Nutritional status and mortality: a prospective validation of the QUAC stick

An Accidental Nutritionist

My career as an accidental nutritionist began with my immersion in cholera control, a cyclone disaster, a smallpox epidemic, and formal training in ophthalmology and epidemiology. Interest in blindness prevention inexplicably led me to (re)pioneer the effects, treatment, and prevention of vitamin A deficiency, while faced with intense criticism by many leading scientists in the nutrition community. The resulting efforts by the World Health Organization and UNICEF in support of programs for the global control of vitamin A deficiency still face vocal opposition by some senior scientists, despite having been estimated to have saved tens of millions of children from unnecessary death and blindness. This entire journey was largely an accident!

Examining Mid-Upper Arm Circumference Malnutrition z-Score Thresholds

BACKGROUND

Anthropometric z-scores used commonly for diagnosis and determining degree of malnutrition, specifically body mass index (BMIz), weight-for-length (WLz), and mid-upper arm circumference (MUACz), are not wholly concordant, yet the proposed thresholds for classification are identical. This study was designed to critically examine MUACz thresholds and their ability to correctly classify nutrition status.

METHODS

This was a 2-year, prospective single-center study of children ≤18 years seen by registered dietitians within a large pediatric institution. The sensitivity, specificity, and predictive performance of the malnutrition classification thresholds were estimated against clinician-based classification.

RESULTS

Sixty-one dietitians enrolled 10,401 patients with distributions of z-scores for weight (-0.5 ± 1.9), length (-0.8 ± 1.6), BMI or WL (-0.1 ± 1.8), and MUAC (-0.4 ± 1.5), suggesting participants were smaller and shorter than the reference U.S.

POPULATION

Distributions of MUACz were broad and overlapped between nutrition classification groups, an observation that extended to BMIz and WLz as well. Consequently, existing thresholds do not accurately classify 100% of children. Misclassification rates increase, with increasing severity ranging from 8% in children with no malnutrition to 71% in children with severe malnutrition. Algorithm- and manually-based refinement of thresholds result in mixed improvements and can be explored by the reader with the associated supplement.

CONCLUSION

The sensitivity of proposed MUACz thresholds systematically decreases with increasing severity of malnutrition and will require optimization if we aim to limit the number of children at risk of misclassification. Indicators for overnutrition remain to be addressed but are explored herein.

Potentiating Effects of Malnutrition on Child Mortality: Epidemiologic Evidence and Policy Implications

The physiological synergism between malnutrition and infection has been recognized for some time, its implications have not been addressed in current child survival policies and programmes. A recent analysis of 28 epidemiologic studies of the malnutrition-mortality relationship concluded that the relationship is consistent across diverse world populations; a significant effect exists of mild to moderate malnutrition (MMM), as well as of severe malnutrition; and the effect is not simply due to confounding by socioeconomic factors or inter-current illness. In addition, evidence supports the hypothesis that malnutrition and infection have multiplicative effects on child mortality, not the additive effects implicitly assumed. An empirically based model suggests that by potentiating infection, malnutrition accounts for 56% of child deaths, 83% of which are due to MMM. These estimates are far higher than conventional figures that do not take account of potentiation and MMM.

The Impact of Siblings’ Death on the Nutrition Status of Children in Peru

The impact of child deaths on the nutrition status of surviving children in the Lake Titicaca basin in the Andes of southern Peru (altitude>3,800 m) is explored. Survey data on obstetric history and social variables were collected in a random sample of 86 households in two Aymara and three Quechua Amerindian peasant communities. Independently of social factors, deaths among older siblings under five years old were associated with improved nutrition stature in children under four. Improved head circumference for age in boys was associated with the death of an older sister. The findings point to a new hypothesis concerning nutrition status in this population: mortality in children under five can be related to improved nutrition status (as evidenced by head circumference and height) in surviving siblings under four.

Ethnic and age differences in prediction of mortality by mid-upper arm circumference in children below 3 years of age in Nepal

OBJECTIVE

To assess ethnicity- and age-modified associations between mid-upper arm circumference (MUAC) and mortality in Nepalese children and whether sociodemographic factors explain these associations.

DESIGN

Secondary data analysis of children followed until 3 years of age. Estimated mortality hazard ratios (HR) for MUAC<11·5cm (recommended cut-off for identifying severe acute malnutrition among children ≥6 months old) compared with ≥11·5cm in younger (<6 months) and older children (≥6 months) of Pahadi and Madhesi ethnicity, adjusting for sex, socio-economic status (SES) and mother's education using Cox proportional hazard models.

SETTING

Sarlahi, Nepal (21 October 2001-2 February 2006).

SUBJECTS

Children (n 48 492) enrolled in the Nepal Nutrition Intervention Project, Sarlahi-4.

RESULTS

Among children aged ≥6 months, MUAC<11·5 cm was associated with increased risk of mortality in both Pahadis (HR=4·01; 95 % CI 1·42, 11·76) and Madhesis (HR=5·60; 95 % CI 3·87, 8·11) compared with those with MUAC≥11·5 cm, after adjusting for sex, SES and maternal literacy. Among children <6 months old, MUAC<11·5 cm was not associated with mortality in Pahadis with (HR=1·12; 95 % CI 0·72, 1·73) or without adjusting (HR=1·17; 95 % CI 0·75, 1·18) as compared with Madeshis (adjusted HR=1·76; 95 % CI 1·35, 2·28).

CONCLUSIONS

Among older children, MUAC<11·5 cm is associated with subsequent mortality in both ethnicities regardless of other characteristics. However, among children aged <6 months, it predicted mortality only among Madhesis, while sociodemographic factors were more strongly associated with mortality than MUAC<11·5cm among Pahadis.

Use of upper arm anthropometry, upper arm muscle area-by-height (UAMAH) and midupper- arm-circumference (MUAC)-for-height as indicators of body composition and nutritional status among children

Upper arm anthropometry has a potential role to provide useful estimations of body composition and nutritional status. Aims of the present cross-sectional study were to assess body composition and nutritional status of rural school-going children using upper arm anthropometric measures such as upper arm muscle area-by-height (UAMAH) and mid-upper arm circumference (MUAC) for-height. The present cross-sectional study was conducted among 1281 children of West Bengal, India (boys 619, girls 662) aged 5-12 years and selected using a stratified random sampling method. Anthropometric measurements of height, weight, MUAC and triceps skinfold (TSF) were recorded. Body composition and nutritional status were assessed using upper arm muscle area (UMA), upper arm fat area (UFA), UAMAH and MUAC-forheight. Age-sex-specific overall adiposity in TSF, UFA, arm fat index and upper-arm fat area estimates were higher among girls than boys (p<0.01), but UMA and upper-arm muscle area estimates were observed to be higher among boys than girls (p<0.05). High prevalence of undernutrition was found among both boys (53.15%) and girls (41.69%) using UAMAH (p<0.01). The overall prevalence of low MUAC-forheight was higher among boys (28.59%) than girls (25.68%) (p>0.05). Upper arm anthropometric measures, UAMAH and MUAC-for-height are useful for assessment of body composition and nutritional status among children.

A Review of Methods to Detect Cases of Severely Malnourished Children in the Community for Their Admission into Community-Based Therapeutic Care Programs

Background

The complexity and cost of measuring weight-for-height make it unsuitable for use by community-based volunteers. This has led community therapeutic care programs to adopt a two-stage screening and admission procedure in which mid-upper-arm circumference (MUAC) is used for referral and weight-for-height is used for admission. Such a procedure results in many individuals being referred for care on the basis of MUAC but subsequently being refused treatment because they do not meet the weight-for-height admission criterion. This “problem of rejected referrals” has proved to be a major barrier to program uptake.

Objective

To systematically review methods to detect cases of severely malnourished children in the community for their admission into community-based therapeutic care programs.

Methods

Clinical and anthropometric methods for case detection of severely malnourished children in the community were reviewed with regard to their ability to reflect both mortality risk and nutritional status.

Results

MUAC, with the addition of the presence of bipedal edema, was found to be the indicator best suited to screening and case detection of malnutrition in the community. The case definition “MUAC < 110 mm OR the presence of bipedal edema,” with MUAC measured by a color-banded strap, is suitable for screening and case detection of malnutrition in the community for children aged between 6 and 59 months. Monitoring and discharge criteria were also reviewed.

Conclusions

There is no compelling evidence to support a move away from using weight in combination with clinical criteria for monitoring and discharge.

Construction of Lambda, Mu, Sigma Values for Determining Mid-Upper Arm Circumference z Scores in U.S. Children Aged 2 Months Through 18 Years

BACKGROUND

Mid-upper arm circumference (MUAC) has proven highly predictive of morbidity and mortality associated with malnutrition better, in some cases, than other growth indicators, including body mass index (BMI) z scores and weight-for-height z scores. A recent consensus statement recommended the inclusion of MUAC and MUAC z scores in the nutrition assessment of children in the United States; however, the requisite data to permit z score calculations for children aged >5 years have not been published.

OBJECTIVE

This investigation was designed to generate lambda mu sigma (LMS) values to permit the calculation of MUAC z scores in U.S. children 2 months through 18 years of age.

DESIGN

Anthropometric data from the Centers for Disease Control and Prevention (CDC) National Health and Nutrition Examination Survey (1999-2012) were used for model development (n = 28,995). Smoothed centiles were constructed and compared with previously described CDC percentiles. Independently collected MUAC data from 2 different U.S. studies were used for external validation (n = 1438).

STATISTICAL ANALYSES

Goodness-of-fit was assessed visually and statistically by examining detrended quantile-quantile plots, Q statistics, and the distribution of z scores.

RESULTS

The curves generated in this investigation fit the raw data well with no systematic bias and no sacrifice in fit for children aged <12 months. The curves were consistent with those published by the CDC, and the distribution z scores approximated 0 ± 1 in all age groups.

CONCLUSIONS

These LMS values derived in this investigation can be used by clinicians to generate MUAC z scores for U.S. children.

Nutritional Status and Other Baseline Predictors of Mortality among HIV-Infected Children Initiating Antiretroviral Therapy in Tanzania

BACKGROUND

We assembled a prospective cohort of 3144 children less than 15 years of age initiating antiretroviral therapy (ART) in Dar es Salaam, Tanzania.

METHODS

The relationships of nutritional status and other baseline characteristics in relation to mortality were examined using Cox proportional hazards model.

RESULTS

Compared with children with weight for age (WAZ) > -1, those with WAZ ≤ -2 to < -3 had a nearly double risk of death (relative risk [RR], 1.85; 95% confidence interval [CI], 1.10-3.11), and among those with WAZ ≤ -3, the risk more than tripled (RR, 3.36; 95% CI, 2.12-5.32). Other baseline risk factors for overall mortality included severe anemia (P < .001), severe immune suppression (P = .02), history of tuberculosis (P = .01), opportunistic infections (P < .001), living in the poorest district (P < .001), and advanced World Health Organization stage (P = .003).

CONCLUSIONS

To sustain the obtained benefit of ART in this setting, interventions to improve nutritional status may be used as an adjunct to ART.

Modeling costs and benefits of adolescent weight control as a mechanism for reproductive suppression

The "reproductive suppression hypothesis" states that the strong desire of adolescent girls in our culture to control their weight may reflect the operation of an adaptive mechanism by which ancestral women controlled the timing of their sexual maturation and hence first reproduction, in response to cues about the probable success of reproduction in the current situation. We develop a model based on this hypothesis and explore its behavior and evolutionary and psychological implications across a range of parameter values. We use the process of model development to identify assumptions implicit in the reproductive suppression hypothesis and variables that need to be measured in order to investigate it more fully. In addition, because costs were probably associated with weight control, an important part of this analysis is the specification of situations in which the benefits of adaptive adjustment of the maturation schedule could have outweighed the costs of achieving that adjustment by slowing adolescent weight gain.

Incidence and duration of severe wasting in two African populations

Objective

The present study aimed to compare two situations of endemic malnutrition among <5-year-old African children and to estimate the incidence, the duration and the case fatality of severe wasting episodes.

Design

Secondary analysis of longitudinal studies, conducted several years ago, which allowed incidence and duration to be calculated from transition rates. The first site was Niakhar in Senegal, an area under demographic surveillance, where we followed a cohort of children in 1983–5. The second site was Bwamanda in the Democratic Republic of Congo, where we followed a cohort of children in 1989–92. Both studies enrolled about 5000 children, who were followed by routine visits and systematic anthropometric assessment, every 6 months in the first case and every 3 months in the second case.

Results

Niakhar had less stunting, more wasting and higher death rates than Bwamanda. Differences in cause-specific mortality included more diarrhoeal diseases, more marasmus, but less malaria and severe anaemia in Niakhar. Severe wasting had a higher incidence, a higher prevalence and a more marked age profile in Niakhar. However, despite the differences, the estimated mean durations of episodes of severe wasting, calculated by multi-state life table, were similar in the two studies (7·5 months). Noteworthy were the differences in the prevalence and incidence of severe wasting depending on the anthropometric indicator (weight-for-height Z-score ≤–3.0 or mid upper-arm circumference <110 mm) and the reference system (National Center for Health Statistics 1977, Centers for Disease Control and Prevention 2000 or Multicentre Growth Reference Study 2006).

Conclusions

Severe wasting appeared as one of the leading cause of death among under-fives: it had a high incidence (about 2 % per child-semester), long duration of episodes and high case fatality rates (6 to 12 %).

The effect of body shape on weight-for-height and mid-upper arm circumference based case definitions of acute malnutrition in Ethiopian children

BACKGROUND

Nutritional anthropometry surveys from Somalia and Ethiopia have reported that standard weight-for-height z-score (WHZ) and mid-upper arm circumference (MUAC) case definitions return different estimates of the prevalence of acute malnutrition in pastoralist livelihood zones but similar estimates of the prevalence of acute malnutrition in the agrarian livelihood zones. A study undertaken in Somalia to investigate this finding reported that children from pastoralist livelihood zones tended to have longer limbs and lower SSRs than children from agrarian livelihood zones.

AIM

The present study investigated the relationship between weight-for-height and body shape and the relationship between MUAC and body shape in different populations of Ethiopian children.

SUBJECTS AND METHODS

Six cross-sectional nutritional anthropometry surveys were undertaken. The combined survey datasets form the study sample. Data sources were grouped according to the livelihood zone from which data originated (either settled agrarian or semi-nomadic pastoralist). Case definitions of acute malnutrition using WHZ calculated using the NCHS and WHO reference populations and MUAC uncorrected for age or height were used. The SSR was used as an index of body shape. The association between body shape and the different case definitions of acute malnutrition were investigated using standard statistical techniques.

RESULTS

Weight-for-height and MUAC case definitions yielded similar estimates of the prevalence of acute malnutrition in agrarian children but different estimates of the prevalence of acute malnutrition in pastoralist children. These populations also exhibit different SSRs. The SSR is an important predictor of weight-for-height. The SSR is a poor predictor of MUAC.

CONCLUSION

WHZ and WHZ case status in children are associated with body shape and may overestimate the prevalence of acute malnutrition in some populations. Consideration should be given as to whether WHZ should be replaced by MUAC for the purposes of estimating the prevalence of acute malnutrition.

Risk factors for pregnancy-related mortality: a prospective study in rural Nepal

OBJECTIVES

This study examined the risk factors of mortality related to pregnancy for the first year post partum in a cohort of 25,580 pregnancies.

STUDY DESIGN

Longitudinal cohort follow-up.

METHODS

Details of socio-economic status, mid-upper arm circumference (MUAC), diet, illness, work, substance use and previous pregnancy history were collected during early to mid-gestation, and these women were followed for 1 year post partum. All-cause mortality rates per 100,000 pregnancies were calculated for deaths during pregnancy or up to 42 days post partum (early period) and 43-364 days post partum (late period). Odds ratios (OR) of mortality were estimated using five groups of risk factors: biological; morbidity; dietary; lifestyle; and socio-economic. Significant factors within each group were included in a single risk model for each time period.

RESULTS

Early and late pregnancy-related mortality rates were 469 [95% confidence interval (CI) 385-553] and 254 (95% CI 192-316), respectively. Maternal age > or = 35 years was associated with a three- to four-fold increase in mortality, whereas increasing parity conferred increasing protection. In the final model, a larger MUAC and consumption of dark green leaves were associated with decreased risk of death in the early period (OR 0.76, 95% CI 0.67-0.87 and 0.64, 95% CI 0.41-0.99, respectively). A larger MUAC was also associated with a lower risk of death in the late period. Diarrhoea/dysentery and pre-eclampsia were associated with increased risk of death in the early period (OR 2.78, 95% CI 1.40-5.51 and 2.95, 95% CI 1.48-5.90, respectively). Factors weakly associated (P<0.1) with mortality in both periods included night blindness, strenuous work activity and cigarette smoking. No socio-economic factors were significant in the models.

CONCLUSIONS

Maternal age, parity, MUAC, diet and illness in early to mid-gestation were associated with risk of death during pregnancy and the first year post partum in rural Nepal.

Distributions of mortality risk attributable to low nutritional status in Niakhar, Senegal

This study proposes a method for computing the distributions of mortality risk attributable to malnutrition among children of developing countries. Population distributions of nutritional status were adjusted with a normal curve and the relation between mortality and nutritional status was fitted with a linear logistic model after controlling for age. The attributable risk for mortality could therefore be computed at any threshold of low nutritional status. The method was applied in Niakhar, Senegal, where a comprehensive study of the relation between nutritional status and mortality was conducted in 1983-1984 on approximately 5,000 children, 6-59 mo of age. The anthropometric indicators used were Z-scores of weight-for-age, weight-for-height, height-for-age, head circumference-for-age, arm circumference-for-age, triceps skinfold-for-age, and subscapular skinfold-for-age, plus arm circumference, body mass index, and 2 composite indicators. Population attributable fraction varied according to indicators selected and ranged from 31% (head circumference) to 65% (arm circumference). The 2 composite indicators summarizing the whole nutritional status provided the same value for the population attributable fraction (59 and 60%, respectively). Classic thresholds of mild, moderate, and severe malnutrition are presented, as well as the bivariate distribution of wasting and stunting. Whatever the indicator used, mortality attributable risks appeared evenly distributed along the scale of low nutritional status. Our findings question the value of using classic thresholds of mild, moderate, and severe malnutrition (developed by clinicians for practical purposes) for nutritional epidemiology.

Micronutrients and child health: studies in international nutrition and HIV infection

Increasing data link micronutrient deficiencies to excess childhood morbidity and mortality, and similar relationships have been noted in the study of nutrition and HIV infection. We review epidemiologic studies that have examined the relationship between micronutrient deficiencies and health outcomes in childhood and HIV infection, as well as clinical trials of micronutrient supplementation. Vitamin A supplementation among communities at risk of deficiency effectively reduces mortality and morbidity in children younger than age 5, and vitamin A may be especially effective in HIV-infected children. Vertical transmission of HIV has not to date been affected by maternal micronutrient supplementation. In children with poor dietary zinc intake and/or bioavailability, zinc supplementation reduces the incidence and severity of diarrheal diseases, as well as the occurrence of pneumonia. Vitamin A therapy has not been associated with improved growth, whereas some trials have shown that zinc supplementation is associated with greater increments in height. Further trials of micronutrient supplementation are warranted.

Modeling the effects of nutritional and socioeconomic factors on the growth and morbidity of Kenyan school children

This paper estimates dynamic models for the height, head circumference, weight, and morbidity of approximately 110 Kenyan school children (6-9 years) in a multivariate longitudinal data framework. Dynamic models allow anthropometric dimensions to depend on the respective measurements in the previous period. The system of 4 equations specified for height, head circumference, weight, and morbidity incorporates the inter-relationships among these variables; explanatory variables in the model consist of nutritional, socioeconomic, demographic, and environmental factors. The model parameters are estimated using the principle of maximum-likelihood, while controlling for the unobserved between-children differences. The main findings are, first, that calcium intakes are positively associated with height while protein and energy intakes are associated with weight. Vitamin A intakes are negatively associated with morbidity. Second, socioeconomic status plus the cash income of the household is a significant predictor of height, head circumference, and morbidity. Third, maternal height is positively associated with children's height and maternal body mass index (BMI) is positively associated with children's weight. Fourth, parents' scores on psychological tests, mother's age, and children's hemoglobin concentration are negatively associated with morbidity while mothers' morbidity is positively associated with children's morbidity. Implications of the modeling results are discussed. Am. J. Hum. Biol. 11:317-326, 1999. Copyright 1999 Wiley-Liss, Inc.

Hypocaloric oral therapy during an episode of diarrhea and vomiting can lead to severe malnutrition

BACKGROUND

Malnutrition associated with diarrhea and vomiting can be prevented if the focus of treatment is on nutritional requirements. Some pediatricians inappropriately continue to recommend clear liquids followed by dilute feedings or hypocaloric diets until the diarrhea clears.

METHODS

Medical records were retrospectively reviewed, and the literature was reviewed.

RESULTS

Severe malnutrition occurred in two children with diarrhea and vomiting who were treated with clear liquids followed by restricted nutrient intake.

CONCLUSION

Severe malnutrition associated with diarrhea and vomiting can occur when the prescribed treatment is bowel rest followed by hypocaloric diets until diarrhea clears. Malnutrition can be prevented if the focus of treatment is on nutritional requirements. Current American Academy of Pediatrics recommendations for treatment of diarrhea and vomiting are discussed.

Nutrition, disease and death in times of famine

In this article we review the relationship between malnutrition and mortality, and the interaction of morbidity, with the aim of clarifying the health risks of malnutrition in situations of famine and food insecurity. Apart from reviewing what is known about this relationship, we highlight areas where further research is needed. Among refugee and famine affected populations living in camps, there appears to be a close association between high rates of malnutrition and excess mortality. Results from community-based prospective studies of malnutrition and mortality among individuals conclude that as nutritional status declines the risk of death increases, although the discriminating power of different nutritional indices and the strength of the association varies considerably in different locations and at different times. These differences are attributed mainly to the different prevailing patterns of morbidity and growth failure, which are influenced by both environmental and social factors. In situations of famine and population displacement, the deterioration in the health environment increases exposure to infection and is likely to raise the threshold of nutritional status which corresponds to an increased risk of mortality. This has important implications for nutritional assessments and interventions.

What proportion of children have a growth deficit?

Cross-sectional anthropometric survey data are frequently summarized to present estimates of the proportion of a child population who might be considered malnourished. A very commonly used summary statistic is the prevalence of standard deviation scores less than -2 (Pz < -2). Pz < -2 is not equivalent to the prevalence of growth retardation in the population, lambda. Identical values of Pz < -2 can arise as a result of a relatively low prevalence of predominantly severe malnutrition, or of universal or near-universal mild growth retardation. Alternative estimators which have been proposed give biased estimates of lambda. In this paper a simple statistical procedure using density ratios is described for estimating lambda from cross-sectional anthropometric data and international growth standards. This gives nearly unbiased estimates of lambda and of the distribution of the growth deficit in the growth retarded sub-set of the population. The analysis provides estimates of the probability that an individual child's growth is retarded. This is illustrated with data from the 1982/3 National Nutrition Survey of Papua New Guinea. Estimation of lambda for different indicators and for different populations could be useful in planning whether interventions should be targeted at the smallest children, or aimed at the population in general. The same estimates might also be used to help determine whether heterogeneity between countries in the reported associations between morbidity or mortality risks and anthropometric indices can be accounted for by differences in the amount of intrapopulation variation in growth retardation.

The potentiating effects of malnutrition on child mortality: epidemiologic evidence and policy implications

The physiologic synergism between malnutrition and infection has been recognized for some time, but its implications have not been addressed in current child survival policies and programs. This paper summarizes the conclusions from a recent analysis of 28 epidemiologic studies of the malnutrition-mortality relationship. It concludes that the relationship is consistent across diverse world populations, that there is a significant effect of both mild-to-moderate malnutrition and severe malnutrition, and that the effect is not simply due to confounding by socioeconomic factors or intercurrent illness. In addition, evidence is provided supporting the hypothesis that malnutrition and infection have multiplicative effects on child mortality, rather than the additive effects implicitly assumed, and the policy implications of these findings are described.

Anthropometry and childhood mortality in northwest and southwest Uganda

Two longitudinal studies were carried out in northwest and southwest Uganda to examine the relationship between anthropometry and childhood mortality. Although the prevalence of malnutrition was significantly different between the two geographic areas, the relative risk for mortality associated with low levels of anthropometry was similar. When the anthropometric parameters were compared among each other, mid-upper arm circumference was found to be the most powerful predictor of mortality. The findings of this study confirm that mid-upper arm circumference is the indicator of choice to identify children at higher risk of death.

The authorship and fate of international health papers submitted to the American Journal of Public Health in 1989

We reviewed the authorship characteristics, editorial processing, and final fate of 126 papers dealing with data from countries other than the United States and Canada and submitted to the American Journal of Public Health in 1989. The acceptance rate of these international health papers was 22%, similar to that of all papers (25%). Authors from developed countries had higher acceptance rates than authors from developing countries, but the highest acceptance rate (36%) was for international health papers with joint authorship from both developed and developing countries. Of 83 rejected papers, 72% were published in other journals. Of these, 45% were published in journals covered by Index Medicus, a figure similar to that for all papers rejected by the Journal.

Nutrition and health in South-East Asia

Poor nutrition remains a significant contributor to morbidity and mortality in South-East Asia. Manifestations of this include protein-energy malnutrition, iodine deficiency diseases, vitamin A deficiency, iron deficiency and some non-communicable diseases of adults. The extent of these diseases, and their interactions with infection, make nutrition the single most important modifiable host factor underlying health status in the region. It is vital that long-term sustainable programs for the control of nutrition problems are accorded a high priority within the health sector.

Influence of nutritional status on child mortality in rural Zaire

Although the association between nutritional status and mortality risk is obvious for extreme malnutrition, the issue is not so clear for mild to moderate undernutrition. We have investigated this association in children of 0-5 years in the rural area of Bwamanda, Zaire, where an integrated development project, with good medical facilities, has operated for 20 years. A random cluster sample of 5167 children was taken; newborn infants and immigrants were included at six quarterly survey rounds from October, 1989, until February, 1991. All surveys included clinical and anthropometric assessment of nutritional status. Deaths were recorded up to April, 1992; there were 246 deaths. Marasmus, kwashiorkor, and other causes of death were defined by the verbal autopsy method and checked against medical records kept at the central hospital and the peripheral dispensaries. As expected, we found an increased risk of death in severe malnutrition. When deaths directly attributed to marasmus or kwashiorkor were excluded, mild to moderate stunting or wasting were not associated with higher mortality in the short term (within 3 months of the previous study round) or in the long term (from 3-30 months after study entry). The commonest causes of death were malaria and anaemia. Extreme marasmus and kwashiorkor caused 16% of deaths, and are important causes of death even in this favoured area with an integrated development project. Nutritional interventions should be targeted more selectively so that children with moderate malnutrition can be protected from progression to marasmus or kwashiorkor.

In search of a contemporary theory for understanding mortality change

This paper represents a speculative approach to the question of changing mortality levels in human populations. The surprising resilience and reluctance of mortality declines to respond to powerful countervailing is considered. A more integrated approach is proposed to examine the interactive roles of income, technology and behavior in relation to life expectancy. The paper concludes by a discussion of the relevance of the accumulation of health assets to national mortality levels.

Malnutrition and child mortality: are socioeconomic factors important?

The influences of household economic condition, maternal education, sex, and nutritional status of children on mortality were examined using multivariate analytical techniques. Weights of around 1700 children aged 2 60 months in five villages of Matlab, Bangladesh, were taken during the first half of 1981. The children were followed for 18 months and their survival was recorded. The severely malnourished children had a risk of death nine times that of their counterparts with better nutritional status. Female children had a higher risk of death than the males. Mother's education and economic condition of household also showed negative relationships with the risk of death, but the effect of mother's education was modified by economic condition and sex of the children.

Limitations of anthropometry during acute food shortages: high mortality can mask refugees' deteriorating nutritional status

Longitudinal comparison of anthropometric data from cross-sectional surveys is commonly used to assess nutritional status in relief operations. In a refugee camp in Sudan, assessment indicated a high level of childhood malnutrition, but nutritional status appeared relatively unchanged between cluster sample surveys in January (26.3% below 80% of median weight-for-height) and March 1985 (28.4% below 80% of median weight-for-height). However, in this interval, which was marked by irregular food supplies and relatively low energy (calorie) intake as well as by a high incidence of diarrhoeal disease and measles, nearly 13% of all children in the camp died. This deceptive appearance of stability in nutritional status in the face of high mortality may be explained by ongoing nutritional deterioration ("replacement malnutrition") among surviving children. These findings demonstrate that collection and analysis of mortality data are essential for the correct interpretation of anthropometric results during periods of uncertain food supply.

Growth and nutritional status of rural preschool children in Saudi Arabia

The attained growth was assessed in a cross-sectional study of Saudi children 0-71 months of age, from 3 different geographical areas of rural Saudi Arabia. Individual data on weight, height, weight for height and head circumference were expressed in SD scores of international standards, and data on upper arm muscle and fat areas in percent of the reference median values. The mean (SEM) weight, height, weight for height and head circumference of the entire material were -1.7 (0.05), -1.6 (0.06), -0.9 (0.05) and -1.6 (0.06), respectively. The median upper arm muscle area was 79 percent, and fat area 57 percent of the reference medians. The differences in mean weight, height and weight for height were trivial between the 3 geographical areas. All mean values, except that of weight for height were clearly below the means of the reference in children 0-5 months. All mean values declined significantly, however, during the next 6 months. The growth deficits thus obtained remained unchanged or increased slightly up to 6 years. According to WHO criteria, 41 percent were classified as chronically, and 12 percent as acutely undernourished. The growth pattern of rural Saudi children was similar to that of children in most developing countries and distinctly different from that of privileged Saudi children, whose growth pattern resembled that of Western reference populations.

Childhood mortality in relation to nutritional status and water supply--a prospective study from rural Malawi

In connection with the introduction of an improved method of water supply in rural Malawi, the nutritional status, morbidity, and mortality among 1,178 children under five were studied during three rainy and three dry seasons. Data were collected at fortnightly home interviews. Nutritional assessment was made twice a year. One hundred and thirty-seven of the children died during the study period, and the probability of dying before the age of five was estimated to 270 per 1,000 children. The mortality risk was related to weight for height (p less than 0.001) and height for age (p less than 0.01) as well as to upper arm circumference (p less than 0.001) and triceps skinfold (p less than 0.05). Mortality among children living in households using the new, piped-water supply tended to be lower than mortality for those using traditional water sources, although the difference was not statistically significant (relative risk 0.4, 95% confidence interval 0.1-1.3).

Health surveys in developing countries: the objectives and design of an international programme

There have been calls recently for a major international effort to collect epidemiological information in developing countries. One approach to a World Health Survey is considered, namely single-round retrospective interview surveys. Surveys can contribute to the improvement of national health information systems by providing person-based, rather than episode-based, measures related to health that apply to the entire population. A programme of health interview surveys could be used to ascertain patterns of morbidity and mortality, to measure access to and use of health services and to develop and disseminate methodologies for collecting and analysing health related data. Single-round surveys could not be used to evaluate the impact of investments on health and would be of limited use for improving our understanding of the determinants of ill health. Attention is drawn to a number of conceptual, technical and logistic issues to be considered in the design of a World Health Survey.

Nutrition surveillance by QUAC stick

The QUAC stick method of nutrition assessment was used as an indicator of change in a nutrition surveillance system in Zaire. The method is quick, simple and can be done by primary school teachers. Results of QUAC stick measurements are reproducible and easy to report.

Measures of nutritional status. Survey of young children in north-east Brazil

In 738 children aged under 5 from three communities in north-east Brazil, nutritional status was assessed by four means-weight for age, height for age, weight for height, and middle upper arm circumference (MUAC). As judged by weight for age, 43% of children were adequately nourished and only 2% were severely malnourished. Stunting (less than 85% height for age) was seen in 8% and wasting (less than 70% weight for height) in 1%. There was poor agreement between MUAC (a measure of wasting) and weight for height when the conventional cut-off points for MUAC were applied. Although agreement improved with new MUAC cut-off points the probability of correct diagnosis of wasting (sensitivity) remained low. Although height for age and weight for height were the most useful measures of nutritional status, MUAC may be the best available in famine victims and refugees.

Excess mortality among children discharged from hospital after treatment for diarrhoea in rural Bangladesh

Five hundred and fifty one children aged between 3 months and 3 years were followed up at home for 12 months after treatment of diarrhoea in a rural treatment centre of the International Centre for Diarrhoeal Disease Research, Bangladesh. During follow up the children were found to have a significantly higher mortality than generally observed in the community. The first three months after discharge appeared to be crucial, some 70% of the deaths occurring in that period. Severely malnourished children (nutritional state below 56% of the American National Center for Health Statistics (NCHS) standard of weight for age ratio) had a risk of death 14 times that of their well nourished counterparts (nutritional state 66% or more of the NCHS standard). The highest mortality occurred in 2 year olds, one in three of the severely malnourished children dying compared with one in 10 of the moderately malnourished. This pattern was not seen in children aged under 2 years. Immediate priority should be given to providing nutritional rehabilitation for malnourished children who contract diarrhoea.

Increased mortality in children with mild vitamin A deficiency

An average of 3481 preschool-age rural Indonesian children were re-examined every 3 months for 18 months. The mortality rate among children with mild xerophthalmia (night blindness and/or Bitot's spots) was on average 4 times the rate, and in some age groups 8 to 12 times the rate, among children without xerophthalmia. Mortality increased, almost linearly, with the severity of mild xerophthalmia (night blindness, Bitot's spots, and the two combined). These relations persisted after stratification for respiratory disease, wasting, gastroenteritis, pedal oedema, and childhood exanthems. Mild vitamin A deficiency was directly associated with at least 16% of all deaths in children aged from 1 to 6 years. These results suggest that mild xerophthalmia justifies vigorous community-wide intervention, as much to reduce childhood mortality as to prevent blindness, and that night blindness and Bitot's spots are as important as anthropometric indices in screening children to determine which of them need medical and nutritional attention.

Anthropometric measurement of malnutrition in children in Zaria, Nigeria

In a combined hospital and community study anthropometric measurements were made on 2134 children under three years of age, of whom 1445 were underweight children attending a hospital nutrition clinic, 484 were unselected village children and 205 were well nourished controls. Weight and length data were analysed to determine the prevalence of different degrees of nutritional deficit in the three groups at different ages. The U.S.A. Academy of Sciences (1976) median weight/age, length/age and weight/length were used as reference standards (1). Prevalence of nutritional deficit in the groups was estimated differently by the three anthropometric indicators, weight/age giving the highest estimate and identifying not only 89% of the "malnourished" but also 48% of "village" children as significantly underweight for age. Analysis of length measurements identified an increased prevalence of stunting with advancing age in all groups and a significant peak prevalence of wasting in village children during the second year of life. The possible reasons for this nutritional crisis during the second year of life are discussed. The operational significance of the different estimates of prevalence of nutritional deficit given by the three anthropometric indicators is also discussed. It is suggested that a combined hospital and community study of malnutrition is of value in planning nutritional intervention.