CONTROVERSIES IN ANTHROPOMETRIC

REFERENCE STANDARDS IN IDENTIFICATION

OF AT RISK PERSONS

Dr. Avula Laxmaiah, MBBS, DPH, MPH, Ph.D, MBA, PG 
Certificate in Applied Nutrition

Scientist ‘F’ & Head, Division of Community studies
National Institute of Nutrition, ICMR
Hyderabad‐500 007

Phones: 91‐040‐27019141,
Mobile  : 09395113419
E‐ Mail: avulalaxman@yahoo.com/laxmanavula09@gmail.com
 Role of Nutrition assessment
¾ Epidemiological data support that the   
association between anthropometric measurements 
and morbidity and mortality.   
¾ Undernutrition – Low resistance – frequent infections.

¾ Obesity and overweight is also associated  with 
increased risk of developing cancer of  the breast, colon, 
pancreas, endometrium, gallbladder, esophagus, kidney.

¾ Assessment of nutritional status  is essential for early 
detection of undernutrition and at risk population in 
the community.

¾ In fact, anthropometry started with the use of 
ergonomics.
 ERGONOMICS

HEIGHT OF DOORWAY WIDTH OF A CHAIR

LEVEL OF DOOR HANDLE
LEVEL OF DOOR HANDLE
 How to assess nutritional status?

The commonly used nutrition assessment

methods are as follows:

• Anthropometric measurements
• Bio-chemical estimations
• Clinical examination
• Dietary intake methods
• Energy requirements (Biophysical measurements)
 Anthropometrics Measurements

Height (Cm)
Weight (Kg)
Head, Chest, Mid Upper Arm, waist and Hip 
Circumferences (Cm)
Fat fold thickness  (mm) at Triceps, Biceps, Sub‐scapular 
and supra‐iliac sites.
 Age Assessment
Accurate age assessment is very essential to compare 
the measurements with age standard references, 
especially in case of pre‐school children. Age 
assessment  is very difficult in rural and tribal areas.
The following methods will be useful: 
™Horoscopy, 
™Birth certificate
™Immunization cards
™Delivery notes
™Local events calendar
 Equipment required
Measurement of Weight 
(Spring and beam balances are available)
Children: Salter balance, TANSI, SECA (electronic)
Adults   : Sattilan, SECA, SECA & Autco electronic

Measurement of Height 
Adults and Children ≥ 2 years
‐ 4 piece Anthropometric rod (up to 190 Cms)
Under 2 years children 
Height will be measured With help of Infantometer ( 
up to 100 Cm)
 Equipment required (Contd.)

Measurement of MUAC: ‐Fiber reinforced non‐elastic tape.
Fat Fold Thickness : ‐Holtain, Harpenden’s, UNA calipers,

Body Fat Measurement :‐ % of total Body Fat (Anthropometry)
: ‐ Bioelectric Impedance Assessment (BIA) 
: ‐ DEXA (Duel Energy X‐Ray Absorptiometry)
:‐ Under water weight (Gold standard)
Criteria and identification of ‘At Risk 
children’
• Criteria used for identification of At Risk 
children is by growth monitoring.
• Growth monitoring involves
– ‐ Regular weighing children
– ‐ 0‐3 years, every month
– ‐ 3‐6 yrs, every 3 months
 Techniques and Tools for GM
• Weighing scales
• Weigh baskets/slings
• Growth charts
• Community growth charts
 Current status of Growth Monitoring

• Currently ICDS is using growth charts developed based 
on Harvard standards as per the recommendation of IAP.
• The ICDS nutritional grades are Normal, Grade I, Grade 
II, Grade III & Grade IV (Mild, moderate, severe and very 
severe respectively).
• While  internationally normal, underweight  and 
severely underweight classification is used.
• Therefore, our ICDS nutrition data is not useful for 
international comparison.
 IAP CLASSIFICATION
(Weight For Age)

NORMAL(M‐1SD) : > 80%of MED
GRADE I (‐1SD‐2SD) : 71‐80%   MILD
GRADE II (‐2SD‐3SD) : 61‐70%MODER
GRADE III (‐3SD‐4SD) : 51‐60%SEVERE GRADE IV 
(<4SD) : <50% VERY SEVERE
In 1966, a simplified combined‐sexes version of 
Harvard growth curves – Reference  (WHO)
ICDS        IAP (Percentage of Median of Harvard Standards)

NCHS & HARVARD – SAME for < 5 Years

NFHS Standard Deviation
NNMB
Nutrition Surveys ‐3 SD = 67% instead 60% IAP
‐2 SD = 78% instead 80 % IAP

It means SEVERELY MALNOURISHED= (UNDERESTIMATION) and Malnutrition = 
OVERESTIMATION
Mechanical weighing scale Digital weighing scale
Measuring child height with 
Anthropometer rod
 Equipment required (Contd.)
Measurement of MUAC : Fiber reinforced non‐
elastic tape.
Fat Fold Thickness : Holtain, Harpendens, UNA 
calipers,

Body Fat % : ‐ Bioelectric impedance 

‐ Under water measurement
‐ Duel Energy X‐Ray Absortiometry
‐ Anthropometry (FTT at multiple sites)
 Measuring MUAC

Measuring mid arm circumference with fiber‐ Measuring length of < 2 year child
reinforced inelastic measuring tape Using Infantometer
Measuring fat fold thickness at biceps 
with Holtain calipers
 References and Standards

References:
‐ Harvard Reference values

‐ NCHS Reference values

‐ ICMR Reference values

Standards:
‐ WHO new child growth standards 2006
 Presentation
Preschool Children:
of Anthropometrics data
Using weights and heights, nutritional grades can be 
computed according to Gomez, IAP and Standard 
Deviation Classification.
Gomez classification

Weight for Age (% of Nutritional Grade

NCHS)
≥ 90 Normal
75 – 89.9 Grade I (Mild)
60 – 74.9 Grade II (Moderate)
< 60 Grade III (Severe)
 IAP Classification
The distribution of 6‐59 months children according to IAP 
classification is presented to enable us to compare the data 
with ICDS growth charts, the details as follows:

Weight for Age (% Nutritional Grade

Harvard)
≥ 80 Normal
70 – 79.9 Grade I (Mild underweight)
60 – 69.9 Grade II (Moderate)
50 – 59.9 Grade III (Severe)
< 50 Grade IV (Very severe)
 SD Classification
The WHO recommends use of SD Classification to categorize 
children in to various grades of nutritional status and it enable us 
to compare Indian Children internationally.

SD Classification Weight/Age Height/Age Wt/Ht

≥ Median
Median – 1SD to Med. Normal Normal Normal
< Median – 2SD to 1SD
Mod. Moderate Moderate
< Median – 3SD to 2SD underweight Stunting wasting
Severe Severe Severe
< Median – 3SD underweight stunting wasting
 16.00
Normal
14.00
I
Mild
12.00
Moderate II
10.00
W eig h t (in k g )

Severe III
8.00

V. Severe IV
6.00

4.00

2.00

0.00
0 3 6 9 12 15 18 21 24 27 30 33 36 39 42 45 48 51 54 57 60
Age in Months
80% of Median 70% of Median 60% of Median 50% of Median
Worldwide practices in child growth
monitoring
Reference population
Reference Countries
Number %
NCHS/WHO 99 68
Tanner 3 2
Harvard 13 9
Local 25 17
Other 17 12
Unknown 6 4

Source: de Onis et al. Worldwide practices in child growth monitoring. Journal of

Pediatrics 2004;144:461-5
Worldwide practices in child growth
monitoring
Anthropometric indexes
Countries
Index Number %

Weight for Age 141 97

Length/height for age 59 41
Weight for length/height 33 23
Head circumference for age 48 33
Others 4 3

Source: de Onis et al. Worldwide practices in child growth monitoring. Journal of

Pediatrics 2004;144:461-5.
Worldwide practices in child growth
monitoring
Problems with use of growth charts
Problems Countries
Number %
Interpreting growth curve 86 48
Inaccurate plotting 71 40
Understanding reference curves 51 29
Lack of trained personnel or equipment 13 7
Other problems 44 25
No problems 35 20

Source: de Onis et al. Worldwide practices in child growth monitoring. Journal of

Pediatrics 2004;144:461-5.
 Limitations of the IAP Grades
• Harvard standards are only reference values, not really 
standards.
• Harvard references are unisex, not used for gender 
differences.
• Harvard references were developed on bottle and mixed 
fed children. Exclusive breast fed children grow 
differently. 
• Below six years children have same potential of growth 
irrespective of their origin of birth, if provided optimal 
nutrition, environment and health. This was not 
considered in developing Harvard references.  
 Limitations of the IAP Grades

• Harvard references were developed based on the 
anthropometric data of only one nation, then 
applicability is big question?
• The ICDS data is not useful for international 
comparison, because internationally standard 
deviation (SD) classification is being used.
• Therefore, there is need to switch over to SD 
classification by using WHO new child growth 
standards.
 Need for New Standards
• Exclusive breast feeding for six months is normative
for growth and development.
• Earlier standards are based on infants receiving
bottle and mixed feeding.
• We should know how children should grow but not
how they are growing.
• Children below six years have same potential to
grow and develop as long as their basic needs of
nutrition, environment and health are met.
• The boys and girls grow differently.
20.0

B
18.0
Graph shows how Boys and Girls grow differently G
16.0

14.0 B
G
B
12.0 G

10.0

8.0

6.0

4.0

2.0

0.0
0 3 6 9 12 15 18 21 24 27 30 33 36 39 42 45 48 51 54 57 60

WHO MED BOYS WHO MED GIRLS WHO 2SD BOYS WHO 2SD GIRLS WHO 3SD BOYS WHO 3SD GIRLS
 New Standards versus Old Standards
• New Standards are based on breast fed
infants while old standards are based on
mixed feeding.
• Old standards are from one community while
new standards are from six different nations.
• New standards are sex specific while old
standards are unisex.
• New standards are based on S.D.
internationally accepted classification.
 New Standards versus Old Standards
• Presently in ICDS Harvard Standards are used 
specifying Normal, Grade I/II/ III & IV (Mild, 
moderate, severe and very severe).
• While  internationally normal, underweight  and 
severely underweight classification is used.
• New standards have prescriptive approach while 
old standard has descriptive approach.
Rationale for promoting healthy growth 
and development

™ Childhood morbidity
™ Childhood mortality
™ Childhood obesity
™ Child cognitive 
development 
™ Adult‐life consequences
WHO Child Growth Standards

The new
standards will
play a key role
in the
prevention and
early
recognition of
childhood
obesity
WHO Child Growth Standards
A growth
chart for 
the 21st

1 year 2 years 3 years 4 years 5 years century

 Growth Reference Study
Prescriptive Approach
z Optimal Nutrition
– Breastfed infants
– Appropriate complementary feeding
z Optimal Environment
– No microbiological contamination
Optimal
– No smoking
Growth
z Optimal Health Care
– Immunization
– Pediatric routines

WHO Multicentre Growth Reference Study

Mean length from birth to 24 months for the six MGRS sites

Brazil
Ghana
India
Norway
Oman
80

USA
Mean of Length (cm)
70
60
50

0 200 400 600

Age (days)
 Errors in Measurement
Inter individual variation 
(Variation between two individual's measurements)

Intra‐individual variation
(Variation between two measurements taken by same individual)

Example: Height (variation <0.2Cm)
Weight (variation < 100g)
MUAC  (variation < 0.2 Cm)
FFT      (variation  < 0.5mm)

Types of errors
Instrumental errors Random errors
Non‐random errors
Recording errors
Reading errors
 What is BIAS?

ƒ To give a particular direction
ƒ To  influence 
ƒ To prejudice
ƒ To cut cloth on the bias
ƒ Inclined to one side 
ƒ swelled on one side 
 Validity and Reliability
Validity is an expression of the degree to which a test is capable 
of measuring what it is intended to measure.
A study is valid if its results corresponding to the truth, there 
should be no systematic error and the random error should be as 
small as possible.
Validity
High Low

Measured values Measured values
High

Reliability
(Repeatability)
Measured values Measured values
Low
 RELATIONSHIP BETWEEN BMI AND
PERCENT BODY FAT AND FIXING ON BMI
CUT-OFFS FOR URBAN MEN AND WOMEN
• Studies have documented that relationship
between BMI and percent body fat varies
with age, gender and ethnicity. Moreover,
Asian Indians have higher fat mass at lower
BMI values than Caucasians.

• It has been recognized that the criteria

currently being used to classify overweight
or obesity in adult Europeans using BMI and
waist circumference may not be appropriate
for Asian populations.
• BMI has a limitation that it can not
distinguish between fat mass and fat
free mass.

• This limitation may become

important issue when comparing
ethnic groups with distinctively
different body proportions or
physique.
• There is a paucity of data on Indian population
especially for South Indians regarding BMI and
% BF relationship.

• Therefore, the present study was carried out

on urban men and women of 20‐60y.
COVERAGE

™ A total of 1032 individuals (HIG 278, MIG 365,

LIG 389) were covered for survey including both
the gender and income category.

™ Blood samples were collected on sub sample of

336 individuals (one third) for estimation of
Fasting blood glucose and lipid profile.
 Mean Anthropometric, Blood Pressure and
Bio chemical profile ‐ by income group‐Males.

Parameter HIG (117) MIG(154) LIG (165) Pooled

Height (Cms) 168.5a 168.0a 166.9a 167.7
Weight (kgs) 72.9a 70.8a 66.5b 69.8
Waist Cir (Cms) 93.0a 90.5a 86.0b 89.5
Hip Cir (cms) 96.3a 94.3a 90.1b 93.2
BMI (kg/m2) 25.6a 25.1a 23.9b 24.8
WHR 0.97a 0.96a 0.95a 0.96
W-HtR 0.55a 0.54a 0.51b 0.52
% Body Fat 29.6a 26.0a 23.4b 25.9
Blood Pressure
Systolic 124a 126a 127a 126
Diastolic 80a 82a 84b 82
Lipid Profile
Fasting Blood glucose 114a 114a 105a 111
Serum Triglycerides 164a 194b 158c 175
Total Cholesterol 173a 177a 161a 171

Different superscripts indicate significantly different from others
 Mean Anthropometric, Blood Pressure and 
Bio chemical profile ‐ by income group‐ Females.
Parameter HIG(161) MIG(211) LIG(228) Pooled
Height (Cms) 156.4a 153.3b 152.3b 153.7
Weight (kgs) 66.2a 60.0b 55.8c 60.1
Waist Cir (Cms) 83.7a 80.1b 75.8c 79.5
Hip Cir (cms) 100.6a 96.4b 91.9c 95.9
BMI (kg/m2) 27.1a 25.6b 24.0c 25.4
WHR 0.83a 0.83a 0.83a 0.83
W-HtR 0.54a 0.52a 0.49b 0.52
% Body Fat 39.0a 34.8b 32.2c 34.9
Blood Pressure
Systolic 120a 120a 111a 119
Diastolic 77a 77a 78a 77
Lipid Profile
Fasting Blood glucose 110a 106a 103a 106
Serum Triglycerides 127a 107a 108a 112
Total Cholesterol 176a 169a 182a 169

Different superscripts indicate significantly different from others
 Correlation between   BMI and other Anthropometric measurements

Income Gender %BF WC WHR

group
Male 0.535** 0.864** 0.223*
HIG
Female 0.626** 0.831** 0.315**
Male 0.766** 0.799** 0.681**
MIG
Female 0.715** 0.748** 0.536**
Male 0.811** 0.871** 0.741**
LIG
Female 0.784** 0.816** 0.303**
Male 0.728** 0.812** 0.653**
Pooled
Female 0.724** 0.759** 0.336**

** Significant at the 0.01 level
* Significant at the 0.05 level
 Correlation between  Anthropometric measurements and Lipid profile

Lipids Gender BMI WC %BF

Fasting blood Male 0.338** 0.330** 0.355**

glucose Female 0.225** 0.282** 0.275**
Male 0.154NS 0.204** 0.195*
Triglycerides
Female 0.273** 0.322** 0.326**

Total Male 0.279** 0.310** 0.309**

Cholesterol Female 0.169* 0.214** 0.358**

** Significant at the 0.01 level
* Significant at the 0.05 level
ROC curve for BMI ‐Males
Area Under the Curve

Test Result Variable(s): bmi

Asymptotic 95% Confidence

Interval

Std. Asymptotic
Area Error(a) Sig.(b) Upper Bound Lower Bound

.874 .017 .000 .842 .907

The test result variable(s): bmi has at least one tie between the positive actual
state group and the negative actual state group. Statistics may be biased.
a Under the nonparametric assumption
b Null hypothesis: true area = 0.5

Test accuracy
0.50‐0.75 –Fair
0.75‐0.92 –good
0.92‐0.97 –V.Good
0.97 ‐1.0 ‐excellent
ROC curve for waist circumference ‐Males
Area Under the Curve

Test Result Variable(s): wc

Asymptotic 95% Confidence
Interval
Std. Asymptotic
Area Error(a) Sig.(b) Upper Bound Lower Bound
.910 .014 .000 .883 .937
The test result variable(s): wc has at least one tie between the positive actual
state group and the negative actual state group. Statistics may be biased.
a Under the nonparametric assumption
b Null hypothesis: true area = 0.5

Test accuracy
0.50‐0.75 –Fair
0.75‐0.92 –good
0.92‐0.97 –V.Good
0.97 ‐1.0 ‐excellent
Central obesity and  Diabetes prevalence
Diabetes prevalence (%) %
insulin resistance: 
30
30
South Asian
South Asian 
susceptibility
20
20

10
10

European

000.8 0.9
0.8 0.9 11
McKeigue et al. Lancet, 1991, 337: 382 Waist // hip
hip ratio
Waist ratio
 Area under curve with 95% confidence interval and 
cut offs for body mass index, waist circumference for 
25% Body fat among Men – Income groups pooled
Obesity AUC (95% CI) Cut off Sensitivity Specificity
index Points (%) (%)
20 99.2 28.6
21 96.5 46.9

BMI 0.874 22 93.8 60.0

(0.842-0.907) 23* 86.9 69.7
24 76.9 78.3
25 67.2 85.1
83 95.0 62.3
0.910 84 93.8 68.6
WC
(00.883-0.937) 85* 91.2 71.4
86 88.1 73.7

*Optimal cut off point
 Relationship Between BMI and Cardiovascular Disease 
Mortality

3.0

2.6
Men
Relative Risk of Death

2.2
Women
1.8

1.4

1.0
Lean Overweight Obese
0.6
<18.5 20 25.0 30.0 >40.0

Body Mass index
Source: Calle et al. N Engl J Med 1999;341:1097.
 Unadjusted Odds ratio (OR) with 95% CI for hypertension: 
Kerala

Men Women
Variables
OR 95% OR 95%
Confidence Confidence
General obesity 2.6 1.89-3.61 2.43 1.92-3.09
(BMI)
Abdominal obesity 7.0 2.92-16.80 3.0 2.29-3.87
(WC)
Central obesity 2.2 1.83-2.66 2.07 1.69-2.53
(WHR)

NNMB tribal data (2008-09)

ROC curve for BMI ‐Females
Area Under the Curve

Test Result Variable(s): bmi

Asymptotic 95% Confidence
Interval
Std. Asymptotic
Area Error(a) Sig.(b) Upper Bound Lower Bound
.949 .011 .000 .928 .970
The test result variable(s): bmi has at least one tie between
the positive actual state group and the negative actual state
group. Statistics may be biased.
a Under the nonparametric assumption
b Null hypothesis: true area = 0.5

Test accuracy
0.50‐0.75 –Fair
0.75‐0.92 –good
0.92‐0.97 –V.Good
0.97 ‐1.0 ‐excellent
ROC curve for waist circumference ‐Females
Area Under the Curve

Test Result Variable(s): wc

Asymptotic 95% Confidence
Interval
Std. Asymptotic
Area Error(a) Sig.(b) Upper Bound Lower Bound
.961 .009 .000 .943 .979
The test result variable(s): wc has at least one tie between the positive actual
state group and the negative actual state group. Statistics may be biased.
a Under the nonparametric assumption
b Null hypothesis: true area = 0.5

Test accuracy
0.50‐0.75 –Fair
0.75‐0.92 –good
0.92‐0.97 –V.Good
0.97 ‐1.0 ‐excellent
 Area under curve and Optimal cut offs for body mass index, waist
circumference for 30% Body fat among –women
income groups pooled

AUC (95% Cut off Sensitivity (%) Specificity (%)

Obesity index
CI) Points
20 96.0 83.0

21 93.0 83.0
0.949
BMI (0.928- 22* 88.0 90.0
0.970) 23
80.1 93.0

24 70.9 97.0

70 90.7 85.7

0.961 71* 88.9 90.8

WC (0.943-
0.979) 72 87.1 93.9

73 84.9 96.9

*Optimal cut off point
SAME BMI 22.3 FOR BOTH OF THEM
Anthropometry and Lipid profile of hypertensive and 
Normotensives‐ income groups pooled
Males Females
Anthropometry Htn Normal Test Htn Normal Test
(n=106) (n=325) sig (n=110) (n=486) sig
Height 166.8 166.0 P<0.001 152.7 153.9 P<0.005
Weight 74.6 68.3 P<0.001 66.6 58.7 P<0.001
BMI 26.7 24.2 P<0.001 28.6 24.7 P<0.001
%BF 29.5 24.8 P<0.001 38.6 34.2 P<0.001
LBM 52.4 50.8 NS 40.6 38.1 P<0.01
WC 95.9 87.5 P<0.001 87.4 77.7 P<0.001
WHR 0.99 0.94 P<0.001 0.86 0.82 P<0.001
W.Ht.R 0.58 0.52 P<0.001 0.57 0.50 P<0.001
Lipids
Fasting blood
133 105 P<0.001 129 102 P<0.001
glucose
Serum
213 163 P<0.05 124 110 NS
Triglycerides
Total cholesterol
181 168 NS 174 168 NS
 Mean± SE of anthropometric, blood pressure and biochemical
parameters of individuals by percent body fat.

Parameter % Body fat % Body fat

Male (436) Female(596)
<25% ≥25% P-Value <30% ≥30% P-Value

Anthropometry
BMI 21.6±0.220 26.9±0.238 P<0.001 19.1±0.239 26.7±0.197 P<0.001
WC 79.5±0.669 96.2±0.553 P<0.001 63.4±0.585 82.6±0.450 P<0.001
WHR 0.90±0.004 0.99±0.058 P<0.001 0.78±0.013 0.84±0.002 P<0.001
W.Ht.R 0.47±0.054 0.57±0.0552 P<0.001 0.41±0.003 0.53±0.003 P<0.001
Blood Pressure (mm/Hg)
Systolic 119±1.189 130±1.100 P<0.001 107±0.1336 121±0.895 P<0.001
Diastolic 79±0.0828 85±0.661 P<0.001 69±0.868 78±0.515 P<0.001
Lipid profile
Fasting blood
101.4±3.921 117.9±4.313 P<0.01 91.3±1.269 109.9±3.053 P<0.01
glucose
Triglycerides 159.0±18.658 185.6±10.629 NS 73.8±5.356 122.5±5.584 P<0.001
Total cholesterol 161.5±5.301 177.6±4.19 P<0.01 146.4±4.705 174.3±3.490 P<0.001
 Mean± SE of blood pressure and biochemical
parameters of individuals by BMI

Body Mass Index

Male Female
Parameter
P- P-
<23 ≥23 <22 ≥22
Value Value
Blood Pressure (mm/Hg)
120.9 ± 128± 110.3 ± 121.7 ±
Systolic 0.001 0.001
1.45 1.03 1.31 0.95
78.7 ± 84.6± 71.4 ± 78.8 ±
Diastolic 0.001 0.001
0.88 0.64 0.79 0.54
Lipid profile
Fasting blood 100.9 ± 118.7± 94.0 ± 110.8 ±
0.01 0.01
glucose 2.67 4.78 1.91 3.31

160.3 ± 185.5± 86.2 ± 122.8 ±

Triglycerides NS 0.001
16.55 11.93 6.44 5.95
Total 161.3 ± 178.2± 157.7 ± 172.8 ±
0.05 0.05
cholesterol 4.87 4.41 5.47 3.61
 Mean± SE of blood pressure and biochemical
parameters of individuals by Waist circumference
WC
Male (436) Female(596)
Parameter
P- P-
<85 ≥85 <71 ≥71
Value Value
Blood Pressure (mm/Hg)
119.4 ± 129.2 ± 109.6 ± 121.8 ±
Systolic 0.001 0.001
1.44 1.01 1.36 0.93
78.3± 84.6 ± 70.9 ± 78.9 ±
Diastolic 0.001 0.001
0.87 0.64 0.81 0.54
Lipid profile
Fasting blood 94.7 ± 120.2 ± 93.3 ± 111.7 ±
0.001 1.54 0.001
glucose 1.39 4.40 3.44

132.0± 198.0 ± 80.0 ± 126.8 ±

Triglycerides 0.001 4.46
0.001
13.09 12.63 6.26
Total 158.7± 177.9 ± 153.4 ± 175.5 ±
0.01 4.90 0.001
cholesterol 5.17 4.17 3.71
Odd’s ratio with 95% CI  of percent Body fat, BMI and waist circumference with 
Hypertension

Anthropometric
Odd’s ratio with 95% CI
indices
Male Female

4.4 6.4
% Body Fat
(2.5-7.6) (2.3-17.9)

3.6
2.5
BMI (1.9-6.9)
(1.5-4.1)

2.7 4.3
WC
(1.6-4.7) (2.1-8.8)
 HTN Vs  WC, WHR,  and  BMI 
(Odds Ratios with 95% CI )

VARIABLE MEN WOMEN

2.6 2.2
WHR
(2.4 - 2.8) (2.0 - 2.4)
3.1 3.2
BMI
(2.7 - 3.5) (2.8 - 3.5)
3.8 4.6
WC
(2.7 - 5.3) (4.0 - 5.2)
 DM & IGT  Vs  WC, WHR,  and  BMI 
(Odds Ratios with 95% CI )

VARIABLE MEN WOMEN

6.5 7.0
WC
(3.1 – 13.9) (4.3 – 11.6)
4.4 1.7
WHR
(2.9 – 6.5) (0.9 – 2.8)
2.5 3.8
BMI
(1.5 – 4.2) (2.5 – 6.0)
 CONCLUSIONS

• Significant correlation was observed between BMI and

percent body fat, waist circumference, waist to Hip
ratio among men and women of different socio-
economic groups.
• Similarly, anthropometric parameters also showed
significant correlation with Fasting Blood Glucose,
Triglycerides and total cholesterol in both the gender.
• Among men, the mean serum triglycerides was
significantly higher in MIG compared to HIG and LIG.
No differences were observed among women in the
mean fasting blood glucose levels, triglycerides and
total cholesterol in different income groups.
• The optimal cut off level of BMI among Men was
23kg/m2 and women was 22kg/m2 arrived to indicate
overweight and obesity using ROC curve analysis,
which are similar to that suggested by WHO cut off
values for Asian Indians (23kg/m2).

• Similarly, the waist circumference cut off levels were

also derived as 85cm for men and 71cm for women
when all the income groups were pooled, which
were below that of WHO cut off levels suggested for
Asian Indians (men:90cm and women:80cm).
• All the anthropometric variables are
significantly higher among hypertensives
compare to normal in both the gender,
except fasting blood glucose and serum
triglycerides among men and only fasting
blood glucose among women were
significantly higher in hypertensives.

• Derived cut off values for BMI and Waist

Circumference in both men and women
showed higher risk for hypertension.
Fat Mass Index

FMI= Fat Mass (kg)
{height (m)}2

Fat Free Mass Index

FFMI = Fat Free Mass (kg)
{height (m)}2
 Area under the curve with optimal cut offs for
fat mass index using percent Body fat as standard

Gender AUC (95% CI) Cut off points Sensitivity (%) Specificity (%)
6.1* 90.0 92.0
6.2 88.0 92.6
0.976 (0.966- 6.3 87.7 93.1
Males
0.987) 6.4 85.8 94.9
6.5 83.5 96.0
6.6 83.1 98.1
6.1 98.0 88.0
6.2 97.4 91.0
6.3 97.0 92.0
0.992 (0.986- 6.4 96.6 93.0
Females
0.997) 6.5 96.0 94.0
6.6* 95.2 97.0
6.7 93.6 98.0
6.8 93.2 98.0
*Optimal cut off point
ROC curve for Fat Mass Index ‐ Males

Area under curve 
0.976      ( 0.966‐0.987 )

Test accuracy
0.50‐0.75 –Fair
0.75‐0.92 –good
0.92‐0.97 –V.Good
0.97 ‐1.0 ‐excellent
ROC curve for Fat Mass Index ‐ Females

Area under curve 
0992      ( 0.986‐0.997 )

Test accuracy
0.50‐0.75 –Fair
0.75‐0.92 –good
0.92‐0.97 –V.Good
0.97 ‐1.0 ‐excellent
 Classification of Nutritional status (Schutz Y, etal 2002)

1. Low FFMI vs high FMI Judged as sarcopenic Obesity

2. Low FFMI vs low FMI Chronic energy deficiency

3. High FFMI vs low FMI Evidence of muscular hypertrophy

4. High FFMI vs high Which suggests combined excess FFM

FMI and FM (such as in a SUMO somatotype)

* low = below 5th centile and High = greater than 95th centile
GROWTH MONITORING
¾ It is necessary to find out whether the child is
growing normally as expected or not. This
process of observing growth of the child at
regular intervals (i.e. monthly or quarterly) is
called growth monitoring.
¾ Growth monitoring provides a visual record of
the growth pattern of the child.
USES OF GROWTH MONITORING

¾ Assess the child’s nutritional status

¾ Early detection of growth failure in children
so as to initiate action at an appropriate
time to improve the growth status
¾ As a tool to educate the mother about the
child’s growth and its relationship with child
care and feeding.
STEPS IN GROWTH MONITORING
¾ Assess the age of the child accurately to the nearest month-using date
of birth/local events calendar.
¾ Record the weight of the child accurately (nearest to 100g) using
standard weighing scale after adjusting the balance for zero error with
minimum clothing on the child.
¾ Plot the child’s weight correctly on the growth chart.
¾ Interpret the growth of the child from the weight recorded for the
consecutive periods on the growth chart to identify growth faltering, if
any.
¾ Use this information to educate the mother about her child’s growth.
¾ Monitor the changes in nutritional status of children in the area.
GROWTH FALTERING
When two marks indicating the weight of the
child for two consecutive periods are joined,
the direction to which the line is pointing will
indicate how the child is growing.
The direction of the line may be
Upward weight gain
Horizontal no change in weight
Downward loss of weight
Standard Deviation classification (weight 
for age)
Cut off level Color zone Nutrition grade
≥-2SD Green Normal

-2SDto -3SD Yellow Moderate

<-3SD Orange Severe

Using WHO Child Growth Standards