1. Assessment of Health and Nutritional Status Dr. Premananda Bharati Professor & Head Indian Statistical Institute 203, B.T. Road, Kolkata 700 108 West Bengal, India E-mail: bharati@isical.ac.in; pbharati@gmail.com

2. 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”.

3. 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.

4.  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.

5.  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.

6. 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.

7. 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

8.  MEASUREMENTS - Using Anthropometric Instruments  REFERENCE VALUES / STANDARDS - National, International  INDICES - Computed; Age dependent / Independent  CLASSIFICATIONS - Grading of Nutritional Status NUTRITIONAL ANTHROPOMETRY

9. 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

10. 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

11. 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

12. 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

13. 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)

14. ANTHROPOMETRIC INDICES Weight for age Height for age Weight for Height Body Mass Index

15. NUTRITIONAL GRADING / CLASSIFICATIONS Preschool Children: GOMEZ CLASSIFICATION WEIGHT FOR AGE (% of NCHS Standards) NUTRITIONAL GRADE  90 Normal 75 – 89.9Grade I (Mild Undernutrition) 60 – 74.9Grade II (Moderate Undernutrition) < 60Grade III (Severe Undernutrition)

16. 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

17. 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)

18. STANDARD NORMAL DISTRIBUTION -3.0 -2.0 -1.0 0.0 1.0 2.0 3.0 34% 14% 2% SD Score (  2SD = 96 %) Normal “Measuring Changes in Nutritional Status” (WHO, Geneva 1983).

19. STANDARD DEVIATION (SD) CLASSIFICATION CUT-OFF LEVEL NUTRITIONAL GRADE WEIGHT FOR AGE HEIGHT FOR AGE WEIGHT FOR HEIGHT  Median – 2 SD Normal Median – 3 SD to Median – 2 SD Moderate Underweight Moderate Stunting Moderate Wasting < Median – 3 SD Severe Underweight Severe Stunting Severe Wasting

20. Nutritional gradation based on BMI (adult) Body Mass Index (BMI) = Weight in kg/ height in meter square Nutritional gradation based on BMI (adult) ClassificationCut-off points (BMI = kg/m 2 ) 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 Normal18.50-24.99 Overweight25.00-29.99 Obese≥ 30.00

21. 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.

22. 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.

23.  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).

24. Consumption unit of household by age and sex in India IndividualAge (years) Calories according to ICMR recommended allowances Consumption unit 1 Male6028752875/2875= 1 Male2528752875/2875= 1 Male1221902190/2875= 0.76 Female5522252225/2875= 0.77 Female2122252225/2875= 0.77 Female1820602060/2875= 0.72 Female1119701970/2875 =0.68 1 Total household consumption unit = 5.70

25. Energy Requirements of Boys and Girls at Different Age Groups: A Comparison Between FAO and ICMR Estimates BoysGirls Age groupsBody weigh t Daily energy requirementsBody weigh t Daily energy requirements FAOICMRFAOICMR Kg.Kcal/d/k g Kcal/ d Kg.Kcal/d/kgKcal/d (1)(2)(3)(4)(5)(6)(7)(8)(9) 0-5 months5.4935025835.492497583 6-11 months8.6806888438.679679843 1-3 years12.2821000124012.2799641240 4-6 years19.0751425169019.07213681690 7-9 years26.9691856195026.96417221950 10-12 years35.4622195219031.55517331970 13-15 years47.8562697245046.74721952060 16-17 years57.1512912264049.94421602060

26. Daily Energy Requirements for Men and Women in India Age groupLifestyleMenWomen Mean weigh t BM R Daily energy requirements Mean weigh t BMRDaily energy requirements FAOICMRFAOICMR Kg.Kcal/ d/kg Kcal/ d Kcal/ d/kg Kcal/dKg.Kcal/ d/kg Kcal/ d Kcal/ d/kg Kcal/d (1)(2)(3)(4)(5)(6)(7)(8)(9)(10)(11)(12) 18-29.9Sedentary6027247941.3-5025191238.2- Moderate60285147.5-50220044.0- Heavy60364560.7-50281256.2- 30-59.9Sedentary6026238739.8-5025191238.2- Moderate60274645.8-50220044.0- Heavy60351058.5-50281256.2- 60 or moreSedentary6022202033.7-5022168333.7- Moderate60232338.7-50191238.2- Heavy60297049.5-50247549.5- 18 or moreSedentary6025.8236739.424255024.6188237.61875 Moderate60272245.4287550216543.32225 Heavy60348058.0380050276855.42925

27. 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)

28. 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.

29. 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).

30. 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)

31. 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: Classification Cut-off points (BMI = kg/m 2 ) 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 Normal18.50-24.99 Overweight25.00-29.99 Obese≥ 30.00

32. Anthropometric ClassificationBMI(kg/m2) Principal cut-off pointsAdditional cut-off points Underweight<18.50 Severe thinness<16.00 Moderate thinness16.00 - 16.99 Mild thinness17.00 - 18.49 Normal range18.50 - 24.99 18.50 - 22.99 23.00 - 24.99 Overweight≥25.00 Pre-obese25.00 - 29.99 25.00 - 27.49 27.50 - 29.99 Obese≥30.00 Obese class I30.00 - 34-99 30.00 - 32.49 32.50 - 34.99 Obese class II35.00 - 39.99 35.00 - 37.49 37.50 - 39.99 Obese class III≥40.00 Source: Adapted from WHO, 1995, WHO, 2000 and WHO 2004

33. 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

34. 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

35. 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: ClassificationCut-off points (gm/dl) MaleFemale Severe anaemia ≤ 7.00 Moderate anaemia 7.01-10.00 Mild anaemia 10.01-12.9910.01-11.99 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).

36. Mean per capita consumption of calories, protein, and fats Calories (kcl)Protein (gms)Fats (gms) YearRound RuralUrbanRuralUrbanRuralUrban 1983382,2402,07063.558.127.137.1 1987–8432,2332,09563.258.628.339.3 1993–4502,1532,07360.357.731.141.9 1999–0552,1482,15559.158.436.049.6 2000–1562,0832,02756.855.334.646.1 2001–2572,0181,98254.854.233.646.1 2002(2)582,0252,01455.454.934.747.0 2003592,1062,02058.055.536.446.7 2004(1)602,0872,03656.955.935.546.8 2004–5612,0472,02155.855.435.447.4 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)

37. Rural per capita calorie consumption, 1983 to 2004-5 (Deaton and Drèze, 2008)

38. Urban per capita fat consumption, 1983 to 2004-5 (Deaton and Drèze, 2008)

39. StateRuralUrban Calories per day Percentage of norm (2400) Calories per day Percentage of norm (2400) Andhra Pradesh24241012457117 Assam225894148171 Bihar2252942605124 Gujarat219792206999 Haryana231196152673 Himachal Pradesh27141132277108 Karnataka2304962682128 Kerala145661200495 Madhya Pradesh25841082360112 Maharashtra2326972451117 Orissa25071042720130 Punjab2266942183104 Rajasthan30161262561122 Tamil Nadu221592205098 Uttar Pradesh226694202797 West Bengal2633110208999 Potential calorie intake of poverty-line class in different states in India (Sen, 2005)

40. State and zone wise percentage distribution of different types of nutritional status among the under six children of India by sex Zones and States BoysGirls N Under wei ght Severely Anemic Under weight and severely anemicN Under w ei gh t Severely anemic Under weight and severely anemic North –East 425424.812.52.9395715.7 12.22.0 Arunachal Pradesh 95629.612.23.390414.7 10.82.2 Assam 115227.412.42.8104623.7 11.62.9 Manipur 100217.710.82.19158.6 12.80.9 Meghalaya 8741.49.22.38339.8 14.53.6 Mizoram 31122.29.31.93369.8 6.50.9 Nagaland 19517.45.61.017818.5 6.21.1 Sikkim 37520.822.14.831510.2 22.22.5 Tripura 17636.419.35.118016.7 18.32.2 East 2099351.119.811.32001050.9 20.911.7 Bihar 875154.021.613.1812755.5 24.115.3 Jharkhand 363555.518.812.3338354.1 18.310.8 Orissa 555946.921.410.5564845.0 21.49.9 West Bengal 304845.212.96.4285245.6 13.76.5 Central 3165657.920.113.02932655.3 20.712.9 Madhya Pradesh 1048258.217.410.7971956.2 17.210.3 Chattisgarh 284550.525.213.5 281647.2 25.213.0 Uttar Pradesh 1832959.520.914.2 1679156.1 22.014.3

41. West 1210951.031.416.91093951.1 31.016.7 Goa 16734.17.24.216234.0 8.63.7 Gujarat 480451.036.420.1417950.7 36.319.6 Daman & Diu 26644.028.914.725841.5 30.211.2 Dadra & Nagar Haveli 26251.150.426.725547.8 49.025.9 Maharashtra 661051.727.814.6608552.4 27.314.9 North 2289947.820.110.81936542.8 20.710.3 Haryana 562937.824.210.2450131.9 25.39.1 Himachal Pradesh 128840.016.57.9114634.6 16.65.8 Jammu 76722.43.40.473820.7 4.60.9 Delhi 124435.517.86.8108935.4 20.17.7 Punjab 368741.823.811.2293936.2 22.910.0 Rajasthan 833059.519.112.8714856.5 20.313.4 Chandigarh 5844.829.315.57226.4 29.26.9 Uttaranchal 189662.015.611.4173245.6 16.09.5 South 1229442.418.08.21171937.2 17.97.4 Andhra Pradesh 264745.622.411.0246938.0 22.09.7 Karnataka 272748.221.110.7260943.8 19.39.7 Kerala 75237.92.91.371434.9 2.71.1 Tamil Nadu 542039.016.96.8520934.3 17.76.3 Pondichery 47839.214.45.671833.6 14.85.6 Islands 42133.318.02.942528.2 10.43.5 Andaman & Nicobar 36033.610.33.136525.2 10.13.0 Lakshadwip 6231.111.51.66046.7 11.76.7 India 10462650.320.811.69574147.4 21.211.4

42. State and zone wise percentages of rural and urban CED and their differences and ranking Percentages of Malnourished (BMI <18.50) RuralUrbanRural and urban differenceRanking of differences North-east 22.517.3 5.20 1 Arunachal Pradesh 10.212.6 -2.402 Assam 28.118.4 9.7010 Manipur 17.618.2 -0.603 Meghalaya 25.318.2 7.107.5 Mizoram 27.915.6 12.3015 Nagaland 18.513.1 5.406 Sikkim 10.613.3 -2.701 Tripura 36.525.1 11.4013.5 East 43.827.2 16.64 Bihar 39.031.4 7.609 Orissa 48.832.9 15.9018 West Bengal 48.922.8 26.1026 Central 38.125.5 12.62 Madhya Pradesh 38.427.0 11.4013.5 Uttar Pradesh 37.823.3 14.5017 West 44.822.5 22.306 Goa 29.622.5 7.107.5

43. Gujarat 46.722.7 24.0024 Maharashtra 48.222.4 25.8025 North 31.315.7 15.603 Haryana 30.413.4 17.0021 Himachal Pradesh 30.216.7 13.5016 Jammu 29.512.8 16.7019 New Delhi 13.212.1 1.104 Punjab 20.39.10 11.2012 Rajasthan 37.627.1 10.5011 South 36.818.8 18.005 Andhra Pradesh 42.419.8 22.6022 Karnataka 46.123.3 22.8023 Kerala 19.514.4 5.105 Tamil Nadu 33.716.8 16.9020 India 36.020.415.6 (Bharati et al., 2008)

44. 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)