Anthropometry
Technique of measuring people Measure
Index
Indicator
Reference
Information
Measurements
Weight Height Length and stature or height Mid Upper Arm Circumference MUAC
Characteristics we need:
easy cheap acceptable reproducible
INDEX
Relation between two measurements weight for age W/A or W//A general appreciation of nutritional status height for age H/A or H//A measure of linear growth deficit or STUNTING weight for height/length W/H or W//H measure of weight deficit according to length WASTING
WEIGHT
Sensitive to changes Changes in two directions up and down Fast change Usually easy to collect Standardisation of scales needed, calibration Small changes are difficult to measure: food intake of the child, urine, dehydration, temp, etc: not very specific community aversion: connotations can be difficult: co-operation of children to nearest 100 gr.
Height
Difficult to measure, accuracy, large variations Differences are small: 24 cm increment in the first year of life, 11 cm second year, 8 third Low sensitivity Large measurement errors Stunted versus stunting
stunted is a heterogeneous group stunting is the active process: determinants are acting
Measure to the nearest mm Below 2 recumbent, above standing
AGE
Usually the most difficult and inaccurate measurement Less of a problem if a trend in the same child is measured, the mistake is repeated every time and thus cancels out
Growth of a child
Indicator
Partial quantification of a concept
partial quantification concept
number or percent of defined group below a cutoff value cut-off : z-scores, -2 and +2 , 95% of population z-score = X-Mean / SD below -2 in normal distribution 2.27 % !! Percentages: value = % of the mean percentiles: range from 1 to 100
The reference
One reference for all?? Reference or standard? Genetic differences
Do they exist Are they important
Reference means operational decisions
Secular trends in height of 9- and 11-year-old schoolboys in Japan
138 136 134
Height (cm)
132 130 128 126 124 122 120 118
11 years old boys 9 years old boys
1900 1910 1920 1930 1940 1950 1960
Figure 2.1. Attained height of early 19th century boys compared to NCHS reference data
Height in centimetre 200 Belgium (1) Britain (2) Cambridge (3) NCHS (4)
150
100
50
0 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 Age in years
(1) Boys from Brussels, Nivelles and Leuven n = 700 /age group (2) Factory workers from Stockfort and Manchester n: not quoted (3) University students from Cambridge at entry at Universty n = 80 (4) NCHS median
Criteria for a reference
1. Measurements should relate to a well-nourished population. 2. Sample : at least 200 individuals in each age and sex group. 3. Sample: cross-sectional, since the comparisons that will be made are of a cross-sectional nature. 4. Sampling procedures should be defined and reproducible. 5. Measurements should be carefully made and recorded by observers trained in anthropometric techniques, using equipment of well tested design and calibrated at frequent intervals. 6. The measurements made on the sample should include all the anthropometric variables that will be used in the evaluation of nutritional status. 7. The data from which reference graphs and tables are prepared should be available for anyone wishing to use them, and the procedures used for smoothing curves and preparing tables should be adequately described and documented.
COMMON ERRORS
First year of life is up to 11.9 months of age and not O-12 Length and height; change technique at 24 mo Percentage and z-score
80% is -1.5 Z-score at 6 mo and -2 Z score at 2 yrs
Lack of distinction between descriptive use and operational use No use of statistics: Confidence intervals and tests to compare prevalence and averages Undernutrition Wasting Stunting
Classifications: GOMEZ
Percentage W/A > = 90 % 75 - 90 % 60 - 74 % < 60 %
TYPE Normal First degree / mild malnutrition Second degree / moderate malnutrition Third degree / severe malnutrition
Classifications: WATERLOW
Waterlow Classification Height for Age > = 90 % < 90 %
Weight for > = 80 % Normal Stunted
Height < 80 % Wasted Wasted and stunted
Anthropometry is an operational tool
Identification serve a purpose , the identified should be dealt with. Capacity of numbers. Sensitivity (Se) is the ability of a test to identify as positive those who are diseased. Specificity (Sp) is the ability of a test to identify as negative those who are healthy. Positive predictive value: If you test positive, what is the chance of really being positive. Negative predictive value is the chance of being healthy whilst being identified as negative. The chance of being really negative is higher when there are no false negatives, i.e. when the sensitivity is higher.
Se and Sp
Truly Malnourished Yes TP FN No FP TN
Diagnosed as malnourished
Yes No
TP= true positive FP= false positive TN= true negative FN= false negative Se= TP/(TP+FN) Sp= TN/(TN+FP) Positive predictive value (PPV) = TP/(TP+FP) Negative predictive value (NPV) = TN/(TN+FN)
Disease + Test + TP Test - FN (Se*P)
Disease FP 1-P (1-Sp)*(1-P) ( Sp*(1-P))
((1-Se)*P) TN
P= prevalence
reformulation
PPV= TP /TP +FP PPV= Se*P / (Se*P) + ((1-Sp) * (1-P)) NPP= TN/FN + TN NPP= Sp(1-P) / (Sp * (1-P) + ((1-Se) * P)
Disease + Test + TP (Se*P) Test - FN ((1-Se)*P) P= prevalence
Disease FP (1-Sp)*(1-P) TN( Sp*(1-P)) 1-P
Use of Anthropometry
Individual Level
SCREENING: ONE TIME ASSESSMENT
to immediately decrease case fatality (emergency situations)
in non-emergency situations GROWTH MONITORING: TREND ASSESSMENT
Population Level
ONE TIME ASSESSMENT under circumstances of food crisis for long-term planning NUTRITIONAL SURVEILLANCE: TREND ASSESSMENT for long-term planning for timely warning for programme management
Indices
W/A: combined measurement: NO individual diagnosis but trend assessment For growth monitoring and FU W/H indicates degree of wasting Individual diagnosis Community diagnosis Sensitive to change H/A indicates linear growth retardation not sensitive to change slow progress Community diagnosis ALL complex causality
Summary of applications
Index AC W/H Application Emergencies (screening) Emergencies (screening) One time assessment of wasting Assessment of impact of short term programme Rapid targeting and early warning Growth monitoring Growth monitoring Long-term planning Surveillance of trends (long term) Programme management growth monitoring Indicator CUa flexible CUa flexible Mean (SD) or Conventional CU Mean (SD) Conventional CU Conventional CU None None Mean (SD) Mean (SD) Mean(SD) None
W/A H/A
CU = Cut-off, conventional CU = - 2SD.
