NUTRITION & MORTALITY

INDICATORS IN THE CADRE

HARMONISÉ

Olutayo Adeyemi

OUTLINE

Brief Introduction

Measurement of nutrition basics

Mortality basics

Nutrition and mortality indicators in Cadre

Harmonisé

INTRODUCTION

The Cadre Harmonisé analytical framework

relies on the conceptual frameworks for:

Food security

Nutrition

Sustainable livelihoods

Danger, hazards and vulnerability

NUTRITION FRAMEWORK

NUTRITION BASICS: FORMS OF MALNUTRITION

Malnutrition

Overnutrition

Overweight & obesity

(High body mass index)

Undernutrition

Anthropometric deficits

Stunting

(Low height-for-age)

Wasting

(Low weight-for-height)

Underweight

(Low weight-for-age or low body mass index)

Micronutrient deficiencies

Indicative of CHRONIC

UNDERNUTRITION

Indicative of ACUTE

MALNUTRITION

Composite indicator

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UNDERNUTRITION BASICS

Acute malnutrition

Short term or sudden onset undernutrition, characterized by weight loss (wasting) and/or or bilateral oedema

Results from significant restrictions in dietary intake and/or presence of infections

Reduces resistance to disease and impairs a range of bodily functions

In the early stages can be reversed through adequate food and health care

Can be moderate or severe

Both moderate and severe acute malnutrition are associated with an increased risk of mortality

ACUTE MALNUTRITION

UNDERNUTRITION BASICS

Chronic malnutrition (stunting)

Slow, cumulative process that develops over the long-term

as a result of inadequate dietary intake or repeated

infections, or both

Does not necessarily mean that current dietary intake or

health is inadequate – the growth failure may have

occurred at some time in the past

May be irreversible by two years of age

Strongly associated with poverty, poor health, impaired

physical and mental development and performance

CHRONIC MALNUTRITION

MEASURING MALNUTRITION OUTCOMES:

ANTHROPOMETRY

Most common method of measuring nutritional status

Includes measurement of:

Weight

Height

Mid Upper Arm Circumference

Measurements are compared with reference standards to

provide information about nutritional status

Reference standards are values that reflect the normal range

for a particular parameter in a healthy population

Reference standards are often age-specific, thus

anthropometric measurements often require accurate

knowledge of age

MEASURING MALNUTRITION OUTCOMES:

ANTHROPOMETRY

1. Measuring weight

2. Measuring Height and length

3. MUAC measurement

MEASURING MALNUTRITION OUTCOMES:

ANTHROPOMETRY

Uses

standardized

methods

Requires skill

and practice

for precision

and accuracy

Measurement

of age also

requires skill

and practice

USING ANTHROPOMETRIC MEASUREMENTS

Acute malnutrition (wasting)

Weight-for-height/length z-scores

MUAC measurements compared to standard

thresholds

Oedema**

Chronic malnutrition (stunting)

Height/length-for-age z-scores

Malnutrition in adults

Body Mass Index (BMI)

WEIGHT-FOR-HEIGHT Z-SCORE

WHZ measures wasting of the entire body

WHZ compares the weight and height of each child to weight and height standards

published by the WHO in 2006

The standards are age and sex specific

WHZ scores are calculated for each child based on the comparison

It is calculated by 𝑧 =𝑥−𝜇

𝜎where x is each child’s measurement, μ is the population average, and σ is the standard deviation

MID UPPER ARM CIRCUMFERENCE

MUAC measures

wasting of the mid

upper arm

The MUAC is

compared to standard

reference cut-offs

The cut-offs are not

age or sex specific

OEDEMA

Not an anthropometric

measurement

A clinical assessment of

signs

Indicator of acute

malnutrition

Used with

anthropometric

measurements to

diagnose acute

malnutrition

CLASSIFICATION OF ACUTE MALNUTRITION

(USED ONLY IN CHILDREN 6 TO 59 MONTHS OLD)

Global Acute Malnutrition (GAM)

Indices

Moderate Acute

Malnutrition

(MAM

Severe Acute

Malnutrition

(SAM)

Weight-for-height

z-score (WHZ)

WHZ between –2 and

–3 SD Less than –3 SD

MUACMUAC between 11.5

cm and 12.5 cmLess than 11.5 cm

Oedema Bilateral

WEIGHT-FOR-HEIGHT Z-SCORE

MUAC

Red <11.5 cm

Severe Acute

Malnutrition

Yellow

11.5 to 12.4 cm

Acute Moderate

Malnutrition

Green

>12.5 cm

Normal

BODY MASS INDEX (BMI)

Suitable for assessing the nutritional status of

adults, except pregnancy and lactating women

Calculated by 𝑊𝑒𝑖𝑔ℎ𝑡 (𝑘𝑔)

𝐻𝑒𝑖𝑔ℎ𝑡 𝑚 × 𝐻𝑒𝑖𝑔ℎ𝑡 (𝑚)

Cut-offs

Underweight = BMI <18.5 kg/m2

Normal weight = BMI between 18.5 kg/m2 and 24.9kg/m2

Overweight = BMI between 25.0kg/m2 and 29.9 kg/m2

Obese = BMI ≥30.0 kg/m2

EXERCISE

Use the WHO reference table given to classify the

following children as having moderate acute

malnutrition, severe acute malnutrition or no

malnutrition

A girl aged 6 months with height of 61 cm and weight

of 4.8kg

A girl aged 10 months with height of 68.5 cm and

weight of 7 kg

A girl of 15 months with height of 74.5 cm and weight

of 6.9 kg

MORTALITY BASICS

Mortality means death, and it describes death or

death related issues

Because death results from so many health

problems, it can provide an overall indicators of

the general health status of a population

It can also provide information on nutritional

status because widespread malnutrition among

children or adults almost always results in an

elevation of the mortality rate, especially if the

level of communicable diseases is also high

MEASURING MORTALITY

Example: If you hear that there have been 139 deaths in a certain population, what exactly does this mean….? What does this tell you about the death rate?

Calculating the mortality rate is more than just counting or recording deaths. Four parameters are taken into account:

The time period during which the deaths occurred;

The number of deaths (the numerator of the mortality rate);

The size of the population at risk from which the deaths came (the denominator of the mortality rate);

A constant: the result of the fraction is multiplied with factor of 10 so as the rate can be expressed as whole number(1000, etc.)

KEY MORTALITY INDICATORS

Crude Death Rate (CDR)

The mortality rate for all causes in a population

Reported as number of deaths per 10,000 people per day

Most commonly measured in surveys conducted in emergency settings (e.g. SMART surveys)

Under-five Death Rate (U5DR)

Rate of mortality in the population of children under five years of age

Reported as number of deaths among children under 5 per 10,000 children under 5 per day

Under-five mortality rate (U5MR)

Probability per 1,000 that a newborn will die before 5 years of age

Commonly measured in censuses, DHS surveys etc.

CALCULATION OF CRUDE DEATH RATE

𝐶𝐷𝑅 =𝑁𝑢𝑚𝑏𝑒𝑟 𝑜𝑓 𝑑𝑒𝑎𝑡ℎ𝑠

𝑇𝑜𝑡𝑎𝑙 𝑝𝑜𝑝𝑢𝑙𝑎𝑡𝑖𝑜𝑛𝑎

10,000∗𝑇𝑖𝑚𝑒 𝑖𝑛𝑡𝑒𝑟𝑣𝑎𝑙

= Deaths/10,000 people/day

aPopulation present at the midpoint of the time

interval

Time interval: length of time (in days) which

respondents are asked to state if any deaths have

occurred (i.e. the “recall period”)

EXAMPLE

Survey team implemented the survey in 1000 households

The sum of the total population across all 1000 households was 4890 people

51 deaths were recorded

Recall period was from February 1, 2013 – April 5, 2013 (64 days)

𝐶𝐷𝑅 =51

4890

10,000∗64

CDR = 51/31.296

CDR = 1.63/10,000/day

CALCULATION OF UNDER 5 DEATH RATE

U5𝐷𝑅 =𝑁𝑢𝑚𝑏𝑒𝑟 𝑜𝑓 𝑑𝑒𝑎𝑡ℎ𝑠 𝑜𝑓 𝑐ℎ𝑖𝑙𝑑𝑟𝑒𝑛 0 −5 𝑦𝑒𝑎𝑟𝑠 𝑜𝑙𝑑

𝑃𝑜𝑝𝑢𝑙𝑎𝑡𝑖𝑜𝑛 𝑜𝑓 𝑐ℎ𝑖𝑙𝑑𝑟𝑒𝑛 0 −5 𝑦𝑒𝑎𝑟𝑠 𝑜𝑙𝑑

10,000∗𝑇𝑖𝑚𝑒 𝑖𝑛𝑡𝑒𝑟𝑣𝑎𝑙

NUTRITION AND MORTALITY IN CADRE

HARMONISÉ

Nutritional status and mortality are two of four

outcome indicators in the Cadre Harmonisé (CH)

Like the other outcomes, the indicators used to

analyze the nutritional status and mortality

situation are categorized into two:

Direct evidence: Measures directly and accurately the

status of the outcome indicators

Indirect evidence: Does not measure the outcome

indicators directly but provides indicative evidence

that can be used to infer the outcomes

NUTRITION OUTCOME INDICATORS

Direct Evidence:

Global Acute Malnutrition (GAM) using WHZ in

children 6 to 59 months old

Body Mass Index for the population

Indirect evidence:

Mid Upper Arm Circumference (MUAC) in children 6

to 59 months old

NUTRITION OUTCOME INDICATORS

CLASSIFICATION SCALE USED FOR PHASING

MORTALITY OUTCOME INDICATORS

Direct Evidence:

Crude Death Rate

Under Five Death Rate

Indirect evidence:

Infant Mortality Rate: The mortality rate for children under 1 year of age

Neonatal Mortality Rate: The mortality rate for children under 1 month of age

Case Fatality Rate (malaria, measles, diarrhoea, acute respiratory infections): Proportion of reported cases of a specified disease or condition that die within a specified time

Under Five Death Probability

Severe Acute Malnutrition

BMI in adults

MORTALITY CLASSIFICATION SCALE USED

FOR PHASING

SOURCES OF NUTRITION AND MORTALITY

DATA

SMART Surveys

Other representative surveys

GAM data from sentinel sites

GAM data from recent screening

CURRENT ANALYSIS MARCH (MARCH – APRIL – MAY)

Use the median of the GAM of the

times series (historical data) for

the phasing of the nutrition

outcome indicator

Use the GAM values (WHZ) or

GAM (MUAC) for the phasing of

the result nutrition outcome

indicator

Times series (historical data) of the

GAM indicator coming form

nutrition surveys conducted in lean

season (April-September).

GAM (WHZ) or MUAC data

coming from sentinel sites or

recent screening (January-

February-March).

We cannot use nutrition indicator

Is there any recent representative

survey (January-February-March)

Use the GAM and/or BMI values

as direct evidence or MUAC as

indirect evidence for the phasing

of the nutrition outcome indicator

PROJECTED SITUATION ANALYSIS

(JUNE-JULY-AUGUST)

Use the median of the

GAM of the times series

(historical data) for the

phasing of the nutrition

outcome indicator

Times series (historical data) of

GAM coming from survey

conducted in the period of (April-

September)?

We cannot use nutrition indicator

Yes

NO