NUTRITIONAL ANTHROPOMETRY

Presented by:

Ekta Belwal

HHM-2013-011

M.Sc (FN) I yr.

WHAT IS INSIDE !!!

What is Anthropometry

Anthropometric measurements

Indices

References used

Classification

Results of different National Surveys

Conclusion

INTRODUCTION

•Anthropos - "man" and Metron "measurement”

•A branch of anthropology that involves the quantitative measurement of the human body.

Nutritional Anthropometry

“Measurement of the variations of the physical Dimensions & the gross composition of the human body at different age levels and degrees of nutrition”

- Jellife (1966)

• It is used to evaluate both under & over nutrition.•The measured values reflects the current nutritional status & don’t differentiate between acute & chronic changes

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USE OF ANTHROPOMETRY· Individual Level

· SCREENING: ONE TIME ASSESSMENT · to immediately decrease case fatality (emergency situations) · in non-emergency situations

· GROWTH MONITORING: TREND ASSESSMENT · Population Level

· ONE TIME ASSESSMENT · under circumstances of food crisis · for long-term planning

· NUTRITIONAL SURVEILLANCE: TREND ASSESSMENT · for long-term planning · for timely warning · for programme management

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SIGNIFICANCE OF ANTHROPOMETRY

Primary measures of past or current nutritional status in children.

Distinguish between stunting & wasting

Identify PEM & obesity

Monitor changes after nutrition intervention

In clinical settings- identify, hospital patients with CED or over nutrition.

Public Health screening

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Advantages

• Simple & Safe procedures• Inexpensive, portable,

durable equipment• Little training• Precise & accurate methods• Info generated on past long-

time nutritional history, not possible with other tech. with equal confidence.

Disadvantages

• Relatively insensitive method & can’t detect disturbances in nutritional status over short period of time or identify specific nutrient deficiency.

• Unable to distinguish disturbances in growth or body composition induced by nutrient(Zn) def. from those caused by imbalances in P&E intake.

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ANTHROPOMETRY

Technique of measuring people

MEASUREMENTS

- Using Anthropometric Instruments

REFERENCE VALUES / STANDARDS- National & International

INDICES

- Computed

-Age dependent/Independent

CLASSIFICATIONS

- Grading of Nutritional Status

Measure

Index

Indicator

Reference

Information

8

Nutritional Anthropometry

Weight : - Total Body mass - Simple, widely used - Sensitive to small changes in nutrition

Height : - Genetically Determined - Environmentally influenced - Stunting Reflects chronic undernutrition

MUAC : - Reflects muscle/fat - Easy to measure, used for quick screening - Independent of age (1-5 years)

FFT: - Measures body fat - Correlates well with total body fat

9

ANTHROPOMETRIC MEASUREMENTS( For New Born & Young Children)

Weight

Recumbent length

Head Circumference

Chest Circumference

Mid Upper Arm Circumference (MUAC)

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ANTHROPOMETRIC MEASUREMENTS

Weight (in Kg)

Height (in cm)

Mid Upper Arm Circumference (MUAC) (in cm)

Waist Circumference (in cm)

Hip Circumference (in cm)

Fat fold thickness (in mm) Triceps Biceps Supra-Iliac Sub-scapular

( For Adults )

11

Standard equipment:- Accuracy / Consistency,

Appropriate techniques: - Training & Standardization

Correct assessment of age:

Reference values: - For comparison and computation of indices

Classification:

- For grading nutritional status

REQUIREMENTS FOR NUTRITIONAL ANTHROPOMETRY

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1. WEIGHT OR BODY MASS

The measurement of weight is most reliable criteria of assessment of health and nutritional status of children.

The weight can be recorded using a : Beam type weighing balance Electronic weighing scales for infants

and children Bathroom type of mechanical scale

(very unreliable) Salter spring machine (in field

conditions)

13

INDICATION

Sensitive indicator of current nutritional status.

Deficit in weight indicates short term under nutrition which can be easily reversed.

PEM is best indentified by weight deficiency in all groups

14

MEASURING CHILD’S WEIGHT USING THE SALTER SCALE. (SOURCE: UNICEF, 1986)

Adjust the pointer of the scale to zero level.

Take off the child’s heavy clothes and shoes.

Hold the child’s legs through the leg holes (arrow 1).

Hold the child’s feet (arrow 2). Hang the child on the Salter

Scale (arrow 3). Read the scale at eye level to the

nearest 0.1 kg (arrow 5). Remove the child slowly and

safely.

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MEASURING WEIGHT OF ADULTS USING THE BEAM BALANCE SCALE .

Participants are asked to remove their heavy outer garments (jacket, coat, trousers, skirts, etc.) and shoes. If subjects refuse to remove trousers or skirt, at least make them empty their pockets and record the fact in the data collection form

The participant stands in the centre of the platform, weight distributed evenly to both feet. Standing off-centre may affect measurement.

The weights are moved until the beam balances (the arrows are aligned).

The weight is recorded to the resolution of the scale (the nearest 0.1 kg or 0.2 kg).

CONTD..

USE OF SALTER SCALE

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OTHER METHODS

Spring Balance Beam Balance

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WEIGHT Sensitive to changes Changes in two directions up and down Fast change Usually easy to collect Standardisation of scales needed, calibration Small changes are difficult to measure: food

intake of the child, urine, dehydration, temp, etc: not very specific

community aversion: connotations can be difficult: co-operation of children to nearest 100 gr.

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2. HEIGHT OR LENGTH Height

vertical distance measured from crown of head to bottom of feet (heels) for children 2 yr of age or older.

Recumbent Length:

distance measured from crown of head to bottom of feet (heels) while child(< 2 yr of age) is measured supine.

Indication Gives a picture of past

nutritional status Deficit inheight

indicates chronic & prolonged under nutrition resulting often in permanently stunted physical staus Stadiometer

Infantometer

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TECHNIQUE OF LENGTH MEASUREMENT The infant is placed supine on the infantometer.

Assistant or mother is asked to keep the vertex or top of the head snugly touching the fixed vertically plank.

The leg are fully extended by pressing over the knee, and feet are kept vertical at 90 , the movable pedal ⁰plank of infantometer is snuggly apposed against soles and length is read from scale.

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TECHNIQUE FOR HEIGHT MEASUREMENT

• In older children who can stand , height can be measured by the rod attached to the lever type machine or by stadiometer.

• Person should stand with bare feet on the flat floor against a wall with fit parallel and with heels buttocks, shoulders and occiput touching the wall.

• Head should be kept in Frankfurt plane.

• With the help of a wooden spatula or plastic ruler. The topmost point of the vertex is identified on the wall.

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HEIGHT

Difficult to measure, accuracy, large variations Differences are small: 24 cm increment in the first

year of life, 11 cm second year, 8 third Low sensitivity Large measurement errors Measure to the nearest mm Below 2 y recumbent, above standing

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3. WAIST-TO-HIP CIRCUMFERENCE RATIO MEASUREMENT TECHNIQUE

Waist circumference A good quality non-stretchable

measuring tape should be used. View the patient from the front. Locate the narrowest point

between ribs and iliac crests. Ensure that the tape measure is at

the same height around the waist. Measure and state the

measurement correctly to the nearest centimetre.

≥102cm (adult male) & ≥88 cm (adult female) considered having abdominal obesity

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WAIST-TO-HIP CIRCUMFERENCE RATIO

Hip circumference

View the person from the front. Hip measurement is taken at

the widest lateral extension of the hips.

Ensure that the tape measure is horizontal.

Measure and state the measurement correctly to the nearest centimetre.

Calculate Waist/Hip Ratio to 2 decimal places.

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MEASURES OF BODY COMPOSITION

Weight loss, per se, does not provide the nutritionist with an indication of type of tissue lost (i.e. weight loss due to loss of adipose tissue or loss of muscle tissue).

Measurements of skin-folds, mid-arm circumference and mid-arm muscle circumference therefore provide a more comprehensive picture of body composition/ changes.

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MID-ARM CIRCUMFERENCE (MAC)Locate the midpoint of the arm. Non-dominant arm elbow flexed at 90deg

with palm facing upwards                   Measurer stands behind the subject & locates

the lateral tip of the acromion and the most distal point on the olecranon process               

Place a tape measure so that it passes between these 2 landmarks and mark the midpoint            

  Measure the midarm circumference The subject stands erect with arms hanging

freely at the sides and the palms facing the thighs

Place the tape measure perpendicular to the long axis of the arm at the marked midpoint & measure the circumference to the nearest mm. (e.g. 18.1 cm)                 

Provide the actual MAC in cm.

29MUAC FOR CHILDREN

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SKIN-FOLD MEASUREMENTS

Approximately half of the total amount of fat tissue in the human body is located below the surface of the skin.

This makes it possible to predict total body fat from skin-fold thicknesses with a relative high degree of accuracy using a simple two-compartmental method.

This accuracy is confirmed by CT scan as well as ultrasonic and radiographic techniques used to measure subcut.fat.

In general, when measuring skin-fold

thickness,

The assessor, using the forefinger and the thumb, grasps and lifts the subcut. tissue and skin from the underlying muscle.

Places the pincers of the skin-fold caliper, applying a constant pressure, 2cm below the fingers at a depth of 1cm.

Holds this position for 3-4seconds.

Takes three measurements for accuracy.

Provides the actual skin-fold thickness in mm.

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DIFFERENT TYPES OF SKIN FOLD CALLIPERS

Sanny Professional Skin fold Caliper Body Caliper

HoltainCescorf

Warrior DigitalBody Mass Calliper

Defender Body Fat Caliper

Lafayette

Accu-Measure

Lange Fat Caliper

Personal Body Fat Tester Harpenden Caliper

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TRICEPS SKIN-FOLD (TSF)

A measure of subcutaneous fat stores taken at the midpoint of the posterior aspect of the humerus.

Correlates closely with percentage of body fat and with total body fat.

Triceps skin-fold thickness varies between

6 -12mm in lean individuals and between

40 - 50mm in obese individuals.

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TRICEPS SKIN-FOLD MEASUREMENT TECHNIQUE

Subject should be standing with arms hanging loosely at the sides.

Assessor to be positioned behind the subject. To locate the triceps skin-fold site, locate the site

previously marked for the midarm circumference measurement (MAC).

The triceps skin-fold site is on the posterior surface of the arm, midway between the shoulder and the elbow.

Using the forefinger and the thumb the assessor grasps and lifts the subcut. tissue and skin 2cm above TSF site.

Place the pincers of the skin-fold caliper at the TSF point at a depth of 1cm.

Hold this position for 3-4seconds. Take three measurements for accuracy. Provide the actual skin-fold thickness in mm.

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BICEPS SKIN-FOLD MEASUREMENT

Locate the biceps skin-fold site: The assessor positioned in front of the

subject.

Subject should be standing erect with arms hanging loosely at their sides.

To locate the biceps skin-fold site, locate the level previously marked for the mid-arm circumference measurement.

The biceps skin-fold site is on the anterior surface of the arm, midway between the shoulder and elbow.

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SUBSCAPULAR SKIN-FOLD MEASUREMENT TECHNIQUE

The assessor is positioned behind the subject.

The subscapular skin-fold site is located 1cm below the inferior angle of the scapula.

The assessor grasps and lifts the subcut. tissue and skin at a downward angle of approximately 45 towards the lateral aspect of the body.

Place the pincers of the skin-fold caliper at a depth of 1cm.                  

Hold this position for 3 to 4 seconds.                

Take three measurements for accuracy (answer in mm).                  

Provide the actual skin-fold thickness in mm.

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SUPRA-ILIAC SKIN-FOLD MEASUREMENT TECHNIQUE The assessor to be positioned in front of

the subject. The supra-iliac site is located 5cm above the

anterior superior iliac spine. The assessor grasps and lifts the subcut.

tissue and skin at a downward angle of 45 towards the medial aspect of the body.

Place the pincers of the skin-fold caliper at a depth of 1cm.                  

Hold this position for 3 to 4 seconds.                

Take three measurements for accuracy (answer in mm).                  

Provide the actual skin-fold thickness in mm.

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HEAD CIRCUMFERENCE• Brain growth takes place 70% during fetallife, 15% during infancy and remaining 10% during pre-school years.

• Head circumference are routinely recorded until 5 years of age.

• If scalp edema or cranial moulding is present , measurement of scalp edema may be inaccurate until fourth or fifth day of life .

•The head circumference is measured by placing the tape over the occipital protuberance at the back and just over the supraorbital ridge and the glabella in front.

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EXPECTED HEAD CIRCUMFERENCE IN CHILDREN

Age Head circumference

(cm)

At birth 34 – 35

2 months 38

3 months 40

4 months 41

6 months 42 - 43

1 year 45 - 46

2 years 47 - 48

5 years 50 - 51

During first year there is 12 cm increase in head circumference , while 1 – 5 year age , only 5 cm gain occur in head size.

Adult head size is achieved between 5 to 6 years .

The term Macrocephaly refers to OFC of more than 2SD above the mean while Microcephaly refers to OFC more than 3SD below the mean for age , sex , height and weight.

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CHEST CIRCUMFERENCE It is usually measured at the level of nipples, preferably

in mid inspiration. Xiphisternum In children

≤ 5years - lying down position

> 5 years - standing position

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RELATIONSHIP BETWEEN HEAD SIZE WITH CHEST CIRCUMFERENCE: At birth:

head circumference > chest circumference by up to 3 cm.

At around 9 months to 1 year of age:

head circumference = chest circumference,

but thereafter chest grows more rapidly compared to the brain.

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Measurements Age groups

Advantage Disadvantage

Weight all

Common in use Difficult in field;Can’t tell body composition;

need accurate age;Need proper scale

Height allCommon in use

Simple to do in fieldDiffers by day time:Other factors play a

role

Head Circumference

0-4 yr simple Other factors play a role

MUAC allSimple; age dependent; child

need not to be denuded; suitable for rapid survey

No limits for over nutrition & no

standard for adults

Skin-fold thickness All

Measure body composition;Detect obesity in adults

Need expensive callipers; difficult with the child & in the field

Chest –head ratio

1-2 yr Simple; age independent For limited age; no classification method

Summary

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AGE

Usually the most difficult and inaccurate measurement

Less of a problem if a trend in the same child is measured, the mistake is repeated every time and thus cancels out

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INDICES Relation between two measurements

weight for age W/A general appreciation of nutritional status combined measurement NO individual diagnosis but trend assessment For growth monitoring

height for age H/A measure of linear growth deficit or STUNTING not sensitive to change slow progress Community diagnosis

weight for height/length W/H measure of weight deficit according to

length WASTING Individual diagnosis Community diagnosis Sensitive to change

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THE REFERENCE

One reference for all? Reference or standard?

International Standards used:Harvard standardsNCHS(U.S. National Centre for Health Sciences)WHO standards

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COMMON ERRORS

First year of life is up to 11.9 months of age and not O-12

Length and height; change technique at 24 mo Lack of distinction between descriptive use and

operational use No use of statistics: Confidence intervals and tests

to compare prevalence and averages Undernutrition Wasting Stunting

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CLASSIFICATION OF NUTRITIONAL STATUS

By SD By % deviation from the Median of Standard

e.g. Gomez classification Using percentiles

Velocity of growth Distance Charts Birth weight( normal is ≥2.5Kg)

Weight for Age: Gomez Classification IAP Classification Jelliffe Classification Wellcome Classification

Height for Age

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Weight/Height ratios Relative weight/indices Power type indices

Quetelet’s index = Wt(in Kg)/Ht(m2) pondreal index = Wt. / Ht. Weight/Height Ratio = Wt (in gm)/ Ht (cm2) Wt/Ht2 x 100 = > 0.15 indicates PEM Wt/Ht % classification = <80 Under Nutrition

80-120 Normal

120-130 over nutrition

>130 obese

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NUTRITIONAL GRADING / CLASSIFICATIONS

Preschool Children:

GOMEZ CLASSIFICATIONWEIGHT FOR AGE

(% of NCHS Standards)

NUTRITIONAL GRADE

90 Normal

75 – 89.9 Grade I (Mild Undernutrition)

60 – 74.9 Grade II (Moderate Undernutrition)

< 60 Grade III (Severe Undernutrition)

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IAP CLASSIFICATION

(INDIAN ACADEMY OF PAEDIATRICS)

WEIGHT FOR AGE

(% of Harvard Standard)

NUTRITIONAL GRADE

80 Normal

70 – 89.9 Grade I (Mild Undernutrition)

60 – 69.9 Grade II (Moderate Undernutrition)

50 – 59.9 Grade III (Severe Undernutrition)

< 50 Grade IV (Severe Undernutrition)

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STANDARD NORMAL DISTRIBUTION

-3.0 -2.0 -1.0 0.0 1.0 2.0 3.0

34% 34%14% 14%

2% 2%

SD Score

( 2SD = 96 %)

Normal

“Measuring Changes in Nutritional Status” (WHO, Geneva 1983).

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STANDARD DEVIATION (SD) CLASSIFICATION

CUT-OFF LEVEL

NUTRITIONAL GRADE

WEIGHT FOR AGE

HEIGHT FOR AGE

WEIGHT FOR HEIGHT

Median – 2 SD Normal Normal Normal

Median – 3 SD to Median – 2 SD

Moderate Underweight

Moderate Stunting

Moderate Wasting

< Median – 3 SDSevere

UnderweightSevere

StuntingSevere

Wasting

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Classification BMI(kg/m2)

Principal cut-off points

Additional cut-off points

Underweight <18.50 <18.50

     Severe thinness <16.00 <16.00

     Moderate thinness 16.00 - 16.99 16.00 - 16.99

     Mild thinness 17.00 - 18.49 17.00 - 18.49

Normal range 18.50 - 24.9918.50 - 22.99

23.00 - 24.99

Overweight ≥25.00 ≥25.00

     Pre-obese 25.00 - 29.9925.00 - 27.49

27.50 - 29.99

     Obese ≥30.00 ≥30.00

          Obese class I 30.00 - 34-99

30.00 - 32.49

32.50 - 34.99

          Obese class II 35.00 - 39.99

35.00 - 37.49

37.50 - 39.99

          Obese class III ≥40.00 ≥40.00

Source: Adapted from WHO, 1995, WHO, 2000 and WHO 2004

Nutritional gradation based on BMI (adult)

Body Mass Index (BMI)

=

Weight in kg / height in meter sq.

57

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BROKA’S INDEX

Height (in cm) ─ 100 = IBW

Persons with IBW Nutritional Status

10-20% more mildly Overweight

20-30% more Overweight

30-40% more Obese

40% + severly Obese

20-30% lower Underweight

30-40% lower Severly Underweight

Between 80-120% normal

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WHAT NATIONAL REPORTS SAYS……

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UNDERWEIGHT CHILDREN < 5 YEARS(PROFILE OF STATES/ UTS)

The 2011 census estimates the population of children below 6 years at 158.8 million.

Nearly 40 % undernourished ( >63 million)

The proportion of children <5years who are underweight was lowest in Sikkim (19.7%) followed by Mizoram (19.9%).

>50 % children <5years of age underweight are in M.P (60%), Jharkhand (56.5%) & Bihar (55.9%).

Other states where more than 40 percent and upto 50% of children are underweight are Meghalaya, Chhattisgarh, Gujarat, Uttar Pradesh, and Orissa.

Although the prevalence of underweight is relatively low in Mizoram, Sikkim, and Manipur, even in those states more than 1/3 of children are stunted.

Stunting was more prevalent in Uttar Pradesh (56.8%), Bihar (55.6%), and Meghalaya (55.1%).

Wasting is most common in Madhya Pradesh (35%), Jharkhand (32%), and Meghalaya (31%).

NF

HS

-3, India, 2005-06TRENDS IN CHILD NUTRITIONAL STATUS

UnderweightWastedStunted

40

23

45 43

20

51

NFHS-3 NFHS-2

Percent of children age under 3 years

(Low height for age)

(Low weight for height)

(Low weight for age)

NF

HS

-3, India, 2005-06

66

Child nutrition: Status of achieving Millennium Development Goals The MDG1 is ‘Eradicate extreme poverty and Hunger’ Under Goal 1, target 2 states, ‘halve, between 1990 and 2015, the proportion of people who suffer from hunger’ with the indicator ‘Prevalence of underweight children<3 years of age’. India is therefore, committed to halving the prevalence of underweight children by 2015..

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Higher is the percentage of underweight female children

(< 5 years) than male children, whereas females are in a slightly better position compared to male children (< 5 years) while considering stunting and wasting.

(Each of these indices is expressed in standard deviation units SD, from the median of the 2006 WHO international reference population)

68

69

NF

HS

-3, India, 2005-06NUTRITIONAL STATUS OF ADULTS

34

9

24

13

55

36

BMI below normal Overweight/ Obese Anaemic

Women Men

Percent of women and men age 15-49

NF

HS

-3, India, 2005-06MALNUTRITION OF WOMEN BY RESIDENCE AND EDUCATION

Total

Urban

Rural

No edu

catio

n

<8 yea

rs

8-9 y

ears

10+ ye

ars

NFHS-2 to

tal0

5

10

15

20

25

30

35

40

45

50

36

25

41 4235 35

25

36

13

24

7 713 14

21

11

Underweight Overweight

Percent of women age 15-49

36

13

25

24

41

7

42

7

35

13

35

14

25

21

36

11

05

101520253035404550

Total

Urban

Rural

No educa

tion

<8 yea

rs

8-9

year

s

10+ y

ears

NFHS-2 to

tal

Underweight Overweight

NF

HS

-3, India, 2005-06MALNUTRITION OF MEN BY RESIDENCE AND EDUCATION

Total

Urban

Rural

No edu

catio

n

<8 yea

rs

8-9 y

ears

10+ ye

ars

0

5

10

15

20

25

30

35

40

45

50

3427

38 40 38 40

25

8

14

5 3 5 6

14

Overweight

Underweight

Percent of men age 15-49

34

8

27

14

38

5

40

3

38

5

40

6

25

14

0

5

10

15

20

25

30

35

40

45

50

Total

Urban

Rural

No educa

tion

<8 ye

ars

8-9

year

s

10+ y

ears

Overweight

Underweight

75

76

The increase in fat fold thickness over the last three decades begins in childhood and increases with age in both males and females. The increase is more in women.

77

DATA FROM NNMB SURVEYS IN URBAN SLUMS

Data from NNMB surveys in urban slums on time trends in weight; mid-upper arm circumference and fat fold thickness at triceps are shown in Figure 7.2.10, 7.2.11, 7.2.12 and 7.2.13.

Mean body weight, mid upper arm circumference and fat fold thickness at triceps are higher in all age groups in 1993 - 94.

The increase in body weight is mainly due to increase fat as shown by rising fat fold thickness.

Data from NNMB reports shows that both in men and women over years, there have been an increase in body weight and fat fold thickness.

The increase in body weight and fat fold is greater in urban slum dwellers.

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79

80

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Conclusion !

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REFERENCES Yasoda Devi. P, Uma Maheshwari. K ; Manual on Nutritional

Anthropometry; PG&RC, ANRAU

Rosalind S. Gibson ;1990, Principles of Nutritional Assessment; Oxford University Press

National Family Health Survey 3 (2005-2006)

CHILDREN IN INDIA 2012 - A Statistical Appraisal ; Ministry of statistics and Programme Implementation Government of India

NNMB surveys Report (1975 -2005) ; DIETARY INTAKES AND NUTRITIONAL STATUS

http://wcd.nic.in/research/nti1947/7.2%20dietary%20intakes%20pr%204.2.pdf

www.pediatrics.about.com

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