Assessment of Health and Nutritional Status
Dr. Premananda BharatiProfessor & Head
Indian Statistical Institute203, B.T. Road, Kolkata 700 108
West Bengal, IndiaE-mail: [email protected]; [email protected]
What is health?
WHO (1971) defined “health” as “a complete physical, mental and social well being and not merely an absence of disease or infirmity”.
Nutrition What is nutrition? Nutrition is the process in which we consume food or
nourishing liquids, digest and absorb them and use them for health and growth.
What is nutrients? Nutrients are chemical elements and compounds found
in the environment that plants and animals need to grow and survive.
What are the different types of nutrient? (i) Energy-producing nutrients (also called energy-
yielding nutrients or macronutrients) like carbohydrates, fat and protein.
(ii) Micronutrients often refer to vitamins and minerals.
What is energy (calorie)?
1) Calorie is an energy measurement unit.
2) One calorie of heat energy is required to raise one gram of water by one degree Celsius.
3) 1,000 calories equal 1 kilocalorie (kcal), which is commonly used in measuring food energy.
4) Estimation of energy requirements for healthy individuals takes account of age, gender, body weight and activity patterns..
What is protein?
1) Proten is mainly used for growth and body repair.
2) When there is an insufficient intake of energy, protein would be broken down and used as body fuel, which may lead to protein-energy malnutrition.
3) One gram of protein provides 4 kcal.
What is carbohydrate?1) Carbohydrate is the major energy source in an average
diet, which is also the preferred fuel. 2) One gram of carbohydrate provides 4 kcal. 3) When adequate carbohydrate is provided in the diet,
protein would be spared for growth and repair. 4) Carbohydrate can be divided into three main types:
monosaccharides, disaccharides and complex carbohydrate (starches and dietary fibres).
What is fat?1) Fat is technically known as triglycerides, which is a
class of lipids. 2) Fat is a concentrated energy source, which provides 9
kcal for each gram of fat. 3) Fat carries fat-soluble vitamins (i.e. vitamin A,D,E and
K). 4) Fat prevents heat loss in extreme temperatures and
protects organs against shock.
5) Fat can be divided into saturated fat and unsaturated fat depending on their chemical structures.
6) Unsaturated fat can be further divided to mono- and poly-unsaturated fats.
7) Excess fat intake has been linked to major health problems, including an increased risk of heart disease, obesity, hypertension, diabetes and certain types of cancers.
Direct Indicators:-- Nutritional Anthropometry-- Clinical Assessment -- Bio-chemical Estimations
INDICATORS OF HEALTH AND NUTRITIONAL STATUS
Indirect Indicators:-- -- Dietary assessment -- Vital Statistics
In addition, Secondary Data: -- Socio-economic -- Socio-demographic -- Environmental
MEASUREMENTS - Using Anthropometric Instruments
REFERENCE VALUES / STANDARDS - National, International
INDICES - Computed; Age dependent / Independent
CLASSIFICATIONS
- Grading of Nutritional Status
NUTRITIONAL ANTHROPOMETRY
ANTHROPOMETRIC MEASUREMENTS
Anthropometry, which measures the dimensions and composition of the human body.
-Weight (kgs)
-Height (cms)
- Mid Upper Arm Circumference (cms)
-Waist Circumference (cms)
-Hip Circumference (cms)
- Fat fold thickness (mms) : at Triceps, Biceps, Supra-Iliac, Sub-scapular
Nutritional Anthropometry
Weight : - Total Body mass - Simple, widely used - Sensitive to small changes in nutrition
Height : - Genetically Determined - Environmentally influenced - Stunting Reflects chronic undernutrition
MUAC : - Reflects muscle/fat - Easy to measure, used for quick screening - Independent of age (1-5 years)
FFT: - Measures body fat - Correlates well with total body fat
Standard equipment: - Accuracy / Consistency,
Appropriate techniques: - Training & Standardization
Correct assessment of age:Reference values:
- For comparison and computation of indices
Classification:
- For grading nutritional status
REQUIREMENTS FOR NUTRITIONAL ANTHROPOMETRY
Reference Values
Anthropometric measurements obtained on statistically adequate number of individuals who are well nourished, living in an environment free from constraints of any sort and have capacity to reach maximum growth potential at each age group/Gender.
-- National Eg. ICMR, Well-to-do Hyderabad pre-school
children, IAP Standards
-- International Eg. NCHS, Harvard, MGRS, WHO, NHANES
CURRENT REFERENCE VALUES
National Center for Health Statistics(NCHS) 0- 18 years / By gender. (Hamill et. al. AJCN, 1979 - WHO/1983)
HARVARD (0-60 months / Gender pooled) (Jelliffe et. al. WHO Mono. 53 - 1966)
The National Health and Nutrition Examination Survey
(NHANES) 9-17 years/Gender Specific BMI Centiles. World Health Organization (1995)
WHO (0- 5 years and 5-18 years / By gender) (Official website of WHO, Child growth standards)
ANTHROPOMETRIC INDICES
Weight for age
Height for age
Weight for Height
Body Mass Index
NUTRITIONAL GRADING / CLASSIFICATIONS
Preschool Children:
GOMEZ CLASSIFICATION
WEIGHT FOR AGE (% of
NCHS Standards)NUTRITIONAL GRADE
90 Normal
75 – 89.9 Grade I (Mild Undernutrition)
60 – 74.9 Grade II (Moderate Undernutrition)
< 60 Grade III (Severe Undernutrition)
GOMEZ CLASSIFICATION
Gomez et. al. (J Trop Ped 1956)
Based on Prognosis of children admitted to Hospitals in Mexico - Significantly higher incidence of mortality among children with <60% of standard wt for age
- Significantly higher morbidity among children with 60-75% of standard weight for age
IAP CLASSIFICATION(Indian Academy of Paediatrics)
WEIGHT FOR AGE
(% of Harvard Standard)
NUTRITIONAL GRADE
80 Normal
70 – 89.9 Grade I (Mild Undernutrition)
60 – 69.9 Grade II (Moderate Undernutrition)
50 – 59.9 Grade III (Severe Undernutrition)
< 50 Grade IV (Severe Undernutrition)
STANDARD NORMAL DISTRIBUTION
-3.0 -2.0 -1.0 0.0 1.0 2.0 3.0
34% 34%14% 14%
2% 2%
SD Score
( 2SD = 96 %)
Normal
“Measuring Changes in Nutritional Status” (WHO, Geneva 1983).
STANDARD DEVIATION (SD) CLASSIFICATION
CUT-OFF LEVEL
NUTRITIONAL GRADE
WEIGHT FOR AGE
HEIGHT FOR AGE
WEIGHT FOR HEIGHT
Median – 2 SD Normal Normal Normal
Median – 3 SD to Median – 2 SD
Moderate Underweight
Moderate Stunting
Moderate
Wasting
< Median – 3 SDSevere
UnderweightSevere
StuntingSevere
Wasting
Nutritional gradation based on BMI (adult) Body Mass Index (BMI) = Weight in kg/ height in meter square
Nutritional gradation based on BMI (adult)
Classification Cut-off points (BMI = kg/m2)
CED grade III (Severe thinness) <16.00
CED grade II (Moderate thinness) 16.00-16.99
CED grade I (Mild thinness) 17.00-18.49
Normal 18.50-24.99
Overweight 25.00-29.99
Obese ≥ 30.00
Urgent need :
There is need to adopt the new WHO growth standards of 0-18 years Children by all.
The Growth charts in ICDS need to be modified using SD classification criteria.
The functionaries have to be trained and oriented to these changes.
The existing data need to be re-analysed using new reference values to enable comparisons.
There is urgent need to build new reference values (age, sex and population specific) for Indian children and adult.
Measuring calorie through diet survey Diet survey (i) One or seven days dietary survey is conducted in
each household. Each raw food item to be cooked for each meal is weighed in a Salter pan type balance prior to cooking. Household members not taking meal at home or guest(s) taking meal in the household are also recorded. Respondents are asked on the next day, whether any food had been left over or consumed by their livestock or shared with neighbour. If yes, the amounts are recorded. Approximate amounts (weight) of food items consumed by member(s) outside home during that day are also recorded.
(ii) 24 hours recall method is conducted in each member of the households through pre-tested structured questionnaire. For children specifically preschool, question should be asked to their mothers.
Nutrient consumption
(i) The nutritive values are estimated from the food composition tables like Indian Council of Medical Research (ICMR) (Gopalan et al., 2007). Calorie need of an individual is taken as the basis of estimation of consumption unit. Besides age and sex of the household members, the physiological status like stage of pregnancy or lactation of the woman of in the household is also taken into consideration.
(ii) Consumption of calories, protein and fat are classified on the basis of Recommendatory Dietary Allowances (RDA) of India (ICMR, 2004).
Consumption unit of household by age and sex in India
Individual Age (years)
Calories according to ICMR recommended allowances
Consumption unit1
Male 60 2875 2875/2875= 1
Male 25 2875 2875/2875= 1
Male 12 2190 2190/2875= 0.76
Female 55 2225 2225/2875= 0.77
Female 21 2225 2225/2875= 0.77
Female 18 2060 2060/2875= 0.72
Female 11 1970 1970/2875 =0.68
1Total household consumption unit = 5.70
Energy Requirements of Boys and Girls at Different Age Groups: A Comparison Between FAO and ICMR Estimates
Boys Girls
Age groups Body weigh
t
Daily energy requirements Body weigh
t
Daily energy requirements
FAO ICMR FAO ICMR
Kg. Kcal/d/kg
Kcal/d
Kcal/d Kg. Kcal/d/kg Kcal/d Kcal/d
(1) (2) (3) (4) (5) (6) (7) (8) (9)
0-5 months 5.4 93 502 583 5.4 92 497 583
6-11 months 8.6 80 688 843 8.6 79 679 843
1-3 years 12.2 82 1000 1240 12.2 79 964 1240
4-6 years 19.0 75 1425 1690 19.0 72 1368 1690
7-9 years 26.9 69 1856 1950 26.9 64 1722 1950
10-12 years 35.4 62 2195 2190 31.5 55 1733 1970
13-15 years 47.8 56 2697 2450 46.7 47 2195 2060
16-17 years 57.1 51 2912 2640 49.9 44 2160 2060
Daily Energy Requirements for Men and Women in India
Age group Lifestyle Men Women
Mean weigh
t
BMR Daily energy requirements
Mean weigh
t
BMR Daily energy requirements
FAO ICMR FAO ICMR
Kg. Kcal/d/kg
Kcal/d
Kcal/d/kg
Kcal/d Kg. Kcal/d/kg
Kcal/d
Kcal/d/kg
Kcal/d
(1) (2) (3) (4) (5) (6) (7) (8) (9) (10) (11) (12)
18-29.9 Sedentary 60 27 2479 41.3 - 50 25 1912 38.2 -
Moderate 60 2851 47.5 - 50 2200 44.0 -
Heavy 60 3645 60.7 - 50 2812 56.2 -
30-59.9 Sedentary 60 26 2387 39.8 - 50 25 1912 38.2 -
Moderate 60 2746 45.8 - 50 2200 44.0 -
Heavy 60 3510 58.5 - 50 2812 56.2 -
60 or more Sedentary 60 22 2020 33.7 - 50 22 1683 33.7 -
Moderate 60 2323 38.7 - 50 1912 38.2 -
Heavy 60 2970 49.5 - 50 2475 49.5 -
18 or more Sedentary 60 25.8 2367 39.4 2425 50 24.6 1882 37.6 1875
Moderate 60 2722 45.4 2875 50 2165 43.3 2225
Heavy 60 3480 58.0 3800 50 2768 55.4 2925
Health What is health?
I. WHO (1971) defined “health” as “a complete physical, mental and social well being and not merely an absence of disease or infirmity”.
II. The concept of health varies among different culture and geographical settings (Colson and Selby, 1974) and the cognition of the concept depends upon the value system of that particular society (Opler, 1963).
III. It is, therefore, important to measure health based on the facts relating to how it is defined (Mc Dowell et al., 2004)
Physical measure of health
a) Infant and child mortality
b) Nutritional status through anthropometric measurements:-
(a) children (b) adult
c) Haemoglobin status
d) Blood glucose status
e) Blood pressure
f) Morbidity pattern etc.
Nutritional status of preschool (0-60 months) and others children (5–19 years)
Three nutritional indices as weight for age z score (WAZ), height for age z score (HAZ), weight for height z score (WHZ) are calculated using World Health Organization (WHO) standard (WHO, 2006) for preschool children.
Similar indices are used along with Body Mass Index (BMI) percentile using National Center for Health Statistics (NCHS) (Frisancho, 1990) and also World Health Organization (WHO, 2000) for children aged 5-19 years.
Z- Scores <-2 SD of the above indices are considered as underweight (WAZ), stunting (HAZ) and wasting (WHZ). <5th percentile of BMI was considered as undernutrition. All the indices were internationally recommended (WHO, 1995).
How to calculate Z score Z-score is defined as the deviation of the value observed
for an individual from the median of the reference population, divided by the standard deviation (SD) of the reference population.
Z- score = (observed value) – (median of the reference population) SD of the reference population
LIKE Z- score = 8 kg in weight – 10 kg in weight 2 kg in weight = - 1 (normal)
Nutritional status among adult
(i) Body Mass Index (BMI) = Weight (kg)/ Height (m2)...…………... (James et al., 1988)
Nutritional gradation based on BMI (adult) The subjects are classified on the basis of chronic energy deficiency (CED) grades (James et al., 1988; WHO, 1995) as follows:
ClassificationCut-off points (BMI = kg/m2)
CED grade III (Severe thinness) <16.00
CED grade II (Moderate thinness) 16.00-16.99
CED grade I (Mild thinness) 17.00-18.49
Normal 18.50-24.99
Overweight 25.00-29.99
Obese ≥ 30.00
Anthropometric Classification BMI(kg/m2)
Principal cut-off points Additional cut-off points
Underweight <18.50 <18.50
Severe thinness <16.00 <16.00
Moderate thinness 16.00 - 16.99 16.00 - 16.99
Mild thinness 17.00 - 18.49 17.00 - 18.49
Normal range 18.50 - 24.9918.50 - 22.99
23.00 - 24.99
Overweight ≥25.00 ≥25.00
Pre-obese 25.00 - 29.9925.00 - 27.49
27.50 - 29.99
Obese ≥30.00 ≥30.00
Obese class I 30.00 - 34-9930.00 - 32.49
32.50 - 34.99
Obese class II 35.00 - 39.9935.00 - 37.49
37.50 - 39.99
Obese class III ≥40.00 ≥40.00
Source: Adapted from WHO, 1995, WHO, 2000 and WHO 2004
General consequences of undernutrition
Increase in morbidity and mortality Constant weight loss, muscular
hypercatabolism Psychological disorder like long depressive
syndromes Immune deficiency Digestive disorder Food-drug interactions and toxicity Consequences of micronutrient deficiencies
General consequences of overnutrition
Increase the risk of Atherosclerosis Increase risk of hypertension, diabetes,
stork, heart disease, and some form of cancer
High mortality rate Disturbance of endocrine function In females, it increases endometrial,
cervical, ovarian cancer
Haemoglobin
• Oxyhaemoglobin is estimated immediately after collection of blood samples using Sahli’s haemomter, following standard technique (WHO,
1968) Classification of haemoglobin (gm/dl) level (adult and adolescents)
The subjects were classified on the basis of different grades of haemoglobin (WHO, 1975) as follows:
Classification Cut-off points (gm/dl)
Male Female
Severe anaemia ≤ 7.00 ≤ 7.00
Moderate anaemia 7.01-10.00 7.01-10.00
Mild anaemia 10.01-12.99 10.01-11.99
Normal anaemia ≥13.00 ≥ 12.00
Haemoglobin level among adolescents is classified on the basis of international standard as normal (≥ 12.0 gm/dl) and anaemic (<12 gm/dl) (WHO, 1992).
Mean per capita consumption of calories, protein, and fats
Calories (kcl) Protein (gms) Fats (gms)
Year Round Rural Urban Rural Urban Rural Urban
1983 38 2,240 2,070 63.5 58.1 27.1 37.1
1987–8 43 2,233 2,095 63.2 58.6 28.3 39.3
1993–4 50 2,153 2,073 60.3 57.7 31.1 41.9
1999–0 55 2,148 2,155 59.1 58.4 36.0 49.6
2000–1 56 2,083 2,027 56.8 55.3 34.6 46.1
2001–2 57 2,018 1,982 54.8 54.2 33.6 46.1
2002(2) 58 2,025 2,014 55.4 54.9 34.7 47.0
2003 59 2,106 2,020 58.0 55.5 36.4 46.7
2004(1) 60 2,087 2,036 56.9 55.9 35.5 46.8
2004–5 61 2,047 2,021 55.8 55.4 35.4 47.4
Source: Authors’ calculations from NSS data. Nutrients are calculated, following the NSS practice, by multiplying reported quantities (purchased, grown, or received outside the market) by a set of nutrient conversion factors which are themselves revised from time to time.
(Deaton and Drèze, 2008)
Rural per capita calorie consumption, 1983 to 2004-5
(Deaton and Drèze, 2008)
Urban per capita fat consumption, 1983 to 2004-5
(Deaton and Drèze, 2008)
State Rural Urban
Calories per day
Percentage of norm (2400)
Calories per day
Percentage of norm (2400)
Andhra Pradesh 2424 101 2457 117
Assam 2258 94 1481 71
Bihar 2252 94 2605 124
Gujarat 2197 92 2069 99
Haryana 2311 96 1526 73
Himachal Pradesh 2714 113 2277 108
Karnataka 2304 96 2682 128
Kerala 1456 61 2004 95
Madhya Pradesh 2584 108 2360 112
Maharashtra 2326 97 2451 117
Orissa 2507 104 2720 130
Punjab 2266 94 2183 104
Rajasthan 3016 126 2561 122
Tamil Nadu 2215 92 2050 98
Uttar Pradesh 2266 94 2027 97
West Bengal 2633 110 2089 99
Potential calorie intake of poverty-line class in different states in India
(Sen, 2005)
State and zone wise percentage distribution of different types of nutritional status among the under six children of India by sex
Zones and States Boys Girls
N
Under weight
SeverelyAnemic
Under weight and
severely anemic N
Under weight
Severelyanemic
Under weight and
severelyanemic
North –East 4254 24.8 12.5 2.9 3957 15.7 12.2 2.0
Arunachal Pradesh 956 29.6 12.2 3.3 904 14.7 10.8 2.2
Assam 1152 27.4 12.4 2.8 1046 23.7 11.6 2.9
Manipur 1002 17.7 10.8 2.1 915 8.6 12.8 0.9
Meghalaya 87 41.4 9.2 2.3 83 39.8 14.5 3.6
Mizoram 311 22.2 9.3 1.9 336 9.8 6.5 0.9
Nagaland 195 17.4 5.6 1.0 178 18.5 6.2 1.1
Sikkim 375 20.8 22.1 4.8 315 10.2 22.2 2.5
Tripura 176 36.4 19.3 5.1 180 16.7 18.3 2.2
East 20993 51.1 19.8 11.3 20010 50.9 20.9 11.7
Bihar 8751 54.0 21.6 13.1 8127 55.5 24.1 15.3
Jharkhand 3635 55.5 18.8 12.3 3383 54.1 18.3 10.8
Orissa 5559 46.9 21.4 10.5 5648 45.0 21.4 9.9
West Bengal 3048 45.2 12.9 6.4 2852 45.6 13.7 6.5
Central 31656 57.9 20.1 13.0 29326 55.3 20.7 12.9
Madhya Pradesh 10482 58.2 17.4 10.7 9719 56.2 17.2 10.3
Chattisgarh 2845 50.5 25.2 13.5 2816 47.2 25.2 13.0
Uttar Pradesh 18329 59.5 20.9 14.2 16791 56.1 22.0 14.3
West 12109 51.0 31.4 16.9 10939 51.1 31.0 16.7
Goa 167 34.1 7.2 4.2 162 34.0 8.6 3.7
Gujarat 4804 51.0 36.4 20.1 4179 50.7 36.3 19.6
Daman & Diu 266 44.0 28.9 14.7 258 41.5 30.2 11.2
Dadra & Nagar Haveli 262 51.1 50.4 26.7 255 47.8 49.0 25.9
Maharashtra 6610 51.7 27.8 14.6 6085 52.4 27.3 14.9
North 22899 47.8 20.1 10.8 19365 42.8 20.7 10.3
Haryana 5629 37.8 24.2 10.2 4501 31.9 25.3 9.1
Himachal Pradesh 1288 40.0 16.5 7.9 1146 34.6 16.6 5.8
Jammu 767 22.4 3.4 0.4 738 20.7 4.6 0.9
Delhi 1244 35.5 17.8 6.8 1089 35.4 20.1 7.7
Punjab 3687 41.8 23.8 11.2 2939 36.2 22.9 10.0
Rajasthan 8330 59.5 19.1 12.8 7148 56.5 20.3 13.4
Chandigarh 58 44.8 29.3 15.5 72 26.4 29.2 6.9
Uttaranchal 1896 62.0 15.6 11.4 1732 45.6 16.0 9.5
South 12294 42.4 18.0 8.2 11719 37.2 17.9 7.4
Andhra Pradesh 2647 45.6 22.4 11.0 2469 38.0 22.0 9.7
Karnataka 2727 48.2 21.1 10.7 2609 43.8 19.3 9.7
Kerala 752 37.9 2.9 1.3 714 34.9 2.7 1.1
Tamil Nadu 5420 39.0 16.9 6.8 5209 34.3 17.7 6.3
Pondichery 478 39.2 14.4 5.6 718 33.6 14.8 5.6
Islands 421 33.3 18.0 2.9 425 28.2 10.4 3.5
Andaman & Nicobar 360 33.6 10.3 3.1 365 25.2 10.1 3.0
Lakshadwip 62 31.1 11.5 1.6 60 46.7 11.7 6.7
India 104626 50.3 20.8 11.6 95741 47.4 21.2 11.4
State and zone wise percentages of rural and urban CED and their differences and ranking
Percentages of Malnourished (BMI <18.50)
Rural UrbanRural and urban
difference Ranking of differences
North-east 22.5 17.3 5.20 1
Arunachal Pradesh 10.2 12.6
-2.40 2
Assam 28.1 18.4 9.70 10
Manipur 17.6 18.2 -0.60 3
Meghalaya 25.3 18.2 7.10 7.5
Mizoram 27.9 15.6 12.30 15
Nagaland 18.5 13.1 5.40 6
Sikkim 10.6 13.3 -2.70 1
Tripura 36.5 25.1 11.40 13.5
East 43.8 27.2 16.6 4
Bihar 39.0 31.4 7.60 9
Orissa 48.8 32.9 15.90 18
West Bengal 48.9 22.8 26.10 26
Central 38.1 25.5 12.6 2
Madhya Pradesh 38.4 27.0 11.40 13.5
Uttar Pradesh 37.8 23.3 14.50 17
West 44.8 22.5 22.30 6
Goa 29.6 22.5 7.10 7.5
Gujarat 46.7 22.7 24.00 24
Maharashtra 48.2 22.4 25.80 25
North 31.3 15.7 15.60 3
Haryana 30.4 13.4 17.00 21
Himachal Pradesh 30.2 16.7
13.50 16
Jammu 29.5 12.8 16.70 19
New Delhi 13.2 12.1 1.10 4
Punjab 20.3 9.10 11.20 12
Rajasthan 37.6 27.1 10.50 11
South 36.8 18.8 18.00 5
Andhra Pradesh 42.4 19.8 22.60 22
Karnataka 46.1 23.3 22.80 23
Kerala 19.5 14.4 5.10 5
Tamil Nadu 33.7 16.8 16.90 20
India 36.0 20.4 15.6(Bharati et al., 2008)
Conclusion Economic condition
Nutrient consumption
Health and Nutritional status
Inequalities
Health condition
However, this inter-relationship is varied population-wise along with their residential status.
(Ompad et al., 2007)
