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LESSON 4 ANTHROPOMETRY (Participant EN)

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ASSESSMENT FOR MALNUTRITION IN ADULTS (NON-PREGNANT AND OVER 6 MONTHS POST PARTUM WOMEN)

BODY MASS INDEX (BMI)

To evaluate the nutritional status of adult PLHIV we must know their weight and height. If we know a person’s weight and height, then we can estimate his/her Body Mass Index (BMI) to establish whether his/her weight is within a normal range or not. BMI is an inexpensive and easy-to-perform method to assess if an adult is malnourished or not. 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. Mid-Upper-Arm Circumference (MUAC) is recommended as the preferred method for women who are pregnant and up to 6 months post partum.

CORRECT POSITION FOR MEASURING HEIGHT:

  • no shoes
  • standing erect
  • looking straight ahead
  • feet together
  • heels against the wall
  • back of the head against the wall
  • (for women) headscarves or hair accessories removed from the top and back of the head
  • standing centered in front of the measuring tape

CORRECT POSITION FOR MEASURING WEIGHT:

  • 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
  • standing on flat ground/floor

FORMULA FOR CALCULATING BMI:

Note: 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.

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

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).

MID UPPER ARM CIRCUMFERENCE (MUAC)

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). 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.

MUAC IN PREGNANCY

The MUAC is relatively stable throughout pregnancy and is not impacted by gestational age. It is a good indicator for malnutrition at all stage 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 BMI is not used to measure women during pregnancy because the body weight will change due to the growing baby in utero/fetus.

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.

STEPS FOR MEASURING MUAC:

1. Finding the midpoint

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 midpoint.

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 color through the window at the point where the two arrows point.

The second type of tape has numbers on the tape, instead of being color 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.

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.

When measuring the MUAC on a woman who is pregnant woman 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)

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.

NUTRITION ASSESSMENT IN 0-6 MONTHS

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 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

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 present on BOTH feet, and record this information on the counselor’s monitoring form for children. It is important to test both feet because if edema is present in only one foot, it is not a nutritional problem. Bilateral edema means that edema is present in both feet.

MEASURE AND INTERPRET THE LENGTH, HEIGHT AND WEIGHT IN CHILDREN AGED 6-59 MONTHS OF AGE

The measurement method of length, weight and height for children is a bit different to the measurement of height and weight for adults. 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.

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. Edema should also be measured on all children, not just less than six months of age.

Edema is measured on the feet of the child and is a sign that the child is severely underweight and should be referred for specialized care (the edema must be present in both feet).

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 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.

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

Many organizations use the WFA measurements, which gives some good information on weight, if the age of the child is known. However MUAC is the recommended measurement for children aged 6-59 months and women who are pregnant and within six month post partum.

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.

MEASURING LENGTH OF CHILDREN UNDER 2 YEARS

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. 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 him/her 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 millimeter (0.1cm) and recorded. When the numbers have been recorded, gently help the child to get off the board and return to his/her mother/carer.

Child Length Measurement – For Infants and Children Under 2 Years

MEASURING HEIGHT OF CHILDREN OVER 2 YEARS OF AGE

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

 Headpiece firmly on head

MEASURING WEIGHT IN CHILDREN

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

A. MEASURING WEIGHT WITH HANGING SCALES

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), and 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. 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.

B. MEASURING WEIGHT WITH STANDING SCALES

  • 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.

MEASURING NUTRITIONAL STATUS FOR CHILDREN AGED 5-19 YEARS OF AGE

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

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

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)

Source: WHO. 2007. Growth reference 5-19 years.
http://www.who.int/growthref/who2007_bmi_for_age/en/

Note: Home-based care team (HBCT) may use a BMI look-up table to work out a child or adolescent’s BMI (weight for height). BMI Look-up Table for determining BMI for children and adolescent 5-18 years of age is available at http://www.fantaproject.org/sites/default/files/resources/FANTA-BMI-charts-Jan2013-ENG_0.pdf

It is important to remember that there are different cut off points for children and adolescents aged 5-19 years of age for the BMI. Do not use the adult BMI categories for children in this age range. There is a special BMI-for-age chart, which is used for children aged 5-19 years of age. There is a different one for boys and a different one for girls. Available at: http://www.who.int/growthref/who2007_bmi_for_age/en/

STEPS FOR USING BMI-FOR-AGE CHART:

Find on the left hand side of the graph is where the BMI numbers are listed and on 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).

Note: The length is measured on children aged under 2 years, and the height is used for children over 2 years. 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.

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

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