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      Assessment of Under Nutrition of Bangladeshi Adults Using Anthropometry: Can Body Mass Index Be Replaced by Mid-Upper-Arm-Circumference?

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          Background and Objective

          Body-mass-index (BMI) is widely accepted as an indicator of nutritional status in adults. Mid-upper-arm-circumference (MUAC) is another anthropometric-measure used primarily among children. The present study attempted to evaluate the use of MUAC as a simpler alternative to BMI cut-off <18.5 to detect adult undernutrition, and thus to suggest a suitable cut-off value.


          A cross-sectional study in 650 adult attendants of the patients of Dhaka-Hospital, of the International Centre for Diarrheal Disease Research, Bangladesh (icddr,b) was conducted during 2012. Height, weight and MUAC of 260 male and 390 female aged 19–60 years were measured. Curve estimation was done to assess the linearity and correlation of BMI and MUAC. Sensitivity and specificity of MUAC against BMI<18.5 was determined. Separate Receiver-operating-characteristic (ROC) analyses were performed for male and female. Area under ROC curve and Youden's index were generated to aid selection of the most suitable cut-off value of MUAC for undernutrition. A value with highest Youden's index was chosen for cut-off.


          Our data shows strong significant positive correlation (linear) between MUAC and BMI, for males r = 0.81, (p<0.001) and for females r = 0.828, (p<0.001). MUAC cut-off <25.1 cm in males (AUC 0.930) and <23.9 cm in females (AUC 0.930) were chosen separately based on highest corresponding Youden's index. These values best correspond with BMI cut-off for under nutrition (BMI <18.5) in either gender.


          MUAC correlates closely with BMI. For the simplicity and easy to remember MUAC <25 cm for male and <24 cm for female may be considered as a simpler alternative to BMI cut-off <18.5 to detect adult undernutrition.

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          Most cited references 25

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          Use and interpretation of anthropometric indicators of nutritional status. WHO Working Group.

          Studies carried out during the last decade have led to a better understanding of the value of anthropometric indicators of nutritional status. The present report concentrates on data concerning 0-5-year-old children and examines the indices of weight and height and the biological significance of "wasting" and "stunting". The need for a reference population as well as for a standard or target is recognized and the advantages and disadvantages of local versus international reference populations are discussed. In the analysis of data, preference is given to the use of standard deviation (SD) scores and to the presentation of whole distributions. Cut-offs, for example -2SD, are needed for comparison of prevalences and for screening of populations. Sequential or serial measurements and the increasing use of growth velocities are discussed and their uses and difficulties are outlined.
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            A comparison of mid upper arm circumference, body mass index and weight loss as indices of undernutrition in acutely hospitalized patients.

            A nutritional supplementation trial (Vlaming et al., Clin Nutr 2001; 20: 517) enabled us to assess the nutrition of 1561 patients on emergency admission to hospital. Patients acutely admitted to the 15 relevant medical, surgical and orthopaedic wards were identified. Mid upper arm circumference (MUAC) measurements were obtained in 95% (848 m, 635f) patients. For clinical reasons, Body mass index (BMI) was assessable in only 44% patients (408 m, 285f). Data on three month weight loss were obtainable in 509 patients. These measurements combined to demonstrate that 18.3% of patients were undernourished (At least one of : BMI or =10%). There was a close relationship between BMI and MUAC. Regression equations (excluding age)were for men : BMI=1.01 x MUAC-4.7, (R(2)=0.76), and for women BMI=1.10 x MUAC-6.7, (R(2)=0.76). After adjustment for age, weight loss > or =10% was the most significant of the three as a predictor of mortality. Among patients in whom weight loss was not recorded MUAC was a significant predictor of mortality either alone (P=0.002) or after adjustment for BMI (P=0.007), but BMI was not significant. All three measures, even when adjusted for age and sex, were poor predictors of hospital stay although MUAC was significant in the larger group with a MUAC measure (R(2)=0.7% P<0.001). MUAC correlates closely with BMI, is easier to measure and predicts poor outcome better.
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              The value of arm circumference measurements in assessing chronic energy deficiency in Third World adults.

              To assess the usefulness of mid-upper arm circumference (MUAC) as a substitute for body mass index (BMI: kg/m2) or an additional measure of adult nutritional state. Variously sampled adults aged 18-60 years from selected regions of five African countries, India, China and Papua New Guinea were measured. 2421 men and 3248 women were measured for their heights, weights and MUAC. Of these, 1569 men and 1905 women also had their triceps skinfold thickness measured, thus allowing additional estimates of muscle area circumferences and fat areas in the arm. MUAC and BMI were highly correlated in each national group; each group's MUAC differed from the overall mean MUAC at any BMI value by 18.5; intermediate grades of BMI were poorly specified by MUAC values. MUAC values of 23.0 cm in men and 22.0 cm in women are useful cut-off points for simple screening of nutritional state. In combination with BMI it may provide a more refined classification of CED. This new combined classification scheme may be a better means of discriminating the at-risk underweight adults from those who are thin but not at risk.

                Author and article information

                Role: Academic Editor
                PLoS One
                PLoS ONE
                PLoS ONE
                Public Library of Science (San Francisco, CA USA )
                14 April 2015
                : 10
                : 4
                [1 ]Center for Nutrition and Food Security, International Centre for Diarrheal Disease Research, Bangladesh (icddr,b), Mohakhali, Dhaka 1212, Bangladesh
                [2 ]Department of Epidemiology and Preventive Medicine; Faculty of Medicine Nursing and Health Science, Monash University, The Alfred, 99 commercial road, Melbourne 3004, Australia
                [3 ]Dhaka Hospital, icddr,b, Mohakhali, Dhaka 1212, Bangladesh
                Vanderbilt University, UNITED STATES
                Author notes

                Competing Interests: The authors have declared that no competing interests exist.

                Conceived and designed the experiments: TS MNK MIH. Performed the experiments: TS MNK MIH. Analyzed the data: TS MNK MIH. Contributed reagents/materials/analysis tools: TS MNK MIH. Wrote the paper: TS MNK TA MIH.


                This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited

                Page count
                Figures: 2, Tables: 4, Pages: 8
                This research study was funded by core donors who provide unrestricted support to icddr,b for its operations and research. Current donors providing unrestricted support include: Australian Agency for International Development (AusAID), Government of the People’s Republic of Bangladesh; Canadian International Development Agency (CIDA), Swedish International Development Cooperation Agency (Sida), and the Department for International Development, UK (DFID). The authors gratefully acknowledge these donors for their support and commitment to icddr,b's research efforts. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.
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                The data is available from Dryad (doi: 10.5061/dryad.14fc6).



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