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.
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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 Blösnner ( 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 édecins
Sans Fr ont ièr 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) .
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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 SCN’s 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
.
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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 child’s 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.
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
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
A N THRO PO M ETRY A N THRO PO M ETRY
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.
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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
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
5
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RNIS Supplement -- July 2 0 0 0 RNIS Supplement -- July 2 0 0 0
6
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
A N THRO PO M ETRY A N THRO PO M ETRY
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
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
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
)
RNIS Supplement -- July 2 0 0 0 RNIS Supplement -- July 2 0 0 0
8
F
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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
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 Médecins Sans
Frontières (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
)
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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 child’s 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 individual’s
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
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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.
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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
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 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.
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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
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 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.
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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 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
RNIS Supplement -- July 2 0 0 0 RNIS Supplement -- July 2 0 0 0
2 0
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
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
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
2 1
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
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

This report is issued on the general responsibility of the Secretariat of the UN ACC/SubCommittee on Nutrition; the material it contains should not be regarded as necessarily endorsed by, or reflecting the official position of the ACC/SCN and its UN member agencies. The designations employed and the presentation of material in this publication do not imply the expression of any opinion whatsoever on the part of the ACC/SCN or its UN member agencies concerning the legal status of any country, territory, city or area of its authorities, or concerning the delimitation of its frontiers or boundaries.

This report was written by: Bradley A. Woodruff, International Emergency and Refugee Health Branch, U.S. Center for Disease Control and Prevention Arabella Duffield, ACC/SCN Secretariat Duffield

We are grateful to the following reviewers for their comments: Monika Blösnner (WHO), Tim Cole (Institute of Child Health), Mary Corbett (Concern), Mercedes de Onis (WHO), Mike Golden (University of Aberdeen), Saskia van der Kam (Médecins Sans Frontières), Carlos Navarro-Colorado (Action Contre La Faim), Nick Norgan (University of Loughborough), Claudine Prudhon (Action Contre La Faim), Simon Strickland (London School of Hygiene and Tropical Medicine), Stanley Ulijaszek (Oxford University).

If you would like to request any of the ACC/Sub-Committee on Nutrition’s publications please contact: ACC/Sub-Committee on Nutrition, 20, avenue Appia, 1211 Geneva 27, SWITZERLAND Tel: +(41 22) 791 04 56, Fax: +(41 22) 798 88 91, E-mail: accscn@who.int, accscn@who.int, Web: http://acc.unsystem.org/scn/ If you have any enquiries about this supplement please contact either the ACC/SCN or: Bradley Woodruff, International Emergency Refugee Health Branch, U.S. Center for Disease Control and Prevention, Mailstop F-48, 4770 Buford Highway, Atlanta, Georgia 30341, U.S.A E-mail: baw4@cdc.gov

This report was made possible through the support provided by the Food and Nutrition Assistance (FANta) Project by the Office of Health and Nutrition Bureau for Global Programs, Field Support and Research at the U.S. Agency for International Development, under the terms of Cooperative Agreement No. HNE-A-00-98-00046-00 awarded to the Academy for Educational Development (AED). The opinions expressed herein are those of the authors and do not necessarily reflect the views of the U.S. Agency for International Development.

Funding support is gratefully acknowledged from CIDA, DFA (Ireland), NORAD, DFID (UK), UNHCR, UNICEF and WFP.

It may not be valid to expect all populations of adolescents. q Body proportions. BMI. Adolescents in many emergency affected populations do not accurately know their ages. the following adjustments may allow better estimates: q q 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. including indices using weight and height measurements. to some extent. POSSIBLE SOLUTIONS These problems affect all anthropometric indices including weight-for-height. change with age. Regardless of the anthropometric index used. making it necessary to compare an individual to adolescents in a reference population who are of the same age.SUMMARY 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. Only tentative and preliminary recommendations can be given at this time. q Body proportions may differ between the reference and survey populations. surveys using these recommendations have found unrealistically high levels of adolescent undernutrition. Cormic Index (sitting height/standing height ratio) may. to achieve the same body proportions as a single. even if well nourished. 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. valid methodology can be widely recommended for anthropometric assessment of adolescents. age must be collected on persons screened for admission to feeding programs or measured as survey subjects. . however. As a result. be used to adjust for ethnic differences in body proportions. 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 change with sexual development. and MUAC (mid-upper arm circumference). PROBLEMS WITH ANTHROPOMETRY IN ADOLESCENTS Anthropometry may be more difficult in adolescents than other age groups because of many complicating factors. CURRENT RECOMMENDATIONS Additional research is necessary before a single. Rohrer Index (weight/height3). universal reference. These recommendations may not be appropriate. this technique has not been studied in adolescents.

cut-off points are age-specifc.q Screening for severe undernutrition Until better methods can be developed and validated. q q q q q . 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. For post-pubertal adolescents. women of childbearing age. and any other ancillary data collected on the population of interest. elderly. how measurements were taken. and information on diet. Estimates of the levels of morbidity and mortality. Corrections for different ages of sexual maturation In surveys. screening for severe undernutrition in order to determine the need for therapeutic feeding should use clinical criteria. the cut-off points used to define various degrees of undernutrition. or other population subgroups should also be assessed. all survey reports should describe in detail the anthropometric index used. adults. as a result. Reference populations The reference population of American adolescents. should not be used. how individuals were compared to this reference. 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. food security. weight-for-height could be used as the anthropometric index and compared to revised weight-for-height tables currently in use. currently recommended by WHO for use with BMI. and food sources should also be collected Comparison of surveys In order to assess the methods and comparability of surveys. which reference population was used. Additional data Adolescents should not undergo nutritional assessment in isolation. age should be collected as accurately as possible on all adolescents measured during screening or survey activities. Young children. Appropriate cut-off points could be used to identify malnourished individuals. Corrections for effect of age on anthropmetric measurements Regardless of which index is used. BMI could be used as the anthropometric index and compared to a new international reference population.

........................................................................................................................ 6 Changes in body proportions with age ........................................................................................................................................................................................................ 8 Figure 3: BMI as a function of Cormic Index........................... 6 Pubertal development..............14 References ..............................................................................................12 Pubertal development................................................................................................................................................................................... 5 Figure 1: Weight-for-height.......................................................... 7 Figure 2: Example of drawing used in self-assessment............................... 2 Current WHO recommendations .................................................................................................................11 Possible solutions for the future ........................................................................................ 3 Box 2: Example of adjustment of BMI for maturational age for girls ......13 Future research needs....................................................................................... BMI.........................12 Interethnic differences in genetic growth potential.........................................................................10 Practical problems with indices using weight and height ....................................................................CONTENTS Introduction 1 Background on anthropometry ............. 3 Description of recommendations ................................................................................................................................. 4 Complications of adolescent anthropometry................................................................................................................................................................................................................... for males and female adolescents......................... 9 Theoretical problems with indices using weight and height .................................................. 3 Application of recommendations................................................................................................................................................................................................................................................................................................................................................................................................................................................................................ 9 ........................................................................................................................................................................ 9 Weight-for-height measures......................................................................................14 Conclusions and recommendations .............................11 Practical problems with the use of MUAC .....................................................................10 MUAC 11 ............................................................................................................................................................................................................................................................... 7 Interethnic differences in genetic growth potential................................................................................................................................19 List of Boxes.... 4 Table 1: Summary of the results of surveys which used WHO recommendations to assess adolescent nutritional status.................................................................................. Theoretical problems with the use of MUAC.......................................................................... and Rohrer Index as a function of age during childhood and adolescence............. Tables and Figures Box 1: An explanation of cut-off points for anthropometric indices in child and adults ..................................................................................... 9 Which anthropometric index? .12 Changes in body proportions with age .............................................16 Annex I: Median and 70% of median weight for various heights......................................................................12 Use of other data .................................................................................................................................................................................

Extract from the ACC/SCN's Strategic Plan. This includes (especially) identifying knowledge gaps and significant areas in dispute or controversy.Signalling the need for norms and standards. standards The SCN will identify for the attention of technical agencies or other bodies critical areas where norms and standards are missing or out-of-date and holding programmes back. April 2000 . and facilitating this work. as well as identifying areas requiring operational research.

UNITED NATIONS Administrative Committee on Coordination SUB-COMMITTEE ON NUTRITION THE UN SYSTEM'S FORUM FOR NUTRITION VISION AND MANDATE Our long-run vision is of a world in which malnutrition is no longer a human development constraint. UN. IFAD. Three main areas for action have been identified: (i) Promote of harmonized approaches among the UN agencies. (ii) Review the UN system response to malnutrition overall. recognized as vital to the achievement of other social and economic goals. The UN members of the ACC/SCN are the FAO. The mandate of the ACC/SCN is to raise awareness of nutrition problems and mobilize commitment to solve them -. ILO. and between the UN agencies and governmental and non-governmental partners. and household food security to capacity building . These three functions are all vital and of equal importance and can be seen as a triangle. UNEP.a one-day Symposium is held during the annual meeting. regional and national levels. for greater overall impact on malnutrition. UNICEF. UNAIDS. founded on human rights and providing a framework for action throughout the UN and international development finance system. one dependent on the other. Quarterly bulletins on the nutritional status of refugees and displaced persons are also published in collaboration with a large network of NGOs. UNHCHR. WHO and the World Bank.at global. The SCN undertakes a range of activities to meet its mandate. The Secretariat is hosted by WHO in Geneva. Nutrition needs to be made a key development priority. UNHCR. . UNFPA. The ADB and IFPRI are also part of this group. implemented in close partnership with NGOs. UNRISD. The SCN convenes working groups on specialized areas of nutrition. The SCN’s reports on the world nutrition situation. supported by a coherent and coordinated international strategy. and to promote cooperation amongst UN agencies and partner organizations in support of national efforts to end malnutrition in this generation. This is possible. Annual meetings have representation from those mentioned above as well as academia -. regional and country levels and mobilize accelerated action against malnutrition. IAEA. WFP. representatives of bilateral donor agencies and NGOs have participated actively in SCN activities. bilaterals and governments. focussing on a subject of current importance for policy. increase the scale and strengthen the coherence and impact of actions against malnutrition world wide. (iii) Advocate and mobilize to raise awareness of nutrition issues at global. monitor resource allocation and collate information on trends and achievements reported to specific UN bodies. nutrition of the school aged child. Nutrition Policy Papers and the SCN News summarise current knowledge on selected topics. Good nutrition facilitates the prompt return to conditions favouring development following disasters. but to achieve it will require decisive action at country level. Good nutrition under normal conditions contributes to the prevention and mitigation of death and malnutrition in emergency situations. currently there are nine working groups in areas ranging from foetal and infant malnutrition. published every two to three years. are authoritative sources of information to guide the international community in its nutrition work. UNDP. UNU. to refine the direction. From the outset. UNESCO.

Improvement in nutritional status can improve pregnancy outcomes. acute undernutrition is often common and. muscle mass. Examples of assessments that have used the recommended procedures are included. such as anaemia and other micronutrient deficiencies. the requirement for many micronutrients. This paper also points out some of the deficiencies of the current recommendations regarding the nutritional assessment of adolescents. poor nutritional habits. and iodine. In adolescents. Moreover. emergencies in Europe. this ration may provide insufficient energy 13. In children and young adolescents. vitamin C. they cannot become stunted. In such situations. including maternal death. eating disorders. Because of the focus on humanitarian emergencies. thiamine. chronic undernutrition also delays normal maturation 2-8. experienced by pregnant adolescents 9. 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. Although chronic undernutrition is an important and widespread problem 9 with multiple adverse health outcomes. chronic undernutrition leads to stunting (low heightfor-age). and Africa have highlighted the nutritional vulnerability of other population subgroups. Nonetheless.Assessment of Nutritional Status of Adolescents in Emergency-Affected Populations assessments have produced misleading results. it is not usually the highest nutritional priority in emergency situations.420 kcal required per day by adolescents 15-19 years of age is the highest energy requirement of any age group. may account for a substantial proportion of overall mortality 10. because of rapid growth in stature. However. and obesity 1. This discussion emphasizes practical issues of anthropometric assessment of nutritional status rather than general knowledge of adolescent growth and development. 15-19. the discussion will include only an evaluation of acute undernutrition. foetal death. 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 report will also not directly address chronic undernutrition. although little is known about the short and long-term effects of acute undernutrition during adolescence. including vitamin A. INTRODUCTION This RNIS supplement discusses the assessment of undernutrition in adolescents in emergency situations. Central Asia. Between 10 and 19 years of age. the requirements for some nutrients is as high or higher in adolescents than in other age groups 13. and thinness may result from either a sudden or longstanding food deficit. such as elderly adults 1. and fat mass during the peak of the adolescent growth spurt. In many cultures. 1 . the distinction between acute and chronic undernutrition among adolescents and adults is not nearly as clear as it is among young children. vitamin B12. The World Health Organization (WHO) defines adolescents as persons aged 10-19 years old. reaches levels required by nonpregnant adults. Since adults and older adolescents no longer increase their height. 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. and at least one has resulted in the implementation of potentially unneeded interventions. niacin. 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. Adolescence may also present a nutritional opportunity. Adolescents have not traditionally been considered at disproportionately elevated nutritional risk in emergency situations. a large proportion of girls have their first pregnancy during adolescence. In populations with a higher proportion of adolescents or adults. riboflavin. Many of these In displaced and emergency-affected populations. The 2. including those published by WHO. Moreover. folic acid. Nonetheless. at least in young children. This paper will not address many other important nutritional problems in adolescents. and preterm delivery.

On the other hand. Only recently has an attempt been made to use anthropometric methods to assess acute undernutrition in adolescents 12. Nonetheless. 20. such as age. cannot provide the complete picture of the nutrition and food situation needed for problem solving and programme planning. Use of anthropometry requires two essential items: an anthropometric indicator and a cut-off point. The index weightfor-height indicates thinness. Skinfold thickness measurements. often called an anthropometric index. The recommended admission criteria are weightfor-height <-3 z-scores or <70% of median (see Box 1 for explanation of cut-off points) or the presence of oedema 14. and other elements are needed to understand the causal factors resulting in undernutrition 23. To identify those in need of nutritional rehabilitation. acute undernutrition may be superimposed over a high level of background chronic undernutrition. Anthropometry can provide an estimate of the prevalence of undernutrition. resulting in a decline in skinfold thickness and MUAC. such as older adults. morbidity and mortality. along with other data on food and health. or the combination of measurements with additional data. adolescents. Anthropometry can be used to evaluate either individuals or populations. 2 . a cut-off point is established below which persons are offered nutritional therapy. In many emergency-affected populations. and children become stunted. anthropometric measurements are relatively easy to obtain in the field and anthropometric surveys can often be carried out in displaced populations.July 2000 BACKGROUND ON ANTHROPOMETRY Anthropometry is the measurement of certain parameters of the human body. such as weight and height. The indicator. Different indices reflect different components of nutritional status. however. both thinness and stunting may be common. Young children 6-59 months of age with severe acute undernutrition are usually treated in inpatient therapeutic feeding centres. As a result. taken at various places on the body. Anthropometry has also been used to study the growth and development of school-aged children and adolescents. Anthropometric measurements are taken frequently during nutritional therapy and. weight-for-height decreases with acute undernutrition. Anthropometry. It is frequently used to assess nutritional status in young children and adults 12. but does interfere with normal linear growth. young children with chronic undernutrition may not be thinner than normal children. but evaluations of food security. but may have retarded growth in height. The proportion of sampled children who are undernourished provides an estimate of the prevalence of undernutrition in the entire population of children. nutrient content. Estimates of the prevalence of undernutrition. 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.RNIS Supplement -. even during the acute phase of a humanitarian emergency. Chronic undernutrition may not be severe enough to cause weight loss. in combination with clinical observations. 21. Anthropometry is also used to determine the prevalence of undernutrition in a population. or pregnant women. but can be undertaken in any population subgroup. Anthropometric measurements for each child selected as part of a representative sample are compared to a reference population to determine each child’s nutritional status. height-for-age is decreased. Such surveys are most commonly performed in children 6-59 months of age. Mid-upper arm circumference (MUAC) is an indicator of the amount of fat and muscle in the upper arm. Weight-for-age reflects both acute and chronic undernutrition because both thin children and stunted children are underweight. and because acutely undernourished persons generally lose body weight but not height. Acutely undernourished persons metabolise fat and muscle to compensate for decreased nutrient intake. or to evaluate the effect of such programs. are used to plan programmes of food aid and nutritional therapy. is a measurement or a combination of measurements made in the field. food distribution. As a result. 22. provide an estimate of the thickness of subcutaneous fat. are used to determine when children can be discharged.

Visual evidence of extreme emaciation can identify those requiring immediate feeding.88 kg. her weight-for-height z-score is -2. The ability to walk or work may also be important in identifying those in greatest need. 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.95 standard deviations below the median.3% of the children in the American reference population will fall below -2 z-score weight-for-height and be defined as acutely undernourished. Each measured child is compared to the reference population to determine how far that child is from the average child in the reference population. she falls 2. there are many studies of the health outcomes of chronic undernutrition. Because the weight of our example child is 2. or examples of. The distribution of weights for all reference children of the same sex and height is described by the median and standard deviation. 2. The z-score cut-offs for moderate and severe undernutrition (<-2 and <-3.Assessment of Nutritional Status of Adolescents in Emergency-Affected Populations Box 1. In a population survey. which is also called the Quetelet Index. centile. a specific level must be determined as the cut-off point which distinguishes the normal nutritional state from undernourished. is to express weight-for-height in centiles. To screen adolescents in less extreme need of nutritional interventions: q Use BMI-for-age to assess acute undernutrition.6 kg lower. That is. An alternate method. The median weight of girls in the reference population who are 80 cm long is 10. the measured child has a weight-for-height which is 75% of median.5 have more frequent illness. less capacity for physical labour. the preferred method for expressing the comparison between a specific child and the reference is by using z-scores. 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 q 3 . CURRENT WHO RECOMMENDATIONS FOR ADOLESCENT ANTHROPOMETRY DESCRIPTION OF WHO RECOMMENDATIONS (SUMMARISED FROM: PHYSICAL STATUS: THE USE AND INTERPRETATION OF ANTHROPOMETRY. An explanation of cut-off points for anthropometric indices in children and adults For each anthropometric index. Cut-off points are also used to distinguish different levels of undernutrition. the standard deviation of the weight for reference girls who are 80 cm long is approximately 0. respectively) were determined from the distribution of weight-for-height values in a sample of American children. In population surveys. One standard deviation is one z-score. we find that our 8 kg. and. Therefore. this child falls on the 16th centile of weight-for-height. This discrepancy between an individual child and the reference can be expressed in a number of ways.95.6 kg. It is calculated as the weight in kilograms divided by the square of the height in meters (Wt/Ht2). poorer birth outcomes 21. if anthropometry is being used to determine who needs nutritional intervention. Therefore. Although very little data are available relating a specific cut-off point to the consequences of acute undernutrition. 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. The cut-off point defining undernutrition is sometimes determined using health outcome data. One frequently used method when assessing individual children is the percent of median. The median weight of these reference girls is 10. by definition. or z-score is used. These studies have shown that adults with a BMI less than 18 or 18. given in kg. adult undernutrition is frequently assessed using the body mass index (BMI). REPORT OF A WHO EXPERT COMMITTEE 12) (2) (1) To screen adolescents for severe undernutrition to determine the need for admission to therapeutic feeding: Use clinical criteria. in women.6 kg (note that age is not necessary). 80 cm girl weighs less than 84% of girls in the reference population who are 80 cm long. It must be remembered that reference populations are used only to develop statistical cut-off points and may not necessarily represent targets for. For example. Regardless of whether percent of median. optimum nutritional status. For example. the most commonly used index of acute undernutrition in young children is weight-for-height. We will use as an example a 17 month-old girl who weighs 8 kg and is 80 cm long. Therefore. now somewhat outdated. Indeed. Using the example girl referred to above. 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. upon looking up in a centile table. Cut-off points for anthropometric indices can be determined statistically. Pregnant and lactating adolescents may need additional nutritional support.

For each sex separately. the differences for the two landmarks are averaged. 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. The difference is calculated between the survey population and the reference population in the median ages of attaining these landmarks. the Tanner genitalia stage and the age of attainment of adult voice should be collected. 25. these are subtracted from the median ages in the NCHS reference population (10. and age. [Note that CDC has recently published new growth charts based on children from the US. Calculate the proportion of adolescents falling below the 5th centile or a locallydefined cut-off point. if the median ages for girls of attainment of breast stage 2 and menarche is 12. The survey population characteristics and the estimated prevalence rates of thinness and stunting are summarised in Table 1. WHO recommendations describe a method to adjust.) Box 2. (See Box 2 for example of adjustment for maturational age in females. This adjustment allows survey girls to be compared to girls in the reference population who are at the same level of sexual maturation APPLICATION OF THE WHO RECOMMENDATIONS Since their publication.cdc. For female adolescents. Adolescents falling below the 3rd centile of the NCHS reference population are defined as stunted26.RNIS Supplement -. the Tanner breast stage and the age of menarche (if postmenarcheal) should be collected. 4 . respectively). 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. see www. q Along with weight. which is then subtracted from the age of each of the girls in the survey population. at least in part. the WHO recommendations have been used to analyse the results of several surveys undertaken in both stable and displaced populations in developing countries. To estimate the prevalence of acute undernutrition in a population of adolescents: q Use BMI-for-age as described above.8 years. In a hypothetical survey population. This adjustment can be undertaken when assessing either acute or chronic undernutrition. For each female adolescent. The average of these two differences is approximately 1. investigators then calculate the median age of reaching the Tanner breast stage 2 and the median age of menarche. height.2 years and 14. although local cut-offs can also be developed which take into account the availability of resources to manage the patient load. For male adolescents.5 years. respectively.July 2000 (3) (4) (5) 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.] q Adolescents falling below the 5th centile of the NCHS reference population may need intervention. For male adolescents q q investigators calculate the median age of attaining the Tanner genitalia stage 3 and median age of attaining adult voice. The age at which 50% of girls have attained these landmarks is the median age. survey workers should collect data on specific landmarks of sexual maturation. Example of adjustment of BMI for maturational age for girls 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. for potential differences in the ages of maturation between survey populations and the reference population.2 years. For each sex.6 and 12. the average difference between the survey and reference populations in these median ages is then used to adjust the age of each survey subject. In addition.gov/nchs.

India 28 Residents of 3 rural villages in Nepal 28 Residents of 4 rural villages in Benin Displaced populations April 1997 November 1998 November 1998 10-19 10-19 10-19 Males: 9-20 Females: 9-17 1011 males 320 females 265 males 124 females 208 males 184 females 225 males 238 females Refugees dependent on food aid Refugees dependent on food aid Refugees dependent on food aid Refugees dependent on food aid Boys: 75% Girls: 55% 57% 61% N. 3 camps in Dadaab District. Bangladesh 27 1992-93 1992-93 1992-93 12-18 179 males 171 females 10-18 179 males 148 females 10-19 69 males 69 females Schoolboys in Calcutta.Table 1 Summary of the results of surveys which used WHO recommendations to assess adolescent nutritional status Date or survey Age of survey subjects (years) of low Number of survey Socioeconomic level of Prevalence of low Prevalence-age height-forBMI (thinness) height -for subjects subjects <5 th centile (stunting) <5 th centile Reference Camp or population Stable populations May . 7 camps in October 1999 Nepal Crude: 36% Adjusted*: 34% Crude: 67% Adjusted*: 55% Assessment of Nutritional Status of Adolescents in Emergency-Affected Populations * Adjusted for differences in age of sexual maturation between survey and reference populations 5 .A.Aug 1995 10-16 16% 384 females 10% 5 1982-83 10-16 570 males Schoolgirls in Dhaka. Kakuma camp. Kenya 30 Population-based sample. Kakuma camp. India Literacy: 98% fathers 95% mothers >10 years school: 82% fathers 64% mothers 52% Residents of urban slums 53% "lower-income areas" "lower-income areas" 36% 23% 12% 32% 47% 41% 28 School students in Bombay. Kenya 31 Population-based sample. 9% 22% 29 School attendees. Kenya 32 Population-based sample.

depending on the region where the survey was done 33. other than the results of the adolescent surveys. Two of the surveys included adolescents from families with relatively high socioeconomic status and yet still found substantial acute undernutrition among adolescents. changes with age in healthy. in the WHO Global Database on Child Growth and Malnutrition. certain considerations cast doubt on the validity of some of these estimates of thinness and the methods employed to produce the estimates. well-nourished children. and adults. Given the questions about the validity of the procedures recommended by WHO. Uncritical use of the WHO recommendations may yield misleading results.as for young children . In the refugee camp surveys there were no indications. the estimated prevalence of thinness exceeded that of stunting by a factor of 1.5-12. In addition. 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. COMPLICATIONS OF ADOLESCENT ANTHROPOMETRY 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. 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.5 times more common that thinness. An analysis of the results of 175 nutrition surveys throughout the world demonstrated that among children 12-23 months of age. In all these populations. relief food was diverted from the general ration distribution to a supplementary feeding programme targeted to school attendees. as a consequence of one survey of adolescents. Although little is known about the usual ratio of the prevalence rates of thinness and stunting among nutritionally compromised adolescents. in turn. only Fiji has a higher prevalence of thinness than of stunting 34.6 . these results would be highly unusual in children up to 5 years of age. four of the surveys chose samples from among children who were well enough to attend school during survey activities. Although the applicability of these data to adolescents is not precisely known. stunting was 2. as measured by weight-for-height and BMI. Eight surveys estimate the prevalence of both thinness and stunting. while thinness is due to relatively recent undernutrition. there was no evidence of elevated morbidity or mortality in these populations 30-32. For example. that substantial undernutrition existed in any segment of the population.RNIS Supplement -. In three surveys undertaken in refugee camps.July 2000 Based on the data contained in Table 1 and in reports from these surveys.the prevalence of stunting would exceed the prevalence of thinness because stunting is cumulative. In populations in industrialised countries. 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. which may. lead to inappropriate interventions. adolescents. In five of these surveys. then rises steadily until 6 .6.3. Nonetheless. q q q q q Although no data were specifically collected on health outcomes. including: q q q Changes in body proportions with age Pubertal development Inter-ethnic differences in genetic growth potential CHANGES IN BODY PROPORTIONS WITH AGE Thinness. recent surveys of children less than 5 years of age had estimated a low prevalence of acute undernutrition 29-32. one might expect that in adolescents . BMI reaches a nadir at about 6 years of age.

Other anthropometric measurements also change with age in adolescence. This delay can exaggerate differences in age of sexual maturation and the growth spurt between undernourished survey populations and well-nourished reference populations 45. 44. The onset of puberty changes the rate of subcutaneous fat deposition and fat distribution. leading to a rise in Cormic Index in later adolescence 38-40. Chronic undernutrition can also delay sexual maturity and the adolescent growth spurt 4. time. PUBERTAL DEVELOPMENT Superimposed on the more gradual age-related changes. Associations are also found between sexual development and skinfold thicknesses and MUAC. the highest rate of weight gain follows the highest rate of height gain 42. 49. 5. The Cormic Index declines throughout childhood because leg length increases faster than trunk length during prepubertal growth 38. MUAC changes with onset of puberty 47. and is sometimes called the sitting height to standing height ratio. Such a technique may be much more difficult when asking about local events which occurred 10-19 years before. as recommended by WHO. Moreover. both in preparation of a local calendar and in posing extra questions during data collection. (see figure 1) The Cormic Index (sitting height divided by standing height) measures the ratio of leg-length to trunk length. constructed from medians of NCHS reference 37) post-pubertal individuals of the population (from Cole. This leads to an acceleration in the rise of BMI shortly after reaching the peak height velocity. differences between study populations and reference populations in sexual maturation can confound comparisons. Each subject must be assessed 7 Populations of many developing countries do not know their own ages. 1991 same age in a reference population would be invalid because the normal BMI for these two persons would be quite different. 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. the Figure 1 Weight-for-height (W/S). In any case. However. comparison of a pre-pubertal Index (W/S3) as a function of age during childhood and ( ) child in a study population to adolescence. and Rohrer ( ). For example. At least one study shows a sharp change in the index with onset of adolescent growth 40. Adjustment for differences between the survey and reference populations.46-49 and these changes occur independently of chronologic age 50. ( ). using such techniques to ascertain age takes substantial . BMI (W/S2). 43. during the adolescent growth spurt. requires the collection of data on the age at which certain landmarks of sexual maturation occur in the survey population. MUAC rises progressively throughout adolescence at a rate greater than that in early childhood 41. more rapid changes in anthropometric measurements occur during sexual development. Therefore. as measured by skinfold thickness. sexual development occurs at different ages in different populations 44. and this rise is more related to pubertal development than chronologic age 42. As a result. Similarly. the adolescent growth spurt is made up disproportionately of growth in the trunk.Assessment of Nutritional Status of Adolescents in Emergency-Affected Populations middle-age 35-37.

July 2000 .8 Figure 2 Examples of line drawings of various Tanner stages of sexual development RNIS Supplement -.

Skinfold thickness may also be a useful measure of body protein and fat stores. in most field situations. WHO recommends the use of BMI. 175 cm man. sexual development. the ideal index used to assess adolescent nutritional status in emergencies would allow compensation for differences between the survey and reference populations in age. height and MUAC. use weight-for-height reference tables extended to older children and adolescents (Michael Golden. 4. Measurements for use in humanitarian emergencies must use inexpensive equipment. 51-53. who may manifest ethnic differences in anthropometric indices. healthy children younger than 5 years of age are of similar size and shape worldwide. Health workers require extensive training and. In addition. personal communication). Although demonstrated to be effective in screening adolescents for admission to therapeutic feeding programs. 49. (from Norgan. particularly in emergencies. including Médecins Sans Frontières (MSF) and Action Contre la Faim (ACF). These height-specific cut-off points are shown in Annex 1. in practice. for whom no such easily obtained landmark exists. the situation is very different for boys. which is one measure of body shape 58. In all populations where adolescents know their ages. Adults display differences in Cormic Index. using photographs or line drawings. it may be inappropriate to compare older adolescents. The measurements most commonly considered for use in emergencies include weight. As a Figure 3 BMI as a function of Cormic Index in a hypothetical 70 kg. (See accompanying report on assessment of adult nutritional status for further details 59.Assessment of Nutritional Status of Adolescents in Emergency-Affected Populations for pubertal changes. this table has not been evaluated for use in defining less severe degrees of undernutrition in order to estimate the prevalence of undernutrition 9 Although well-nourished. (See figure 2 for an example of drawings used in self-assessment. As described above. other organizations. However.) INTER-ETHNIC DIFFERENCES IN BODY SIZE AND SHAPE result. and ethnicity. Older adolescents who have completed their growth spurt and have essentially become adults may reflect adult differences in body shape. WEIGHT-FOR-HEIGHT MEASURES Indices which use weight and height are currently the most frequently used tools to assess adolescent undernutrition. The single maturational landmark which might easily be collected in the field is age of menarche. 1994 58) . Self-assessment of genital and breast stage. 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. exposing breasts and genitals of adolescents is not culturally acceptable. and be easy to interpret in the field. but has not been evaluated in developing countries or in a variety of cultures 54-56.) WHICH ANTHROPOMETRIC INDEX? There are several body measurements and combinations of body measurements that may be useful in assessing the nutritional status of adolescents. age at menarche can be recalled by girls and women. to a single universal reference population. and has been measured successfully in many surveys 2. has been validated in some countries. however. To screen adolescents for admission to nutrition programs. 43. judging Tanner breast or genital stages during field surveys is very difficult.57 school-age children and adolescents may not be similar. be simple to teach to health workers. Figure 3 demonstrates the substantial effect which differences in Cormic Index have on BMI. but is not considered useful in emergencies as it is difficult to obtain accurate measurements.

During severe famines where adolescents are affected. the Rohrer Index may be less age-dependent during adolescence than other indices combining weight and height. may not be available. Many studies have reported that gross weakness and flexor contractions prevented measurements of weight or height in a substantial proportion of severely undernourished adults.RNIS Supplement -. 63. especially during sexual development. The Rohrer Index is calculated as the weight in kilograms divided by the height in meters cubed (wt/ht3). evaluation of nutritional status must take into account the presence or absence of oedema.some studies have found that the Rohrer Index is correlated with height. In addition. there is no widely available reference population or established cutoff points for this index. the necessary equipment. a wellnourished three year-old child is assumed to have the same “ideal” weight as a stunted five year-old child of the same height. Many adolescents and adults develop oedema when severely undernourished 1. such as percent body fat. including scales and height boards. when using weight-for-height. This leakage of fluid into tissues artificially increases an individual’s weight. (See accompanying report on assessment of adult nutritional status for further details 59. As with weight-for-height. because adolescents add substantial muscle and fat. the use of BMI still requires the collection of accurate ages. BMI. and Rohrer Index may be difficult to obtain during an emergency.) Moreover.indices using weight and height are correlated with age. Correlations with height . Practical problems with indices using weight and height Difficulties in obtaining the component measures during famine . Although this association with age is not so strong as with weight-for-height. which may result in a weight-for-height. Age . As seen in figure 1. 10 Moreover.July 2000 in a population of adolescents. Although oedema in both feet or legs may be due to other causes. and also ages of maturational landmarks from individual subjects. Difficulties in the calculation of the indices the calculation of BMI and Rohrer Index may be unfamiliar to field workers and therefore more difficult to use than other anthropometric indices. Moreover. They should then be admitted for . because adolescents and adults with oedema have a poorer prognosis than those who are equally undernourished but do not have oedema. as yet there are no validated cut-offs for these indices to define undernutrition in adolescents. Theoretical problems with indices using weight and height Lack of data directly correlating measurements to health outcomes . That is. Hence. adolescents with bilateral oedema may be severely undernourished and should be referred to a clinician for further diagnosis. many of the same drawbacks listed below apply to this use of weight-for-height. it is assumed that the index weight-for-height is constant regardless of a child’s age. it does not grossly interfere with the use of weight-for-height in children less than five years of age.regardless of the specific index used. In young children. BMI. the normal weight for adolescents of a given height changes substantially depending on their age and pubertal development (figure 1). adolescents with oedema should be identified and admitted to appropriate therapy. 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. In contrast. Moreover. many of the most severely undernourished requiring admission to therapeutic feeding centres cannot stand. or Rohrer Index which appears more normal than would be expected given the degree of emaciation.there are no data directly correlating weight-for-height. making measurement of height impossible.the height and weight measurements required to assess weight-forheight. BMI also changes with age 37 (figure 1). Although this assumption may not be entirely true. it is necessary to collect and record accurate ages. As a result. especially among older adolescents 60-62. Famine oedema . in a situation with a high prevalence of undernutrition. And finally. there has been very little research on the correlation of the Rohrer Index with other measurements of body protein and fat stores. BMI. or the Rohrer Index with functional or health outcomes in adolescents.

Theoretical problems with the use of MUAC Lack of data directly correlating measurements to measurements of body fat and protein stores . One study clearly demonstrates a greater MUAC in postmenarcheal female adolescents than premenarcheal female adolescents of the same age 53. MUAC measurement requires careful training and supervision in order to prevent wrapping the measuring tape too tightly or too loosely. which occurs with puberty results in a more rapid rise in MUAC at this time than prior to or following puberty. indices using weight and height may not accurately indicate the nutritional status of pregnant adolescents. This requires an 11 . 59. Although this not critical in young children who often have little muscle contour in the upper arm. no estimate of the prevalence of undernutrition could be made 4. Ethnicity . such as BMI.in spite of the convenience and ease of measurement. because of the lack of a reference population and cut-off points. In many well-nourished populations. accurate age for each survey subject in order to judge whether they fall above or below an agespecific cut-off point. as yet there are no validated cut-off points to define undernutrition with MUAC measurements in adolescents. During pregnancy. Therefore workers will have to be carefully trained to measure adolescent MUACs.MUAC changes substantially with age during adolescence. Because of the extra weight of the foetus. 53. No MUAC cut-offs have been established for the diagnosis of adolescent undernutrition yet. As a result.there are no data directly correlating MUAC with other measures of body fat and undernutrition. 51. MUAC 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 programme19. there are no data relating MUAC cut-off points with functional or health outcomes in adolescents. 64. A scheme using a combination of MUAC and BMI has been proposed to categorise the degree of undernutrition in adults 65. 7. which results in an erroneous estimate. 72. Sexual development . must be used to judge nutritional status.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. as shown in several reference populations from industrialised countries 41. One study estimated that the smallest change over time detectable in MUAC was 8-10%. a different cut-off point must be used for adolescents of different ages. such as weight gain during pregnancy or MUAC. predominantly muscle tissue in males and subcutaneous fat in females. 65. when measurements were taken by different observers73. 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). it becomes increasingly important in post-pubertal adolescents who have developed adult musculature.MUAC changes with sexual development. In addition. other measures. A second study demonstrated that MUAC measurements show more inter-observer variability than weight and height measurements 74.indices comparing weight and height cannot be used to assess pregnant adolescents. a reasonable correlation exists between MUAC and BMI in adults. Age . 66-71. however. Hence. Pregnancy . Practical problems with the use of MUAC Measurement error . other products of conception. The published results of several nutrition assessment surveys of adolescents in developing countries include MUAC data. 63. The rapid addition of soft tissue. in adolescents. and added maternal tissue.Assessment of Nutritional Status of Adolescents in Emergency-Affected Populations therapeutic feeding if famine oedema is diagnosed 59.

creation of a reference population is a difficult task requiring substantial resources. personal communication). The application of this technique to adolescents may be complicated by the normal 12 . Theoretically.July 2000 POSSIBLE SOLUTIONS FOR THE FUTURE No single method has proved adequate for assessment of undernutrition in adolescents in emergency situations. PUBERTAL DEVELOPMENT changes in Cormic Index throughout adolescence. rather than the determination of different levels of a development indicator. INTER-ETHNIC DIFFERENCES IN GENETIC GROWTH POTENTIAL 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. some data indicate that chronic undernutrition changes the Cormic Index 78. Further research is required in this area. in the future. 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. Separate reference populations cannot be created for each nationality or ethnicity.RNIS Supplement -. Stunted children may have a greater Cormic Index than comparable children without stunting. Investigators could then choose a reference which most closely matches the survey population. However. 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. more appropriate cut-off points (either % of median or zscores) to define undernutrition when using a reference population whose ethnicity differs from that of the survey population. the investigators would use a reference population with a similar average Cormic Index. Of course. BMI. such as weight-for-height or the Rohrer Index. Some populations may be genetically thinner than the reference population. allow adjustment for this complicating factor. it may be easier and more accurate when assessing adolescents to consider pre-pubertal and postpubertal adolescents separately. such as Tanner breast or genital stages. Nonetheless. An alternate possibility would be to create a few reference populations for use with major ethnic categories. if a survey population is known to have an average Cormic Index of 0. similar to that currently under Simpler methods of determining pubertal stage may. An additional method of compensating for ethnic differences would be to choose different. it would require measuring sitting height as well as standing height in all surveys of adolescents. 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. WHO recommends such a procedure when using anthropometry to screen persons for admission to nutritional rehabilitation 12. A single. such an adjustment could also be applied to other anthropometric indices calculated from weight and height. 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. requiring a lower cut-off to define undernutrition. this procedure remains untested in adolescents (Nicholas Norgan. or MUAC. international reference population consisting of adolescents from multiple countries could be used. Collection of such data for multiple ethnic groups would be expensive and timeconsuming. The Rohrer Index may offer such advantages over weight-for-height. In addition. In contrast. Below are listed some possible strategies for overcoming the major difficulties. Ideally. For example. this would require the assessment of the presence or absence of only one landmark of sexual development. Moreover. Such methods could include appropriate line drawings or photographs of different Tanner stages.50. CHANGES IN BODY PROPORTIONS WITH AGE An anthropometric index that is unrelated to age is required if adolescents do not know their ages.

e. In one study among surgical patients. may better reflect an individual's risk of nutrition-related morbidity or mortality. such as American adolescents. 17. the prevalence of undernutrition in adults. USE OF OTHER DATA When assessing adolescents. BMI of 16.5 kg m-2.. i. although as yet untested in adolescents. and 18. was greater in normally-nourished children 46. they truly measure nutrition and health. 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 84.5 years to determine the cut-off BMI value at for each age and sex group. However. muscle strength. oedema. and it does not correct for differing ages of sexual maturation. 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. to describe a reference population and cut-off points. may be able to distinguish adolescents in need of therapeutic feeding from those who could benefit from a less intensive feeding program. and after removing the effect of this variable. It is unlikely that adolescents are the only population group with substantial undernutrition. and to determine the sensitivity and specificity of proposed methods to detect moderate and severe undernutrition. they may not be useful at all. Experience in screening adults for admission to therapeutic feeding programmes has demonstrated that three clinical signs (apparent dehydration. The cutoff points for each national population were then averaged to produce age. Such an approach. endurance run.and sex-specific cut-off points for the combined international reference. and alternate sources of food.e.5 years of age than undernourished children 83. food distribution. and standing long jump. such as Nilotic Africans and Australian aborigines. in this study. hand grip was associated with MUAC. the reference proposed may not be appropriate for populations with different body shape. and information on food security. The same procedure could be used to determine cut-off points which correspond to the adult cut-off points for various degrees of undernutrition. One author proposes that muscle performance may actually be affected earlier in the course of undernutrition than body composition 81. such as strength or other functional outcomes. distance throw. i. 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. Unless anthropometric measures are valid. In this proposal. Such data could include the prevalence of undernutrition in young children. shuttle run. However. may be able to detect moderate degrees of wasting. rates of morbidity and mortality. 13 . In a second study. muscle strength was correlated with stature.Assessment of Nutritional Status of Adolescents in Emergency-Affected Populations development for children less than 5 years of age. adults. well-nourished and poorlynourished children no longer differed in muscle strength. Measures of muscle function. Clearly. In addition. and those patients with hand grip less than 85% of normal did much poorer postoperatively 82. or maximum jump height. That centile was then applied separately for males and females to each one-half year age group from 2-17. such as grip strength. However. Much more work needs to be done to determine whether appropriate measures of muscle function exist. additional data from the same population should be collected. it is very important to look critically at the adolescent data. but data on young children. 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. its use still requires accurate ages because the BMI cut-offs change substantially with age. and inability to stand) predict mortality better than BMI 59. Other measures. 63. A reference population described in recently published work includes children and adolescents from national surveys done in six countries 80. such measures are not ready to be used in the field. as measured by grip strength. If a survey of adolescents indicates substantial undernutrition.. and other population groups do not demonstrate undernutrition or elevated morbidity or mortality. shuttle run.

both normallynourished and undernourished. as well as assessing inter-observer variability when measuring adolescents. such as strength or other functional outcomes.RNIS Supplement -. Given the lack of validated anthropometric procedures. or decreased work ability or physical performance measures.July 2000 FUTURE RESEARCH NEEDS Certain questions need to be answered before definite recommendations can be made regarding the best method of assessing nutritional status in adolescents. such as weight-for-height. Use of anthropometry at all . These studies should be conducted in a variety of situations among adolescents with different levels of undernutrition. suppressed growth. MUAC.longitudinal studies are required to determine whether adolescents falling below specific cut-off points for weight-for-height. adolescents' self-assessment upon viewing drawings or photographs of different 14 . poor pregnancy outcome. adolescents. and Rohrer Index have elevated morbidity or mortality. BMI. current recommendations regarding the use of anthropometry in adolescents must be critically examined. Anthropometric index . women of child-bearing age. In addition to investigating the association between anthropometric indices and age and height. and other population subgroups in different types of humanitarian emergencies. Moreover. Adjusting for differences 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. such as the extent of axillary hair. Survey organizers should assess the ease of training survey workers in measuring MUAC. but the reality of adolescent undernutrition is very complex. BMI. Their use may yield misleading results that stimulate inappropriate interventions. and Rohrer Index. 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. Markers of pubertal development . may better reflect an individual's risk of nutrition-related morbidity or mortality and should be explored as indicators of adolescent nutritional status. Studies could also explore the use of other markers of sexual development. height. Re-analyses using data from populations with a variety of health conditions and various degrees of undernutrition could be undertaken. weight.other measures. Such assessments should include evaluation of the self-reported Tanner stage for breast and genital development among female and male adolescents needs to be tested in a variety of populations. Defining functional cut-offs . and age of adolescents. with age and height should be further explored in adolescents. Vulnerability . Practicality of measurements and calculations the practicality of obtaining various measures should be explored in field situations. anthropometric measurement of adolescents should not currently be used as the sole technique for the nutritional assessment of adolescents. in order to determine which markers can be used for adjusting for different developmental ages between survey and reference populations. elderly. the ages at which various landmarks of sexual development are achieved should be described in many different populations.the accuracy of Tanner stages could be compared to findings of physical examinations.the association of various indices. and height. CONCLUSIONS AND RECOMMENDATIONS A fundamental dilemma exists in trying to measure adolescent undernutrition: a system simple enough for a non-expert is required for use in emergencies. Until better tools for nutritional assessment of adolescents are developed. For example. Such exploration should include analysis of existing data from past surveys that measured weight.more nutrition surveys should include assessments of the nutritional status of different age groups to determine the relative vulnerability of young children. The index chosen should be the least dependent on age in order to minimize the effect of using inaccurate ages.

17. the cut-off points used to define various degrees of undernutrition. how individuals were compared to this reference. Young children. evaluation of food uses and access. cut-off points should be age-specific. Data from this original reference population should be recalculated to provide direct weight-for-height cut-off points. Unfortunately. However. at least until other indices are more fully investigated. and measurement of the levels of morbidity and mortality among adolescents and adults. It may be necessary to construct a local calendar to determine ages. Adolescents should not undergo nutritional assessment in isolation. the most appropriate index for use in measuring undernutrition prevalence among prepubertal adolescents may be weight-forheight.5 kg m-2. or other population subgroups should also be assessed. Comparison of surveys. Reference populations. corresponding to the adult BMI cut-off points of 16. BMI should be used until other indices have been more fully investigated. The reference population of American adolescents. Although several reference populations exist for which BMI centiles and/or z-scores have been calculated. Measures that may be useful include age of menarche in females. No standard method of anthropometric assessment of the nutritional status of adolescents can be recommended at this time. Individuals can be compared to an existing reference using the preliminary weight-for-height tables in Annex 1. q Prepubertal adolescents. 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. how measurements were taken. adults. It may also be necessary to investigate the existence of systematically biased reporting of age which could lead to substantial under. Some measure of the age of specific pubertal landmarks should be measured during nutrition surveys of adolescents.or over. currently recommended by WHO for use with BMI. As a result. Age. some linear growth continues and BMI continues to change with age after attaining q q q q sexual maturity. screening for severe undernutrition in order to determine the need for therapeutic feeding should use clinical criteria as recommended for adults 59. Therefore. Additional data. In order to assess the methods and comparability of surveys. the international reference population described by Cole 80 may be the best reference currently available for use in the developing world. Until better methods can be developed and validated. when these indices are used. Nonetheless. Both weight-for-height and BMI are age-dependent. and any other ancillary data collected on the population of interest. women of child-bearing age. validated markers that are practical for field use do not exist for males. The method for creating age-specific cut-off points described by Cole should be used to determine cut-off points. 15 . age must be collected as accurately as possible for each survey subject or individual screened. clinical evaluation of adolescents. although this may be difficult with adolescents because of the many years since birth. all survey reports should describe in detail the anthropometric index used. Because older adolescents may be more similar to adults. which reference population was used. should not be used. Because young adolescents may be more similar to children. The following components should be included in any anthropometric assessment of adolescents: q Screening for severe undernutrition.Assessment of Nutritional Status of Adolescents in Emergency-Affected Populations nutritional status of other population subgroups. elderly. q Correction for differences in age of sexual maturation. 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 Postpubertal adolescents. 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. in both percent of median and zscores.estimation of the prevalence of undernutrition when using weight-for-height or BMI. and 18.

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978 11.232 16.5 119.705 21.036 22.021 12.271 17.154 19.5 126.000 20.701 24.842 11.929 16.131 14.301 17.707 11.0 125.697 17.744 19.544 12.5 104.773 18.540 18.833 21.177 11.521 13.0 109.884 17.172 16.189 14.390 14.111 12.5 111.5 102.112 15.963 13.367 20.095 21.5 118.862 24.0 124.0 103.409 16.000 13.350 15.050 16.0 101.308 11.313 13.757 15.649 14.753 20.589 15.666 16.432 17.394 18.5 117.0 112.579 12.789 22.109 18.876 12.189 13.565 15.574 11.492 11.331 20.5 108.0 104.694 13.044 17.238 19 Height (cm) 100.0 123.114 11.978 13.5 123.233 23.250 18.0 122.267 15.066 24.5 107.297 13.469 17.570 18.917 17.141 16.695 16.578 21.510 22. for males and female adolescents.192 19.666 11.193 24. Weight (kgs) (kgs) Males Median 70% of median 15.763 15.811 22.173 17.530 12.813 12.841 18.650 19.934 22.473 13.789 16.0 120.076 17.826 14.5 110.5 115.803 17.645 22.127 14.300 19.101 12.0 111.371 21.388 12.970 18.5 116.859 16.0 107.0 119.406 11.896 10.527 23.0 102.980 11.561 17.876 18.375 14.0 108.625 .5 122.391 12.876 14.508 16.601 16.408 13.040 17.519 19.008 23.980 17.5 105.483 12.957 12.756 23.5 113.362 Females 70% of median 10.0 116.046 11.0 100.686 15. Data from Michael Golden.247 12.416 16.181 20.344 24.440 11.676 12.5 109.083 13.092 20.928 16.754 11.006 14.160 21.931 12.974 20.846 17.0 114.000 14.089 16.807 15.0 106.229 21.960 15.370 17.425 15.981 18.541 16.316 19.0 118.235 11.265 23.086 18.0 110.257 14.564 15.083 23.631 19.026 24.190 16.555 15.963 21.842 11.0 105.755 13.996 19.323 17.797 13.295 12.0 117.301 14.0 115.320 11.588 21.5 125.637 13.5 112.211 20.812 14.454 20.775 12.794 24.387 23.846 13.504 22.395 12.0 Median 15.5 114.634 13.149 15.5 103.916 11.156 13.564 17.954 21.5 121.656 16.294 16.579 11.527 14.5 106.150 11.5 101.671 12.975 16.285 16.270 22.202 12.756 15.558 20.105 16.Assessment of Nutritional Status of Adolescents in Emergency-Affected Populations ANNEX 1 Median and 70% of median weights for various heights.172 17.418 16.671 18.481 19.951 15.324 16.791 16.5 124.0 113.689 18.632 16.469 16.252 12.823 20.0 121.474 14.833 17.366 22.409 19.065 11.668 14.542 23.5 120.858 19.

831 146.787 29.080 28.0 37.0 26.274 20.148 23.260 25.093 37.973 31.957 149.912 25.457 131.919 19.099 39.779 44.343 27.393 151.5 25.5 38.044 20.923 31.809 29.732 25.0 27.790 144.571 29.259 18.404 139.0 33.046 29.918 22.670 20.458 40.445 144.757 151.763 39.662 27.0 33.635 18.735 140.605 27.057 29.602 148.023 25.748 138.887 21.867 153.095 38.5 44.308 127.727 35.070 24.0 28.022 19.0 29.771 21.369 27.140 19.616 42.805 41.444 21.571 24.0 44.331 24.057 18.621 133.618 23.0 36.282 26.150 136.995 43.386 34.223 134.199 26.530 28.464 136.424 138.446 18.243 153.483 18.714 27.703 34.0 39.5 25.202 25.563 128.831 30.436 39.456 20.367 30.963 29.5 39.269 18.716 17.275 28.018 33.351 129.5 38.762 38.075 18.816 20.101 143.021 27.483 145.5 40.781 26.0 31.896 130.528 .101 137.224 31.391 155.961 30.645 30.032 132.136 145.084 129.0 40.854 24.325 133.270 27.622 130.5 34.041 Females 70% of median 17.915 23.0 41.0 35.403 141.835 30.044 34.5 30.873 23.627 29.334 32.973 21.0 43.770 28.115 40.220 19.538 25.134 27.0 31.404 26.878 42.786 25.848 18.295 25.634 22.760 37.308 28.325 21.July 2000 Weight (kgs) (kgs) Height (cm) Median 126.068 140.739 141.5 26.175 156.5 31.035 20.0 28.519 27.0 29.497 25.113 23.546 147.027 27.249 148.984 28.831 24.433 26.5 36.743 132.0 37.676 33.0 35.382 43.428 37.622 154.634 30.822 128.307 29.026 26.506 20.774 27.635 28.5 28.842 28.774 40.313 149.5 35.312 31.360 33.781 155.5 37.796 26.739 20.529 135.535 17.547 21.564 28.202 Median 24.420 19.179 146.309 24.5 30.0 32.395 22.700 18.894 18.5 28.053 25.031 150.827 20.838 135.424 36.0 40.0 25.5 27.667 26.965 26.993 32.429 38.897 147.075 139.5 32.497 25.321 28.297 30.494 152.510 41.828 19.382 23.315 29.589 19.021 28.417 142.0 42.453 22.921 134.0 38.606 45.156 22.208 21.642 17.155 41.438 17.086 36.5 32.5 43.294 29.652 31.681 21.0 30.105 21.548 24.0 34.224 22.186 44.408 35.5 26.900 27.683 22.244 42.5 34.782 137.103 30.352 23.175 131.124 152.671 150.5 42.930 31.5 29.0 25.647 30.004 154.622 19.0 43.098 26.5 41.373 30.RNIS Supplement -.363 19.5 27.244 20.811 25.997 22.0 26.5 41.092 24.592 23.050 127.078 142.068 35.570 29.096 30.748 36.528 26.5 33.574 20 Males 70% of median 17.5 36.758 143.

174 34.531 42.713 174.496 160.588 48.101 42.955 171.0 50.0 47.570 166.088 165.0 48.5 60.149 37.5 44.384 157.5 56.5 46.962 38.064 159.820 161.0 60.5 48.862 34.5 57.633 168.5 59.797 158.390 173.932 160.575 38.686 21 .040 174.728 162.178 32.0 55.899 44.379 171.128 164.803 37.5 45.499 37.750 34.085 36.459 35.391 Median 45.0 46.5 58.078 40.0 61.494 45.350 32.907 33.945 33.262 39.706 169.269 41.462 36.255 170.901 49.5 47.428 43.694 40.114 39.490 34.5 49.969 46.215 48.576 165.124 36.588 167.107 168.473 47.976 157.316 39.070 166.5 54.865 41.483 31.769 32.5 50.662 56.011 47.5 62.058 32.812 170.973 43.Assessment of Nutritional Status of Adolescents in Emergency-Affected Populations Weight (kgs) (kgs) Height (cm) Median 156.166 169.0 45.0 58.0 47.655 163.790 36.0 56.5 55.271 162.0 53.0 52.449 56.646 32.533 51.373 36.803 54.231 34.5 53.0 57.0 51.605 164.247 33.416 Males 70% of median 31.132 35.637 159.664 39.680 42.0 54.853 38.809 35.312 33.665 50.214 158.943 39.089 56.468 40.0 49.543 172.5 52.5 51.5 63.694 Females 70% of median 31.845 32.374 161.0 62.076 167.189 163.212 38.553 33.765 35.759 173.550 52.144 172.531 32.

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