Use of Z-Scores for the classification of Malnutrition.

Dr. N. Seetharaman, M.D., Assistant Professor,

Department of Community Medicine

PSG Institute of Medical Sciences & Research
Coimbatore.

Presented at the XXII ISMS Conference, JIPMER

1. Objectives

2. Introduction

3. Methodology

4. Results & Discussion

5. Conclusion

6. Recommendations

7. References
 Objectives

To assess the nutritional status of under-five children in the urban

slums of Coimbatore, coming under the field practice area of the
Urban Health Centre of PSG Institute of Medical Sciences &
Research, and to express the results in terms of the Z-Score system
of classification.
 Introduction
Prevalence of Malnutrition, among our children
60

50
SOWC, 1998
40

30

20

10
Underweight
0
India Sub-saharan World Stunted
Africa Wasted

60

50

40 NFHS II, 1999

30

20

10

0
Kerala Tamilnadu India Bihar
 “Classification”s of Malnutrition.

IAP’s, Gomez, Waterlow’s

Underweight – Low Weight for age

Wt-for-age
Stunting – Low Height for age classifications
most common
Wasting – Low Weight for height

Reference population Cut-off points

 Z Score system

Widely Recommended, Scarcely Used.

If we use the usual systems of classification, we usually express undernutrition

in terms of only one index – weight-for-age. (Underweight).

By using the Z score system, we are able to express undernutrition in terms of

all the three indices, with the same cut-off values.

Malnourished ~~ below – 2 SD (of the median value of the reference pop).

Severely Malnourished ~~ below – 3 SD.

Comparable Across sex and ages and Across indicators.

Distinct Statistical advantages in using SD classification based upon Z-Scores.

The mean and SD of all the Z-Scores reflect the quality of the data collected.
 Methodology

Study area : Ten slums coming under the field-practice area of the Urban
Health Centre, PSG IMS & R, Coimbatore.

Study Population : Children less than five years of age residing in these
slums. The total number of under-five children in these 10 slums is 625.

Inclusion criteria : All children up to 59 months of age Living in the selected

slums.

Exclusion criteria :
1. Children who are not resident of the slum, but visiting.
2. Children of families who have moved into the slum within the past 1 month.
 Design of the study : Cross-sectional study (Prevalence study)
Sampling :
Prevalence (p) of malnutrition in slums = 50 % (based on the previous studies)
allowable error (d) = 10% (of the prevalence)
Sample size ( n ) = 4PQ / d2
the estimated Sample size is 400.

To arrive at this sample size,

a) From the ten slum areas coming under the field practice area of the UHC, six slums
were selected using a random number table .

b) All the under-five children in these six slum areas were taken as study subjects.
(n = 405)

Data collection was done over a period of 3 months.

Children were weighed and measured as per the WHO guidelines1 on Anthropometry.
Statistical Analysis :

Data Analysis done with EPI-INFO 2002 software package – CDC*.

The prevalence of underweight, stunting and wasting were calculated in

reference to the WHO recommended NCHS** standard population by using
the EPI-NUT component of the EPI-INFO program.

The Cut-off levels of

less than -2SD [Z score <2] for “malnourished” and
less than -3SD [Z score <3] for “severely malnourished” were used.

Chi-square test was used to verify the statistical significance of the

associations.

P value < 0.05 was considered statistically significant.

The strength of the association is expressed using Odds Ratio

* Center for Disease Control, Atlanta, USA ** National Center for Health Statistics, USA
 Results & Discussion
100
Normal
90
32.1 %
80
70
48.4 % 49.6 %
60
50
40 Malnourished
22.7 % 67.9 %
30
20
10
0
Wasted Stunted Underweight TOTAL

More than two-thirds of the children studied are malnourished.

No significant gender difference in the prevalence.

 70 Comparative Prevalence of Malnutrition
60
50 Malnourished
49.6 47 50.3
40 36.7 49.6

48.4 45.5
30 29.4 48.8 60
22.7 19.9
17
20 15.5
9.1
10
0
Current Study, India NFHS II Tamilnadu NFHS II Rajeshkumar Haryana Laxmiah, Punjab
Coimbatore slums

70 Underweight Stunting Wasting

60
50
40
Severely malnourished
30 23
21.2 22.3
18.1 19
20 18
20.3 12 11.5 12
9.4 10.6
10 2.8 3.8
0.6
0
 70 Stunting Wasting
60 30
50 25
% stunted

40 20

% wasted
30 15
20 10
10 5
0
0
0-11 12 _ 23 24-35 36-47 48-59 0-11 12 _ 23 24-35 36-47 48-59
Age group
Age group

Underweight
80
60
% underweight

40
20
0
0 - 11 12 _ 23 24-35 36 - 47 48 - 59
Age - group

Significantly lower prevalence of malnutrition among infants (0-11 months) compared to

other age-groups. (P < 0.05)
 Conclusions
WHO guidelines for assessing the severity of malnutrition in a community.

Severity of malnutrition by prevalence ranges (%)

Prevalence in Prevalence in
Indicator Low Indicator
Medium Current
Highstudy Very high Current study

Stunting <20 20-29

Stunting 30-39
49.6 % > 40 49.6 %

Underweight <10 10-19

Underweight 20-29
48.4 % > 30 48.4 %

Wasting <5 5-9

Wasting 10-14
22.7 % > 15 22.7 %

There is no significant gender difference in the prevalence of malnutrition.

The prevalence of malnutrition is a Significantly lower among infants (0-11 months)

compared to other age-groups. (P < 0.05)

The prevalence of malnutrition peaks in the 24-36 months age-group.

 Recommendations

Need for more studies that report prevalence in terms of the

Standard Deviation (or) Z-Score system of classification of
malnutrition, for meaningful comparisons.

Make use of the statistical software “Epi-Info 2002” available for

free download from www.cdc.org for calculating the Z-Scores.

For nutritional interventions, ‘Catch’ the children young – before 3

years – before malnutrition sets in and before the child gets
stunted for life.
 References
1. UNICEF. The state of the world’s children 1998. United Nations Children’s Fund, Geneva. 1998 :
1-41.

2. International Institute of Population Science. National Family Health Survey India. (NFHS II).
I.I.P.S, Mumbai. 1999.

3. WHO. Physical status: the use and interpretation of anthropometry. Report of a WHO Expert
Committee. WHO Technical Report Series No. 854. World Health Organization, Geneva. 1995.

4. H.P.S. Sachdev. Assessing Child Malnutrition - Some Basic Issues, NFI archives 156. Nutritional
Foundation of India, New Delhi. 1996.

5. C.Gopalan. Combating Malnutrition – Basic Issues and Practical Approaches. Nutrition

Foundation of India Special publication series 3. Nutrition Foundation of India , New Delhi. 1994

6. A.K.Nigam. Determining Grades of Malnutrition in Children: Standard Deviation Classification

and the Alternative. Demography India 2003 January; 32:1:137-155.

7. A. Laxmaiah, K.Mallikharjuna Rao, GNV Brahmam, Sharad Kumar, M.Ravindrenath, K.Kasinah

et al. Diet and Nutritional Status of Rural Preschool Children in Punjab. Indian Pediatrics 2002 April;
39: 331-338.

8. Rajesh Kumar, Arun K.Agarwal, Sharad D.Iyengar. Nutritional Status of Children: Validity of Mid-
Upper Arm Circumference for Screening Undernutrition. Indian Pediatrics 1996 march; 33: 189-196.