.5 30.150 21.105 30.634 21.444
136.0 30.464 21.325 30.973 21.681
136.5 30.782 21.547 31.312 21.918
137.0 31.101 21.771 31.652 22.156
137.5 31.424 21.997 31.993 22.395
138.0 31.748 22.224 32.334 22.634
138.5 32.075 22.453 32.676 22.873
139.0 32.404 22.683 33.018 23.113
139.5 32.735 22.915 33.360 23.352
140.0 33.068 23.148 33.703 23.592
140.5 33.403 23.382 34.044 23.831
141.0 33.739 23.618 34.386 24.070
141.5 34.078 23.854 34.727 24.309
142.0 34.417 24.092 35.068 24.548
142.5 34.758 24.331 35.408 24.786
143.0 35.101 24.571 35.748 25.023
143.5 35.445 24.811 36.086 25.260
144.0 35.790 25.053 36.424 25.497
144.5 36.136 25.295 36.760 25.732
145.0 36.483 25.538 37.093 25.965
145.5 36.831 25.781 37.428 26.199
146.0 37.179 26.026 37.762 26.433
146.5 37.546 26.282 38.095 26.667
147.0 37.897 26.528 38.429 26.900
147.5 38.249 26.774 38.763 27.134
148.0 38.602 27.021 39.099 27.369
148.5 38.957 27.270 39.436 27.605
149.0 39.313 27.519 39.774 27.842
149.5 39.671 27.770 40.115 28.080
150.0 40.031 28.021 40.458 28.321
150.5 40.393 28.275 40.805 28.564
151.0 40.757 28.530 41.155 28.809
151.5 41.124 28.787 41.510 29.057
152.0 41.494 29.046 41.878 29.315
152.5 41.867 29.307 42.244 29.571
153.0 42.243 29.570 42.616 29.831
153.5 42.622 29.835 42.995 30.096
154.0 43.004 30.103 43.382 30.367
154.5 43.391 30.373 43.779 30.645
155.0 43.781 30.647 44.186 30.930
155.5 44.175 30.923 44.606 31.224
156.0 44.574 31.202 45.041 31.528
2 1
156.5 44.976 31.483 45.494 31.845
157.0 45.384 31.769 45.969 32.178
157.5 45.797 32.058 46.473 32.531
158.0 46.214 32.350 47.011 32.907
158.5 46.637 32.646 47.588 33.312
159.0 47.064 32.945 48.215 33.750
159.5 47.496 33.247 48.901 34.231
160.0 47.932 33.553 49.665 34.765
160.5 48.374 33.862 50.533 35.373
161.0 48.820 34.174 51.550 36.085
161.5 49.271 34.490 52.803 36.962
162.0 49.728 34.809 54.449 38.114
162.5 50.189 35.132 56.089 39.262
163.0 50.655 35.459 56.662 39.664
163.5 51.128 35.790 56.694 39.686
164.0 51.605 36.124
164.5 52.088 36.462
165.0 52.576 36.803
165.5 53.070 37.149
166.0 53.570 37.499
166.5 54.076 37.853
167.0 54.588 38.212
167.5 55.107 38.575
168.0 55.633 38.943
168.5 56.166 39.316
169.0 56.706 39.694
169.5 57.255 40.078
170.0 57.812 40.468
170.5 58.379 40.865
171.0 58.955 41.269
171.5 59.543 41.680
172.0 60.144 42.101
172.5 60.759 42.531
173.0 61.390 42.973
173.5 62.040 43.428
174.0 62.713 43.899
174.5 63.416 44.391

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