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A Manual:Measuringand InterpretingMalnutrition and Mortality

ASMR Age-specific mortality rateASMR-U5 Age-specific mortality rate for children under 5BMI Body Mass IndexCDC Centers for Disease Control and PreventionCMR Crude Mortality Rate/Crude Death RateDHS Demographic and Health SurveysENA Emergency Needs AssessmentEPI WHO Expanded Programme on ImmunizationHIV/AIDS Human immunodeficiency virus/acquired immune deficiency syndromeHPLC High-performance liquid chromatographyICCIDD International Council for Control of Iodine Deficiency DisordersIDD Iodine deficiency disordersIMR Infant mortality rateINACG International Nutritional Anaemia Consultative GroupLBW Low birth weightMICS Multi-indicator cluster surveysMMR Maternal mortality rateMUAC Mid-upper arm circumferenceNCHS National Center for Health StatisticsNGO Non-governmental organizationPPS Probability proportional to sizePSU Primary sampling unitRBM Results-based managementSCN United Nations Standing Committee on NutritionSRS Systematic (or simple) random samplingU5MR Under-5 mortality rateUI Urinary iodineUNICEF United Nations Childrens FundVAD Vitamin A deficiencyVAM Vulnerability Analysis and MappingWFP World Food ProgrammeWHO World Health Organization


Acknowledgements 3

Purpose of the Manual 5

Foreword 7

Introduction 9

Chapter 1 Defining and measuring malnutrition 15

Chapter 2 Defining and measuring mortality 33

Chapter 3 Designing a survey 53

Chapter 4 Using and interpreting survey results 107for decision making

Chapter 5 Ethical issues 127

Chapter 6 The end point: example of a good survey report 131


1.1 Policy Paper Brief: Food for Nutrition 1751.2 Policy Paper Brief: Micronutrient Fortification 1771.3 Policy Paper Brief: Nutrition in Emergencies 1792 Anthropometry 1813.1 Weight for height reference in Z-scores 1913.2 Weight for height reference in percentage of the median 195

both boys and girls3.3 Height for age index in Z-scores 1973.4 Weight for age reference values for boys 1993.5 Weight for age reference values for girls 2014 Sample data collection forms for a nutrition 203

and mortality survey5 Random number table 2076 Example of ethical clearance form 2097 Resources 2178 Glossary of terms 2199 Q&A sheet 227

Table of Contents


As a joint collaboration between the World Food Programme (WFP) and the Centers forDisease Control and Prevention (CDC), we would like to acknowledge the hard work ofthe persons involved in the development of this manual.

The key technical advisors were Bradley Woodruff and Reinhard Kaiser from the CDC.Many thanks for their technical wisdom, patience and persistence. In addition, warmthanks are given to Roodly Archer and Fiona Galloway of the CDC for their consistentsupport and input into the manual development process.

The core WFP team consisted of Rita Bhatia and Leah Richardson. Patrick Webb,Andrew Thorne-Lyman and Soha Moussa were also intimately involved in the develop-ment process - warm thanks for their technical input and illuminating visions.

Additional thanks to Kevin Sullivan for his technical review and comments.

There are many people who have contributed by providing comments on this manu-al and who deserve special mention, for without their help, advice and support, thismanual would not have been possible. In particular, thanks are given to all the staffof Nutrition Service and to the staff involved in the accompanying Pilot AdvancedNutrition Training.



The Purpose of this ManualWHY THIS MANUAL? To provide guidance on issues relating to nutrition and mortality surveys. To standardize survey methodology used by WFP staff, consultants and implementing

partners as a means of ensuring quality. To standardize survey data interpretation and reporting.

WHO IS IT FOR? WFP staff involved in nutrition-related data collection and/or nutrition interventions. WFP staff involved in nutrition intervention decision-making. WFP consultants and partners involved in nutrition surveys and interventions.

WHAT DOES IT CONTAIN? A chapter on anthropometry and micronutrient deficiencies. A chapter on mortality. Guidance on deciding when secondary data are of sufficient quality for WFP purposes,

thereby rendering a new survey unnecessary. A chapter on survey methodology, including an essential guide on selecting appropriate

survey methods and calculating sample size. Guidance on interpreting and using survey results along with available complementary

materials to make informed decisions. Guidance on reviewing survey reports for quality. Example of a good survey in comparison to a less valid one.

HOW SHOULD IT BE USED? As a reference guide. As complementary material for the WFP Advanced Nutrition Training. As a basis for framing questions/discussions with nutrition experts.

WHAT IT DOES NOT DO! Does not absolve you of carefully thinking about decisions. Does not provide programmatic guidance on what to do with survey results (guidance

on such issues can be found in the WFP Food & Nutrition Handbook). Does not provide guidance on identifying malnutrition on an individual basis, but

focuses on population-based malnutrition. Does not provide guidance on screening for either malnutrition or nutrition surveillance.


While nutrition has been central to WFP's mandate for the past 40 years, its importanceto WFP is growing. Already recognized as a key player in nutrition, WFP plays an increa-singly visible role in micronutrient fortification, HIV/AIDS-nutrition programming, scho-ol nutrition and enhanced maternal and child interventions. Following the ExecutiveBoard's endorsement of three nutrition policies in 2004, WFP's Strategic Plan for 2006-2009 reconfirms the organization's commitment to support improved nutrition amongchildren, mothers and other vulnerable people in both crisis and non-crisis settings.

However, achieving greater impact, and more clearly documenting results, will be a chal-lenge. The adoption of nutrition indicators in the context of Results-Based Managementrepresents a significant shift in WFP's use of nutrition data - going beyond monitoringand evaluation to the corporate reporting of nutrition and mortality outcomes. Enhancingthe capacity of WFP staff, partners and national counterparts to collect and interpret sur-vey-derived data will be a key to future successes. It is of utmost importance that suchdata are collected using appropriate methods, interpreted meaningfully (in light of com-plementary information on food security, health, markets, etc.), and presented and usedin transparent, appropriate ways.

This manual was prepared to support such capacity-enhancement, providing rigorousyet accessible advice on survey dos and don'ts. It provides step-by-step guidanceintended not only for nutritionists and nutrition focal points, but for all staff involvedwith data management, programme design and reporting. This is not to suggest thatWFP staff collect most nutrition information; such data are collected frequently bypartners. However, even when they do not themselves design and conduct surveys,WFP staff must be conversant with data quality issues to be able to interpret and useinformation appropriately. In other cases, WFP country offices, often with headquar-ters and regional bureaux support, will indeed directly oversee data collection andanalysis. This manual tells you how.

The manual (and its associated training modules) is a team product, combining inputfrom many individuals whose contributions are much appreciated. Future editions areenvisaged, with updates occurring according to developments in nutrition science, sur-vey methods and WFP needs. Feedback is therefore always welcome. We hope that theinformation provided will be widely used and lead to further improvements both in pro-gramming and in our ability to report on successful interventions.

Patrick Webb and Rita BhatiaNutrition Service

WFP, RomeJuly 2005




THE IMPORTANCE OF NUTRITION ANDMORTALITY INFORMATION FOR WFPSince its first operations in the early 1960s,the World Food Programme (WFP) hasprovided food to beneficiaries with thedual objectives of saving lives in crises andseeking to enhance lives and livelihoods indevelopment settings. Very often this hasrequired explicit attention to nutrition. Forexample, in emergencies malnutrition isan important determinant of mortality;food interventions therefore play a key rolein saving lives through their impact on thenutrition and health of affected popula-tions. That is, WFP emergency interven-tions seek to prevent the deterioration, orpromote recovery, of nutritional status ofcrisis-affected people. Outside of emergen-cies, WFP also seeks to improve the nutri-tion of vulnerable subpopulations at criti-cal times in their lives (particularly pre-gnant and lactating women, preschoolchildren, and certain adolescents).

In both contexts, operational success(i.e., positive impacts on nutrition)depends on effective use of nutrition data- information that helps define the pro-

blem, design appropriate responses, docu-ment change and allow for reporting oneffectiveness. Since 2004, the use of dataon nutrition (and now mortality) has takenon a much higher significance. This can betraced to five important developments:

First, in 2004, WFP's Executive Boardendorsed three new nutrition policy papers(see Annexes 1.1-1.3). These pol


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