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NANCY M DALE
Using Anthropometry
to Optimize Nutrition Programs
for Management of Acute Malnutrition
Acta Universitatis Tamperensis 2253
Tampere University Press
Tampere 2017
ACADEMIC DISSERTATION
University of Tampere, Faculty of Medicine and Life Sciences
Finland
Supervised by Reviewed by
Adjunct Professor André Briend Docent Merja Ashorn
University of Tampere University of Tampere
Finland Finland
Professor Jussi Kauhanen
University of Eastern Finland
Finland
The originality of this thesis has been checked using the Turnitin OriginalityCheck service
in accordance with the quality management system of the University of Tampere.
Copyright ©2017 Tampere University Press and the author
Cover design by
Mikko Reinikka
Acta Universitatis Tamperensis 2253 Acta Electronica Universitatis Tamperensis 1754
ISBN 978-952-03-0338-9 (print) ISBN 978-952-03-0339-6 (pdf)
ISSN-L 1455-1616 ISSN 1456-954X
ISSN 1455-1616 http://tampub.uta.fi
Suomen Yliopistopaino Oy – Juvenes Print
Tampere 2017
P4a4i1n o t7u2o9te
NANCY M DALE
Using Anthropometry
to Optimize Nutrition Programs
for Management of Acute Malnutrition
Acta Universitatis Tamperensis 2253
Tampere University Press
Tampere 2017
ACADEMIC DISSERTATION
University of Tampere, Faculty of Medicine and Life Sciences
Finland
Supervised by Reviewed by
Adjunct Professor André Briend Docent Merja Ashorn
University of Tampere University of Tampere
Finland Finland
Professor Jussi Kauhanen
University of Eastern Finland
Finland
The originality of this thesis has been checked using the Turnitin OriginalityCheck service
in accordance with the quality management system of the University of Tampere.
Copyright ©2017 Tampere University Press and the author
Cover design by
Mikko Reinikka
Acta Universitatis Tamperensis 2253 Acta Electronica Universitatis Tamperensis 1754
ISBN 978-952-03-0338-9 (print) ISBN 978-952-03-0339-6 (pdf)
ISSN-L 1455-1616 ISSN 1456-954X
ISSN 1455-1616 http://tampub.uta.fi
Suomen Yliopistopaino Oy – Juvenes Print
Tampere 2017
P4a4i1n o t7u2o9te
In memory of my father, Dr. Gordon G. Dale
ABSTRACT
Millions of children under 5 years of age suffer from severe acute malnutrition
(SAM), worldwide, at any given time contributing to 1 million deaths per year, if not
more.
Anthropometric measurements including weight, height, and mid-upper arm
circumference (MUAC) are used to measure nutritional status of children. Growth
references/standards have been created to show expected growth in children who
are living in conditions favorable for growth and are often displayed in tables
showing weight-for-height (WFH) as percentage of the median or in the form of Z-
scores such as weight-for-height Z-scores (WHZ). The references/standards are
used to determine the degree of malnutrition that children are experiencing and thus
whether they meet the admission criteria for treatment programs. They are also used
to determine the prevalence of malnutrition in a population present at a given time.
MUAC differs from growth references/standards as it assesses risk of mortality
rather than expectation of growth.
The community-based management of acute malnutrition (CMAM) model is
commonly used for children with SAM between the ages of 6 and 59 months. This
involves both outpatient care in outpatient therapeutic programs (OTP) for SAM
cases without complication and/or inpatient care in stabilization centres (SC), for
SAM cases with complications. The main priority of treatment programs for SAM is
to minimize mortality. There are many factors involved in the process of counting,
predicting, identifying, and selecting children in need of treatment in nutrition
programs as well as determining criteria for discharge from programs. This PhD
consisted of five studies which explored how to use anthropometric indices in
nutritional programs.
The first study involved examining an alternative method for estimating the
prevalence of acute malnutrition, specifically the PROBIT method, which is based
on properties of the normal distribution. A simulation of 1.26 million virtual surveys
generated from 560 real nutrition surveys from 31 different countries was used to
compare bias and precision of this approach with the standard method. The results
of this study showed that the PROBIT method can estimate prevalence of global
acute malnutrition (GAM) and moderate acute malnutrition (MAM) using WHZ or
MUAC. The study shows, however, that the PROBIT method is inferior to the
classical method for estimating the prevalence for SAM by WHZ or MUAC at
sample sizes n >150. It does seem suitable for small sample sizes and thus perhaps
could be useful for surveillance.
The second study involved determining an incidence conversion factor (J)
empirically that could be used to estimate annual incidence of SAM based on
prevalence data taken from nutrition surveys. This estimate is useful in predicting
the expected number of children to be admitted into therapeutic nutrition programs
and subsequent resources required. Organizations often include an incidence
conversion factor (J = 1.6) in the formula to calculate expected yearly case load into
programs. The estimation of J was done by correlating expected number of children
to be treated, based on prevalence surveys and population estimates, with the
number of children actually treated in CMAM programs. Twenty-four data sets from
six different countries were used that included prevalence surveys and program
admission data for 5 months following the survey. The results showed a significant
relationship between the number of SAM cases admitted to CMAM programs and
the estimated burden of SAM from prevalence surveys. The value for J extrapolated
from our results was found to be higher than the one currently used by organizations.
The value also may vary between regions.
The third study was done to determine, if WFH is used, which growth standard
or reference is best to identify children most at risk of death and thus ensure
inclusion into the nutrition program. Data from 54,661 children treated in a nutrition
program in Maradi, Niger were analyzed. Difference in classification of children as
either moderate or severely malnourished as per the National Centre for Health
Statistics (NCHS) growth reference and the WHO growth standards was
investigated as well as risk of mortality based on different growth
reference/standards. Results showed that 40% of the total children in the program
which were classified as moderately malnourished as per NCHS standards would
have been classified as severely malnourished if they had been assessed by the WHO
standards. Almost half the deaths in the program were in this group and the children
had three times the risk of dying during the program than the children classified as
moderately wasted by both standards. The results of this study showed that the
subgroup who would be reclassified is vulnerable to mortality and thus would benefit
from being classified using the WHO growth standards to ensure admission into a
nutritional program.
The last two studies evaluated the use of MUAC in nutrition programs as an
independent anthropometric measurement for malnutrition and examined the
response of MUAC to treatment and the outcomes of children after being discharged
from a nutrition program with a MUAC-based protocol. Both studies compared
length of stay and percent weight gain of children in relation to nutritional status on
admission as well as response to treatment based on height at admission. In addition,
the fifth study evaluated the outcomes of children 3 months after discharge from the
treatment program to determine the safety of using MUAC-based protocol. The data
from study four was from a nutrition program in Gedaref, North Sudan consisting
of 753 children. The data from study five was from a nutrition program in Malawi
consisting of 257 children and 155 children for follow-up after discharge. The results
of these studies showed that with these MUAC-based protocols, the duration of
treatment and percent of weight gain are higher in the most malnourished children,
regardless of their height. The results of study five also showed MUAC ≥ 125 mm
as a safe discharge criterion with an acceptable level of negative outcomes at three
months’ post discharge in the context of Malawian Ministry of Health outpatient
care facilities.
In conclusion, the classical method of counting individual cases of malnutrition
in surveys is preferred to over the PROBIT method for estimating acute malnutrition
prevalence from large sample surveys. The PROBIT method may be useful in
sentinel-site surveillance systems with small sample sizes. The estimation of expected
cases of malnutrition from prevalence surveys may require revision of the currently
used incidence conversion factor (J). If using WFH in treatment programs, it is highly
recommended to use the WHO growth standards instead of the NCHS reference to
ensure inclusion of children with high mortality risk into the program. Lastly, if using
MUAC-based protocol in treatment programs it is recommended to use MUAC for
both admission and discharge criteria to ensure the most effective and safe treatment
is delivered to the children most at risk of mortality.
Description:cases without complication and/or inpatient care in stabilization centres (SC), for. SAM cases with complications. The main priority of treatment programs for SAM is to minimize mortality. There are many factors involved in the process of counting, predicting, identifying, and selecting children in
