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LESSON 4 ANTHROPOMETRY (Facilitator EN)

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Learning objectives

At the end of this session, participants will be able to:

  1. name three ways of assessing nutritional status of adult men, women and children
  2. accurately measure and record the height and weight of an adult
  3. calculate Body Mass Index (BMI) using an adult’s weight and height
  4. accurately measure, record and interpret the Mid Upper Arm Circumference (MUAC) of an adult (pregnant or within 6 months post-partum) and a child 6-59 months of age
  5. accurately measure and interpret the length, height and weight in children aged 6-59 months of age, and BMI-for age in children and adolescents 5- 19 years of age

Duration: 3hours 45 minutes

Methods

  • Participatory Lecture
  • Demonstration
  • Practice

Materials

  • Lesson 4 Learning Objectives written on large paper
  • Tape measure (cm) (1 per small group)
  • Strong tape
  • Hard-cover book, clip board, or rectangular board of wood of about the same size (1 per small group)
  • Large paper
  • Pen or fine-tip marker
  • Sample weight charts from OI/ART clinic
  • Body Mass Index (BMI) table (1 per participant)
  • BMI Look-up Table for determining BMI for children and adolescents
  • Calculator
  • MUAC for children aged 6-59 months
  • MUAC tape for adults
  • Height/length board
  • Uniscale (standalone scale)
  • Infant scale
  • World Health Organization (WHO) Health Records
  • Felt pen/biro/pen
  • Toy baby for practicing measurements or members of the community who are available to have measurements taken for practice (if appropriate)

Presentation of learning objectives:

  • Note to the facilitator

    Providing the community members of the home-based care team with the BMI portion of this lesson is not recommended. It is more appropriate that HC staff, OI/ART clinic staff and NGO staff are trained on calculating and using BMI to monitor PLHIV nutritional status. Community members can be trained to collect quality weight and height data, but we encourage the HC, OI/ART clinic and NGO staff to calculate and interpret the BMI, and to provide appropriate counseling to the client.

The facilitator shows the learning objectives (written on the large paper) and asks one participant to read them aloud to the group. Discuss each objective with participants to make sure that they understand.

Does anyone have questions about what you have heard?

By the end of the lesson, participants will be able to:

  1. Name three ways of assessing the nutritional status of adult men, women and children
  2. Accurately measure and record the height and weight of an adult
  3. Calculate Body-Mass Index using an adult’s weight and height
  4. Accurately measure, record and interpret the Mid Upper Arm Circumference of an adult (pregnant or 6 months post-partum) and child 6-59 months of age
  5. Accurately measure and interpret the length, height and weight in children aged 6-59 months of age and children and adolescents 5-19 years of age

Learning objective 1:

Participants will be able to name three ways of assessing the nutritional status of adult men, women and children (anthropometric assessment, in other words – measurement of body size).

Methodology: Participatory Lecture, Practice, Group Discussion

  • Step 1: Participatory Lecture

Introduction

When there are questions, participants should first be allowed time to think of the answers on their own.

Does anyone know what ‘Anthropometry’ means?

The word has two parts: “Anthropo” means “related to humans”, and “metry” means “measurement”. So Anthropometry is the measurement of the human body including the rate the children grows, to understand their nutritional status. Recording weight and height/length are two of the most common ways of measuring the human body.

Many PLHIV in Cambodia do not know whether their body weight is within a healthy, normal range or not. As we learned in Lesson 2 and 3, there is a very close relationship between nutrition and infection. PLHIV often experience symptoms that lead to the reduction of food intake, thus are more at risk of malnutrition.

The causes of malnutrition are categorized in three broad categories; immediate, underlying and basic. Malnutrition means “poor nutrition” or “inappropriate nutrition” and includes both over and under-nutrition. Although under-nutrition is generally the main issue of concern in the developing countries, industrialization and changes in lifestyle and eating habits have increased the prevalence of over nutrition in many of these countries. With respect to this training manual, malnutrition refers to under-nutrition unless otherwise specified. Immediate causes of malnutrition in PLHIV can be due to: disease/illness; inadequate food intake; inability to use, digest or absorbs some nutrients because of diarrhea, infections, HIV itself etc. Underlying causes of malnutrition can be due to food insecurity; lack of money to buy food or medicines; inadequate access to food; lack of knowledge and/or ability to practice optimal feeding behavior; and social/cultural beliefs.

Without appropriate helps, people with illness, decreased appetite or poor nutrients absorption and utilization can become malnourished. Some signs and symptoms of malnutrition (under-nutrition) are:

General

In adults

  • Reduced lean body mass
  • Loss of body fat
  • Weight loss
  • Severe wasting

In children

In pregnant women

  • Growth faltering (poor growth)
  • Slower rate of growth
  • Weight loss
  • Stunting (be short for their age)
  • Pitting edema (fluid retention)
  • Lower weight
  • Anemia
  • Low birth weight
  • Pre-term delivery

In Cambodia, most PLHIV have a normal weight or are underweight. However, there are also PLHIV who are overweight. Therefore, programs should monitor the weight of PLHIV every month, to make sure they are maintaining a healthy weight, or are gaining weight (if they are underweight). If PLHIV are losing weight, it is dangerous for their health, as it may be a sign of infection, or make them more vulnerable to infection. If they are noticing weight loss, they should seek care from the OI/ART clinic immediately.

There are three ways to identify malnutrition risk for PLHIV depending on their age and life stage: (1) they have recently lost weight; (2) they have a low body-mass-index or BMI (low weight for their height); and (3) they have a thin arm or a low MUAC. Trained medical persons must be able to identify risk factors in order to give the best possible nutrition counseling and encouragement. Most PLHIV have their weight monitored during monthly visits to the OI/ART clinics, and they are often aware of their own weight or have it recorded in their OI/ART booklets. However, many PLHIV are interested to know if their current weight is within a normal range or not. To determine what a “normal weight” is, we need to know a person’s correct height.

People with HIV should monitor their weight regularly at the HC or hospital and the health personnel should record the information on their charts or in their health books. We are now going to practice identifying weight gain or loss.

  • Step 2: Practice and Group Discussion

Practice using examples of the weight charts from the OI/ART clinics. On flipchart paper compare the two most recent weight measurements. For example, if this month is September, the most recent weight was recorded last week (September). Compare weight of a PLHIV weight from August with the weight recorded in September to determine whether there has been any weight loss or gain, or whether it has stayed the same. Add the weight for October and again assess whether there has been any weight loss or gain, or whether it has stayed the same.

Did the person lose weight? If so, he/she needs to be advised to eat more of the three food groups to gain weight, or if he/she is not at the OI/ART clinic already, to seek proper medical care there at once.

Do another example with a patient who has not changed or has increased his or her weight. Note that we do not want to confuse the participants – if there is a weight gain that is not a very large one, the patient should NOT be advised to lose weight but instead be congratulated and encouraged to maintain his/her weight.

Lead a discussion with participants regarding monitoring weight with the following questions:

  • Are the PLHIV that you work with usually weighed?
  • Where are they weighed?
  • Where is the information recorded?
  • Do you usually have access to that information?
  • If not, what do you think that you or your clients could do to get that information so you can assist them to track their weight?

Continue the lecture, Now, we will focus on adult PLHIV (non-pregnant and over 6 months post-partum women). We will learn the correct way to measure height, weight and to calculate BMI based on a person’s weight and height. Then, we will focus on measuring the MUAC in children, pregnant and within 6 months post-partum women. Finally we will measure and interpret weight, height and BMI-for-age in children and adolescents 5-19 years of age.

Learning objective 2:

Participants will be able to accurately measure and record the height and weight of an adult.

Methodology: Participatory Lecture, Activity, Demonstration, Practice

Measuring Height

  • Step 1: Activity

Explain that, We will now learn about the common ways of measuring a person’s nutritional status.

Ask participants to organize themselves in a line from shortest to tallest. Ask the group, What do you think determines height?

Then explain about HEIGHT: The height of a person is determined by two factors. One factor comes from our parents and grandparents – tall parents have tall children, and short parents have short children. This is generally true in every country in the world. The other factor is nutrition. Infants and children who are eating enough body-building foods (meat and non-meat proteins) and protective foods (fruit and vegetables), will grow to be taller than children who do not eat enough meat, fruit and vegetables. Ask participants if they have noticed this with the younger generation of middle-class or wealthy Cambodians? Some of the teenagers are taller than their parents!

If participants know their body weight, ask them to organize themselves in a line from lightest to heaviest.

Ask, Is this the same order as for height?

Explain that You will notice that this is not the same order as the order of height. A person can be tall, but still weigh less than a shorter person.

Explain to participants, “Ideally a wall-mounted unit stadiometer (i.e. measuring board with tape and moveable headboard) should be used to obtain the most accurate measurement. Height rods attached to scales do not provide reliable measurements. If a stadiometer is not available, improvise by attaching a metal measure tape to the wall.”

  • Step 2: Demonstration – Secure the measuring tape

Ask participants to join you at the wall at the back or side of the room. Explain the following information and demonstrate the steps as you are doing them. Stop periodically and ask participants to repeat information or repeat the step just demonstrated, and whether they have any questions.

Explain, It takes two people to secure the measuring tape and to measure the height of a person properly. Select a location where the wall and floor are concrete, flat, and smooth. Make sure that the wall is flat all the way down to the floor, and that there is no baseboard or other interruption in the flat surface of the wall. This is very important.

(If possible, show an example in another part of the room with a baseboard or moulding so participants know what not to do.)

Instruct, Use adhesive tape to secure a measuring tape firmly to the wall, with the zero centimetre (0 cm) mark exactly at the point where the floor and wall meet. The tape should be firmly secured, perfectly perpendicular to the floor, and flat against the wall at all points. Secure the measuring tape well with strong adhesive tape.

If the measuring tape is longer than the person(s) you are measuring, you only need to secure the tape at the floor and pull it up as far as it can go – flat against the wall at all points. (Demonstrate with a long measuring tape and ask a volunteer to help you secure it.)

If you have a 1-meter tape, measure according to the directions below:

  • Note to Facilitator

    Step one on securing the measuring tape only needs to be conducted if you are using a short tape. The tape provided in the toolkit does not require this step.

Instruct, Use adhesive tape to secure a measuring tape firmly to the wall, with the zero centimeter (0 cm) mark exactly at the point where the floor and wall meet and have one person pull the tape measure up against the wall as high as it will go and hold it in place tight against the wall. A second person places a mark on the wall using a fine tip permanent marker at the 100 cm mark (the line above the 100. Be sure to read the tape carefully, as the numbers will be upside down).

After you have made a permanent mark on the wall, move the measuring tape upward so that the zero centimeter (0cm) mark is exactly at the 1 meter mark on the wall and secure it in place.

Pull the measuring tape upwards flat against the wall securing it with tape along the way.

Practice reading the tape. Explain to participants, Remember that the line

above the upside down number is the correct place to read that number. Also remember to add 100 centimeters, since the tape now starts at 1 meter. For example: if we want to measure 105 cm we have to use the 5 cm mark as our placer on the measuring tape and add 100 cm.

Ask a participant to find 105 on the measuring tape – make sure they are using the line above the number as the mark.

Height should be measured with

  • no shoes
  • standing erect
  • looking straight ahead
  • feet together
  • heels against the wall
  • back of the head against the wall
  • head scarves, hats and/or hair accessories removed from the top and back of the head

Now we are ready to measure a person’s height.

Review the following information on the big paper with the participants.

Ask a volunteer to take his/her shoes off and to stand against the tape measure. Explain the following while demonstrating with the volunteer.

The person you are measuring should be directly centered in front of the tape so that the tape appears to come out of the center of the top of the head. Tell the person to look straight ahead and not to tip their head forward or backward. A thick hardcover book, rectangular block of wood or another similar device should be lowered to rest flat on the top of the head. Hold the book firmly against the wall. Ask the person to step down and out from under the book without moving the book. Read the measurement at eye level where the lower edge of the book intersects the measuring tape. Read and record the height of the person to the nearest 1 cm. Care should be taken when measuring individuals who are taller than the person taking the height. A step-tool may be needed to receive accurate results.

Write the height on the large paper in centimeters and in meters (for example, 153 cm and 1.53 meters). Explain to participants that 153 cm is the same as 1.53 m.

Here is a tip: Participants who work at a HC or other permanent facility should use a fine tip permanent marker to mark the wall of the HC with some bench mark measurements, for example, 10 cm increments. A measuring tape can slide or be pulled away, becoming inaccurate or even lost. Having permanent bench mark measurements on the wall will help to insure that the tape measure is placed on the wall correctly each time a client is measured.

  • Step 3: Demonstration – Measuring height

Ask for another two volunteers: one to stand against the measuring tape and the other to take the measurement. Repeat the instructions as they are doing the demonstration.

  • Step 4: Practice

Ask participants to divide themselves into small groups of three or four people. Give each group a measuring tape, a few pieces of adhesive tape, and a marker. Let them practice taping it to the wall as was demonstrated earlier. Facilitators should supervise this practice exercise and give feedback to ensure that the tape is being correctly mounted to the wall.

Once all the groups have successfully and correctly secured their tape measures to the wall, ask them to take turns measuring each other’s heights to the nearest centimeter and recording them. Tell them to refer to their Lesson 4 (participant manual) for a reminder of how to correctly position the person they are measuring. Facilitators should supervise this practice exercise and give feedback to ensure that the groups are positioning the subjects correctly, using the books/boards correctly, and correctly reading and recording the height of participants to the nearest 1cm (using the number below the measurement line). Small groups should record each person’s height in centimeters and in meters.

If time permits for a fun quality assurance exercise, ask one person to go to each of the groups to be measured. The height measurement by each group should be the same for that person (or at least within 1 cm). If not, it is a sign that the groups need more practice measuring or that their measurement tape is not properly hung.

In supervising this exercise, facilitators should make sure that each participant practices the correct technique for measuring adult height. Provide encouragement and praise for correct technique. Gently correct any problems and answer any questions from participants.

Explain that, If a height measurement is not available, or it is not possible to measure height, it is still possible to measure weight gain and weight loss over time. This is an easy way to monitor the health of PLHIV, but it is less accurate than BMI, because we must know a person’s height before we can determine his or her normal, healthy weight.

Measuring weight

  • Step 1: Lecture and Demonstration

Explain to participants, We have learnt how to measure height of an adult, now we will learn how to accurately measure the weight of an adult. The weight measurement is extremely important as weight is used in combination with height to calculate nutritional status of an adult. With the anthropometric measurements, we will be able to monitor nutritional status of an adult PLHIV over time.

Ask the group –What factors do you think determine weight?

Then explain about WEIGHT: The weight of a person is mostly determined by the amount of food (or ENERGY) that they eat. An adult person’s weight can change a lot over time, depending on factors like food (adds energy), illness (burns energy), age, and for women, whether or not she is pregnant.

Explain, HEIGHT and WEIGHT can be used to evaluate a person’s BMI. The BMI tells us how fat or thin a person is, because it describes the person’s weight in relationship to their height. We will look more at BMI later in the training.

Ask participants: When was the last time you weighed yourself? Do you think the weight was accurate? Why / Why not?

Then explain to participants and demonstrate the steps as you are doing them, Weight can be measured using a balance beam scale or adult bench scale, according to the MOH standards. The actual weight of an adult can vary for different reasons. For example, weight can be affected by:

  • The clothes a person is wearing
  • Incorrect calibration of the scales
  • Incorrect placement of the scales
  • Use of poor quality equipment
  • Improper weighing technique

If using a balance beam scale, always check the zero weight on the horizontal beam by sliding the main and fractional weights to their respective zero positions and adjusting zero weight until the beam balances at zero reading. Standard weights should be available to calibrate the scale. If using an adult bench scale, first calibrate and zero the scale (i.e. ensure that the scale reads 0.0kg when nothing is on them). The scale needs to be placed on a flat hard surface.

Now we are ready to measure a person’s weight. Review the following information on the big paper or in the lesson (participant manual) with the participants.

Weight should be measured with

  • zero scale
  • no shoes/sandals
  • minimal, light clothing
  • heavy items removed from pockets
  • standing still on the centre of scale platform, without touching other objects or persons.

The scale needs to be on flat ground – and if possible the person should be weighted with the scale in the same spot in the clinic each time

Read the scale at eye level. Take the reading to the nearest 0.1kg (100g) and record immediately. Repeat the measurement twice and ensure that two readings taken immediately in succession should agree within 100g (0.1kg) difference.

  • Step 2: Practice

Tell participants that they now have a sound protocol for taking weight measurements that they can use when practicing taking weights. Divide the participants into small groups (the number of groups will depend on how many scales you have). Let them practice the series of steps you just demonstrated. Ask a volunteer from each group to be weighed while another participant measures their weight and another person records the measurement. Facilitators should move around among the groups to make sure proper procedure is being followed. Provide encouragement and praise for correct technique. Gently correct any problems and answer any questions from participants.

Learning objective 3:

Participants will be able to calculate Body Mass Index (BMI) using an adult’s weight and height

  • Step 1: Lecture, demonstration, and practice using BMI formula

Explain: Now we know how to measure the height of an adult. As we learned earlier, if we have the height and weight of a person, we can calculate their “Body Mass Index,” or BMI. BMI is one of the methods used to assess an adult’s nutritional status. BMI is an inexpensive and easy to perform method to measure thinness. BMI cannot be used for pregnant women because a pregnant woman’s weight will be related to the growth of the baby and changes in the body related to pregnancy. MUAC is recommended as the preferred method for pregnant and women up to 6 months post-partum. For children and adolescents (5-19 years old), BMI is age and sex specific and it is often referred as BMI-for-age. In the next session we will learn other anthropometric measurements to assess malnutrition in children and pregnant woman.

Write on the big paper:

Body Mass Index (BMI) = describes a person’s weight
in relationship to his or her height.

Explain, The BMI tells us how fat or thin a person is. BMI is not a percentage (%); it is a ratio of a person’s weight relative to his/her height, expressed as a number.

Review the formula on the big paper and ask participants to refer to their Lesson 4 (in the participant manual). Remind them that a kilogram is a measure of weight and a meter is a measure of height – BMI is a ratio. The formula for calculating BMI is:

  • Note to Facilitator

    For HBCT, it is important just to remember that someone with a BMI of below 18.5 is considered to be malnourished. However, it is important that HC, OI/ART and NGO staff understand the classification of adult malnutrition.

Explain to participants, The formula for BMI requires the height to be in meters. Since height is commonly measured in centimeters, divide the height in centimeters by 100 to obtain in meters before you use the formula. The normal range of BMI is from 18.5 to 25. A BMI of less than 18.5 means that the person is underweight. A BMI of greater than 25 means the person is classified overweight (though there are reasons that this could occur – limitations of BMI).

Ask participants to look at the Lesson 4 (in the participant manual) at the Table showing the classifications of BMI. Review the table and classifications with them.

WHO International Classification of Adult Nutritional Status Using BMI:

Range of BMI categories (kg/m2)

Underweight

<18.5

Normal weight range

18.5 – 24.99

Overweight

> 25.00

Obese

> 30

Malnutrition classification

BMI <18.5

Mild malnutrition

17.00 – 18.49

Moderate malnutrition

16.00 – 16.99

Severe malnutrition

< 16.00

Source: World Health Organization (WHO), 2006
http://apps.who.int/bmi/index.jsp?introPage=intro_3.html

  • Note to facilitator

    Please conduct this exercise with only those medical personnel who are going to calculate and interpret BMI, such as HC staff, OI/ART staff and NGO staff. Trained medical personnel must be able to interpret BMI using the formula and the BMI table; however trained HBCTs are recommended to use the BMI table.

Use the following examples to demonstrate how to calculate BMI, walking them through the steps on the big paper:

Example 1: What is the BMI of a person who is 150 cm (1.5 m) tall and weighs 50 kg?

BMI = 50 / (1.5×1.5)

BMI = 50 / (2.25)

BMI = 22.2

Ask participants, Is this person overweight, normal, or malnourished?

After they answer, explain The person in Example 1 is within the normal range because the BMI (22.2) is between 18.5 and 25.

Example 1: What is the BMI of a person who is 165 cm tall and weighs 50 kg?

BMI = 50 / (1.65×1.65)

BMI = 50 / (2.72)

BMI = 18.4

Ask participants, Is this person overweight, normal, or malnourished?

After they answer, explain The person in Example 2 is malnourished because their BMI (18.4) is less than 18.5.

Discussion

  1. What are the weights of the two people in the examples? (both weigh 50 kg)
  2. What are the BMIs of the two people in the examples? (22.2 and 18.4. One is normal, and the other is underweight)
  3. Why do people who have the same weight have different BMI? (Because one is taller than the other)
  • Step 2: Lecture, demonstration, and practice using BMI Table

Explain that, A tool has been prepared to help estimate BMI in a simple way without having to compute using the formula.

Give one copy of the BMI table to each participant.

Explain that the colors represent the categories of nutritional status, as shown at the bottom of the table. Review the following information on the big paper:

  • Underweight is <18.5
  • Normal is 18.5 to 24.9. The lower end of this range (BMI 19 to 20) is normal but PLHIV in this category should be monitored to prevent them from becoming underweight
  • Overweight is 25 to 29.9
  • Obese is 30 and above

Explain to participants that the BMI table calculates BMI based on weight in kilograms and height in centimeters therefore participants can use directly the recorded reading directly from the measurement taken without needing to convert the height into meters.

Refer participants to Lesson 4 (participant manual) and the steps for using the BMI Table.

Steps for using the BMI Table

  1. Find the person’s height in the far left column.
  2. Find the person’s weight in the top row.
  3. Use your finger or a straight edge (such as a pencil, or the edge of a piece of paper) to follow a straight line that runs from Left to Right from the person’s height.
  4. Imagine another straight line that runs from Top to Bottom from the person’s weight.
  5. Look at the number where the two lines meet. This is the person’s BMI.
  6. If the two lines meet between two numbers, the BMI is the lower number plus 0.5 (for example, between 19 and 20, the BMI is 19.5). If the lines meet between two of the same numbers, that is the BMI.
  7. If the two lines meet in the middle of four numbers, take the lowest number and the highest number, the midpoint between is the BMI (for example: between 19, 19, 20, and 20, the BMI is 19.5; and between 23, 24, 25, and 26, the BMI is 24.5). See the example in the practice exercises below.

Have participants practice using the BMI table to calculate their own BMI. Ask participants to then sit in pairs. Each person takes turns to give his/her height and weight information to his /her partner and the partner uses the table to calculate his/her BMI again. Partners compare their answers to see if they have calculated the same BMI. Facilitators should help participants understand any mistakes that lead to inconsistent answers.

Practice exercises

One at a time, the facilitator reads the heights and weights listed below. Give participants a short time to use the table to estimate the BMI of a person with that height and weight and to interpret the result (normal, overweight, underweight) Ask participants to write their answers on a piece of paper. Ask a volunteer to give the answer and see if the rest of the participants agree. Encourage participants to use the straight edge of a piece of paper to help follow straight lines. Give assistance to participants who do not have the correct answer, so that they can understand what they did wrong.

No

Height (cm)

Weight (kg)

BMI

Interpretation

1

160

56

22

Normal

2

144

40

19

Normal but on the low side for a PLHIV and could be a warning sign

3

155

44

18.5

Borderline between normal and malnourished and is a definite warning sign

4

154

47

19.5

Normal but on the low side for a PLHIV and could be a warning sign

5

161

53

20.5

Normal

6

170

36

12

Very malnourished – severe

7

140

70

36

Overweight – obese

8

157

51

20.5

Normal

9

153

49

21

Normal

Explain that sometimes (as in numbers 8 and 9 above) the two lines of height and weight will meet at a point that is between four numbers.

For example:

  • No. 8 above: A person is 157 cm tall and weighs 51kg.
    The red circle is where the height and weight lines meet. Here we can say that the BMI is 20.5
  • No. 9 above: A person is 153 cm tall and weighs 49kg.
    The red circle is where the height and weight lines meet. Here we can say that the BMI is 21.

The facilitator should call out other heights and weights for as long as participants need to continue practicing.

Ask: What was your BMI when you used the formula to calculate it? What was your BMI when you used the table to estimate it? The BMI should be the same (or very similar). The formula is more specific, but the table is more practical for the field. It is good to know how to calculate BMI both ways – using the formula, and using the table.

MEASURING THE BODY TO ASSESS MALNUTRITION IN

PREGNANT WOMEN AND CHILDREN

Introduction to MUAC

Ask participants, Does anyone know what MUAC stands for?

Explain, MUAC stands for Mid Upper Arm Circumference. It is the circumference of the LEFT upper arm. It is measured at the midpoint between the tip of the shoulder and the tip of the elbow (olecranon process and the acronium). We are going to refer to MUAC as the abbreviation for this term.

Pass around one MUAC tape per participants (they will keep them) and ask participants – Has anyone in the group seen or used a tape like this before? If yes, ask the person (or persons) to briefly describe the experience.

Ask participants, “Why is a child’s MUAC taken?

Explain, The MUAC is a quick and easy measurement to detect malnutrition. A thinner arm reflects wasted lean mass (e.g. malnutrition), so MUAC is a good indicator of the protein reserves of a body. Muscle mass is known to be important in maintaining body functions and in fighting infections. MUAC can be applied to rapid triage settings especially when quick assessment of children is needed. MUAC is not used to measure malnutrition in children under 6 months because we don’t have established cut-off levels for this age group.

Hold up one tape and explain, We measure MUAC with special bands or tapes likes this. A MUAC tape is a simple tool to measure a person’s nutrition status. Different types of MUAC tapes are available. Some have numbers, same have numbers and colours, and some have colours only. When available, use colour-coded tapes because this makes measuring MUAC much simpler. There are 3 different colour zones on the armband, each representing a nutritional status. Position and placement of tape are critical so that proper interpretation can be made.

Ask participants, Why is MUAC a good measurement to use during pregnancy?

Explain, The MUAC is relatively stable throughout pregnancy and is not impacted by gestational age. It is a good indicator for malnutrition at all stages of pregnancy and no other information is required such as maternal age. The MUAC measurement is cheap, requires little equipment and is easy to perform, however training on how to take the measurement is needed.

The Body Mass Index (BMI) is not used to monitor weight in pregnancy because the body weight will change due to the growing baby in utero/fetus.

However the pre-pregnancy BMI (how much the woman weighed before pregnancy) will have an impact on how much weight should be gained during pregnancy. As a general rule, a woman who was underweight before she became pregnant will need to gain more weight than a woman who was a healthy weight, or overweight before pregnancy.

Ask participants, Do you remember the table that provides an estimate of the recommended weight gain during pregnancy, based on pre-pregnancy weight in Lesson 2?

Refer participants to Lesson 2 (participant manual).

Ask participants, Does anyone have any questions so far about what you have heard? We are now going to go through Learning Objective 4.

Learning objective 4:

Participants will be able to accurately measure, record and interpret the MUAC of an adult (pregnant or within 6 months post-partum) and child 6-59 months.

Methodology: Demonstration, Lecture, Practice and Quiz

  • Step 1: Demonstration- Steps to accurately use a MUAC tape

Step 1 – Finding the mid-point

The left arm is always used when measuring the MUAC. Locate the tip of the shoulder and mark with a felt pen/biro. Then find the tip of the elbow, while the elbow is bent and mark this point also.

Once both points have been found, use a tape measure from the tip of the elbow to the tip of the shoulder (keep the elbow still bent). Mark the middle point between the two points with a felt pen/biro. This is your mid-point.

Step 2 – Measuring the MUAC

With the arm hanging straight down, wrap a MUAC tape around the arm at the midpoint mark.

There are two types of MUAC tapes. The first type of tape is marked with red, yellow and green. For this tape, slide the end through the first opening and then through the second opening. The MUAC measurement is shown by the colour through the window at the point where the two arrows point.

The second type of tape has numbers on the tape, instead of being colour coded. Feed the end of the tape through the first opening and up through the third opening. The measurement is the number in the box that is completely visible in the middle window. All of the arrows will be pointing inward at the window where the measurement is.

Step 3 – Recording the MUAC correctly

The measurement is recorded to the nearest 1mm. It is important to be careful with the amount of tension on the tape. Try to use enough tension to hold the tape against the skin, but don’t pull the skin.

The tape is too tight where the skin is pinched, or too loose where the tape isn’t touching the skin. This will lead to an inaccurate measurement.

Refer participants to “Child Mid-Upper Arm Circumference Measurement” in Lesson 4 (participant manual).

Note to FacilitatoR

Remember to check which type of MUAC tape you are using for this activity. There are different MUAC tapes for adults and children – a MUAC tape for a child cannot be used on an adult.

If the internet and YouTube access, there is a short video that shows how to measure a MUAC, as well as check for edema: http://www.youtube.com/watch?v=3pQUtOsjjSY

The video should be fast forwarded until 3 minutes and twenty five seconds into the video (3 minutes and 25 seconds).

If there is no internet access available, the following steps can be demonstrated to the class. If there is an experienced participant in the group, they may like to assist with the demonstration.

  • Step 2: Lecture

Explain to participants the cut off points for MUAC in children 6-59 months.

The new cut off points for MUAC in children 6-59 months are:

Red

<11.5cm

Severe acute malnutrition

Yellow

≥11.5 – ≤12.5cm

Moderate acute malnutrition

Green

>12.5 cm

Growing well

Source: WHO. 2009. Guidelines for an Integrated Approach to the Nutritional care of HIV-infected children (6 months–14 years).

The previously used cut off points for MUAC in children 6-59 months are:

Red

0-11.0cm

Severe acute malnutrition

Yellow

11.0-12.5cm

Moderate acute malnutrition

Green

12.5 cm and above

Growing well

Source: WHO. 2009. Guidelines for an Integrated Approach to the Nutritional care of HIV-infected children (6 months–14 years).

The old cut off points are still used in many places and the MUAC tape you have may have the old measurements on it.

When measuring the MUAC on a woman who is pregnant or within six months post-partum, you must use a special adult MUAC tape. The tape does not have the color coding, so you must use the following cut off points.

MUAC

Classification

<19.0cm

Severe acute malnutrition

≥19.0-<22.0

Moderate acute malnutrition

≥22.0-<23.0cm

Mild malnutrition

Above 23cm

Normal

Source: Tumilowicz, A. 2010. Guide to screening for food and nutrition services among adolescents and adults living with HIV. Washington, DC: Food and Nutrition Technical Assistance II Project (FANTA-2)

  • Step 3: Practice

There are several ways that the MUAC measurement can be practiced. Split into pairs and firstly practice finding the midpoint. This is important to get correct. The pairs can then practice measuring the MUAC correctly.

If the participants have young children and the group felt this was suitable, it is good to practice the MUAC measurement on children also. A doll can be used, however is not ideal for the MUAC measurement in the arm does not bend. Also, dolls stay a lot more still than young children so this will not be realistic when taking the MUAC measurement in a real setting!

The facilitator should supervise this section carefully to make sure the tape is not being pulled too tight, or too loose. Measurements should not be taken over the top of the shirt sleeve, the left arm should be measured, and the correct tape should be used for the adults and children.

Encourage group learning for this section, with any experienced group members assisting to teach their group members.

  • Step 4: Quiz: Revision and questions

Instructions for activity:

These are some questions that can be answered as a group or you can give the participants a few minutes to answer them individually and then discuss as a group.

Why do we use MUAC instead of BMI to determine nutritional status in pregnant women?

What do we need to remember when measuring the MUAC to make sure the measurement is accurate? (What can cause the measurement to be inaccurate)?

If a child aged 12 months of age had a MUAC of 13cm, what classification would you give him?

If a child aged 4 months of age had a MUAC of 11.5cm, what classification would you give her?

Which arm should the MUAC be measured on?

Praise the participants for answering the questions well, gently correcting any mistakes in the discussion while providing a summary of the major points. Remember that MUAC is not conducted on children less than 6 months of age.

Explain, We will now go through the measurement of length, height and weight in children aged 6-59 months.

Learning objective 5:

To accurately measure and interpret the length, height and weight in children under 5 and children and adolescents 5-19 years of age

Methodology: Lecture, demonstration

measure length, height and weight in children under 5

  • Step 1 – Lecture and demonstration

Identifying bilateral edema

Explain to participants, There is another method that we can use to identify malnutrition in children. It is to check to see if the child has edema.

Ask participants, Does anyone know what I mean by edema? Can you tell me how to measure edema?

Then explain, Edema is when there is excessive amounts of fluid in the body tissues. It happens when a child is severely malnourished. Edema is measured on the feet of the child and should be referred for specialized care (The edema must be present in both feet).

Ask participants, When do we measure edema?

Explain to participants, We check for edema in children (6-59 months) when conducting nutrition assessment that include weighing and measuring

  • Note to Facilitator

    Infants less than six months of age are usually not measured using anthropometry, except for birth weight and visual indicators such as visible wasting and edema. Criteria for malnutrition in this age group are based on clinical signs (e.g. edema, visible wasting, too weak too suckle, not gaining weight despite feeding) and risk factors (e.g. insufficient breast milk, absence of mother).

    If these clinical signs or risk factors are identified, weight-for-length is the best indicator to measure malnutrition in this 0-6 month age group. Weight-for-age can also be used to determine if weight gain is adequate, especially if resources are limited and a length cannot be measured. In the context of HIV, it is important to conduct additional monitoring in infants 0-6 months, as they have additional risk factors for malnutrition including infant HIV infection, and very sick mothers. Close monitoring of infants and mothers in the 0-6 month age range should identify infants at risk of poor growth.

children. We need to note edema when we measure children because it affects the child’s weight (that is, the child weighs more, but it is not a healthy weight). Children with edema are automatically considered wasted or severely malnourished.

To measure the edema, grasp the foot so that it rests in your hand, with your thumb on top. Press your thumb gently on the foot for a few seconds. If a pit (dent) remains in the foot for several seconds when you lift your thumb, the child has edema and must be referred. Make sure you check that the edema is there on BOTH feet, and record this information on the counselor’s monitoring form for children. It is important to test both feet because if there is edema only in one foot, it is not a nutritional problem. Bilateral edema means that edema is present in both feet.

Checking for edema

Explain, We are now going to learn how to measure the length, weight and height for children aged 6-59 months. This method is a bit different to the measurement of height and weight for adults you learnt in an earlier section.

Ask participants, Does anyone have experience in measuring the height and/or length of children under 5 years of age? Or the measurement of weight? Can you tell us about your experience? What tools did you use? Was it easy to conduct the measurement on the child?

Then explain, There are two measurements for children – length and height. These depend on how old the child is.

If the child is less than two years of age, a length measurement of the child will be taken. This can be taken with a special length board, or by fixing a measuring tape to a flat surface.

If the child is more than two years of age, a height measurement of the child is taken, with the child standing upright. The tape that is used for measuring adults can also be used here otherwise a special height board can be used.

We measure the weight, height and length of a child so we can calculate the following:

  • Weight-for-height (WFH): a measure of wasting or acute malnutrition
  • Height-for-age (HFA): a measure of stunting or chronic malnutrition
  • Weight-for-age (WFA): a measure of underweight or wasting and stunting combined

Some anthropometry measurements are presented as indices, including HFA, WFA and WFH and BMI-for-age. Each index is recorded as a z-score that describes how far and in what direction an individual’s anthropometric measurement deviates from the median in the 2006 WHO Child Growth Standards for his or her sex. A z-score is measured in standard deviations.

  • Note to Facilitator

    Table below presents clear information on the body measurements used to assess the nutritional status of children under 5 years of age.

  • Note to Facilitator

    Please see the National Interim Guidelines for the Management of Acute Malnutrition (National Nutrition Program, 2011) for details on the identification and management of acute malnutrition.

Definition

Index or Measure

Moderate Malnutrition

Severe Malnutrition

Stunting reflects chronic malnutrition

Inadequate length or height* relative to age

HFA

< -2 and ≥ -3 z score

< -3 z score

Underweight reflects both chronic malnutrition and acute malnutrition

Inadequate weight relative to age

WFA

< -2 and ≥ -3 z score

< -3 z score

Wasting reflects acute malnutrition

Inadequate weight relative to length or height

WFH

< -2 and ≥ -3 z score

< -3 z score

Inadequate muscle tissue and fat stores in the body

MUAC (6-59 months)

≤12.5 cm and ≥ 11.5 cm

<11.5 cm

Bilateral Pitting Edema reflects severe acute malnutrition

An accumulation of fluid that starts in both feet and that can progress to other parts of body

Any bilateral pitting edema indicates severe acute malnutrition

Overnutrition

Overweight

Obese

excessive fat accumulation that presents a risk to health

WFH

> +2 and ≤ +3 z score

> +3 z score

Source: Adapted from Assessing Children Under 5 Pocket Reference, FANTA 2011
http://www.fsnnetwork.org/sites/default/files/fanta_anthro_children_under_5_032120121.pdf

Explain, Malnutrition and inadequate growth are extremely common in HIV-infected infants and children, and is often the earliest sign of HIV infection.

Ask participants, Which measurements are you currently using in your workplace? How do you use these measurements and record them?

Then explain, Many organizations use the Weight-for-age measurements, which gives some good information on weight, if the age of the child is known. Weight-for-age tells you how heavy a child for their age. Weight-for-age will indicate whether the child is underweight. The Height/Length-for-age is also a measurement that can be used in addition to MUAC, to identify the chronic malnutrition such as stunting. Best practice for determination of undernutrition is generally considered to be weight-for-length/height. However MUAC and/or the presence of bilateral putting edema is the recommended measurement to screen malnutrition in children aged 6-59 months in the community setting. Weight-for-height measurements are used for assessment of malnutrition at hospital level.

Ask participants, Does anyone have questions about what you have heard?

Then explain, We will first practice measuring the length and height of a child 6-59 months of age.

  • Step 2 – Practical demonstration and activity

Length

Explain, For a child under 2 years of age we will measure the length. Use a measuring board with a headboard and sliding foot piece. If you don’t have access to a measuring board, you can make one using a measuring tape. Remember how you made the height measurement for adults? This time, the tape measure will need to be laid flat on a piece of wood/board/table and fixed securely. Two pieces of board can then be used gently, to place at the feet and head of the child while being measured.

Make sure the board is placed flat on a stable or level table. Having the mother or carer nearby will be a help to comfort the child and to help them stay still.

The child should be measured with no clothes on (if appropriate) and with a cloth laid down on the board. Remove anything from the child’s head such as a hat or hair ornaments. Remember to remove the shoes and socks.

With a partner, have one person standing behind the headboard. Position the child on their back, while supporting the head. Hold the head with two hands to gently tilt the head so the child is looking straight upwards.

The other person should stand alongside the measuring board to support the child’s body, pressing gently on the shins and knees to straighten the legs. The soles of the child’s feet should be flat on the foot piece, and the toes pointing upwards.

The length measurement is taken to the nearest millimetre (0.1cm) and recorded on the Growth Record. (0.1cm = 1mm)

Remember: If the age is difficult to assess, children with a height of 87 cm tall or above are measured standing and those less than 87 cm are measured lying down (WHO Standards). The difference in recumbent length versus standing height is 0.7cm, meaning that a child who is measured lying down will appear artificially taller than they would if they were measured standing up. Therefore, if the children whose length you measured is 2 years old or more, subtract 0.7cm from the length and record the result as height in the notes.

Height

Explain, For a child over 2 years of age we will measure the height of the child in standing position. This is measured the same as the method for measuring the height of an adult.

Ask the participants, Do you remember how to correctly measure the height? What do you need to remember to do so the measurement is accurate?

  • Note to Facilitator

    Remember to have the child standing with the back of their head, legs and buttocks touching the board or wall. They should be standing looking straight ahead with their feet together, on a flat piece of ground/floor.

    In pairs practice measuring the height and length, using a toy doll or children aged under 5 years of age. Where possible it is good to practice the measurements on children, if this is appropriate for the group. This may be accompanied children from the community, or participants’ children/family.

Provide a brief summary of the how to measure the height, and congratulating the participants if they remember correctly from the previous session. Refer participants to Child Height Measurement – Height for Children 24 Months and Older in Lesson 4 (participant manual).

Weight

Explain, There are many different types of scales which can be used to weigh a child 6-59 months of age.

Ask the participants Which type of scales have you used before? Which scales do you have available in your workplace or community? What was your experience using these?

After a brief discussion, show the pictures of the different types of scales that can be used.

Method 1

There are special scales available to weigh children under 5 years of age, which are different to the standing scales used by adults. The scales measure the weight of the child while they are lying down or hanging in a sling.

  • When measuring the child, remove their clothes (if appropriate) and put a cloth on the scale before placing the child down.
  • Check that the measurement on the scale is “0” after you have put the cloth on the scale and that the scale is placed on a flat surface. This could be a table, a piece of wood or a bench top.
  • Place the child in the scale (or sling), make sure their whole body is on the scale and they are settled before reading the weight measurement. Some children may become distressed or move around, make sure the mother or carer is close by to comfort the child.
  • Measure the weight to the nearest 10g or as accurately as possible. Record the weight on the Child Growth Chart.
  • If you do not have access to a special child scale, then an adult scale can be used to measure the weight of the child.

Method 2

  • Put the scale on a flat and even surface, and check that the measurement is on 0.
  • Ask the adult, preferably the mother or carer, to take off their shoes and stand on the scale. They should be standing with both feet on the scale, and looking straight ahead.
  • Record the weight of the adult.
  • Take the clothes, shoes and socks off the child being weighed. Check that the scale is back to 0.
  • Ask the adult to hold the child to their chest and stand on the scale, looking straight ahead. The child should not be moving around, and the weight measurement taken when they are settled.
  • Record the weight of the adult + child together and subtract the adult weight measurement from this. The result will be the weight of the child.

Now ask the participants to work in pairs or small groups to measure the weight of the child, using the toy doll or children from the community. Practice using both methods and compare the results.

Is the weight the same with both methods?

We will now practice using the recording the measurements on the Growth Charts.

Measuring nutritional status for children and adolescents aged 5-19 years of age: BMI-for-age

Begin by saying, Children and adolescents aged 5-19 years of age also need to have regular growth monitoring, including height, weight and calculation of BMI.

Ask participants, what type of growth measurements do you currently take on children in this age group? And how do you record this?

At the start of the lesson we talked about measuring the height and weight of adults, and the same scale and height measure can be used for children and adolescents aged 5-19 years of age. The Body Mass Index can then be calculated. Do you remember how to calculate the BMI?

The Body Mass Index in children or adolescents is calculated based on the weight (in kg) divided by the height multiplied by the height (in meters). So if the child had a weight of 20 kg and a height of 1.2 meters, the calculation would be 20/(1.2 x 1.2)=13.8

Counsellors may use a table to work out a child or adolescents BMI (weight for height). E.g. if child is 92cm tall and 15kg, BMI is 17.7.

Trained medical personnel must be able to interpret BMI using the formula and the BMI table; however trained HBCTs are recommended to use the BMI Look-up Table.

The cut-off points for BMI-for-age are:

Classification

BMI-for-age

Severe malnutrition

<-3SD

Malnutrition

-3SD to -2SD

Normal

-2SD to +1SD

Overweight

+1SD to +2SD (equivalent to adult BMI of 24kg/m2

Obesity

>+2SD (equivalent to adult BMI of 30)

Now we will practice using the BMI-for-age chart – does everyone know how to do this? Here is a hand out of the 5-19 years of age chart for children and adolescents 5-19 years of age. There is a different one for boys and a different one for girls.

On the left hand side of the graph the BMI numbers are listed. The bottom part of the chart is where the age of the child is listed.

Mark of the graph where the BMI and the age meet up. So if we use the example of Shan, who is 15 years of age, and has a BMI of 13.8, where would you plot her BMI-for-age on the chart? What z score does she have? Is she considered to be thin, severely thin, obese or overweight? (HINT: use the cut-off points in the above table).

Does anyone have any questions about using the BMI-for-age chart for children and adolescents aged 5-19 years?

Now let’s summarize and do some revision questions.

In this section we have learnt to measure the length, height and weight of children aged 6-59 months, and how to determine the nutritional status of children and adolescents aged 5-19 years of age.

The length is measured on children aged under 2 years of age, and the height is used for children over 2 years of age. The weight of children can be measured using a sling, baby scale or with an adult holding the child on a standing scale. It is important that the measurements are taken on a flat surface and that the equipment is checked before use so the measurements are accurate.

The measurements taken can then be plotted on the Child Health Chart. For children aged 5-19 years of age, the height and weight are measured, and the BMI calculated. This is plotted on a special BMI Child Health Chart for children in this age range. The BMI cut-offs for adults are different for children aged 5-19 years of age.

Ask participants

  • What measurements do you need to take on a child aged 6-59 months of age?
  • What are some good tips to remember when measuring the height of a child so the measurement is accurate (e.g. looking straight ahead)?
  • If a child is 18 months old should the measurement of length or height be taken?
  • How can the weight of a child aged 18 months of age be measured?
  • For children and adolescents aged over 5 years of age, how can we tell if they are growing well? What type of measurements should be taken?
  • What are the BMI-for-age cut-offs for children and adolescents aged over 5 years of age?
  • How do we measure and check if a child under 6 months of age is growing well?

Congratulate the participants for their correct answers, and gently correct any incorrect answers by facilitating a discussion.

Summary

Ask participants to look at the Lesson 4 (participant manual). Ask participants to take turns reading it aloud to the group.

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