Mid-upper arm circumference cut-offs for screening thinness and severe thinness in Indian adolescent girls aged 10-19 years in field settings

Allergies, body mass, and hospitalization due to arbovirus infection: A prospective surveillance study in Machala, Ecuador

Dengue, chikungunya, and Zika are arboviruses that cause 390 million infections annually. Risk factors for hospitalization are poorly understood. Communities affected by these diseases have an escalating prevalence of allergies and obesity, which are linked to immune dysfunction. We assessed the association of allergies or body mass with hospitalization for an arbovirus infection. From 2014 to 2017, we recruited participants with a clinical diagnosis of arbovirus infection. Arbovirus infections were laboratory-confirmed and allergies were self-reported. Mid-upper arm circumference (MUAC), weight, and height were measured. We used two logistic regression models to assess the relationships between hospitalization and allergies and between hospitalization and body mass (MUAC for participants <20 years old and body mass index (BMI) for adults ≥20 years old). Models were stratified by age group and adjusted for confounders. For allergies, 41 of 265 were hospitalized. There was no association between allergies and hospitalization. For body mass, 34 of 251 were hospitalized. There was a 43% decrease in hospitalization odds for each additional centimetre MUAC among children (aOR 0.566, 95% CI 0.252-1.019) and a 12% decrease in hospitalization odds for each additional BMI unit among adults (aOR 0.877, 95% CI 0.752-0.998). Our work encourages the exploration of the underlying mechanisms.

Mid-upper arm circumference as a screening tool for identifying underweight adolescents

Background

Mid-upper arm circumference (MUAC) is a potentially credible alternative method for body mass index (BMI) to assess nutritional status. We aimed to assess the correlation between MUAC and BMI- Z-score and to identify a reliable MUAC cut-off point to detect underweight (BMI- Z-score of < -2 standard deviation) Sudanese adolescents.

Methods

A cross-sectional study was conducted in eastern Sudan. After obtaining adolescents' age and sex, their weight, height, and MUAC were measured using the standard procedures. The MUAC (cm) cut-off corresponding to underweight was calculated using receiver operating characteristic (ROC) curve analysis.

Results

In total, 390 adolescents were enrolled in the study and 205 (52.6%) of them were females. The median (interquartile range, IQR) age was 15.1 (14.0-16.3) years. The medians (IQR) of MUAC and BMI- Z-score were 22.0 (20.0-24.0) cm and - 0.62 (-1.5-0.3), respectively. MUAC was positively correlated with BMI Z-score in all participants (r = 0.534, p < 0.001), in females (r = 0.715, p < 0.001), and in males (r = 0.404, p < 0.001). Of the 390 enrolled adolescents, 61(15.6%) were underweight. The MUAC cut-off for underweight was ≤21.2 cm in all participants (Youden's Index, YI = 0.50; sensitivity = 82.0%; specificity = 68.0%, AUROCC = 0.78), in females (YI = 0.66, sensitivity = 86.0%, specificity = 80.0%, AUROCC = 0.87), and in males (YI = 0.32, sensitivity = 80.0%, specificity = 52.0%, AUROCC = 0.69).

Conclusion

MUAC has good accuracy results and can be adopted for community-based screening of underweight adolescents.

Comparison of Different Anthropometric Indicators for Assessment of Nutritional Status Among Adolescent Girls in an Urban Resettlement Colony in New Delhi: A Cross-Sectional Study

Background In India, 44.8% of adolescent girls are under-nourished, while about 8%-13% of girls are overweight. Though several studies have been done regarding the nutritional status of adolescent girls over the years, there have been no significant changes. Also, there are several different anthropometric indicators for nutritional status assessment, due to which there are huge variations in the prevalence of malnutrition across different studies. So the objectives of this study were to determine the prevalence of malnutrition using different anthropometric indicators and compare them. Methods A random sample of 426 girls was taken from Health Management Information Systems (HMIS) of the Centre for Community Medicine (CCM), All India Institute of Medical Sciences (AIIMS), and a semi-structured questionnaire was administered among 386 of them to determine associated factors. Height, weight, and mid-upper arm circumference (MUAC) were measured for 386 girls, and BMI for age and height for age z scores were calculated using WHO AnthroPlus. Mid-upper arm circumference for age z scores (MUAC for age) were calculated using Lambda-Mu-Sigma (LMS) charts by the CDC for girls aged one year to 20 years. Results It was found in this study that using BMI for age z scores (BAZ), 33.4% of the adolescent girls were malnourished; 18.9% (95% CI 15.1-23.2) being underweight, 10.6% (95% CI: 7.7-14.1) being overweight, and 3.9% (95% CI: 2.2-6.3) were obese. While using BMI solely as an indicator, the prevalence of thinness was 51.8% (95% CI: 46.9-56.9), while that of overweight and obesity was 10.6% (95% CI: 5.7-11.5) and 1.0% (95% CI: 0.2-2.6), respectively. The prevalence of under-nutrition by MUAC for age z scores was 53.4% (95% CI: 48.2-58.4), and that of over-nutrition was 1.8% (95% CI: 1.0-3.7). BMI for age z scores positively and strongly correlated with both MUAC and MUAC for age z scores and had a significant association with both on univariable linear regression. Though there was a negative correlation between BMI for age z scores and height-for-age z scores, it was not significant. Height-for-age z scores, even though positively correlated with MUAC for age z scores, the correlation was not that strong.

The performance of mid-upper arm circumference for identifying children and adolescents with overweight and obesity: a systematic review and meta-analysis

OBJECTIVE

This study aimed to synthesise the existing evidence on the performance of mid-upper arm circumference (MUAC) to identify children and adolescents with overweight and obesity.

DESIGN

Systematic review and meta-analysis.

SETTING

We searched PubMed, EMBASE, SCOPUS, Cochrane Library, Web of Science, CINAHL and Google scholar databases from their inception to December 10, 2021, for relevant studies. There were no restrictions regarding the language of publication. Studies reporting measures for the diagnostic performance of MUAC compared with a reference standard for diagnosing overweight and obesity in children and adolescents aged 2-19 years were included.

PARTICIPANTS

A total of 54 381 children and adolescents from twenty-one studies were reviewed; ten studies contributed to meta-analyses.

RESULTS

In boys, MUAC showed a pooled AUC of 0·92 (95 % CI 0·89, 0·94), sensitivity of 84·4 (95 % CI 84·6, 90·8) and a specificity of 86·0 (95 % CI 79·2, 90·8), when compared against BMI z-score, defined overweight and obesity. As for girls, MUAC showed a pooled AUC of 0·93 (95 % CI 0·90, 0·95), sensitivity of 86·4 (95 % CI 79·8, 91·0), specificity of 86·6 (95 % CI 82·2, 90·1) when compared against overweight and obesity defined using BMI z-scores.

CONCLUSION

In comparison with BMI, MUAC has an excellent performance to identify overweight and obesity in children and adolescents. However, no sufficient evidence on the performance of MUAC compared with gold standard measures of adiposity. Future research should compare performance of MUAC to the 'golden standard' measure of excess adiposity.

Discriminatory performance of mid-upper arm circumference for identifying thin and severely thin adolescents: a secondary data analysis using Comprehensive National Nutrition Survey

Background

Timely identification of adolescents with undernutrition is of utmost importance, and recently, mid-upper circumference (MUAC) had been considered as an alternative to body mass index (BMI) and BMI for age z-score (BAZ) for its screening. However, little is known about the MUAC cut-offs, specific to age and sex. The study was planned to assess the discriminatory performance of MUAC in identifying thin and severely thin adolescents and estimating age specific MUAC cut-offs, separately for males and females, against BAZ as the gold standard.

Methods

The Comprehensive National Nutrition Survey (CNNS), India data was used for this analysis. The Receiver Operating Characteristic curve (ROC), area under curve (AUC), and Youden Index were used to estimate MUAC cut-off values for thin (BAZ < -2) and severely thin (BAZ < -3) adolescents. The current analysis was done on 31471 adolescents.

Results

The MUAC cut-offs for identifying thin adolescents were: for 10-14 years - 19.2/19.4 cm, for 15-19 years - 22.9/21.7 cm for males and females respectively; and for severe thinness were: for 10-14 years - 18.4/18.3 cm, for 15-19 years - 21.9/20.2 cm for males/females. For thinness, the cut-off varied between 17.4-24.5 cm (for 10-19 years) among males, and for females, it varied between 17.5-20.9 cm (for 10-19 years). For severe thinness, MUAC cut-off ranged between 16.4-23.7 cm (for 10-19 years) among males, and for females, between 17.3-20.7 cm (for 10-19 years).

Conclusion

MUAC, a easy to use measure demonstrated an equivalent diagnostic performance for the identification of thinness and severe thinness against BAZ. Thus, age- and sex-specific cut-offs could be considered for screening thin and severely thin adolescents.

Reference centile curves for mid-upper arm circumference for assessment of under- and overnutrition in school-aged Indian children and adolescents

OBJECTIVES

Malnutrition is common in developing countries and is not restricted to young children. It has been suggested that measuring mid-upper arm circumference (MUAC) is an easy, accurate, and low-cost method of identifying malnutrition in the early stages. The aims of this study were to construct age- and sex-specific MUAC reference centiles, and to define and validate cutoffs for assessment of under- and overnutrition in Indian children 5 to 17 y of age.

METHODS

This was a cross-sectional, multicentric, observational study conducted in seven schools in seven states from June 2018 to November 2019. The study included 6680 healthy 5- to17-y-old children. MUAC was measured using non-stretch tapes (UNICEF). Sex-specific MUAC percentiles were computed for age and height. Cutoffs for MUAC z-scores for thinness and overnutrition were defined and validated for healthy school children (n = 726) and children with cancer (n = 500).

RESULTS

Reference centiles for MUAC for age (and height) for boys and girls are presented. Cutoffs defined for thinness and for obesity were -0.7 and +1.5 z-score, respectively (corresponding to 25th and 95th percentiles of the MUAC for age/height). For ease of use, rounded cutoffs for thinness were 16 and 18.5 cm from 5 to 9 and 10 to 14 y of age, respectively, in both sexes, and a cutoff of 22 cm in boys and 20 cm in girl from 15 to 17 y of age. For obesity, 20 and 25.5 cm from 5 to 9 and 10 to 14 y of age, respectively, in both girls and boys and a rounded cutoff of 29 cm in boys and 27 cm in girls from 15 to17 y are proposed.

CONCLUSIONS

We presented MUAC percentiles and cutoffs for screening for thinness and overnutrition in Indian children from 5 to 17 y of age. These data may also be used in children with cancer and other chronic disorders with growth failure.

Associated factors and socio-economic inequality in the prevalence of thinness and stunting among adolescent boys and girls in Uttar Pradesh and Bihar, India

Background

Despite economic growth observed in developing countries, under-nutrition still continues to be a major health problem. Undernutrition in adolescence can disrupt normal growth and puberty development and may have long-term impact. Therefore, it is important to study the undernutrition among adolescents. This study aimed to assess the prevalence and the associated factors of stunting, thinness and the coexistence of both (stunting and thinness) among the adolescent belonging to Uttar Pradesh and Bihar, India.

Methods

The study utilized data from Understanding the Lives of Adolescents and Young Adults (UDAYA) project survey, which was conducted in two Indian states Uttar Pradesh and Bihar, in 2016 by Population Council under the guidance of Ministry of Health and Family Welfare, Government of India. Utilizing information on 20,594 adolescents aged 10–19 years (adolescent boys-5,969 and adolescent girls-14,625), the study examined three outcome variables, i.e., thinness, stunting, and co-existence of both. The study used descriptive and bivariate analysis. Furthermore, the study examined income-related inequality in stunting and thinness through concentration index. At last, the study used Wagstaff decomposition analysis to decompose the concentration index.

Results

The prevalence of thinness was higher among adolescent boys as compared to girls (25.8 per cent vs. 13.1 per cent). However, stunting was more prevalent among girls (25.6 per cent) than in boys (39.3 per cent). The odds of stunting were higher among late adolescents [Boys- OR:1.79; CI: 1.39, 2.30] and [Girls- OR: 2.25; CI: 1.90,2.67], uneducated adolescents [Boys- OR:2.90; CI: 1.67, 5.05] and [Girls- OR: 1.82; CI: 1.44,2.30], and poorest adolescents [Boys- OR:2.54; CI: 1.80, 3.58] and [Girls- OR: 1.79; CI: 1.38,2.32]. Similarly age, educational status, working status and wealth index were significantly associated with thinness among adolescent boys and girls. Media exposure [Boys- OR: 11.8% and Girls- 58.1%] and Wealth index [Boys: 80.1% and Girls: 66.2%] contributed significantly to the inequality in the prevalence of thinness among adolescents. Similarly, wealth index [Boys: 85.2% and Girls: 84.1%] was the only significant contributor to the inequality in the prevalence of stunting among adolescents.

Conclusion

The study provides an understanding that stunting and thinness is a significant public health concern among adolescents, and there is a need to tackle the issue comprehensively. By tackling the issue comprehensively, we mean that the state government of Uttar Pradesh and Bihar shall screen, assess, and monitor the nutritional status of adolescent boys and girls. The interventions shall focus towards both boys as well as girl adolescents, and particular emphasis should be given to adolescents who belonged to poor households. Also, efforts should be taken by stakeholders to increase family wealth status.

Mid-upper arm circumference as a screening tool for identifying adolescents with thinness

OBJECTIVE

To evaluate the performance of mid-upper arm circumference (MUAC) to identify thinness in the late adolescence period (aged 15-19 years) in Ethiopia.

DESIGN

We conducted a school-based cross-sectional study. The receiver operating characteristics curve was used to examine the validity of MUAC compared with BMI Z-score to identify adolescents with thinness (BMI Z-score <-2 sd).

SETTINGS

Fifteen high schools (grade 9-12) located in Addis Ababa, Ethiopia.

PARTICIPANTS

A total of 851 adolescent (456 males and 395 females) were included in the study.

RESULTS

The prevalence of thinness and severe thinness among high-school adolescents in Addis Ababa was 9·5 % (95 % CI 7·7, 11·7 %). The overall AUC for MUAC against BMI Z-score <-2 SD was 0·91 (95 % CI 0·88, 0·93). The optimal MUAC cut-offs to identify thinness were 23·3 cm for males and 22·6 cm for females. These cut-off points give high sensitivity and specificity for both males (a sensitivity of 87·9 % and a specificity of 75·9 %) and females (a sensitivity of 100 % and a specificity 88·2 %).

CONCLUSIONS

MUAC has a comparable level of accuracy with BMI Z-score to identify thinness in adolescents aged 15-19 years. Hence, MUAC could be used as an alternative tool for surveillance and screening of thinness among adolescents aged 15-19 years. The optimum cut-off proposed by this study may incorrectly include a large number of adolescents when used in a relatively well-nourished population. In this situation, it would be necessary to choose a cut-off with greater positive predictive value.

Nutritional status of Indian adolescents (15-19 years) from National Family Health Surveys 3 and 4: Revised estimates using WHO 2007 Growth reference

BACKGROUND

The National Family Health Surveys (NFHS) in India apply adult cutoffs of nutritional status for the estimation of undernutrition/overweight in the 15-19 age group. The prevalence of thinness in boys and girls thus estimated is 58.1% and 46.8% in NFHS-3, and 45% and 42% in NFHS-4 respectively. But the WHO recommends using age and sex-specific reference for adolescents. We reanalyzed the nutritional status of the adolescents using the WHO 2007 Growth Reference to obtain revised estimates of thinness, overweight and stunting across states, rural-urban residence, and wealth quintiles.

METHODS AND FINDINGS

Demographic information, anthropometric data, and wealth index were accessed from the Demographic and Health Survey (DHS) database. We re-analyzed the anthropometric data using WHO AnthroPlus software which uses the WHO 2007 Growth reference. The revised estimates of thinness assessed by BMI-for-age z-scores in boys and girls was 22.3% (95%CI: 21.6, 23.0) and 9.9% (95%CI: 9.5, 10.3) in NFHS-3 and 16.5% (95%CI: 16.0,17.0) and 9% (95%CI: 8.9, 9.2) in NFHS-4 respectively. Stunting was found to be 32.2% (95% CI: 31.6, 32.9) in boys and 34.4% (95% CI: 34.2, 34.7) in girls in NFHS-4. This was higher than that in NFHS-3; 25.2% (95% CI: 24.4, 26) in boys and 31.2 (95% CI: 30.6, 31.8) in girls. There was a clear socioeconomic gradient as there were higher thinness and stunting in rural areas. There was wide variation among the states with pockets of a double burden of malnutrition.

CONCLUSION

Using the adult cutoffs significantly overestimates thinness in adolescents in the age group of 15-19 years old in India. Stunting, which is an indicator of long term nutrition is also widely prevalent in them. Future editions of DHS and NFHS should consider adolescents as a separate age group for nutritional assessment for a better understanding of nutritional transition in the population.