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
NO
Tm
utu
ally
exclu
siv
e
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