Association of maternal nutritional status and small for gestational age neonates in peri-urban communities of Karachi, Pakistan: findings from the PRISMA study

BACKGROUND

Early pregnancy nutritional status can be associated with adverse birth outcomes such as small-for-gestational age (SGA) and low birth weight (LBW). BMI (Body Mass Index) and MUAC (Mid-upper arm circumference) are easy to use assessments and are indicative of the pre-pregnancy nutritional status if obtained in the first trimester. This study primarily assesses the association of maternal nutritional status using BMI and MUAC with SGA in a community-based cohort of Pakistani women. It also aims to determine the predictive ability of MUAC and BMI in predicting SGA. Secondarily, we assessed the association between maternal nutrition and large for gestational age (LGA) and LBW.

METHODS

This study is a secondary analysis of an ongoing pregnancy cohort "Pregnancy Risk Infant Surveillance and Measurement Alliance (PRISMA)"in Ibrahim Hyderi and Rehri Goth, Karachi. PRISMA participants who were enrolled between January 2021 to August 2022 were included given they had a gestational age < 14 weeks confirmed via ultrasound, MUAC and BMI measurements were available and birth weight was captured within 72 hours. Multivariable logistic regression was used to determine an association between maternal nutritional status and SGA. The PRISMA study was approved by the Aga Khan University Ethics Review Committee (2021-5920-15,518).

RESULTS

Of 926 women included in the analysis, 26.6% (n = 247) had a low MUAC (< 23 cm) while 18.4% (n = 171) were underweight (BMI < 18.5 kg/m2). Nearly one third of low MUAC and underweight women delivered SGA infants (34.4 and 35.1% respectively). Underweight women and women with low MUAC had a statistically significant association with SGA (Underweight: OR 1.49, 95% CI 1.1,2.4; Low MUAC-OR 1.64, 95% CI 1.2,2.3) as well as LBW (Underweight: OR-1.63, 95% CI 1.1,2.4; Low MUAC-OR-1.63, 95% CI 1.2,2.3). ROC curves showed that MUAC and BMI had modest predictability for SGA (AUC < 0.7).

CONCLUSION

Maternal nutritional status as indicated by BMI and MUAC are strongly associated with adverse pregnancy outcomes including SGA, LGA and LBW. Although MUAC and BMI are widely used to determine maternal nutritional status, they have poor predictive ability for newborn size. Further research is needed to identify other tools or a combination of tools to better predict adverse birth outcomes in resource-limited settings and plan interventions.

Mid-upper arm circumference only protocol in Pakistan: missed opportunities for children suffering from severe acute malnutrition? A mixed-methods observational study

OBJECTIVE

We investigated the missed treatment opportunities affecting programmes using mid-upper arm circumference (MUAC) as the sole anthropometric criterion for identification and monitoring of children suffering from severe acute malnutrition (SAM).

DESIGN

Alongside MUAC, we assessed weight-for-height Z-score (WHZ) in children screened and treated according to the national MUAC only protocol in Pakistan. Besides, we collected parents' perceptions regarding the treatment received by their children through qualitative interviews.

SETTING

Data were collected from October to December 2021 in Tando Allah Yar District, Sindh.

SUBJECTS

All children screened in the health facilities (n 8818) and all those discharged as recovered (n 686), throughout the district, contributed to the study. All children screened in the community in the catchment areas of five selected health facilities also contributed (n 8459). Parents of forty-one children randomly selected from these same facilities participated in the interviews.

RESULTS

Overall, 80·3 % of the SAM cases identified during community screening and 64·1 % of those identified in the health facilities presented a 'WHZ-only' diagnosis. These figures reached 93·9 % and 84·5 %, respectively, in children aged over 24 months. Among children treated for SAM and discharged as recovered, 25·3 % were still severely wasted according to WHZ. While parents positively appraised the treatment received by their children, they also recommended to extend eligibility to other malnourished children in their neighbourhood.

CONCLUSION

In this context, using MUAC as the sole anthropometric criterion for treatment decisions (referral, admission and discharge) resulted in a large number of missed opportunities for children in need of timely and adequate care.

Association of sarcopenia defined by different skeletal muscle mass measurements with prognosis and quality of life in older patients with heart failure

BACKGROUND

Diagnosing sarcopenia in heart failure (HF) patients is important, but how to assess skeletal muscle mass in HF patients with fluid retention is controversial. We aimed to examine the association between sarcopenia, defined by different skeletal muscle mass measurements, and clinical outcomes in older HF patients.

METHODS

We included 546 older HF patients (≥ 65 years) who were assessed for sarcopenia at discharge (median age 77 years, 309 males). Sarcopenia was diagnosed using grip strength, usual gait speed, and skeletal muscle mass according to international criteria. We used mid-upper arm circumference (MUAC), mid-upper arm muscle circumference (MAMC), calf circumference (CC), and skeletal muscle mass index (SMI) assessed by bioelectrical impedance analysis to assess skeletal muscle mass and defined sarcopenia in each of these measurements. Prognostic outcomes were composite events (all-cause death and HF rehospitalization) and cardiovascular disease (CVD) events (CVD death and CVD rehospitalization). Quality of life (QOL) was assessed using the 36-item Short-Form Health Survey physical functioning (SF-36PF) score.

RESULTS

The sarcopenia defined by MUAC [hazard ratio (HR): 2.50; 95 % confidence interval (95 % CI): 1.64-3.81; p < 0.001] or MAMC (HR: 1.98; 95 % CI: 1.35-2.92; p = 0.001) were associated with higher composite event rates than the non-sarcopenia. The sarcopenia defined by MUAC (HR: 1.88; 95 % CI: 1.25-2.83; p = 0.002) or MAMC (HR: 1.70; 95 % CI: 1.16-2.49; p = 0.007) were associated with higher CVD event rates than the non-sarcopenia. The sarcopenia defined by CC or SMI were not associated with prognoses. The sarcopenia defined by MUAC, MAMC, or CC were associated with low SF-36PF scores (all p < 0.05).

CONCLUSIONS

These results suggest that a diagnosis of sarcopenia based on MUAC or MAMC rather than CC or SMI reflects prognosis and QOL in older HF patients.

The L-shaped association of mid-upper arm circumference with all-cause and cause-specific mortality in US adults: a population-based prospective cohort study

BACKGROUND

The arm circumference is a feasible and reliable indicator in evaluating the nutritional status of children. However, its application in general adults has yet to be thoroughly investigated.

OBJECTIVE

This study aimed to evaluate the association between mid-upper arm circumferences (MUACs) and mortality in general adults.

METHODS

The nationally representative cohort from the National Health and Nutrition Examination Survey (1999-2018) was analyzed with mortality information obtained through linkage to the National Death Index. The baseline MUACs were collected as exposure. Survey-weighted Cox proportional hazard regressions were performed to estimate the hazard ratios (HRs) and 95% confidential intervals (CIs) of mortality risk for individuals with different MUACs. Restricted cubic spline analyses were performed to examine the nonlinear association of MUAC with all-cause and cause-specific mortality.

RESULTS

A total of 52,159 participants were included in this study. During a median follow-up time of 117 months, 7157 deaths were documented, with leading causes of cardiovascular disease (CVD), cancer, and respiratory disease. Individuals in the first quartile (Q1) of MUAC tended to have higher all-cause mortality risk than the rest after full adjustment. Similarly, CVD mortality risk in Q1 was higher than that in the second quartile (Q2) and the third quartile (Q3); respiratory mortality risk in Q1 was higher than in Q2. MUAC was non-linearly associated with all-cause mortality and CVD mortality. Individuals in Q1 MUAC (≤ 29.3) tended to have higher all-cause mortality risk, with HRs (95% CIs) estimated to be 0.76 (0.67-0.87) for Q2 (29.4, 32.5), 0.69 (0.59-0.81) for Q3 (32.6, 36.0), and 0.59 (0.46-0.75) for Q4 (≥ 36.1) after adjustment of demographic, lifestyle, and comorbidity covariates. Similarly, compared with Q1, HRs (95% CIs) for CVD mortality were estimated to be 0.73 (0.58-0.93) for Q2 and 0.57 (0.43-0.47) for Q3; HRs (95% CIs) for respiratory mortality was estimated to be 0.57 (95% CI, 0.37-0.87) for Q2 with other differences not significant.

CONCLUSION

The MUAC was inversely associated with long-term mortality in general adults in the United States and may serve as a valuable measurement in adult health evaluations.

Validation of mid-arm circumference for surveillance of obesity in African adolescent girls and adult women

This study aimed to assess the validity of mid-arm circumference (MAC), also known as mid-upper arm circumference (MUAC), for classification of high body fatness in Namibian adolescent girls and women and to test whether classification accuracy of MUAC was higher than the traditional simple proxy for high fatness, the BMI. In 206 adolescent girls aged 13-19 years and 207 adult women aged 20-40 years, we defined obesity conventionally (BMI-for-age Z score ≥ 2·00, adolescents; adults BMI ≥ 30·0 kg/m2) and also defined obesity using published MAC cut-off values. 2H oxide dilution was used to measure total body water (TBW) to define high body fat percentage (≥ 30 % in the adolescents, ≥ 38 % in the adults), and we compared the ability of BMI and MAC to classify high body fatness correctly using sensitivity, specificity and predictive values. In the adolescents, obesity prevalence was 9·2 % (19/206) using BMI-for-age and 63·2 % (131/206) using TBW; sensitivity of BMI-for-age was 14·5 % (95 % CI 9·1, 22·0 %) but was improved significantly using MAC of 22·6 cm (sensitivity 96·9 %; 95 % CI 92·1 %, 99·3 %). In the adults, obesity prevalence was 30·4 % (63/207) using BMI and 57·0 % (118/207) using TBW, and sensitivity of BMI was 52·5 % (95 % CI 43·6, 62·2 %), but using a MAC of 30·6 cm sensitivity was 72·8 % (95 % CI 66·4, 82·6 %). Surveillance of obesity in African adolescent girls and adult women is likely to be improved substantially by use of MAC as an alternative to the BMI-for-age and BMI.

Validating a linear regression equation using mid-upper arm circumference to predict body mass index

BACKGROUND

Estimating body mass index (BMI) in hospitalised patients for nutritional assessment is challenging when measurement of weight and height is not feasible. The study aimed to validate a previously published regression equation to predict BMI using mid-upper arm circumference (MUAC). We also evaluated the proposed global MUAC cut-off of ≤24 cm to detect undernutrition.

METHODS

We measured standing height, weight, and MUAC prospectively in a sample of stable patients. Agreement between calculated and predicted BMI was evaluated using Bland-Altman analysis.

RESULTS

We studied 201 patients; 102 (51%) were male. Median (IQR age was 42 (29-50) years. 95% limits of agreement between predicted and calculated BMI were +0.6767 to +1.712 and the bias was +1.076. MUAC ≤24 cm was 97% sensitive and 83% specific to detect undernutrition.

CONCLUSION

BMI derived from MUAC had poor calibration for estimating actual BMI. However, low MUAC has good discriminative accuracy to detect undernutrition.

Mid-upper arm circumference (MUAC) measurement usage among children with disabilities: A systematic review

Background: Anthropometric measurements, including mid-upper arm circumference (MUAC), are used for monitoring and evaluating children's nutritional status. Evidence is limited on optimal nutritional assessment for children with disabilities, who are at high risk for malnutrition. Aim: This study describes MUAC use among children with disabilities. Methods: Four databases (Embase, Global Health, Medline, and CINHAL) were searched from January 1990 through September 2021 using a predefined search strategy. Of the 305 publications screened, 32 papers were included. Data included children 6 months to 18 years old with disabilities. Data including general study characteristics, methods for MUAC measurement, terminology, and measurement references were extracted into Excel. Due to heterogeneity of the data, a narrative synthesis was used. Results: Studies from 24 countries indicate that MUAC is being used as part of nutritional assessment, but MUAC measurement methods, references, and cutoffs were inconsistent. Sixteen (50%) reported MUAC as a mean ± standard deviation (SD), 11 (34%) reported ranges or percentiles, 6 (19%) reported z-scores, and 4 (13%) used other methods. Fourteen (45%) studies included both MUAC and weight-for-height but nonstandard reporting limited comparability of the indicators for identifying those at risk of malnutrition. Conclusion: Although its speed, simplicity, and ease of use afford MUAC great potential for assessing children with disabilities, more research is needed to understand its appropriateness, and how it performs at identifying nutritionally high-risk children in comparison to other measures. Without validated inclusive measures to identify malnutrition and monitor growth and health, millions of children could have severe consequences for their development.

Prognostic value of different anthropometric indices over different measurement intervals to predict mortality in 6-59-month-old children

OBJECTIVE

To compare the prognostic value of mid-upper arm circumference (MUAC), weight-for-height Z-score (WHZ) and weight-for-age Z-score (WAZ) for predicting death over periods of 1, 3 and 6 months follow-up in children.

DESIGN

Pooled analysis of twelve prospective studies examining survival after anthropometric assessment. Sensitivity and false-positive ratios to predict death within 1, 3 and 6 months were compared for three individual anthropometric indices and their combinations.

SETTING

Community-based, prospective studies from twelve countries in Africa and Asia.

PARTICIPANTS

Children aged 6-59 months living in the study areas.

RESULTS

For all anthropometric indices, the receiver operating characteristic curves were higher for shorter than for longer durations of follow-up. Sensitivity was higher for death with 1-month follow-up compared with 6 months by 49 % (95 % CI (30, 69)) for MUAC < 115 mm (P < 0·001), 48 % (95 % CI (9·4, 87)) for WHZ < -3 (P < 0·01) and 28 % (95 % CI (7·6, 42)) for WAZ < -3 (P < 0·005). This was accompanied by an increase in false positives of only 3 % or less. For all durations of follow-up, WAZ < -3 identified more children who died and were not identified by WHZ < -3 or by MUAC < 115 mm, 120 mm or 125 mm, but the use of WAZ < -3 led to an increased false-positive ratio up to 16·4 % (95 % CI (12·0, 20·9)) compared with 3·5 % (95 % CI (0·4, 6·5)) for MUAC < 115 mm alone.

CONCLUSIONS

Frequent anthropometric measurements significantly improve the identification of malnourished children with a high risk of death without markedly increasing false positives. Combining two indices increases sensitivity but also increases false positives among children meeting case definitions.

Anthropometric criteria for best-identifying children at high risk of mortality: a pooled analysis of twelve cohorts

OBJECTIVE

To understand which anthropometric diagnostic criteria best discriminate higher from lower risk of death in children and explore programme implications.

DESIGN

A multiple cohort individual data meta-analysis of mortality risk (within 6 months of measurement) by anthropometric case definitions. Sensitivity, specificity, informedness and inclusivity in predicting mortality, face validity and compatibility with current standards and practice were assessed and operational consequences were modelled.

SETTING

Community-based cohort studies in twelve low-income countries between 1977 and 2013 in settings where treatment of wasting was not widespread.

PARTICIPANTS

Children aged 6 to 59 months.

RESULTS

Of the twelve anthropometric case definitions examined, four (weight-for-age Z-score (WAZ) <-2), (mid-upper arm circumference (MUAC) <125 mm), (MUAC < 115 mm or WAZ < -3) and (WAZ < -3) had the highest informedness in predicting mortality. A combined case definition (MUAC < 115 mm or WAZ < -3) was better at predicting deaths associated with weight-for-height Z-score <-3 and concurrent wasting and stunting (WaSt) than the single WAZ < -3 case definition. After the assessment of all criteria, the combined case definition performed best. The simulated workload for programmes admitting based on MUAC < 115 mm or WAZ < -3, when adjusted with a proxy for required intensity and/or duration of treatment, was 1·87 times larger than programmes admitting on MUAC < 115 mm alone.

CONCLUSIONS

A combined case definition detects nearly all deaths associated with severe anthropometric deficits suggesting that therapeutic feeding programmes may achieve higher impact (prevent mortality and improve coverage) by using it. There remain operational questions to examine further before wide-scale adoption can be recommended.

A new method to estimate children's weight accurately in emergency settings using foot length and mid-upper arm circumference

BACKGROUND

In emergency settings, medication dosages are primarily determined based on the child's weight; however, the healthcare personnel sometimes may have to make the first intervention without knowing the patient's weight, which may result in an underdose or overdose of the medication. We aimed to find a reliable method to estimate children's bodyweight, including the obese and malnourished.

METHODS

We conducted the study with children between the ages of 3 and 17 years. We measured the children's bodyweight, right foot length, and mid-upper arm circumference in centimeters during their examination. We created a concise formula through regression analysis to estimate the patients' weight based on the right foot length and mid-upper arm circumference. Finally, we compared this formula to other conventional formulae.

RESULTS

The study included 741 patients whose average age was 8.4±3.9 (3-17) years. A high correlation was found between the patients' foot length, arm circumference, and bodyweight (R: 0.866, p<0.001 and R: 0.910, p<0.001, respectively). A single formula was created by regression analysis based on foot length and the mid-upper arm circumference without including sex and age in the calculation to make a more straightforward and faster calculation in emergency cases.

CONCLUSION

The formula created may be advantageous for reliably and easily estimating the weight of children aged 3-17 of any sex and body habitus in emergency settings without special equipment. This newly developed formula may enable a low-cost optimal level of weight estimation without the need for special equipment.

Mid-upper arm circumference and neck circumference to screen for overweight-obesity in young adults in South India

Introduction

There are many anthropometric techniques to screen for overweight-obesity like the body mass index (BMI), waist circumference (WC), and waist-hip ratio (WHR). These may be difficult or less acceptable in community and outpatient settings. We determine the cut-offs of mid-upper arm circumference (MUAC) and neck-circumference (NC) to screen overweight (BMI ≥25 kg/m²), abdominal obesity by waist circumference (WC; men: ≥90 cm; women: ≥80 cm) and high percent body fat (PBF) (men: ≥20%; women: ≥30%) and explore participant preference for various anthropometric methods.

Method

ology: We enrolled 282 medical students in South India and performed anthropometry (height, weight, WC, MUAC and NC), bio-impedance analysis (BIA, Inbody 770) to detect PBF. Receiver operator curves were generated and best cut-offs derived using highest Youden Index (sensitivity + specificity-1).

Results

Of the 282 participants, 83 (29.4%) were overweight, 113 (38.7%) had abdominal obesity and 186 (66%) had higher PBF. The MUAC cut-off was 31.3cm for men (sensitivity: 86%; specificity: 74%) to detect overweight and 31.2 cm (sensitivity: 85%; specificity: 73%) to detect abdominal obesity. The corresponding cut-offs in women were 28.5 cm (sensitivity:88%; specificity: 83%) to detect overweight and 28.3 cm (sensitivity: 74%; specificity: 92%) for abdominal obesity. For NC, the proposed cut-off in men was 36.6 cm (sensitivity: 81%; specificity: 82%) for overweight and 37.1 cm (sensitivity:78%; specificity:82%) for abdominal obesity. In women, this was 31.4 cm for both overweight as per BMI (sensitivity: 88%; specificity: 71%) and for abdominal obesity (sensitivity: 75%; specificity: 81%). Neck circumference was preferred by 225 (79.8%) participants.

Conclusion

Both MUAC and NC can be considered for screening overweight and abdominal obesity with good sensitivity and specificity but their sensitivity and specificity for screening high PFB were not very good. Neck circumference was the most preferred anthropometric method.

Mid-upper Arm Circumference as an Indicator of Quality of Life of Patients with Advanced Cancer

OBJECTIVE

Mid-upper arm circumference (MUAC) has been used to assess malnutrition and health status across various disease groups. However, it is unclear whether MUAC is associated with quality of life (QOL) of patients with advanced cancer. Our goal was to investigate the relationship between MUAC and QOL in ambulatory out-patients with advanced cancer.

METHOD

This was a cross-sectional study conducted in a tertiary cancer center in South Korea. A total of 200 patients with advanced cancer at oncology clinics of Seoul National University Bundang Hospital from March 2016 to January 2019 were enrolled. Out-patients with advanced cancer whose survival was expected to be less than one year by their oncologists were enrolled. QOL of patients was evaluated using the European Organization for Research and Treatment of Cancer quality of life questionnaire core 30 (EORTC QLQ-C30). Associations of QOL with MUAC and nutritional parameters were examined with generalized linear models.

RESULTS

The most common cancer sites were the lung, colon or rectum, and genitourinary tract. In univariate analyses, significant factors associated with higher summary score of EORTC QLQ-C30 were higher MUAC (≥ 26.5 cm, p < 0.001), higher body mass index (BMI) (≥ 22 kg/m², p < 0.001), higher serum albumin (≥ 3.7 g/dL, p < 0.01), higher creatinine (≥ 0.8 mg/dL, p = 0.023), and higher uric acid (≥ 5 mg/dL, p < 0.01). In multivariate analysis, higher serum albumin (≥ 3.7 g/dL, p < 0.01) and higher MUAC (≥ 26.5 cm, p = 0.03) were independently associated with better summary score of EORTC QLQ-C-30.

CONCLUSION

MUAC was highly associated with QOL in terms of summary score and overall health status. Thus, MUAC, with its simplicity, can be a useful tool to reflect QOL in patients with advanced cancer.

Pre-operative nutritional status and its association with short-term post-operative outcomes in Iranian children with CHD

BACKGROUND

Nutritional assessment appears to be an essential component of the evaluation of children with CHD undergoing surgery because nutritional status may impact corrective surgery-associated morbidity.

METHODS

A prospective single-centre cohort study with children between 6 and 24 months of age. Patients who had genetic syndromes or those who were premature or low birthweight at birth were excluded. Pre-operative nutritional parameters included anthropometric measurements and serum concentrations of total protein, vitamin D, iron, and ferritin. Outcome measures included ICU length of stay, mechanical ventilation, vasoactive-inotropic score, and duration of inotropes. Linear regression analysis was performed to determine whether pre-operative variables were associated with outcomes.

RESULTS

Analysis was performed on 120 patients (median age of 8 months), of whom 67 were male. Prior to surgery, 50.8% of patients had reduced (z ≤ -2.0) weight-for-age z score, 23.3% had reduced length-for-age z score, and 59.2% had reduced mid-upper arm circumference z score. Pre-operative serum total protein levels were 59.36 ± 9.16 g/L. Multiple regression analysis showed that low serum protein was associated with longer ICU length of stay and length of mechanical ventilation, while mid-upper arm circumference z score ≤ -2 was associated with longer ICU length of stay and mechanical ventilation and inotropes duration.

CONCLUSIONS

Pre-operative assessment of nutritional status by performing anthropometric and biochemical measurements including mid-upper arm circumference z score and serum protein concentrations in children undergoing CHD surgery appears to be predictors of some post-operative short-term outcomes and could be used as a guide to highlight patients needing appropriate perioperative nutritional interventions.

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.

Use of mid-upper arm circumference to screen for thinness among sub-Saharan African male detainees

OBJECTIVE

BMI is a time-intensive measurement to assess nutritional status. Mid-upper arm circumference (MUAC) has been studied as a proxy for BMI in adults, but there is no consensus on its optimal use.

DESIGN

We calculated sensitivity, specificity and area under receiver operating characteristic curve (AUROCC) of MUAC for BMI < 18·5, <17 and <16 kg/m2. We designed a system using two MUAC cut-offs, with a healthy (non-thin) 'green' group, a 'yellow' group requiring BMI measurement and a 'red' group who could proceed directly to treatment for thinness.

SETTING

We retrospectively analysed monitoring data collected by the International Committee of the Red Cross in places of detention.

PARTICIPANTS

11 917 male detainees in eight African countries.

RESULTS

MUAC had excellent discriminatory ability with AUROCC: 0·87, 0·90 and 0·92 for BMI < 18·5, BMI < 17 and BMI < 16 kg/m2, respectively. An upper cut-off of MUAC 25·5 cm to exclude healthy detainees would result in 64 % fewer detainees requiring BMI screening and had sensitivity 77 % (95 % CI 69·4, 84·7) and specificity 79·6 % (95 % CI 72·6, 86·5) for BMI < 18·5 kg/m2. A lower cut-off of MUAC < 21·0 cm had sensitivity 25·4 % (95 % CI 11·7, 39·1) and specificity 99·0 % (95 % CI 97·9, 100·0) for BMI < 16 kg/m2. An additional 50 kg weight requirement improved specificity to 99·6 % (95 % CI 99·0, 100·0) with similar sensitivity.

CONCLUSIONS

A MUAC cut-off of 25·5 cm, above which detainees are classified as healthy and below receive further screening, would result in significant time savings. A cut-off of <21·0 cm and weight <50 kg can identify some detainees with BMI < 16 kg/m2 who require immediate treatment.

A feasibility study using mid-upper arm circumference as the sole anthropometric criterion for admission and discharge in the outpatient treatment for severe acute malnutrition

BACKGROUND

The World Health Organization recommends the use of a weight-for-height Z-score (WHZ) and/or mid-upper arm circumference (MUAC) as anthropometric criteria for the admission and discharge of young children for the community-based management of severe acute malnutrition. However, using MUAC as a single anthropometric criterion for admission and discharge in therapeutic nutritional programs may offer operational advantages to simplify admission processes at therapeutic nutritional centers and improve program coverage.

METHODS

This pragmatic, non-randomized, intervention study compared a standard outpatient nutritional program (n = 824) for the treatment of uncomplicated severe acute malnutrition using WHZ < - 3 and/or MUAC< 115 mm and/or bipedal edema for admission and discharge to a program (n = 1019) using MUAC as the sole anthropometric criterion for admission (MUAC< 120 mm) and discharge (MUAC ≥125 mm at two consecutive visits) in the Tahoua Region of Niger.

RESULTS

Compared to the standard program, the MUAC-only program discharged more children as recovered (70.1% vs. 51.6%; aOR 2.31, 95%CI 1.79-2.98) and fewer children as non-respondent or defaulters, based on respective program definitions. The risk of non-response was high in both programs. Three months post-discharge, children who were discharged after recovery in the MUAC-only program had lower WHZ and MUAC measures. Sixty-three children ineligible for the MUAC-only program but eligible for a standard program (MUAC ≥120 mm and WHZ < -3) were followed for twelve weeks and the anthropometric status of 69.8% of these children did not deteriorate (i.e. MUAC ≥120 mm) despite not immediately receiving treatment in the MUAC-only program.

CONCLUSIONS

The results from this study share the first operational experience of using MUAC as sole anthropometric criterion for admission and discharge in Niger and overall support the consideration for MUAC-only programming: the MUAC-only model of care was associated with a higher recovery and a lower defaulter rate than the standard program with very few children found to be excluded from treatment with an admission criterion of MUAC < 120 mm. Further consideration of the appropriate MUAC-based discharge criterion as it relates to an increased risk of non-response and adverse post-discharge outcomes would be prudent.

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.

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.

Towards identifying malnutrition among infants under 6 months: a mixed-methods study of South-Sudanese refugees in Ethiopia

OBJECTIVES

To determine (i) whether distinct groups of infants under 6 months old (U6M) were identifiable as malnourished based on anthropometric measures and if so to determine the probability of admittance to GOAL Ethiopia's Management of At Risk Mothers and Infants (MAMI) programme based on group membership; (ii) whether there were discrepancies in admission using recognised anthropometric criteria, compared with group membership and (iii) the barriers and potential solutions to identifying malnutrition within U6M.

DESIGN

Mixed-methods approaches were used, whereby data collected by GOAL Ethiopia underwent: factor mixture modelling, χ2 analysis and logistic regression analysis. Qualitative analysis was performed through coding of key informant interviews.

SETTING

Data were collected in two refugee camps in Ethiopia. Key informant interviews were conducted remotely with international MAMI programmers and nutrition experts.

PARTICIPANTS

Participants were 3444 South-Sudanese U6M and eleven key informants experienced in MAMI programming.

RESULTS

Well-nourished and malnourished groups were identified, with notable discrepancies between group membership and MAMI programme admittance. Despite weight for age z-scores (WAZ) emerging as the most discriminant measure to identify malnutrition, admittance was most strongly associated with mid-upper arm circumference (MUAC). Misconceptions surrounding malnutrition, a dearth of evidence and issues with the current identification protocol emerged as barriers to identifying malnutrition among U6M.

CONCLUSIONS

Our model suggests that WAZ is the most discriminating anthropometric measure for malnutrition in this population. However, the challenges of using WAZ should be weighed up against the more scalable, but potentially overly sensitive and less accurate use of MUAC among U6M.

Anthropometrical measurements and maternal visceral fat during first half of pregnancy: a cross-sectional survey

Background

Determining anthropometric measures that indicate different fat deposits can be useful to predict metabolic risk and set specific treatment goals, reducing negative consequences for maternal and fetal health. In cases where pre-gestational weight measure and subsequent body mass index (BMI) values cannot be determined, other anthropometric measurements may be ideal for measuring the nutritional status of pregnant women, especially in low- and middle-income countries. This study aims to identify which anthropometric measurements correlate better with the maternal fat deposits measured by ultrasound.

Methods

A cross-sectional study was conducted with pregnant women from the city of Porto Alegre (city), capital of Rio Grande do Sul (state), southern Brazil, from October 2016 until January 2018. Anthropometrical variables (weight, height, mid-upper arm circumference [MUAC], circumferences of calf and neck and triceps skinfolds [TSF] and subscapular skinfolds [SBSF]), and ultrasound variables (visceral adipose tissue [VAT] and total adipose tissue [TAT]) were collected. To verify the correlation of anthropometric and ultrasound measurements, a non-adjusted and adjusted Spearman correlation was used. The study was approved by the ethics committees.

Results

The age median of the 149 pregnant women was 25 years [21–31], pre-pregnancy BMI was 26.22 kg/m² [22.16–31.21] and gestational age was 16.2 weeks [13.05–18.10]. The best measurements correlated with VAT and TAT were MUAC and SBSF, both of which showed a higher correlation than pre-pregnancy BMI.

Conclusions

It is possible to provide a practical and reliable estimate of VAT and TAT from the anthropometric evaluation (MUAC or SBSF) that is low cost, efficient and replicable in an outpatient clinic environment, especially in low- and middle-income countries.

Determining a global mid-upper arm circumference cut-off to assess underweight in adults (men and non-pregnant women)

OBJECTIVE

To determine if a global mid-upper arm circumference (MUAC) cut-off can be established to classify underweight in adults (men and non-pregnant women).

DESIGN

We conducted an individual participant data meta-analysis (IPDMA) to explore the sensitivity (SENS) and specificity (SPEC) of various MUAC cut-offs for identifying underweight among adults (defined as BMI < 18·5 kg/m2). Measures of diagnostic accuracy were determined every 0·5 cm across MUAC values from 19·0 to 26·5 cm. A bivariate random effects model was used to jointly estimate SENS and SPEC while accounting for heterogeneity between studies. Various subgroup analyses were performed.

SETTING

Twenty datasets from Africa, South Asia, Southeast Asia, North America and South America were included.

PARTICIPANTS

All eligible participants from the original datasets were included.

RESULTS

The total sample size was 13 835. Mean age was 32·6 years and 65 % of participants were female. Mean MUAC was 25·7 cm, and 28 % of all participants had low BMI (<18·5 kg/m2). The area under the receiver operating characteristic curve for the pooled dataset was 0·91 (range across studies 0·61-0·98). Results showed that MUAC cut-offs in the range of ≤23·5 to ≤25·0 cm could serve as an appropriate screening indicator for underweight.

CONCLUSIONS

MUAC is highly discriminatory in its ability to distinguish adults with BMI above and below 18·5 kg/m2. This IPDMA is the first step towards determining a global MUAC cut-off for adults. Validation studies are needed to determine whether the proposed MUAC cut-off of 24 cm is associated with poor functional outcomes.

Mid-upper arm circumference as an indicator of underweight in adults: a cross-sectional study from Nepal

Background

Undernourished people have an increased risk of premature mortality from both infectious and non-communicable diseases. Aside from screening purposes, assessment of nutritional status is a useful tool in management and evaluation of various chronic diseases. Body-Mass-Index (BMI) is today the most commonly used marker of nutritional status however, this method presents a challenge in many low resource settings and immobile patients. Mid-upper arm circumference (MUAC) is another anthropometric measure that requires minimal equipment and little training. So far, MUAC cutoffs for undernutrition are well established in children < 5 years but there is still no consensus for a specific cutoff in adults. The objective of this study was to compare MUAC with BMI and suggest a MUAC cut-off corresponding to a BMI of 18.5 kg/m2 to identify underweight in adults.

Methods

A cross-sectional study was conducted at two urban public hospitals in Nepal. The following variables where collected: MUAC, weight, height, sex, age and self-reported medical history. Exclusion criteria: < 19 years of age, pregnancy and oedema. Sensitivity and specificity for a MUAC value corresponding to BMI < 18.5 was calculated. ROC analysis was performed for male and female as well as Pearson’s correlation of MUAC and BMI.

Results

A total of 302 people between 18 and 86 years of age, 197 women and 105 men, were included. Of these, 90 people suffered from rheumatic heart disease. MUAC was highly correlated with BMI in both women r = 0.889 and men r = 0.846. Best statistically derived MUAC cutoff corresponding to a BMI < 18.5 kg/m² was 24.5 cm (Youdens Index = 0.75; sensitivity 92.86; specificity 82.48), with high predictive value (AUROCC> 0.9). The setting based optimal MUAC cutoff was also 24.5 cm. No considerable variation was found in sex- and disease specific subgroups.

Conclusion

MUAC is strongly correlated with BMI in adults in Nepal. For simplicity, a MUAC of 24.5 cm is the optimal statistically and setting based cutoff in both women and men to identify underweight (BMI < 18.5 kg/m²).

Differentiating effects of socio-economic factors on relative weight and nutritional status in Polish schoolchildren across intergenerational changes

OBJECTIVE

The aim of this study was an assessment of the effects of urbanisation level, family size and parental education on body mass index (BMI) and mid-upper arm circumference (MUAC) among Polish schoolchildren in cross-sectional surveys conducted between 1966 and 2012.

DESIGN

The analysis involved schoolchildren measured in four Polish Anthropological Surveys (1966, 1978, 1988 and 2012). Socio-economic factors involved: urbanisation level (city, town and village), family size (one child, two children, three children, four or more children), and father's and mother's education (lower and higher education).

SETTING

Regions in Poland - cities: Warsaw, Lodz and Wroclaw; towns: Bystrzyca Klodzka, Pinczow, Siemiatycze, Wolsztyn and their rural surroundings.

PARTICIPANTS

A total sample consisted of 63 757 children (31 774 boys and 31 983 girls) aged 7-18 years.

RESULTS

Between 1966 and 1988, both BMI and MUAC had significantly higher values in children from cities, in families with one child and with higher parental education (P < 0·05). However, MUAC revealed significant differences between particular socio-economic groups more frequently than BMI. In 2012, urbanisation level and parental education ceased to show a differentiating effect on both indicators, while family size remained a significant social factor for both measures (BMI: P < 0·05; MUAC: P < 0·01).

CONCLUSIONS

Since MUAC reflected socio-economic differences more frequently than BMI, it could be a more sensitive and reliable anthropometric measure revealing the effects of socio-economic factors on children's nutritional status.

Large mid-upper arm circumference is associated with metabolic syndrome in middle-aged and elderly individuals: a community-based study

BACKGROUND

The mid-upper arm circumference (MUAC) is a proxy for subcutaneous fat in the upper body and is a reliable screening measure for identifying individuals with abnormal regional fat distribution. The purpose of this study was to evaluate the association between MUAC and metabolic syndrome (MetS) in middle-aged and elderly individuals.

METHODS

We measured the MUAC in a cross-sectional sample with a total of 9787 subjects aged 40 years and older. The measurement of MUAC is performed on the right arm using a non-elastic tape held midway between the acromion and the olecranon processes in duplicate, with the arm hanging loosely at the side of the body. The MetS was defined according to the Joint Statement of the International Diabetes Federation Task Force on Epidemiology and Prevention.

RESULTS

MUAC was positively correlated with waist circumference (r = 0.437, P < 0.001), BMI (r = 0.334, P < 0.001), fasting insulin (r = 0.348, P < 0.001), HOMA-IR (r = 0.134, P < 0.001), triglycerides (r = 0.138, P < 0.001), SBP (r = 0.124, P < 0.001), and DBP (r = 0.123, P < 0.001), and inversely correlated with adiponectin (r = - 0.147, P < 0.001) and HDL-cholesterol (r = - 0.176, P < 0.001) after adjusting for age and gender. Compared with the lowest quartile group, the odds ratios were substantially higher for MetS (OR 1.77; 95% CI 1.51-2.09, P for trend< 0.001) in the highest MUAC quartile group after adjustment for potential cofounder.

CONCLUSION

Large mid-upper arm circumference is significantly associated with metabolic syndrome in middle-aged and elderly individuals.

Severe acute malnutrition and its associated factors among children under-five years: a facility-based cross-sectional study

Background

Despite consistent efforts to enhance child nutrition, poor nutritional status of children continues to be a major public health problem in Nepal. This study identified the predictors of severe acute malnutrition (SAM) among children aged 6 to 59 months in the two districts of Nepal.

Methods

We used data from a cross-sectional study conducted among 6 to 59 months children admitted to the Outpatient Therapeutic Care Centers (OTCC). The nutritional status of children was assessed using mid-upper arm circumference (MUAC) measurement. To determine which variables predict the occurrence of SAM, adjusted odds ratio was computed using multivariate logistic regression and p-value < 0.05 was considered as significant.

Results

Out of 398 children, 5.8% were severely malnourished and the higher percentage of female children were malnourished. Multivariate analysis showed that severe acute malnutrition was significantly associated with family size (five or more members) (Adjusted Odds Ratio [AOR]: 3.96; 95% Confidence Interval [CI]: 1.23–12.71). Children from severely food insecure households (AOR: 4.04; 95% CI: 1.88–10.53) were four times more likely to be severely malnourished. Higher odds of SAM were found among younger age-group (AOR: 12.10; 95% CI: 2.06–71.09) children (0–12 vs. 24–59 months).

Conclusions

The findings of this study indicated that household size, household food access, and the child’s age were the major predictors of severe acute malnutrition. Engaging poor families in kitchen gardening to ensure household food access and nutritious diet to the children, along with health education and promotion to the mothers of young children are therefore recommended to reduce child undernutrition.

Nutritional status of neurologically impaired children: Impact on comorbidity

BACKGROUND AND AIMS

Malnutrition is common in neurologically impaired (NI) children. It is, however, ill-defined and under-diagnosed. If not recognized and treated, it increases the burden of comorbidities and affects the quality of life of these children. The aim of this study was to characterize the nutritional status of a cohort of children followed up at a reference center for cerebral palsy (CP) in Brussels, Belgium, and to investigate possible links with the occurrence of comorbidities.

MATERIAL AND METHODS

We conducted a single-center retrospective study including all the children followed up at the Inter-university Reference Center for Cerebral Palsy ULB-VUB-ULg. The data were obtained by reviewing medical files. Anthropometric measurements as well as the etiology of neurological impairment, comorbidities, feeding patterns, and laboratory test results were collected. The children were assigned a nutritional diagnosis according to the World Health Organization and Waterlow definitions.

RESULTS

A total of 260 children with cerebral palsy were included, 148 males and 112 females. Their mean age was 10.9±4.3 years. The gross motor function classification system (GMFCS) level was I for 79 children, II for 63 children, III for 35 children, IV for 33 children, and V for 50 children. Of the children, 54% had a normal nutritional status, 34% showed malnutrition, and 8% were obese; 38% had oropharyngeal dysphagia. The sensitivity of mean upper arm circumference of<p10 to detect severe malnutrition was 95%. Specific growth charts for CP were neither sensitive nor specific for predicting the risk of comorbidities. Malnutrition was associated with an increased risk of comorbidities (relative risk of 2.4 [1.7; 3.4]). It was also associated with the occurrence of pneumonia, pressure ulcers, and pathological bone fracture.

DISCUSSION AND CONCLUSION

Children who are NI should be systematically and thoroughly screened for malnutrition, in the hope of offering early nutritional support and reduce comorbidities.

Nutritional status among young adolescents attending primary school in Tanzania: contributions of mid-upper arm circumference (MUAC) for adolescent assessment

Background

Adolescence is a critical time of development and nutritional status in adolescence influences both current and future adult health outcomes. However, data on adolescent nutritional status is limited in low-resource settings. Mid-upper arm circumference (MUAC) has the potential to offer a simple, low-resource alternative or supplement to body mass index (BMI) in assessing nutrition in adolescent populations.

Methods

This is secondary data analysis, from a cross-sectional pilot study, which analyses anthropometric data from a sample of young adolescents attending their last year of primary school in Pwani Region and Dar es Salaam Region, Tanzania (n = 154; 92 girls & 62 boys; mean age 13.2 years).

Results

The majority of adolescents (75%) were of normal nutritional status defined by BMI. Significantly more males were stunted than females, while significantly more females were overweight than males. Among those identified as outside the normal nutrition ranges, there was inconsistency between MUAC and BMI cut-offs. Bivariate analyses indicate that BMI and MUAC show a positive correlation for both female and male participants, and the relationship between BMI and MUAC was more strongly correlated among adolescent females.

Conclusions

Further studies are needed with more nutritionally and demographically diverse populations to better understand the nutritional status of adolescents and the practical contribution of MUAC cut-offs to measure adolescent nutrition.

Mid-upper arm circumference as a substitute of the body mass index for assessment of nutritional status among adult and adolescent females: learning from an impoverished Indian state

OBJECTIVES

For population-level screening of malnutrition among adults-especially in developing-country settings-the body mass index (BMI) can be impractical because of logistical requirements for weight and height measurement. We analyzed anthropometric data collected from a large-scale nutritional survey on women of rural Bihar to determine the mid-upper arm circumference (MUAC) cutoffs corresponding to standard BMI cutoffs and the predictive accuracies of the determined cutoffs.

STUDY DESIGN

It was a cross-sectional study using multistage cluster sampling.

METHODS

The current analysis used anthropometric data from a study on dietary practices of rural women (adolescents, lactating mothers, and women in the interpregnancy period). The MUAC (cm) cutoffs corresponding to four standard BMI (kg/m²) values were determined using receiver operating characteristic (ROC) curve analysis.

RESULT

We detected a significant positive correlation between BMI and MUAC (r = 0.81, P < 0.0001). In ROC curve analysis, the MUAC cutoffs corresponding to BMI cutoffs of 18.5, 23, 25, and 30 kg/m² were estimated to be 23.2, 26.0, 27.3, and 30.5 kg/m², respectively. The predictive accuracy of the determined cutoffs was good, as indicated by the area under the ROC curve for the four different cutoffs-which ranged between 88% and 97%. Other than the cutoff for 'obese' (BMI, 30 kg/m²), the Kappa coefficients for the rest of the MUAC cutoffs showed 'substantial' agreement (>0.6) with their BMI counterparts.

CONCLUSION

The results suggest that the cutoffs based on MUAC-a less resource-intensive measure than BMI-can be used for community-based screening of malnutrition among women of Bihar.

Assessing effectiveness of a novel mid-upper arm circumference Z-score tape in a community setting in Guatemala

Background

Mid-Upper Arm Circumference (MUAC) is an independent anthropometric measurement used to identify malnutrition in children. While much research has been dedicated to applying fixed estimates of MUAC to identify cases of malnutrition in children under 5 years of age, far less has been done with age-specific MUAC Z-score values across the continuum of age from birth through adolescence.

Methods

The present study examined the effectiveness of a novel MUAC Z-score tape, in the hands of community health volunteers, to identify children over the age of 5 who would benefit from nutritional rehabilitation. In January of 2019, 112 community health volunteers working within Children International in Guatemala were trained to use the MUAC Z-score tape and asked to collect measurements on children or youth in their communities.

Results

Of the 818 MUAC Z-score tape measurements obtained by volunteers, 88.26% (722/818) were concordant with nutritional risk status as predicted by BMI Z-score, and 90.95% (744/818) were concordant with MUAC Z-score tape measurements made by field medical staff. MUAC Z-scores identified 87.10% (27/31) of the severely or moderately undernourished children as determined by the BMI Z-score who would be candidates for the nutrition rehabilitation program (Z-score ≤ − 2) along with an additional six children that would not have been classified as such with BMI Z-score. A qualitative survey distributed to the volunteers showed moderate rates of understanding of nutritional risk using the tape, and 62.50% reported the tape was easy to use.

Conclusions

These quantitative and qualitative findings suggest that with more in-depth training and education the MUAC Z-score tape is a viable, low-cost, low-burden alternative for community-level nutritional status assessment among the population served by Children International in Guatemala.

Supplementary information

Supplementary information accompanies this paper at (10.1186/s13690-019-0370-0).

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

Objective:

(i) To assess diagnostic accuracy of mid-upper arm circumference (MUAC) for screening thinness and severe thinness in Indian adolescent girls aged 10–14 and 15–19 years compared with BMI-for-age Z-score (BAZ) <−2 and <−3 as the gold standard and (ii) to identify appropriate MUAC cut-offs for screening thinness and severe thinness in Indian girls aged 10–14 and 15–19 years.

Design:

Cross-sectional, conducted October 2016–April 2017.

Setting:

Four tribal blocks of two eastern India states, Chhattisgarh and Odisha.

Participants:

Girls (n 4628) aged 10–19 years. Measurements included height, weight and MUAC to calculate BAZ. Standard diagnostic accuracy tests, receiver–operating characteristic curves and Youden index helped arrive at MUAC cut-offs at BAZ < −2 and <−3, as gold standard.

Results:

Mean MUAC and BMI correlation was positive (0·78, P = 0·001 and r² = 0·61). Among 10–14 years, MUAC cut-off corresponding to BAZ < −2 and BAZ < −3 was ≤19·4 and ≤18·9 cm. Among 15–19 years, corresponding values were ≤21·6 and ≤20·7 cm. For both BAZ < −2 and BAZ < −3, specificity was higher in 15–19 v. 10–14 years. State-wise variations existed. MUAC cut-offs ranged from 17·7 cm (10 years) to 22·5 cm (19 years) for BAZ < −2, and from 17·0 cm (10 years) to 21·5 cm (19 years) for BAZ < −3. Single-age area under the curve range was 0·82–0·97.

Conclusions:

Study provides a case for use of year-wise and sex-wise context-specific MUAC-cut-offs for screening thinness/severe thinness in adolescents, rather than one MUAC cut-off across 10–19 years, depending on purpose and logistic constraints.

Relationship between mid-upper arm circumference and BMI for identifying maternal wasting and severe wasting: a cross-sectional assessment

OBJECTIVE

To assess the strength of correlation and agreement between mid-upper arm circumference (MUAC) and BMI, and determine suitable MUAC cut-offs, to detect wasting and severe wasting among non-pregnant adult women in India.

DESIGN

Cross-sectional studies were conducted in five high-burden pockets of four Indian states.

SETTING

Prevalence of malnutrition among women and children is very high in these pockets and the government plans to implement community-based pilot projects to address malnutrition in these areas.

PARTICIPANTS

Anthropometric measurements were carried out on 1716 women with children <5 years of age. However, analyses were conducted on 1538 non-pregnant adult women.

RESULTS

The results showed a strong correlation between MUAC and BMI in the non-pregnant women, with correlation coefficient of 0·860 (95 % CI 0·831, 0·883; P < 0·001). Cohen's κ of 0·812 and 0·884 also showed good agreement between MUAC and BMI in identifying maternal wasting and severe wasting, respectively. The univariate regression model between MUAC and BMI explained 0·734 or 73 % of the variation in BMI. The MUAC cut-offs for wasting (BMI < 18·5 kg/m2) and severe wasting (BMI < 16·0 kg/m2) were calculated as 232 and 214·5 mm, respectively.

CONCLUSIONS

MUAC is a strong predictor of maternal BMI among non-pregnant women with children <5 years in high-burden pockets of four Indian states. In a resource-constrained setting where BMI may not be feasible, the MUAC cut-offs could reliably be used to screen wasting and severe wasting in non-pregnant women for providing appropriate care.

Improving screening for malnourished children at high risk of death: a study of children aged 6-59 months in rural Senegal

Objective

To investigate whether children with concurrent wasting and stunting require therapeutic feeding and to better understand whether multiple diagnostic criteria are needed to identify children with a high risk of death and in need of treatment.

Design

Community-based cohort study, following 5751 children through time. Each child was visited up to four times at 6-month intervals. Anthropometric measurements were taken at each visit. Survival was monitored using a demographic surveillance system operating in the study villages.

Setting

Niakhar, a rural area of the Fatick region of central Senegal.

Participants

Children aged 6–59 months living in thirty villages in the study area.

Results

Weight-for-age Z-score (WAZ) and mid-upper arm circumference (MUAC) were independently associated with near-term mortality. The lowest WAZ threshold that, in combination with MUAC, detected all deaths associated with severe wasting or concurrent wasting and stunting was WAZ <−2·8. Performance for detecting deaths was best when only WAZ and MUAC were used. Additional criteria did not improve performance. Risk ratios for near-term death in children identified using WAZ and MUAC suggest that children identified by WAZ <−2·8 but with MUAC≥115 mm may require lower-intensity treatment than children identified using MUAC <115 mm.

Conclusions

A combination of MUAC and WAZ detected all near-term deaths associated with severe anthropometric deficits including concurrent wasting and stunting. Therapeutic feeding programmes may achieve higher impact if WAZ and MUAC admission criteria are used.

Ethnic and age differences in prediction of mortality by mid-upper arm circumference in children below 3 years of age in Nepal

OBJECTIVE

To assess ethnicity- and age-modified associations between mid-upper arm circumference (MUAC) and mortality in Nepalese children and whether sociodemographic factors explain these associations.

DESIGN

Secondary data analysis of children followed until 3 years of age. Estimated mortality hazard ratios (HR) for MUAC<11·5cm (recommended cut-off for identifying severe acute malnutrition among children ≥6 months old) compared with ≥11·5cm in younger (<6 months) and older children (≥6 months) of Pahadi and Madhesi ethnicity, adjusting for sex, socio-economic status (SES) and mother's education using Cox proportional hazard models.

SETTING

Sarlahi, Nepal (21 October 2001-2 February 2006).

SUBJECTS

Children (n 48 492) enrolled in the Nepal Nutrition Intervention Project, Sarlahi-4.

RESULTS

Among children aged ≥6 months, MUAC<11·5 cm was associated with increased risk of mortality in both Pahadis (HR=4·01; 95 % CI 1·42, 11·76) and Madhesis (HR=5·60; 95 % CI 3·87, 8·11) compared with those with MUAC≥11·5 cm, after adjusting for sex, SES and maternal literacy. Among children <6 months old, MUAC<11·5 cm was not associated with mortality in Pahadis with (HR=1·12; 95 % CI 0·72, 1·73) or without adjusting (HR=1·17; 95 % CI 0·75, 1·18) as compared with Madeshis (adjusted HR=1·76; 95 % CI 1·35, 2·28).

CONCLUSIONS

Among older children, MUAC<11·5 cm is associated with subsequent mortality in both ethnicities regardless of other characteristics. However, among children aged <6 months, it predicted mortality only among Madhesis, while sociodemographic factors were more strongly associated with mortality than MUAC<11·5cm among Pahadis.

The validity of mid-upper arm circumference as an indicator of low BMI in population screening for undernutrition: a study among adult slum dwellers in eastern India

OBJECTIVE

To explore the possibility for a statistically appropriate value of mid-upper arm circumference (MUAC) to identify the state of severe undernutrition, based on very low BMI, among adult Indian slum dwellers.

DESIGN

Cross-sectional study on adults. Height and MUAC were recorded and BMI was computed. Chronic energy deficiency (CED) was determined using the WHO international guidelines as BMI<18·5 kg/m2 and normal as BMI≥18·5 kg/m2. Besides calculating mean, sd and 25th, 50th and 75th percentile values, multiple linear regression analysis was undertaken to assess the associations between age, MUAC and BMI. Receiver-operating characteristic curve analysis was performed to determine the best MUAC cut-off to identify CED status. The χ 2 test was used to assess significance of the difference in CED prevalence across MUAC categories.

SETTING

An urban slum in Midnapore town, West Bengal State, India.

SUBJECTS

Male (n 467) and female (n 488) Indian slum dwellers.

RESULTS

MUAC of 22·7 and 21·9 cm, respectively, in males and females were the best cut-off points to differentiate CED from non-CED.

CONCLUSIONS

Results supported the validity of the WHO-recommended MUAC cut-offs for adults. There is still a need to establish statistically appropriate MUAC cut-offs to predict undernutrition and morbidity.

Change in quality of malnutrition surveys between 1986 and 2015

BACKGROUND

Representative surveys collecting weight, height and MUAC are used to estimate the prevalence of acute malnutrition. The results are then used to assess the scale of malnutrition in a population and type of nutritional intervention required. There have been changes in methodology over recent decades; the objective of this study was to determine if these have resulted in higher quality surveys.

METHODS

In order to examine the change in reliability of such surveys we have analysed the statistical distributions of the derived anthropometric parameters from 1843 surveys conducted by 19 agencies between 1986 and 2015.

RESULTS

With the introduction of standardised guidelines and software by 2003 and their more general application from 2007 the mean standard deviation, kurtosis and skewness of the parameters used to assess nutritional status have each moved to now approximate the distribution of the WHO standards when the exclusion of outliers from analysis is based upon SMART flagging procedure. Where WHO flags, that only exclude data incompatible with life, are used the quality of anthropometric surveys has improved and the results now approach those seen with SMART flags and the WHO standards distribution. Agencies vary in their uptake and adherence to standard guidelines. Those agencies that fully implement the guidelines achieve the most consistently reliable results.

CONCLUSIONS

Standard methods should be universally used to produce reliable data and tests of data quality and SMART type flagging procedures should be applied and reported to ensure that the data are credible and therefore inform appropriate intervention. Use of SMART guidelines has coincided with reliable anthropometric data since 2007.

Combined Protocol for Acute Malnutrition Study (ComPAS) in rural South Sudan and urban Kenya: study protocol for a randomized controlled trial

Background

Acute malnutrition is a continuum condition, but severe and moderate forms are treated separately, with different protocols and therapeutic products, managed by separate United Nations agencies. The Combined Protocol for Acute Malnutrition Study (ComPAS) aims to simplify and unify the treatment of uncomplicated severe and moderate acute malnutrition (SAM and MAM) for children 6–59 months into one protocol in order to improve the global coverage, quality, continuity of care and cost-effectiveness of acute malnutrition treatment in resource-constrained settings.

Methods/design

This study is a multi-site, cluster randomized non-inferiority trial with 12 clusters in Kenya and 12 clusters in South Sudan. Participants are 3600 children aged 6–59 months with uncomplicated acute malnutrition. This study will evaluate the impact of a simplified and combined protocol for the treatment of SAM and MAM compared to the standard protocol, which is the national treatment protocol in each country. We will assess recovery rate as a primary outcome and coverage, defaulting, death, length of stay, average weekly weight gain and average weekly mid-upper arm circumference (MUAC) gain as secondary outcomes. Recovery rate is defined across both treatment arms as MUAC ≥125 mm and no oedema for two consecutive visits. Per-protocol and intention-to-treat analyses will be conducted.

Discussion

If the combined protocol is shown to be non-inferior to the standard protocol, updating guidelines to use the combined protocol would eliminate the need for separate products, resources and procedures for MAM treatment. This would likely be more cost-effective, increase availability of services, enable earlier case finding and treatment before deterioration of MAM into SAM, promote better continuity of care and improve community perceptions of the programme.

Trial registration

ISRCTN, ISRCTN30393230. Registered on 16 March 2017.

Electronic supplementary material

The online version of this article (10.1186/s13063-018-2643-2) contains supplementary material, which is available to authorized users.

Comparing performance of mothers using simplified mid-upper arm circumference (MUAC) classification devices with an improved MUAC insertion tape in Isiolo County, Kenya

Background

A novel approach for improving community case-detection of acute malnutrition involves mothers/caregivers screening their children for acute malnutrition using a mid-upper arm circumference (MUAC) insertion tape. The objective of this study was to test three simple MUAC classification devices to determine whether they improved the sensitivity of mothers/caregivers at detecting acute malnutrition.

Methods

Prospective, non-randomised, partially-blinded, clinical diagnostic trial describing and comparing the performance of three “Click-MUAC” devices and a MUAC insertion tape. The study took place in twenty-one health facilities providing integrated management of acute malnutrition (IMAM) services in Isiolo County, Kenya. Mothers/caregivers classified their child (n=1040), aged 6–59 months, using the “Click-MUAC” devices and a MUAC insertion tape. These classifications were compared to a “gold standard” classification (the mean of three measurements taken by a research assistant using the MUAC insertion tape).

Results

The sensitivity of mother/caregiver classifications was high for all devices (>93% for severe acute malnutrition (SAM), defined by MUAC < 115 mm, and > 90% for global acute malnutrition (GAM), defined by MUAC < 125 mm). Mother/caregiver sensitivity for SAM and GAM classification was higher using the MUAC insertion tape (100% sensitivity for SAM and 99% sensitivity for GAM) than using “Click-MUAC” devices. Younden’s J for SAM classification, and sensitivity for GAM classification, were significantly higher for the MUAC insertion tape (99% and 99% respectively). Specificity was high for all devices (>96%) with no significant difference between the “Click-MUAC” devices and the MUAC insertion tape.

Conclusions

The results of this study indicate that, although the “Click-MUAC” devices performed well, the MUAC insertion tape performed best. The results for sensitivity are higher than found in previous studies. The high sensitivity for both SAM and GAM classification by mothers/caregivers with the MUAC insertion tape could be due to the use of an improved MUAC tape design which has a number of new design features. The one-on-one demonstration provided to mothers/caregivers on the use of the devices may also have helped improve sensitivity. The results of this study provide evidence that mothers/caregivers can perform sensitive and specific classifications of their child’s nutritional status using MUAC.

Trial registrations

Clinical trials registration number: NCT02833740

Mid-upper arm circumference in detection of weight-for-height Z-score below -3 in children aged 6-59 months

OBJECTIVE

To evaluate the predictive ability of mid-upper arm circumference (MUAC) for detecting severe wasting (weight-for-height Z-score (WHZ) <-3) among children aged 6-59 months.

DESIGN

Cross-sectional survey.

SETTING

Rural Uttar Pradesh, India.

SUBJECTS

Children (n 18 456) for whom both WHZ (n 18 463) and MUAC were available.

RESULTS

The diagnostic test accuracy of MUAC for severe wasting was excellent (area under receiver-operating characteristic curve = 0·933). Across the lower range of MUAC cut-offs (110-120 mm), specificity was excellent (99·1-99·9 %) but sensitivity was poor (13·4-37·2 %); with higher cut-offs (140-150 mm), sensitivity increased substantially (94·9-98·8 %) but at the expense of specificity (37·6-71·9 %). The optimal MUAC cut-off to detect severe wasting was 135 mm. Although the prevalence of severe wasting was constant at 2·2 %, the burden of severe acute malnutrition, defined as either severe wasting or low MUAC, increased from 2·46 to 17·26 % with cut-offs of <115 and <135 mm, respectively. An MUAC cut-off <115 mm preferentially selected children aged ≤12 months (OR=11·8; 95 % CI 8·4, 16·6) or ≤24 months (OR=23·4; 95 % CI 12·7, 43·4) and girls (OR=2·2; 95 % CI 1·6, 3·2).

CONCLUSIONS

Based on important considerations for screening and case detection in the community, modification of the current WHO definition of severe acute malnutrition may not be warranted, especially in the Indian context.

Changes in body mass index and mid-upper arm circumference in relation to all-cause mortality in older adults

BACKGROUND & AIMS

The assessment of weight loss as an indicator of poor nutritional status in older persons is currently widely applied to establish risk of mortality. Little is known about the relationship between changes in mid-upper arm circumference (MUAC) and mortality in older individuals. The aim of the present study was to examine the association between 3-year change in MUAC and 20-year mortality in community-dwelling older adults and compare this to the association between body mass index (BMI) change and mortality.

METHODS

Data on changes in MUAC (cm) and BMI (kg/m²), covariates, and mortality were available for 1307 Dutch older adults (49.7% men) aged 65 years and older in 1995/96 (mean 75.6 years, SD 6.5) from Longitudinal Aging Study Amsterdam (LASA). Anthropometric measurements were performed in 1992/93 with repeated measurements in 1995/96 (baseline), and a mortality follow up until July 2015. BMI and MUAC change were divided into quintiles, with the quintile including zero defined as the reference category. Cox regression analyses were performed to examine the associations of 3-year changes in MUAC and BMI with subsequent 20-year all-cause mortality, adjusted for demographic and health factors. Age, sex and initial measurement of BMI and MUAC (1992/93) were tested for effect modification (P = <0.10).

RESULTS

Mean baseline BMI was 26.7 kg/m² (SD 4.2) with a 3-year change of -0.2 (SD 1.5). Mean baseline MUAC was 30.5 cm (SD 3.5) with a 3-year change of -0.8 (SD 1.6). Age, sex, and BMI and MUAC 3 years prior were effect modifiers in the associations between change in anthropometric measurement and mortality. Decrease in MUAC was not associated with mortality in persons with a higher initial MUAC (≥31 cm), while for persons with a lower initial MUAC, a decrease in MUAC of ≤-2.15 was associated with increased mortality risk (HR 1.54; 95% CI: 1.14-2.09), also when further stratified on median age and sex. In stratified analysis of BMI change for median initial BMI (26.5) and additionally stratified for median age and sex, the associations between a BMI decrease of ≤-1.19 and mortality fluctuated, mostly statistically not significant. No associations were found for gain in MUAC or BMI.

CONCLUSIONS

Given that MUAC loss is more strongly and consistently associated with an increased mortality risk in older individuals with a low initial MUAC compared to BMI loss, this may be a more recommendable measure to use in clinical practice for assessing poor nutritional status, instead of weight loss.

Monitoring and discharging children being treated for severe acute malnutrition using mid-upper arm circumference: secondary data analysis from rural Gambia

Background

Severe acute malnutrition (SAM) is a major public health problem. Mid-upper arm circumference (MUAC) is widely used to admit children to treatment programmes. However, insufficient data supporting MUAC discharge criterion limits its use as a stand-alone tool. Our aim was to evaluate MUAC for monitoring nutritional recovery and discharge.

Methods

This was a secondary analysis of clinical data from children 6-59 months-old treated for SAM from January 2003 to December 2013 at the Nutritional Rehabilitation Unit in rural Gambia. Weight, weight-for-height z-score (WHZ) and MUAC response to treatment were assessed. Treatment indicators and regression models controlled for admission measurement and age were compared by discharge MUAC and WHZ.

Results

Four hundred and sixty-three children with marasmus were included. MUAC, WHZ and weight showed parallel responses to treatment. MUAC≥125 mm as a discharge criterion performed well, showing good prediction of default and referral to hospital, acceptable duration of stay, and a higher absolute MUAC measure compared to WHZ≥-2.00, closely related to lower risk of mortality.

Conclusions

MUAC can be used as a standalone tool for monitoring nutritional recovery. MUAC≥125 mm performs well as a discharge criterion; however, follow-up data is needed to assess its safety. Further research is needed on children meeting MUAC discharge criterion but with WHZ≤2.0.

Anthropometric indices for non-pregnant women of childbearing age differ widely among four low-middle income populations

Background

Maternal stature and body mass indices (BMI) of non-pregnant women (NPW) of child bearing age are relevant to maternal and offspring health. The objective was to compare anthropometric indices of NPW in four rural communities in low- to low-middle income countries (LMIC).

Methods

Anthropometry and maternal characteristics/household wealth questionnaires were obtained for NPW enrolled in the Women First Preconception Maternal Nutrition Trial. Body mass index (BMI, kg/m²) was calculated. Z-scores were determined using WHO reference data.

Results

A total of 7268 NPW participated in Equateur, DRC (n = 1741); Chimaltenango, Guatemala (n = 1695); North Karnataka, India (n = 1823); and Thatta, Sindh, Pakistan (n = 2009). Mean age was 23 y and mean parity 1.5. Median (P25-P75) height (cm) ranged from 145.5 (142.2–148.9) in Guatemala to 156.0 (152.0–160.0) in DRC. Median weight (kg) ranged from 44.7 (39.9–50.3) in India to 52.7 (46.9–59.8) in Guatemala. Median BMI ranged from 19.4 (17.6–21.9) in India to 24.9 (22.3–28.0) in Guatemala. Percent stunted (<−2SD height for age z-score) ranged from 13.9% in DRC to 80.5% in Guatemala; % underweight (BMI <18.5) ranged from 1.2% in Guatemala to 37.1% in India; % overweight/obese (OW, BMI ≥25.0) ranged from 5.7% in DRC to 49.3% in Guatemala. For all sites, indicators for higher SES and higher age were associated with BMI. Lower SES women were underweight more frequently and higher SES women were OW more frequently at all sites. Younger women tended to be underweight, while older women tended to be OW.

Conclusions

Anthropometric data for NPW varied widely among low-income rural populations in four countries located on three different continents. Global comparisons of anthropometric measurements across sites using standard reference data serve to highlight major differences among populations of low-income rural NPW and assist in evaluating the rationale for and the design of optimal intervention trials.

Trial registration

ClinicalTrials.gov #NCT01883193 (18 June 2013, retrospectively registered)

Mothers screening for malnutrition by mid-upper arm circumference is non-inferior to community health workers: results from a large-scale pragmatic trial in rural Niger

Background

Community health workers (CHWs) are recommended to screen for acute malnutrition in the community by assessing mid-upper arm circumference (MUAC) on children between 6 and 59 months of age. MUAC is a simple screening tool that has been shown to be a better predictor of mortality in acutely malnourished children than other practicable anthropometric indicators. This study compared, under program conditions, mothers and CHWs in screening for severe acute malnutrition (SAM) by color-banded MUAC tapes.

Methods

This pragmatic interventional, non-randomized efficacy study took place in two health zones of Niger’s Mirriah District from May 2013 to April 2014. Mothers in Dogo (Mothers Zone) and CHWs in Takieta (CHWs Zone) were trained to screen for malnutrition by MUAC color-coded class and check for edema. Exhaustive coverage surveys were conducted quarterly, and relevant data collected routinely in the health and nutrition program. An efficacy and cost analysis of each screening strategy was performed.

Results

A total of 12,893 mothers and caretakers were trained in the Mothers Zone and 36 CHWs in the CHWs Zone, and point coverage was similar in both zones at the end of the study (35.14 % Mothers Zone vs 32.35 % CHWs Zone, p = 0.9484). In the Mothers Zone, there was a higher rate of MUAC agreement (75.4 % vs 40.1 %, p <0.0001) and earlier detection of cases, with median MUAC at admission for those enrolled by MUAC <115 mm estimated to be 1.6 mm higher using a smoothed bootstrap procedure. Children in the Mothers Zone were much less likely to require inpatient care, both at admission and during treatment, with the most pronounced difference at admission for those enrolled by MUAC < 115 mm (risk ratio = 0.09 [95 % CI 0.03; 0.25], p < 0.0001). Training mothers required higher up-front costs, but overall costs for the year were much lower ($8,600 USD vs $21,980 USD.)

Conclusions

Mothers were not inferior to CHWs in screening for malnutrition at a substantially lower cost. Children in the Mothers Zone were admitted at an earlier stage of SAM and required fewer hospitalizations. Making mothers the focal point of screening strategies should be included in malnutrition treatment programs.

Trial registration

The trial is registered with clinicaltrials.gov (Trial number NCT01863394).

Retention and Treatment Outcomes of an Undernutrition Program for HIV patients involving Ready-to-Use Therapeutic Food at Gondar University Hospital, Ethiopia: A Cross-Sectional Study

INTRODUCTION

Despite global efforts to eradicate poverty and hunger, under-nutrition is still a major health problem, especially in Sub-Saharan Africa, where HIV/AIDS prevalence is also a serious burden.

AIM

To assess the retention and outcomes of under-nutrition treatment program in Gondar University Hospital, Ethiopia.

SETTINGS AND DESIGN

A cross-sectional study was conducted in HIV positive children and adults participating in the Ready-to-use Therapeutic Food (RUTF) treatment program at Gondar University Hospital ART clinic for one year from November 2012 to November 2013.

MATERIALS AND METHODS

Six hundred and thirty six patient records were followed-up for one year. Outcome variables were Mid-Upper Arm Circumference (MUAC) values measured as severe, moderate acute malnutrition, normal after treatment, non-respondent, relapsed and lost to follow-up using the hospital records of HIV positive children and adults eligible for the program.

STATISTICAL ANALYSIS

Univariate and multivariate analysis were performed to compute Crude Odds Ratio (COR) and Adjusted Odds Ratio (AOR). Statistical significance was set at p-value<0.05.

RESULTS

Among 636 clients, 44.2% achieved MUAC measures ≥ 125 mm for children and ≥ 21 cm for adults at 4 and 6 months. 70.1% of those were children while 29.9% of the 281 were adults. Moreover, a more positive initial response to ready-to-use therapeutic food was found among children as there was significant increase (p<0.05) in MUAC value after the second month of initiating treatment while adults achieved a significant (p<0.05, p<0.01) in MUAC at the 4(th) and 6(th) month respectively. There was a significant association between age, nutrition status and treatment outcome, while sex, HIV status, education and residency were not associated with treatment outcome.

CONCLUSION

Recovery and weight gain rates were below 50%. Defaulter rates were higher than the Sphere standards and recovery was better in children than adults. Integrated RUTF and HIV program and strict follow-up and education or counselling of HIV positive patients should be strengthened.

weight-for-height Z-score for predicting mortality in hospitalized children under 5 years of age

OBJECTIVE

To compare the performance of mid-upper arm circumference (MUAC) against weight-for-height Z-score (WHZ) for predicting inpatient deaths in children under 5 years of age.

DESIGN

Diagnostic test accuracy study.

SETTING

Paediatric emergency department of a tertiary care hospital catering to semi-urban and rural population in Delhi, India.

SUBJECTS

Hospitalized children (n 1663) aged 6 months to 5 years, for whom discharge outcome was available, were consecutively recruited over 14 months. MUAC (cm), weight (kg) height (cm), clinical details and the outcome were recorded. MUAC (index test) was compared with WHZ based on the WHO growth standards (reference test) for predicting the outcome.

RESULTS

One hundred and twenty-four (7 %) children died during hospital stay. Both MUAC < 11·5 cm (adjusted OR (95 % CI): 3·7 (2·43, 5·60), P<0·001) and WHZ<-3 (2·0 (1·37, 2·99), P<0·001) served as independent predictors of inpatient mortality. However, MUAC was a significantly better predictor of mortality compared with WHZ in terms of area under the receiver-operating characteristic curve (MUAC=0·698, WHZ=0·541, P<0·001). MUAC<11·5 cm had the best trade-off of sensitivity and specificity for predicting inpatient mortality. A combination of WHZ<-3 and/or MUAC<11·5 cm did not significantly improve the predictive value over that of MUAC/WHZ, assessed individually.

CONCLUSION

MUAC<11·5 cm is a better predictor of mortality in hospitalized under-5 children, as compared with WHZ<-3. It should be measured in all emergency settings to identify the children at higher risk of death.

Risk of malnutrition in a sample of nonagenarians: Specific versus classic bioelectrical impedance vector analysis

OBJECTIVES

The aims were to describe the body composition and the risk of malnutrition in a sample of nonagenarians and to identify what bioelectrical impedance vector analysis (BIVA) approach (classic or specific) is more correlated with either the risk of malnutrition or various anthropometric parameters.

METHODS

In the Mugello area (Italy), a representative sample of nonagenarians was enrolled in a survey aimed at investigating various health issues, including those related to nutritional status. The nutritional status was investigated using body mass index (BMI), mid-upper arm circumference (MUAC), calf circumference (CC), Malnutrition Universal Screening Tool (MUST), and BIVA. Two different approaches were used for the BIVA data analysis: the classic method and the specific method.

RESULTS

All measurements were obtained from 321 nonagenarians (65.7% of the enrolled sample; 92 men and 229 women); 74.8% of the subjects were at low risk of malnutrition according to MUST, 62.5% exhibited CC values higher than 31 cm, and 86.8% exhibited MUAC values higher than 22 cm. The bioelectrical parameters varied with nutritional status, independent of the nutritional indicator used; the parameters also varied based on sex and BIVA approach. The bioelectrical parameters obtained by the specific BIVA approach were more strongly correlated with MUST score, MUAC, and CC values compared with the parameters calculated using the classic approach.

CONCLUSIONS

Our study produced findings relevant to particular aspects of population aging. Above all, the specific BIVA was more effective at assessing nutritional status based on both anthropometric parameters and the risk of malnutrition.

Predictors of the risk of malnutrition among children under the age of 5 years in Somalia

OBJECTIVE

To investigate the predictors of wasting, stunting and low mid-upper arm circumference among children aged 6-59 months in Somalia using data from household cross-sectional surveys from 2007 to 2010 in order to help inform better targeting of nutritional interventions.

DESIGN

Cross-sectional nutritional assessment surveys using structured interviews were conducted among communities in Somalia each year from 2007 to 2010. A two-stage cluster sampling methodology was used to select children aged 6-59 months from households across three livelihood zones (pastoral, agro-pastoral and riverine). Predictors of three anthropometric measures, weight-for-height (wasting), height-for-age (stunting) and mid-upper arm circumference, were analysed using Bayesian binomial regression, controlling for both spatial and temporal dependence in the data.

SETTING

The study was conducted in randomly sampled villages, representative of three livelihood zones in Somalia.

SUBJECTS

Children between the ages of 6 and 59 months in Somalia.

RESULTS

The estimated national prevalence of wasting, stunting and low mid-upper arm circumference in children aged 6-59 months was 21 %, 31 % and 36 %, respectively. Although fever, diarrhoea, sex and age of the child, household size and access to foods were significant predictors of malnutrition, the strongest association was observed between all three indicators of malnutrition and the enhanced vegetation index. A 1-unit increase in enhanced vegetation index was associated with a 38 %, 49 % and 59 % reduction in wasting, stunting and low mid-upper arm circumference, respectively.

CONCLUSIONS

Infection and climatic variations are likely to be key drivers of malnutrition in Somalia. Better health data and close monitoring and forecasting of droughts may provide valuable information for nutritional intervention planning in Somalia.

The relationships between height and arm span, mid-upper arm and waist circumferences and sum of four skinfolds in Ellisras rural children aged 8-18 years

OBJECTIVE

Height is required for the assessment of growth and nutritional status, as well as for predictions and standardization of physiological parameters. To determine whether arm span, mid-upper arm and waist circumferences and sum of four skinfolds can be used to predict height, the relationships between these anthropometric variables were assessed among Ellisras rural children aged 8-18 years.

DESIGN

The following parameters were measured according to the International Society for the Advancement of Kinathropometry: height, arm span, mid-upper arm circumference, waist circumference and four skinfolds (suprailiac, subscapular, triceps and biceps). Associations between the variables were assessed using Pearson correlation coefficients and linear regression models.

SETTING

Ellisras Longitudinal Study (ELS), Limpopo Province, South Africa.

SUBJECTS

Boys (n 911) and girls (n 858) aged 8-18 years.

RESULTS

Mean height was higher than arm span, with differences ranging from 4 cm to 11·5 cm between boys and girls. The correlation between height and arm span was high (ranging from 0·74 to 0·91) with P<0·001. The correlation between height and mid-upper arm circumference, waist circumference and sum of four skinfolds was low (ranging from 0·15 to 0·47) with P<0·00 among girls in the 15-18 years age group.

CONCLUSIONS

Arm span was found to be a good predictor of height. The sum of four skinfolds was significantly associated with height in the older age groups for girls, while waist circumference showed a negative significant association in the same groups.

Mothers Understand And Can do it (MUAC): a comparison of mothers and community health workers determining mid-upper arm circumference in 103 children aged from 6 months to 5 years

BACKGROUND

Mid-upper arm circumference (MUAC) was recently endorsed and recommended for screening for acute malnutrition in the community. The objective of this study was to determine whether a colour-banded MUAC strap would allow minimally trained mothers to screen their own children for malnutrition, without locating the mid-point of the left upper arm by measurement, as currently recommended.

METHODS

A non-randomised non-blinded evaluation of mothers' performance when measuring MUAC after minimal training, compared with trained Community Health Workers (CHW) following current MUAC protocols. The study was conducted in 2 villages in Mirriah, Zinder region, Niger where mothers classified one of their children (n = 103) aged 6-59 months (the current age range for admission into community malnutrition programs) using the MUAC tape.

RESULTS

Mothers' had a sensitivity and specificity for classification of their child's nutritional status of > 90% and > 80% respectively for global acute malnutrition (GAM, defined by a MUAC < 125 mm) and > 73% and > 98% for severe acute malnutrition (SAM, defined by a MUAC < 115 mm). The few children misclassified as not having SAM, were classified as having moderate acute malnutrition (MAM). The choice of arm did not influence the classification results; weighted Kappa of 0.88 for mothers and 0.91 for CHW represent almost perfect agreement. Errors occurred at the class boundaries and no gross errors were made.

CONCLUSIONS

Advanced SAM is associated with severe complications, which often require hospital admission or cause death. Mothers (with MUAC tapes costing $0.06) can screen their children frequently allowing early diagnosis and treatment thereby becoming the focal point in scaling-up community management of acute malnutrition.

TRIAL REGISTRATION

The trial is registered with clinicaltrials.gov (Trial number NCT01790815).

Comparison of weight-for-height and mid-upper arm circumference (MUAC) in a therapeutic feeding programme in South Sudan: is MUAC alone a sufficient criterion for admission of children at high risk of mortality?

OBJECTIVE

The present study was performed to describe the operational implications of using mid-upper arm circumference (MUAC) as a single admission criterion for treatment of severe acute malnutrition in South Sudan.

DESIGN

We performed a retrospective analysis of routine programme data of children with severe acute malnutrition aged 6-59 months admitted to a therapeutic feeding programme using weight-for-height Z-score (WHZ) and/or MUAC. To understand the implications of using MUAC as a single admission criterion, we compared patient characteristics and treatment outcomes for children admitted with MUAC<115 mm (irrespective of WHZ) v. children admitted with WHZ<-3 and MUAC≥115 mm.

RESULTS

Of 2205 children included for analysis, 719 (32·6 %) were admitted to the programme with MUAC<115 mm and 1486 (67·4 %) with WHZ<-3 and MUAC≥115 mm. Children who would have been admitted using a single MUAC<115 mm criterion were more severely malnourished and more likely to be female and younger. Compared with children admitted with WHZ<-3 and MUAC≥115 mm, children who would have been admitted using MUAC<115 mm were less likely to recover (54 % v. 69 %) and had higher risk of death (4 % v. 1 %), but responded to treatment with greater weight and MUAC gains. MUAC<115 mm would have failed to identify 33 % of deaths, while 98 % were identified by WHZ<-3 alone and 100 % by MUAC<130 mm.

CONCLUSIONS

The study shows that MUAC<115 mm identified more severely malnourished children with a higher risk of mortality but failed to identify a third of the children who died. Admission criteria for therapeutic feeding should be adapted to the programmatic context with consideration for both operational and public health implications.