Recognition and Management of Malnutrition

Initial Assessment

The initial assessment of the nutritional status and food resources of a population affected by a disaster is part of the overall emergency needs assessment (Box 1). Obtain all available information regarding the pre-disaster prevalence of macro- and micronutrient deficiencies in the community. Information from public health authorities, health care professionals, and other health workers in the local community is critical for that purpose. Also, identify any nutrition programs active in the community before the disaster. This information helps to identify nutritionally vulnerable groups (Box 2). Finally, determine the quantity and quality of food stores readily available to the affected population. The data obtained through the initial assessment, together with accurate demographic data from the affected population, are needed to design and implement an adequate food response following a disaster.

Assessment during the recovery phase

In the recovery phase, as more outside resources become available and the local community becomes more organized, one of the goals is the development of programs to guarantee that available food resources will be targeted efficiently and effectively to populations in need. This requires the systematic assessment of the nutritional status of the population. Box 1 outlines the basic components of ongoing recovery phase nutritional assessments. These measures should be continued until adequate nutrition resources are appropriately and efficiently distributed.

Anthropometric assessment in the pediatric population

Anthropometric methods provide information regarding the height, weight, and proportions of a person. These data are used, particularly in children, to assess an individual’s nutritional status. Interpretation of anthropometric data requires the comparison of the individual’s measurements to standards for the appropriate population. When ­anthropometrics are systematically collected in a population, it is possible to characterize the community’s overall nutritional status. Generally the data from children under 5 years of age reflect the status of the community. In disaster situations, such data help to determine the global nutritional needs for all the affected population and how resources should be efficiently allocated.

Anthropometric indexes

Box 3 shows the anthropometric indexes most commonly used in the assessment of children.

Weight-for-age index (W/A)

The W/A index represents the weight of a child in relation to his or her age. Consider the presence of dehydration and edema, which alter the weight when determining the index. A precision scale is required for weight measurement.

Weight-for-height index (W/H)

The W/H index represents the weight of a child in relation to the height. It reflects the current nutritional status of the child and is the index used to diagnose acute (wasting) or subacute malnutrition. It also requires a precision scale and a measuring board or tape, which are not usually readily available in disaster situations and even if available take considerable time to obtain. W/H is also affected by dehydration and edema.

Anthropometric methods provide information regarding the height, weight, and proportions of a person. These data are used, particularly in children, to assess the nutritional status of an individual.

Height-for-age (H/A) index

The H/A index represents the height of a child in relation to his or her age. This index basically reflects the nutritional history, since children with chronic malnutrition— whether primary or secondary to an underlying chronic disease—will experience stunted growth. Height, however, is also strongly determined by genetic factors as well as mothers nutritional status.

Mid-upper arm circumference (MUAC)

The MUAC gives a measure of the amount of fat and muscle in the upper arm. It is measured with a standard tape on the left arm, midpoint between the shoulder and the tip of the elbow. It is used in children 6 months to 5 years of age to screen large numbers of children for malnutrition. For children from 10-18 years of age, MUAC is an unreliable method to identify malnutrition. For adults above 18 years of age, an MUAC cut off of less than 185 mm indicates severe acute malnutrition.

Body mass index (BMI)

BMI is the weight in kilograms divided by the height in meters, squared (weight in kg/[height in m]2). BMI reference tables are now available to be used in children and adolescents from 2 to 20 years old. As an index, BMI does not reflect small changes in weight that may be clinically relevant, and it is also affected by dehydration and edema. Cut-off values for BMI percentiles in children and adolescents are as follows:

Percentiles

Percentiles are determined by the position of an individual’s measure in the reference values in terms of the percentage of values exceeded or equaled. In the reference population, the weight for a given height shows a normal distribution. The 50th percentile is the weight that divides the reference population into two equal parts: with 50% above and 50% below. As an example, if 25% of the reference population weighs less than the child being examined, the child is in the 25th percentile.

A review of how these anthropometric tools may be used to determine nutritional status of an individual is shown in Table 1.

TABLE 1. Assessment of nutritional status with anthropometric indexes

Reference tables

Regardless of the anthropometric parameter used, the measurements obtained are useful only if the standards with which they are compared truly reflect the population that is being evaluated. Many countries have developed their own growth tables and graphics reflecting the ­standard for their own population, but many regions have not been included. WHO recently published new growth reference charts developed with data gathered from Brazil, Ghana, India, Norway, Oman, and the United States. The children selected were exclusively breastfed, healthy, and had their basic needs met. There is solid evidence to suggest that all children up to age 5 years grow very similarly when their physiologic needs are adequately met, so these reference charts are valid for evaluating growth in children all over the world. More information can be found at http:/www.who.int/childgrowth/en/.