Anthropometry:

standardization procedure
Ilmia Fahmi, M.Gizi
Important concepts in nutritional assessment

Validity: adequacy to which any measurement or index reflects

the nutritional parameter of interest

Precision/reproducibility: the degree to which repeated

measurement of the same variable give the same value

Accuracy: the extent to which the measurement is close to the

true value
Standardization Anthropometry

to assess precision and accuracy prior to doing

data collection and to ensure measurer/observer
collects accurate anthropometry data
Precision / reproducibility
• Usually expressed as coefficient of variation (CV%) 
𝑠𝑡𝑎𝑛𝑑𝑎𝑟𝑑 𝑑𝑒𝑣𝑖𝑎𝑡𝑖𝑜𝑛
CV%= 𝑥 100%
𝑚𝑒𝑎𝑛
• Could reduced by random measurement errors  individual
variation, sampling error or measurement error
• Random measurement errors increase the variability about the mean,
reduce the precision of the measurement, but do not influence the
mean or median
Accuracy
• Extent to which the measurement is close to the true value
• Reduced due to systematic errors (bias), which can be introduced by
biased equipment, analytical bias, social desirability bias, interviewer
bias, or recall/respondent bias
• Systematic errors (bias) do not affect the variance or precision of the
measurement but reduce accuracy of the measurement by
introducing a bias that alters the mean or median
 Errors in Anthropometry

1. Random measurement errors and precision, can be minimized by:

1. Training of personnel
2. Standardized techniques
3. Correctly-calibrated instruments
4. Multiple measurements on each individual
Precision can be assessed by:
1. TEM=technical error of the measurement
2. Percentage technical error (%TEM)
3. Coefficient of reliability (R)
 ...Errors in Anthropometry

1. TEM = √ (∑D2) / 2N, where D=difference b/t two measurements and

N=number of subjects  infl. by the size of measurement
2. %TEM = (TEM/mean) x 100%  can be used to make direct
comparisons of all types of anthropometric measurements
3. Coeff. Reliability (R) = 1-( (TEM)2/s2 ) where s2=between-subject
variance  indicates proportion b/t-subject variance which is not due to
measurement error; ideally R>0.95
 ...Errors in Anthropometry
Measurement Trainee-trainer
2. Systematic measurement
errors and inaccuracy, difference
can be caused by: Good Fair Poor
• Equipment bias Height/ 0-5 6-9 10-19
• Timing (e.g. height during
length (mm)
the day)
Repeat-measures protocol Weight (kg) 0-0.1 0.2 0.3-0.4
(Zerfas, 1985)  Table
Arm circ. 0-5 6-9 10-19
(mm)
Skinfolds-any 0-0.9 1.0-1.9 2.0-4.9
(mm)
Assessment of Precision and Accuracy in WHO MGRS

Precision: Technical error of measurement (TEM): √(Σdi2/2n)

• di = the difference between the i-th subject’s test and retest measurements by the
observer
• n = number of measured subjects
Average bias: Observer ΣΔi /n
• Δi = the difference between the observer’s mean and the lead anthropometrist’s mean
measurement for the ith subject (or overall mean measurement for the ith subject)
Strategies:
• initial and bimonthly standardization;
• daily calibration of equipments;
• assessment of proportions of difference between two measurers above allowable
difference (<5% of measurements above allowable difference)

10
Assessment of standardization session:
example from Rotterdam length data
(De Onis et al, Food Nutr Bull 25(1): S27-S36

11
Standardization procedure
Each observer and “expert anthropometrist” (gold standard) measures 10 subjects (1st
measurement = a).

Each observer and “expert anthropometrist” measures the 10 subjects (2nd measurement,
independent of 1st measurement = b).

Calculate the difference between 1st and 2nd measurement within observer (precision) and
difference between measurement of observer and “expert anthropometrist” (accuracy)
 ...Anthropometry
standardization procedure
Example: calculations taken for the raw data of height measurements collected by one
observer/measurer (A). Conclusion: NOT precise and NOT accurate.

TEM > 0.70 cm Bias > 0.7 cm

( 1st vs 2nd measurement) (team vs gold standard)
 ...Anthropometry
standardization procedure
Example: calculations taken for the raw data of height measurements collected by one
observer/measurer (A). Conclusion: precise and accurate.

TEM < 0.70 cm Bias < 0.7 cm

( 1st vs 2nd measurement) (team vs gold standard)
Quality control
dari pengukuran serial
• Periksa selisih pengukuran ke-1 dan ke-2, TIDAK LEBIH
dari:
• 0,2 kg untuk berat badan ibu / berat badan baduta
• 0,5 cm untuk tinggi badan ibu / panjang badan baduta
• 0,5 cm untuk LILA bumil.
• Periksa Z - skor, cek hasil pengukuran dan tanggal lahir
jika Z-skor berada di luar rentang sbb:
• Jika LAZ kurang dari -6 SD atau lebih besar dari +6 SD: cek
hasil pengukuran panjang badan dan tanggal lahir
• Jika WAZ kurang dari -6 SD atau lebih besar dari 5 SD: cek
hasil pengukuran berat badan dan tanggal lahir
• Jika WLZ kurang dari -5 SD atau lebih besar dari 5 SD: cek
hasil pengukuran berat badan dan panjang badan
Sensitivity, specificity, predictive
values and prevalence
Sensitivity and specificity
Sensitivity (Se)  the extent to which an index/measurement
reflects nutritional or predicts changes in nutriture

In other words  the ability to identify and classify genuinely

malnourished person

Specificity (Sp)  the ability of an index/measurement to

identify and classify genuinely well-nourished persons

Sensitivity and specificity are characteristics of the test. The

population does not affect the results
Predictive value and prevalence
• Predictive value (V)  the likelihood that an index correctly predicts
presence or absence of malnutrition or disease
• Positive and negative predictive values are influenced by the
prevalence of disease in the population that is being tested.
• If we test in a high prevalence setting, it is more likely that persons
who test positive truly have disease than if the test is performed in a
population with low prevalence
• Prevalence  number of persons with malnutrition/disease during a
given period
Test Results Malnutrition
Present Not Present
Positive True Positive (TP) False Positive (FP)
Negative False Negative (FN) True Negative (TN)

Sensitivity (Se) = TP / (TP+FN)

Specificity (Sp) = TN / (TN+FP)

Predictive Value (V) = (TP+TN) / (TP+TN+FP+FN)

Positive predictive value (V+) = TP / (TP+FP)
Negative predictive value (V-) = TN / (TN+FN)

Prevalence (P) = (TP+FN) / (TP+TN+FP+FN)