Research Article Analysis and Interpretation 2-3 page double-spaced paper answering short questions, requirements in Assignment #1. RESEARCH Research and P

Research Article Analysis and Interpretation 2-3 page double-spaced paper answering short questions, requirements in Assignment #1. RESEARCH
Research and Professional Briefs
Prevalence of Malnutrition in Human
Immunodeficiency Virus/Acquired Immunodeficiency
Syndrome Orphans in the Nyanza Province of
Kenya: A Comparison of Conventional Indexes with
a Composite Index of Anthropometric Failure
MICHELLE R. BERGER, MS, RD; CADE FIELDS-GARDNER, MS, RD; ASHWINI WAGLE, MS, RD; CLARIE B. HOLLENBECK, PhD
ABSTRACT
The prevalence of undernutrition in children is commonly
reported using a conventional index, which identifies
three conventional categories: stunting, underweight,
and wasting. Recently, a composite index of anthropometric failure was developed to categorize undernutrition
into seven mutually exclusive categories, including single
failures (stunting, underweight, or wasting) and multiple
failures (stunting and underweight, stunting and wasting, underweight and wasting, and stunting and underweight and wasting). This cross-sectional study used
baseline data gathered during a feeding program targeting orphans and vulnerable children impacted by human
immunodeficiency virus and/or acquired immunodeficiency syndrome (HIV/AIDS) in Kenya to compare the
conventional index with the composite index of anthropometric failure. Children younger than 5 years of age who
participated in the feeding trial were included in the
analysis (n⫽170). The conventional index found that the
prevalence of undernutrition included 31.2% stunted,
14.1% underweight, and 5.9% wasted children, whereas
the composite index of anthropometric failure estimated
M. R. Berger is a registered dietitian with the Sacramento County Department of Health and Human Services, Sacramento, CA; at the time of the study, she was
a graduate student, Department of Nutrition and Food
Science, San Jose State University, San Jose, CA. A.
Wagle is an assistant professor and C. B. Hollenbeck is
a professor and graduate research coordinator, Department of Nutrition and Food Science, San Jose State
University, San Jose, CA. C. Fields-Gardner is program
director, The Cutting Edge, Cary, IL.
Address correspondence to: Michelle R. Berger, MS, RD,
Department of Nutrition and Food Science, One Washington Square, Central Classroom Bldg 200, San Jose State
University, San Jose, CA 95192. E-mail: shellrose11@
gmail.com
Manuscript accepted: August 22, 2007.
Copyright © 2008 by the American Dietetic
Association.
0002-8223/08/10806-0012$34.00/0
doi: 10.1016/j.jada.2008.03.008
1014
Journal of the AMERICAN DIETETIC ASSOCIATION
a more severe overall prevalence rate (38.2%); thus, the
conventional index did not uncover the complexity of malnutrition experienced. Of the 53 children classified as
stunted by the conventional index, the composite index of
anthropometric failure identified 36 (67.9%) as stunted
and 17 (32.1%) as stunted and underweight. Thus, the
composite index of anthropometric failure was able to
distinguish children with multiple anthropometric failures. In total, multiple anthropometric failures were
found in 22 of the 65 children with anthropometric failure. These data suggest that the complexity and prevalence of undernutrition may be underestimated using the
conventional index because it does not identify children
experiencing multiple anthropometric failures. The ability of the composite index of anthropometric failure to
identify children with multiple anthropometric failures
may have profound implications for prioritizing, designing, and targeting nutritional interventions.
J Am Diet Assoc. 2008;108:1014-1017.
T
hroughout the world malnutrition is a primary contributing factor to childhood morbidity and premature
mortality (1). The complexity of malnutrition transcends health issues, impacting children’s growth and development, productivity, poverty, and overall quality of life
for millions of people. Good nutrition is the foundation for
reducing childhood morbidity and premature mortality.
Since the 1970s, the World Health Organization (WHO) has
examined ways to assess nutritional status and determine
the prevalence of malnutrition in populations using anthropometric measurements (2). The estimated prevalence of
malnutrition in a population often determines the design
and timing of nutrition programming aimed at combating
childhood malnutrition (2). Accurate prevalence data and
an understanding of the relative risk for single and multiple
anthropometric failures could improve the targeting and
design of successful programming.
Currently, the conventional index is accepted and used as
a tool to describe the nutritional status of a population. The
prevalence of malnutrition in children is commonly reported
using this index, which identifies three conventional categories: stunting, underweight, and wasting (3). Although
this method allows for a differentiation into the general
categories of malnutrition, it does not provide the opportu-
© 2008 by the American Dietetic Association
Table. Prevalence of undernutrition in children age 5 years and
younger (n⫽170) using the conventional index and the composite
index of anthropometric failure
Index
Frequency
Conventional Index
No failure
105
Stunted
53
Underweight
24
Wasted
10
Total prevalence of
anthropometric failure
Undeterminablea
Composite Index of
Anthropometric Failure
Categories
A No failure
105
B Wasted only
5
C Wasted and underweight
5
D Wasted, stunted, and
underweight
0
E Stunted and underweight 17
F Stunted only
36
Y Underweight only
2
Total Prevalence of
Anthropometric Failure
65
% of population
61.8
31.2
14.1
5.9
Undeterminablea
61.8
2.9
2.9
0
10.0
21.2
1.2
38.2
a
The conventional index categories, by definition, are not mutually exclusive and the
total percentage prevalence will not equal 100%. Therefore, the total prevalence of
anthropometric failure in a population cannot be determined.
nity to determine the overall prevalence of malnutrition or
the risk for adverse health and survival outcomes that are
associated with multiple failures. Developmental economist
Peter Svedberg proposed that the conventional index
method, which attempts to measure the prevalence of malnutrition in children, is not sufficient (4). Svedberg argued
that the number of malnourished children is underestimated due to the overlap found in children who fall into
multiple categories of anthropometric failure (eg, children
who are both stunted and underweight) (4). The conventional index cannot determine the overall prevalence of
malnutrition in a population because it requires its users to
“choose” one category of anthropometric failure to represent
the nutritional status of the targeted population.
The composite index of anthropometric failure method
was developed to address the need to determine multiple
failures and report accurate prevalence data. The composite index of anthropometric failure uses mutually exclusive categories to determine overall prevalence of anthropometric failure. This method can identify children
who experience single and multiple anthropometric failures and better describe the complexity of undernutrition. In 2005 researchers from India tested an alternate
scheme to categorize undernutrition in children into
seven mutually exclusive categories, including single failures (stunting, underweight, or wasting) and multiple
failures (stunting plus underweight, stunting plus wasting, underweight plus wasting, and stunting plus underweight plus wasting) through the use of a composite index
of anthropometric failure (5). The Table illustrates both
methods of categorizing anthropometric failure.
The three objectives of this study were to compare the
conventional index method of describing anthropometric
failure to the composite index of anthropometric failure
method, to determine the overall prevalence of undernutrition in this population, and to explore and suggest the
potential impact that indexes of anthropometric failure
may have on nutrition-related programming and reported outcomes. It is hypothesized that a composite index of anthropometric failure— due to its ability to categorize children with multiple anthropometric failure who
may be at increased risk for poor health and survival
outcomes—will better describe the prevalence of anthropometric failure and improve the reporting of outcomes
for nutrition-related programming.
METHODS
Study Setting and Sites
The project used existing data from a large feeding trial
implemented by community-based organization partners
of Catholic Relief Services-Kenya targeting orphans with
a program funded to support orphans and vulnerable
children impacted by human immunodeficiency virus
and/or acquired immunodeficiency syndrome (HIV/
AIDS). The feeding trial was conducted at four sites in
the Nyanza Province of Kenya, including one site in Kisii,
one in Kisumu, and two in Homa Bay. The Institutional
Review Board from San Jose State University approved
the study protocol and the use of existing anonymous
human subject data.
Study Design
This cross-sectional study included data on all children
younger than age 5 years gathered as part of the feeding
trial. By definition, the targeted population included orphans who were orphaned because one or both of their
parents died with HIV infection. The disease status of the
targeted population was not released for this study but
likely included children with and without HIV/AIDS.
Trained health educators and program directors of the
feeding trial measured height, weight, and surveyed disease symptoms. Weights were measured using a standard hospital electronic scale (Seca Onda 843 Digital
Scale, Seca Corporation, Columbia, MD). Height was
measured using a standard calibrated stadiometer (Seca
222 Mechanical Telescopic Measuring Rod, Seca Corporation, Columbia, MD) and a length mat for infants (Seca
210 Mobile Measuring Mat for Babies and Toddlers, Columbia, MD). For all measurements, children wore light
clothing, but no shoes. Caretakers of the children were
asked to report sex, date of birth, and age information to
the health educators. The data represent baseline data
collected before the feeding intervention trial and therefore are not influenced by the feeding intervention.
Statistical Analysis
Descriptive statistics including age, calculated as
mean⫾standard deviation, were determined. Z scores
(and standard deviations from the mean in a reference
population) for the specific categories of anthropometric
failure were calculated using the recently released draft
June 2008 ● Journal of the AMERICAN DIETETIC ASSOCIATION
1015
Indexes
Description
Type of Indicator
Conventional Index
Stunting
Low height-for-age
Wasting
Low weight-for-height
Underweight
Low weight-for-age
Indicator of chronic undernutrition, prolonged food
deprivation, and/or disease.
Indicator of acute undernutrition, more recent food
deprivation.
Indicates both acute/chronic undernutrition but
does not distinguish between them.
Composite Index of Anthropometric Failure Categoriesa
A No failure
Adequate height and weight (⬎⫺2 z score)
B Wasting only
Low weight-for-height
C
Wasting and underweight
Low weight-for-age and low weight-for-height
D
Wasting, stunting, and
underweight
E Stunting and underweight
F Stunting only
Low weight-for-age, low weight-for-height,
and low height-for-age
Low height-for-age, low weight-for-age
Low height-for-age
Y Underweight only
Low weight-for-age
Children in acceptable range for height and weight.
Indicator of acute undernutrition, more recent food
deprivation.
Multiple failures indicating both acute and chronic
undernutrition.
Multiple failures indicating both acute and chronic
undernutrition.
Multiple failures indicating chronic undernutrition.
Indicator of chronic undernutrition, prolonged food
deprivation, and/or disease.
Indicates chronic undernutrition.
Figure. Description of the conventional index and the composite index of anthropometric failure. aThe composite index of anthropometric failure category
“stunting and wasting” does not exist because it is not physically possible to be both stunted and wasted and not be underweight (reference 1).
of the WHO Anthro 2005 PC software (beta version, 2006,
World Health Organization, Geneva, Switzerland) to categorize children into both the conventional index and
composite index of anthropometric failure schemes for
comparison. A description of the conventional and composite index categories is shown in the Figure.
RESULTS AND DISCUSSION
Existing anonymous data were provided on 173 children
younger than age 5 years. Three children were excluded
in the analysis due to missing age, height, and/or weight
data. Records for 170 children, including 93 (54.7%) girls
and 77 (45.3%) boys, were evaluated.
Evaluation of undernutrition using the conventional
index and composite index of anthropometric failure
methods are shown in the Table. Using the conventional
index, the data suggest that 31.2% were stunted, 14.1%
were underweight, and 5.9% were wasted. Because these
categories are not mutually exclusive, the total prevalence of undernutrition could not be determined; therefore, the highest prevalence of undernutrition for the
population would be 32.1% (stunted). Conversely, because the composite index of anthropometric failure provides mutually exclusive categories, it allows the determination of total prevalence of undernutrition. The total
prevalence of undernutrition in this population using the
composite index of anthropometric failure can be estimated to be much higher (38.2%).
In addition, the composite index of anthropometric failure method was able to distinguish children with multiple anthropometric failures and who may be at risk for
poor health and survival outcomes. For example, of the 53
children identified as stunted by the conventional index,
the composite index of anthropometric failure indicated
that 36 of the 53 (67.9%) were stunted alone, whereas 17
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June 2008 Volume 108 Number 6
(32.1%) were both stunted and underweight. Overall,
multiple anthropometric failures were shown in one third
(22 of 65) of the children with anthropometric failure.
This includes 2.9% who were wasted and underweight
(Category B, see Figure for category definitions) and
10.0% who were stunted and underweight (Category E).
These data suggest that the complexity as well as the
prevalence of undernutrition may be underestimated using conventional index classifications, especially for children who experience multiple anthropometric failures.
The composite index of anthropometric failure more accurately identifies the prevalence of all types of malnutrition for children 0 to 5 years of age. Programming for food
and nutrition assistance in limited-resource settings may be
best served by the composite index of anthropometric failure method because it identifies children who are at highest
risk for adverse health and survival outcomes through types
and overlap of anthropometric failures. In addition, the
composite index of anthropometric failure may better determine if the prevalence of higher risk malnutrition warrants
therapeutic feeding programs that target malnourished individuals or blanketed feeding interventions that provide
rations in geographical areas or populations with a higher
prevalence of malnutrition (5). In a previous study of children in India by Nandy and colleagues in 2005 (5), children
categorized with all three anthropometric failures (composite index of anthropometric failure category D: stunting,
wasting, and underweight) were also more likely to have
symptoms of diarrheal diseases and upper respiratory infections. This relationship highlights the importance of
identifying those most at risk for poor health outcomes and
therefore most in need of nutrition assistance. In the
present population, multiple anthropometric failures that
include higher-risk weight-related failure (composite index
of anthropometric failure categories C, D, and E) suggest
that 22 of 170 (12.9%) may require urgent intervention to
prevent adverse outcomes; the conventional index does not
differentiate this more severe nutrition and health risk.
Thus, the composite index of anthropometric failure can
allow more specific targeting for urgent and aggressive nutrition and food programming.
The number of children in anthropometric failure influences the timing and type of feeding program to be implemented. According to WHO, this population would be categorized by the conventional index schematic as high
severity if represented by stunting (⬎30% stunted), medium severity for underweight (10% to 19% underweight),
and low to medium severity for wasting (ⱕ5%) (2). However,
if the total percentage of undernourished children by the
composite index of anthropometric failure method was used
this population would likely shift to high severity (⬎30%)
(2,6). Planning and response decisions also depend on the
percentage of malnutrition in a population.
The type of nutrition-related programming could also
be influenced by the use of the conventional index or
composite index of anthropometric failure methods. For
instance, 10% to 19% malnutrition rates trigger targeted
responses only to those most at risk, whereas more than
20% results in blanket feeding program assistance (2). In
this population, the total prevalence of undernutrition
determined by the composite index of anthropometric
failure would likely result in a blanketed feeding program. In contrast, the conventional index indicates the
need for a targeted response using the prevalence of underweight, no response using prevalence of wasting, and
blanket feeding using prevalence of stunting.
As with all studies, this research has some limitations.
First, the sample population used for analysis represented children younger than age 5 who were involved in
the feeding program intervention and may not be representative of the population at large. Although these children are impacted by HIV/AIDS, it is unknown if these
children have HIV/AIDS. As a result, as in most nutrition
studies using anthropometric data only, the presence of
nonsymptomatic disease cannot be ruled out, and the
nutritional status of this population may be compromised
when compared with a “healthy” population. Finally, as
in most rural research settings, birthdates are not always
known and therefore minor discrepancies may exist in
this population between a child’s actual and reported
birthdate and age. These differences, however, are believed to be small and would not be expected to change
the overall conclusion of the present study.
CONCLUSIONS
The present study highlights the value of using the composite index of anthropometric failure to determine the
prevalence of malnutrition in a population. Specifically,
the composite index of anthropometric failure categories
was able to account for the children with multiple anthropometric failures and determine the overall prevalence of
malnutrition in this population. This valuable tool may
have profound implications on prevalence reporting as
well as nutrition programming and outcomes. Reporting
of accurate prevalence data and targeting of highest risk
populations for appropriate interventions using the composite index of anthropometric failure may improve the
quality and outcomes of global nutrition efforts in the face
of varying funding and other cost constraints.
Future research should investigate the relationship between anthropometric failure and disease symptoms, such
as upper respiratory infections and diarrheal diseases. Follow-up research should compare the two methods of evaluating populations younger than 5 years of age to determine
the value in using the composite index of anthropometric
failure vs the conventional index for monitoring the impact
of interventions. Additional categories to include overnutrition counterparts in the schematic, such as obesity with or
without stunting, may be appropriate to fully evaluate prevalence of nutritional risk of all types and programming
outcomes targeted to…
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