Chapter 2

Anthropometric
Assessment
 Anthropometric Assessment
• Anthropometry (from Greek anthropos, "man" and
metron, "measure") refers to the measurement of the
human individual.

• Thus, anthropometric assessment comprises

measurements of the variations of the physical
dimensions and the gross composition of the body.

• It provides information on past nutritional history, which

cannot be obtained with equal confidence using the
other assessment methods.
 Cont’d
 Anthropometry is the most commonly used method
for the assessment of two of the most widespread
nutrition problems in the world:
1. Protein-energy malnutrition
2. Obesity, or overweight, in all age-groups.

 It can be used both at clinical & field setups

 Weight

1. Growth
Height/stature
measurements

Head
circumference
Anthropometric
measurements
Fat-free mass
Of 2 types - Mid-upper Arm
2. Body Circumference
composition (MUAC)
Of 2 types
Body fat
- Skin-folds
- Hip circumference
- Waist circumference
 Advantages of anthropometric
- The procedures use simple, safe, non-invasive
techniques and applicable to large sample sizes.
- Equipment required is inexpensive, portable, and
durable and can be made or purchased locally.
- Relatively unskilled personnel can perform
measurement procedures.
- The methods are precise and accurate.
- Infn is generated on past long-term nutritional history,
which cannot be obtained with equal confidence using
other techniques.
- The procedures can assist in the identification of mild
to moderate malnutrition, as well as severe states of
malnutrition.
Parameters of anthropometry
 Body Weight

• represents the sum of protein, fat, water, and bone mineral

mass.
• In healthy persons, daily variations in body weight are
generally small (i.e. less than ±0.5 kg).
• In conditions of acute or chronic illness, however, a decline
in body weight can occur.
• Total starvation, the maximal weight loss is approximately
30% of the initial body weight, at which point death occurs.
• To measure BW in infants and children,
▫ a pediatric scale is recommended, although in the field, a
suspended spring balance and a weighing sling may be used.
▫ For older children and adults a beam balance with non-
detachable weights is recommended.
• All equipment should be calibrated regularly and
whenever it is moved to another location.
• To assess weight changes, the actual and usual weight of
the patient must be known from which the percentage of
usual weight, percentage weight loss, and rate of change
can be calculated.
Cont’d
What is the expected weight of a
child who is 5 years old?
(5*2) + 8 = 18 Kg
 Recumbent Length and Stature

• As a deficit in recumbent length or height takes some

time to develop, assessment of nutritional status
based on recumbent length- or height-for age alone
may result in an underestimation of malnutrition in
infants.
• Factors influencing the measurement of recumbent
length and stature for age include:
▫ genetic and
▫ ethnic differences
• Recumbent length should be measured for infants
and children less than two years of age using a
measuring board.
• For field use, a portable infant-length measuring
scale or a plastic measuring mat can be used.
• > 2 years of age in the standing position using
a stadiometer or portable anthropometre.
 Cont’d
• Figure 2.2, practical
aspects of measuring
height
a. infantometer
b. stadiometer
Growth Indices
• Anthropometric measurements can be adjusted for non-
anthropometric parameters (e.g. age and sex) to infer
childhood growth and states of under or overnutrition.
• These adjustments can be performed internally, using means
and standard deviations from the study population at hand,
or externally, by comparison against published growth
reference data.
• The resulting values are expressed as percentiles or Z-scores
(or standard deviation scores), which quantify the extent to
which an individual deviates from the population average.
 Percentiles and Z-scores
• Percentiles and Z-scores are a widely used format to display and interpret
growth measurements.
• In childhood, sex and age-adjusted percentiles and Z-scores for weight,
height (supine length if aged less than two years), BMI and ponderal
index (at birth) are routinely used in clinical practice and in research
studies.
• They are derived by comparing individual growth measurements against
growth data or growth charts from a reference (‘normal’) population (a
“growth reference” or “growth standard”). 
• Percentile indicates the percentage of observations that fall below a
certain value.
• Z-score is the distance and direction of an observation away from the
population mean.
 16

Z-score/Bell curve
The nutritional status of children on anthropometric
data can also be interpreted by Z-scores
 17

≥ -2 z-score Normal
Cont’d
-3.0- (-2.0) z-score Moderately malnourished

< -3 Z-score Severely malnourished

Eg. Absence of acute protein energy malnutrition is

defined as weight for height Z-score of ≥-2
Individual and population cut-off values for BMI-for-age percentiles used in the UK
WHO Child Growth Standards
• These are simple charts used to assess whether
children are growing and developing as they should.
• They can also be used to see whether efforts to
reduce child mortality and disease are effective.
• The standards are also used for detecting children not
growing to full capacity or those who are under- or
overweight on average
 20

Growth charts
21
22
 23

Drawing growth curve

Steps
1. Find the child’s age on the chart
2. Find the child’s weight on the chart
3. Draw the growth curve
24
25
26
Assignment
• Bring WHO weight, height, head circumference
growth chart for boys and girls aged 0-5 years.
Other Growth Standards
• The WHO's position is that all economically
advantaged children who were breastfed as infants
grow similarly. As a result, they developed a single
set of growth chart that can be used to judge growth
in any child, regardless of race or ethnicity.
• Some countries (e.g. China, UK, USA, and several
other European countries) have growth reference data
based on their national population.
Some Nutritional indices
• BMI-for-age
• Height-for-age
• Length-for age
• Weight-for-age
• Head circumference-for-age
• Arm circumference -for age
• Subscapular skinfold-for-age
• Triceps skinfold-for-age
• Weight for-height
• Weight-for-length
 Weight for age
• indicates a child’s body weight for their age and sex
relative to the reference population.
• used as an index of acute malnutrition for children from 6
months to 7 years provided the exact age of the child is
known.
• Failure to gain weight as expected or a weight loss
indicates an inadequate diet, infection, and/or lack of care
and should be investigated.
• Maintenance of weight or weight gain may mask the loss
of lean body fat and the increased edema of kwashiorkor.
Height for age (Stunting)
• “Height (or length)-for-age” indicates a child’s
height (or supine length in children less than two years
old) for their age and sex relative to the reference
population.
• It is used in clinical practice to monitor a child’s
growth and is influenced by genetic potential (parents’
heights), nutritional factors, and the ‘tempo’ of growth,
which a measure of the rapidity or slowness in timing
to achieve final adult height and is closely related to
puberty timing.
 32

Height/Length for age

Height is affected less immediately by diet
than weight

Height-for-age is a relative indicator of

chronic food deficiency

Knee height is used to estimate height in

persons with severe spinal curvature or who
are unable to stand.
Knee height is measured on the left leg with
a caliper
 Weight for Height (Wasting)
Weight-for-height: can be used to indicate body composition in
adults.
• For children weight-for-height is relatively independent of age
between 1 and 10 years and ethnic group for those aged 1–5 years.
edema and obesity can make the interpretation…
Weight-for-height by sex is a sensitive indicator of body composition
in children.
• Children with weights less than 85% of the median reference
weight-for-height are considered as wasted.
• Useful screening tool for current malnutrition, especially if used
with height-for-age.
 34

Assessing body size in adults

The standard in assessing body size in adults is the
body mass index(BMI)
BMI(Kg/m2) Interpretation
Eg: Wt=68Kg,
<16 Severe under nutrition
Ht=150cm(1.50m)
16-18.5 Under weight BMI=30.22

18.5-24.9 Normal
Interpretation=Obese
25.0-29.9 Overweight(Grade 1 obesity)

30.0-40.0 Obese(Grade 2 obesity )

> 40.0 Very Obese(morbid or grade 3

obesity)
 35

BMI
For adults 20 years and older, BMI is interpreted
using standard weight status categories that are the
same for all ages and sex

The correlation between BMI number and body

fatness is fairly strong
 36

Limitation-The correlation varies by sex, age and race

Cont’d
Example:-
At the same BMI, women tend to have more body fat
than men

At the same BMI, older people tend to have more

body fat than younger people

Highly trained athletes may have high BMI bcs

increased muscularity than body fat
 37

BMI for children and teens

For children and teens, BMI is age specific and sex
specific percentiles are used bcs:

1.The amount of body fat changes with age

2. The amount of fat differs over sex

 Head circumference
• Chronic malnutrition during the first few months of life, or
intrauterine growth retardation, the no. of brain cells and
result in an abnormally low head circumference.
 It can be used as an index of chronic protein-energy
nutritional status during the first two years of life.
 Beyond two years, HC no longer in use WHY?
 Cont’d
• HC is used with other measurements
to detect pathological conditions
associated with an unusually large
(hydrocephalic) or small (microcephalic)
head.
• Certain non-nutritional factors, including:
▫ disease and pathological conditions,
▫ genetic variation, and
▫ cultural practices (such as binding of the head during
infancy) may also influence HC.
• HC is measured with a narrow, flexible non-stretch tape
made of fiber glass or steel about 0.6 cm wide;
alternatively fiber glass insertion tape can be used.
 40

Waist circumference
• Is measured at the umbilicus
level to the nearest 0.5cm

• The measurement should be

taken at the end of a normal
expiration

• The subject stands erect with

relaxed abdominal muscles, arms
at the side, and feet together
 41

Cont’d
Levels Male Female

I >94 cm > 80 cm

II >102 cm > 88 cm

Level 1 is the maximum acceptable waist circumference

irrespective of the adult age and there should be no more
weight gain

Level 2 denotes obesity and requires weight management

 42

Waist-hip circumference ratio

 Cont’d

Body composition measurements

• Anthropometric techniques can indirectly assess two
body compartments:

 fat-free mass and fat mass and

o variations in their amount and proportion can be used
as indices of nutritional status.
 Cont’d
• Fat-free mass consists of:
▫ Skeletal muscle,
▫ Non skeletal muscle and
▫ Soft lean tissues, and
▫ The skeleton.
• Body muscle is composed largely of protein.
• Hence, assessment of body muscle can provide an
index of the protein reserves of the body; these
reserves become depleted during chronic
undernutrition, resulting in muscle wasting.
• The body fat content is the most variable component
of the body, differing among individuals of the same
sex, height, and weight.
 Cont’d
• Body fat includes storage fat, found:
 inter- and intra-muscularly,
 around the organs and gastrointestinal tract and
 subcutaneously, as well as
• lipids found in:
 bone marrow,
 central nervous tissue,
 mammary glands, and other organs.
• Fat content of women > men representing 27%
of their total body weight while 15% in men.
• Normal-weight men and women have about 10 and
20% body fat, respectively.
 Cont’d
• Fat is the main storage form of energy in the body
and is sensitive to acute malnutrition.
• Alterations in body fat content provide indirect
estimates of changes in energy balance.
• A large and rapid loss of body fat is indicative of
severe negative energy balance.
• Small changes in body fat (i.e. <0.5 kg) cannot be
measured accurately using anthropometry.
• Body fat can be measured either in absolute terms
(the weight of total body fat, expressed in kilograms)
or as a percentage of the total body weight.
 Measurements of Body Composition
1. Mid upper-arm circumference:
• The arm contains subcutaneous fat and muscle;
decrease in UAC, reflect either:
▫ reduction in muscle mass,
▫ a reduction in subcutaneous tissue, or
▫ both.
• It is used for children under 5 years of age.
• MUAC measurements should be taken with a flexible,
nonstretch tape made of fibreglass or steel; alternatively,
a fibreglass insertion tape can be used.
• The measurement is taken at the midpoint of the upper
left arm, between the acromion and the tip of the
olecranon process.
Cont’d • Fig., Location of the
midpoint of the upper
arm

A MUAC < 12.5 cm suggests

malnutrition.
A MUAC > 13.5 cm is normal
in children.
 Cont’d
2. Skinfold thicknesses:
• One-third of the total body fat in reference man and woman
is estimated to be subcutaneous fat.
• Skinfold thickness measurements are said to provide an
estimate of the size of the subcutaneous fat depot, which in
turn is said to provide an estimate of the total body fat.
Such estimates are based on two assumptions:
1. the thickness of the subcutaneous adipose tissue reflects
a constant proportion of the total body fat, and
2. the skinfold sites selected for measurement, either singly
or in combination, represent the average thickness of the
entire subcutaneous adipose tissue.
• Neither of these assumptions is true.
 Cont’d
• Variations in the distribution of subcutaneous fat do
occur with:
▫ sex,
▫ race,
▫ age,
▫ disease states,
▫ body weight, and
▫ malnutrition.
• Hence, the most representative skinfold site is not the
same for both sexes, nor for all age and ethnic groups.
• Skinfold measurements are best made using precision
skinfold thickness calipers: they measure the
compressed double fold of the fat plus skin.
 Cont’d
• Three types of precision calipers most commonly used
are:
i. Harpenden
ii. Lange, and
iii. Holtain.
• Low-cost plastic McGaw calipers are also available.
• The following skinfold sites are commonly used:
1. Triceps skinfold measured at the midpoint of the back of
the upper left arm, between the acromion process and
the tip of the olecranon.
2. Biceps skinfold measured as the thickness of a vertical
fold on the front of the upper left armabove the centre
of the cubital fossa, at the same level as the triceps
skinfold.
 Cont’d
• Fig., the three types of • Fig., Triceps skinfold
calipers used to measure
skinfold
a. Harpenden
b. Lange, and
c. Holtain.
 53

Different types of Skin Fold Callipers

Holtain
Cescorf
Sanny Professional
Skin fold Caliper Body Caliper

Lange Fat Caliper

Defender Body Warrior Digital
Fat Caliper Body Mass Calliper Accu-Measure

Personal Body Fat Tester Harpenden Caliper

Lafayette
 Cont’d
3. Subscapular skinfold
measured just below and
laterally to the inferior angle
of the left scapula, with the
shoulder and arm relaxed
4. Suprailiac skinfold measured
in the midaxillary line
immediately superior to the
iliac crest.
A. Subscapular skinfold
B. Suprailiac skinfold
 Cont’d
• The triceps is most frequently selected because it is assumed to be
most representative of the whole of the subcutaneous fat layer.
• However, because subcutaneous fat is not uniformly distributed
about the body, a body skinfold site such as the subscapular
skinfold, as well as a limb skinfold, are often used with the triceps
skinfold to improve the estimate of total body fat and provide
information on the distribution of body fat.
• The optimum combination of skinfold measurements sites varies
with age, race, sex, and with the presence of particular disease
states.
 Cont’d
• If only one skinfold thickness measurement is made,
TSFT is most commonly selected.
• TSFT correlates with estimates of total body fat in
women and children.
• SSFT is better than TSFT as an indicator of total body
fat in men. SSFT has been shown to be a predictor of
blood pressure in adults independently of age and
racial group.
 Step by step skinfold measurement
• Generally the measure is done on the left side of the body
• Identify the measurement site and mark it with a pencil
• Keep the caliper in the right hand and pitch the skin with
thumb and index fingers, avoiding pinching the muscle
• Pinch the skinfold with the caliper
• Read the measurement on the caliper
• Open and remove the caliper
• Repeat twice (with at least 2 minutes interval)
• If the second measure differs by more than 10% from the
first, repeat a third time
 Summary
The most common anthropometric measurements:
• Growth
Height
Recumbent length (for the first two years of life)
Weight
Head circumference
• Body composition
Skin-folds
Hip circumference
Waist circumference
Mid-upper Arm Circumference (MUAC) < 5 years
 Cont’d
 Growth measurements are then used to construct the following indices:
 W/L,H (weight in relation to the normal weight for a given H/L)
 L,H/A (Height in relation to the normal height at a given age)
 W/A (weight in relation to the normal weight at a given age)
i. W/H is a sensitive index for the assessment of current
nutritional status (acute malnutrition).
A child with a low weight-for-height is thin
Extreme thinness is called wasting and is generally the result
of:
 Acute (or short) periods of insufficient dietary intake
 Repeated episodes of illness such as diarrhoea
 Failure to gain weight or actual weight loss
 Cont’d
An advantage of WFH over other indices of
anthropometric status is that there is no need to
collection information on the age of the child.
Therefore it is particularly useful in situations where
dates of birth are not registered.
The two extreme forms of severe wasting,
kwashiorkor and marasmus, occur in situations of
extreme undernutrition.
 61

Normal
hair Alert and
irritable

Thin,
flaccid Severe
skin wasting
hanging in -prominent
folds ribs, spine,
(baggy scapulae
pants) -Old man
face
Source: NutritionWorks
 62

Hair -
thinner
and lighter
Apathetic
Moon face and
No appetite miserable

Oedema
(symmetrical
oedema
involving at
Skin least the
lesions feet)

Source: NutritionWorks
 Cont’d
2. HFA is a measure of long-term/chronic nutritional status in children.

Children who suffer from chronic under-nutrition:

Grow poorly and have low height for their age i.e. they are short.
Children who are short for their age relative to a reference standard are
classified as “stunted.”. This results from:

Chronic consumption of diets of poor nutritional quality

Repeated infectious disease and

Deficiencies in specific nutrients such as zinc and calcium.

 Cont’d
This index is used primarily with children under five years of age
▫ Low H/A commonly not appearing before 3 months of age.
▫ The prevalence of stunting among children generally
increases with age up to 24–36 months
▫ Then remains relatively constant thereafter (Window of
opportunity closed)
• How to Identify HFA/stunting status?
• To identify whether a child is stunted
▫ His/Her actual height is compared with height of a reference
child of the same sex at exactly the same age.
STUNTING (inadequate height-for-age)
125 cm
7 years old

103 cm 100 cm
7 years old 4 years old

Reference: Vilma Q. Tyler, UNICEF-CEE/CIS

 Cont’d
3. W/A: Weight is influenced both by height and thinness.
• Low W/A (underweight) is a combination indicator of H/A &
W/H.
• W/A is the most commonly reported anthropometric index &
used frequently for:
▫ Monitoring growth &Identifying children at risk of
growth failure & malnourished.
▫ Index of acute malnutrition (current nutritional status )
in children 6 months to seven years of age when the
measurement of length is difficult
▫ Guide preventive measures such as nutrition counselling and
entry into short-term food supplementation programs.
▫ Assessing the impact of intervention actions in growth
Monitoring programs.
 Cont’d
• Indices of body composition measurements
i. Skinfold thickness: The measurement is of
considerable value in assessing the amount of fat
& therefore the reserve of energy in the body.
 Cont’d
ii. Mid Upper Arm Circumference: is widely used method
of assessing body composition.
• Fat free mass is a mixture of water, protein, and minerals,
with muscle serving as the major protein store.
• MUAC Provides an index of the protein reserves of the body
• MUAC is a proxy indicator of nutrient reserves and
Wasting
• Measurement is not time consuming, and is an effective
predictor of risk of U5 death
Errors in nutritional anthropometry
- Errors may occur in nutritional anthropometry which
affect the precision, accuracy, and validity of the
measurements/indices.
I. Measurement errors:
 these may be random or systematic, and may
include examiner error resulting from inadequate
training, instrument error, and measurement
difficulties.
- These can be minimized by training personnel to use
instruments that are precise and correctly calibrated,
and standardized, validated measurement techniques.
 Cont’d
2. Alterations in the composition and physical properties of
certain tissues. These may occur in both healthy and
diseased subjects, resulting in inaccuracies in certain
anthropometric measurements/indices.
• In healthy individuals, body weight may be affected by
variations in tissue hydration with the menstrual cycle,
whereas skin folds may be influenced by alterations in
compressibility with age and site of the measurements.
• Anthropometric measurements are not corrected to
account for these effects.
 Cont’d
3. Use of prediction equations developed on healthy lean
subjects for patients with certain diseases in whom
increases in total body water and alterations in the
distribution of body fat may occur.
Looking into this distribution,
say True or False
1. 50% of the population have
height >152 cm
2. 50% of the population have
height <152 cm
3. 10% of the population have
height < 141.8 cm
4. 10 % of the population have
height > 141.8 cm
A 5 1/2 month old girl was weighed by the Measurement
Team in training. The Team measured her length and
recorded the measures before comparing them. The
lengths ranged from 54.4 to 61.0 cm.
Calculate the child’s score

Measurer   Measure
1   54.4 cm
2   60.9 cm
3   61.0 cm
4   60.8 cm
A 10 year old girl was weighed by the Measurement Teams
in training. Her measured weights ranged from 25.8 to 26.8
kg with an ‘outlier’ of 20.6 kg. Calculate the child’s score

Measurer   Measure
1   25.8 kg
2   26.8 kg
3   25.9 kg
4   20.6 kg
Interpret this chart. Should the mother
of this child be concerned, why?
Interpret this chart. Should the mother
of this child be concerned, why?
Interpret this chart. Should the mother
of this child be concerned, why?