André Renzaho, Cate Burns & Daniel Reidpath
|This article reviews the merit of using the World Health Organization (WHO) / National Center for Health Statistics (NCHS) references to evaluate the nutritional status of refugees and famine-affected populations and the implication of the findings for further development of Public Health Nutrition programs. Public health nutrition interventions, in order to change the nutritional status of refugees and famine affected-populations, need to be based on accurate and appropriate reference criteria in order to satisfy demands for cost-effectiveness and preserve the human right to adequate food. However, many are confused by the current practice of estimating malnutrition in complex emergencies and it appears that the use of WHO/NCHS references may not be appropriate for use under these conditions in particular, and in the third world in general. To verify this claim, we conducted a literature review. Factors to be reviewed were selected a priori. Computer-assisted searches for English-language publications in the MEDLINE database were conducted and references cited in related publications were reviewed. The literature was restricted to published papers from 1975 to 2000, which focused on malnutrition and its measurement. Findings from the literature review indicate that there is a need to develop more appropriate references that are reflective of the field of intervention. In the absence of more appropriate references, this paper presents the advantages and disadvantages of using these references and some policy recommendations.|
Civil unrest, war, armed conflicts, drought, floods, crop failure and other disasters which have been experienced by developing countries around the world in the last three decades have been shown to be contributing factors to the deterioration of the health and nutritional status of the affected populations (Medecins Sans Frontieres, 1997; Young, 1992). Inadequate dietary intake, high crude and disease-specific mortality rates, epidemics of measles or infectious disease outbreaks, a high prevalence of respiratory or diarrhoeal diseases, or a high prevalence of malnutrition have been used as proxy measures of an impaired health environment (UNHCR/WFP, 1999; WHO et al., 2000). A favorable health environment is that which allows children to attain their genetic growth potential (WHO Working Group, 1995). Hence, an impaired health environment is an environment that in some way limits children attaining their genetic growth potential. A number of factors which characterise an impaired health environment have been identified by organizations working and researching in the field such as Medecins Sans Frontieres (1997) and the World Health Organization (WHO Working Group, 1995). These include household food insecurity, food availability and accessibility, inadequate social and care environment (direct caring behaviors, feeding behaviors, hygiene behaviors, psychosocial behaviors and health behaviors), limitations and restrictions on women's and children's roles, status and rights (access to resources, workload and responsibilities), higher exposure to communicable diseases, a lower standard of health services, lack of water, poor hygiene, poor public health measures (low immunization coverage, low level of breast-feeding, high prevalence of low birth weight infants), and chronic poverty and its consequences.
Thus, malnutrition is a complex and multidimensional disease and is related to these factors that characterise an impaired health environment. For example, research has shown a direct relationship between infection and malnutrition (King & Burgess, 1992), poverty and malnutrition (Bronner, 1996) and food insecurity and malnutrition (Young, 1992). Hence, it has been suggested that nutritional status be used as a predictor of child survival (Schroeder & Brown, 1994). In addition, both the World Food Summit and the consultation of the High Commissioner for Human Rights on the right to adequate food recognized in their forums, held in November 1996 and November 1998 respectively, that access to adequate and nutritious food is a basic human right (Marchione, 2001). Human right to food means that people must have access to adequate food at all times with the ultimate objective to achieve nutritional well-being. The human right to food also applies in refugee settings. However, in many refugee camps across the world, the principle of human right to food is being violated. The amount of energy provided by the general food ration is being drastically reduced by the World Food Program in response to dwindling funds as a result of what is currently known as "Donor Compassion Fatigue" or "Donor Apathy" (Presbyterian World Service & Development, 2002). According to Moeller, donor compassion fatigue refers to the result of donors feeling that, no matter what they do, it is ineffectual and hence preferring to no longer donate (Moeller, 1999).
The result of this policy is illustrated by the current development in Kakuma Refugee Camp, Kenya. For example, Graham Greene, the manager of the camp indicates that he had to discharge 70 of his 120 permanent staff running the camp and 200 refugee incentive workers as a result of dwindling donations. In this camp, the general food ration has been reduced by 30.4%, that is, from 2300 Kcal to 1600 Kcal (Presbyterian World Service & Development, 2002).
The only way to measure the impact of "Donor Compassion Fatigue" and the nutritional well-being, both at individual and the community, level of the refugee community is to estimate the nutritional status of that community or of the individual. This implies the existence of appropriate standardized reference values against which the evaluation of the nutritional status of the target population is possible. In the absence of such standardized reference values, this paper examines the merits and ramifications of using WHO/NCHS references as a tool to assess the nutritional well-being of refugee children.
A child is said to have adequate nutritional status if he/she meets milestones for growth and development. Different parameters have been used to evaluate individual nutritional status. For children, however, growth has been considered a sensitive marker of nutritional status (King & Burgess, 1992; Pipes & Trahms, 1993). Children's growth and/or nutritional status is assessed using body measurements (WHO et al., 2000; Bhargava, 2000; Bronner, 1996). The various approaches used to gather the data necessary to assess the nutritional status of children can be summarized into four categories:
|ANTHROPOMETRIC MEASUREMENTS IN REFUGEE CAMPS: APPLICATION OF WHO/NCHS REFERENCES|
Malnutrition can be defined using three different indices and these are: height-for-age (H/A), weight-for-age (W/A) and weight-for-height (W/H). The H/A, W/A and W/H are used to measure chronic malnutrition, underweight and acute malnutrition respectively. Chronic malnutrition or stunting is a nutritional disorder that reflects deficits in linear growth both before and after birth due to the long-term collective consequences of insufficient nutrition and/or poor health (UN ACC/SCN, 2000). In contrast, acute malnutrition or wasting reflects the current situation and is influenced by factors such as recent infectious disease as a result of poor hygiene, lack of clean water, and an inadequate immunization strategy; or seasonal differences in food availability and inadequate access to food as a consequence of poverty or poor crop yield (Schroeder & Brown, 1994; Medecins Sans Frontieres, 1995). Underweight is nutritional disorder encompassing a component of both stunting and wasting since the W/A index is affected by weight and height of a child (WHO et al., 2000). It represents a long-term effect of inadequate nutrition and/or health experienced by refugee or other communities in the situation where wasting is non-existent. Therefore, the W/A index is better as a tool for growth monitoring of children in communities rather than as a planning tool for decision-making
Given that refugee settings are characterized more by fluctuation in weight than height as a result of sudden change in food supply, disease outbreaks or inadequate water and sanitation and so forth, the W/H index as a measure of nutritional status is preferred in these circumstances. The refugee child's actual weight is compared with the WHO/NCHS reference median weight for a child of the same height expressed either as a Z-score or a proportion of median (WHO et al., 2000). The percentage of median represents the ratio of the child's weight to the reference median weight of a child of the same height. The Z-score determines the distance between the child's weight value and the expected median value of the reference population for a child of the same height.
Therefore, in complex emergencies, the most commonly used variable to assess the nutritional status of children is the anthropometry because of its ease of use, reliability, validity (Renzaho et al., 1996; Dewey et al, 1995, Mathews et al., 1997) and affordability, especially in developing countries and refugee settings. Children are weighed, measured and have their age determined. Obtained anthropometric data are compared with the WHO/NCHS references for interpretation.
In practice, the pitfalls of adopting the WHO/NCHS references fall into two major categories: 1) the suitability of the WHO/NCHS reference values for use in refugee settings and 2) the appropriateness of the WHO/NCHS reference values to define malnutrition in the refugee community.
|1. Suitability of the WHO/NCHS reference values|
Regardless of the index being used to define malnutrition in refugee settings, the current growth references have some drawbacks. The WHO/NCHS references were derived from two sets of data measuring children: the 0-24 months dataset and the 2-18 years old dataset. Reference values for the 2-18 dataset were based on nation-wide data from the United State NCHS. The reference values for children aged from 0 to 24 months were obtained from a sample of children who were involved in the Fels Longitudinal study, Yellow Springs, Ohio, which was conducted from 1929-1975 (Hautvast, 2000). Firstly, children recruited for this study were constituted of a sample of Caucasian infants, the majority of whom were born to middle-class families. Secondly, although repeated measurements were performed during the data collection, the measurements were, however, performed on a three-monthly interval basis rather than every month. This frequency of monitoring was more likely to distort the growth curve especially during the first 6 months of life when monthly repeated measurements are required to accurately describe the growth curve. Finally, the majority of children who participated in the Fels Longitudinal study were bottle-fed and the few who were breast-fed did so for a period as short as 3 months. The application and validity of the use of these reference values in refugee and famine-affected populations remains contentious since refugees are as ethnically different to those children from whom references were obtained as they are socio-economically.
Through a review of the literature a WHO working group (WHO Working Group 1995) obtained a dataset of children who were similar environmentally to those from whom the growth references were obtained ; that is, born in an environment that helped them attain their genetic potential. But these children were different to the growth references in terms of feeding practices. They provide a comparative sample to the WHO/NCHS reference dataset. A sample size of 221 children was obtained and came from developed countries including Canada, Denmark, Finland, Sweden, the United Kingdom and the United States of America. These children were exclusively breast-fed for the first four months and breast-feeding continued until 12 months of age; solid food was introduced by six months and non-human milk products (formulae) were not initiated in the first 12 months for more than half of the children (62%). This group has been referred to as the "12-month breast-fed pooled data set".
In addition, the analysis of the 12-month breast-fed pooled data set did not include low-birth-weight or pre-term babies or large-for-gestational infants. The study found that, during the first two months of life, breast-fed children were more likely to grow rapidly in both weight and height than those of the WHO/NCHS statistics. But from three months of age and over, breast-fed children showed slower growth than the WHO/NCHS reference group with the growth curve lying below the WHO/NCHS curve. This variance was more noticeable in terms of weight than in height. Differential Z-score patterns were reported at 12 months between the "12 month breast-fed pooled data set" and the WHO/NCHS reference group. Mean Z-scores for W/A, and W/H were below the respective mean Z-scores of the WHO/NCHS reference. These findings suggest that children whose feeding followed the WHO feeding guidelines (which encourage breast-feeding) and who lived in an environment favouring the achievement of their hereditary growth potential showed a growth trend that diverged considerably from the WHO/NCHS growth reference group.
Would this be the case for children living in an impaired public health environment such as children living in poverty or refugee camps where breast-feeding is a key to survival? An evaluation study was carried out to appraise the applicability of both the "12-month breast-fed pooled data set" and the standard WHO/NCHS growth references in an impaired public health environment. The study was carried out in Zambia (Hautvast et al, 2000). A sample size of 518 children aged between 0-12.5 years of age who are similar to the 12-month breast-fed pooled data set in terms of feeding practices (e.g., fed according to WHO feeding guidelines), but dissimilar in terms of health environment, was obtained. These children were attending the Maternal and Child Health clinics and were selected from 11 randomly chosen villages. These villages were located in a district with poor quality health care facilities and an infant mortality rate of 149 per 1000 births. The study found that, compared with breast-fed children, the growth reference curve shifted toward the left during the first 7 months of life meaning that, at that age, the breast-fed dataset predicted a higher proportion of stunted and underweight children than the WHO/NCHS growth reference. In addition, regardless of the index used to classify malnutrition, the breast-fed children dataset had higher medians and showed smaller standard deviations than the WHO/NCHS growth reference during the first seven months of life. At this age, the WHO/NCHS growth reference misses a proportion of malnourished children who should be benefiting from nutritional interventions. In the light of these findings, it is clear that during the first 7 months after birth, the WHO/NCHS growth reference tends to misclassify malnutrition prevalence and misdiagnose the time of growth failure in breast-fed children who are socio-economically deprived and living in an impaired health environment. These results suggest that references that are reflective of infant growth, feeding practices, the health environment in which children are growing and inclusive of all ethnicities are needed in order to accurately measure malnutrition for public health planning purposes.
|2. Defining malnutrition: appropriateness of reference values in refugee settings|
When planning nutritional interventions in refugee settings, a nutritional survey needs to be carried out. The results of the nutritional survey are used for decision-making. During the nutritional survey, the weights and heights of children are taken and compared to the WHO/NCHS references, expressed either as a percentage of the median or as a Z-score. However, the percentage of the median seems to be the most commonly used in refugee settings due to its ease of use. This scale is commonly used for estimating the size of feeding programs and for admission criteria to feeding centres.
By virtue of its nature, unlike the Z-score which illustrates how distant a measured child's weight is from the median reference weight for a standard child of the same height, the percentage of the median fails to recognize the variation in weights at different heights, hence leading to misclassification of malnutrition with the likelihood of false negatives ; that is classifying malnourished children as being well nourished. For example, cut-offs currently being used to classify malnutrition in refugee settings are presented in table 1. Now, if we consider a child who has a height of 123 cm and weighs 18.7 kg without oedema, the W/H of this child as a proportion of median is 80.2% or -2.3 Z-score if Z-score is used as the scale. In practice, the proportion of median classifies this child as well nourished (W/H=80.2%: >80%) whilst the Z-score indicates that the child is moderately malnourished (W/H=-2.3 Z-score: < -2 Z-score) and should be admitted to a supplementary feeding centre (SFC). Despite the Z-score being more sensitive and specific than the proportion of median, it is less commonly used by health professionals and nutritionists working in refugee settings because it is harder to calculate than the proportion of median and it is poorly understood.
Global acute malnutrition (encompasses both severe and
<80% or < -2 Zscore and/or oedema
Admitted to TFC (a) for medical and nutritional treatment
< 70% or <-3 Zscore or oedema
Admitted to SFC for nutritional support to prevent severe malnutrition
between 70-80% or between -2Zscore and -3 Zscore
(a) TFC = Therapeutic Feeding Centre
In the same line of reasoning, different surveys have shown that when both the proportion of median and Z-score are used in nutritional surveys they provide different pictures of the malnutrition prevalence. For instance, in an evaluation of the impact of nutritional interventions in Rwandan refugees, Katale Camp, Renzaho et al. (1996) carried out a nutritional survey using a 2-stage cluster sampling method. 30 different clusters were identified and in total, anthropometric data were obtained from 441 children aged between 6-59 months. The malnutrition prevalence using the proportion of median was 1.9% (95%CI: 0.5%-5%) and using Z-score the malnutrition prevalence was 3.5% (95% CI: 1.5%-7.2%). The Z-score predicted a malnutrition prevalence that was 1.9 times greater than that estimated by the proportion of median. Since the malnutrition prevalence is used to plan and estimate the size of feeding centres and food needs, the current use of the proportion of median may deprive a large proportion of children in high need access to nutritionally adequate food and nutritional and medical care and hence violate the human right to an adequate standard of living and the human right to freedom from degrading treatment.
|PUBLIC HEALTH IMPLICATIONS|
Median weights derived from the WHO/NCHS references are not representative of the populations for whom these are used as reference values. The sample was constituted predominantly of middle-class Caucasian children primarily fed infant formula. Hence, the sample was not representative in terms of infant feeding habits (breast-feeding versus infant formula), socio-economic status (developed countries versus poor countries versus refugee camps) and ethnicity (white American/European versus black African and Asian). Although widely used as reference data, the WHO/NCHS data cannot really be considered to represent infant growth in general. Current studies have shown that the WHO/NCHS reference data do not reflect the growth of healthy breast-fed children (WHO Working Group, 1995; Dewey et al, 1995). This may also be true in refugee settings where breast-feeding is a key to survival and preventing morbidity from infectious disease. Applied to a poor population such as the test population used by the WHO Working Group on Infant Growth and in a malnourished population such as in Zambia, an alternate reference data set; the " 12-month breast-fed pooled data set" classifies larger proportions of children as stunted and/or underweight during the first 6 months of life than the WHO/NCHS reference.
The advantage of using appropriate references is that malnourished refugee children will be diagnosed early and appropriate interventions delivered accordingly. Hence, public health nutritionists will be able to prevent long-term negative effects caused by malnutrition including reduced adult size and reduced work capacity, greater risk of obstetric complications for women (Medecins Sans Frontieres, 1997), reduced economic productivity at both regional and national level and concurrent and later delay in psychomotor development (King & Burgess, 1992).
In the absence of ethno-specific reference values, findings from this paper indicate that the use of Z-score may be the answer. This is because the Z-score is more likely to detect all acutely malnourished children. In addition, studies in Angola by Concern Worldwide (Mathews et al, 1997) found that the introduction of Z-score in feeding centres, where admission were previously based on the proportion of median, resulted in a numeric increase of children admitted to feeding centres by 55%-65%. Hence, the proportion of median is not an appropriate index for either nutritional surveys or selection criteria for feeding centres using the WHO/NCHS reference values. Z-score seems to give greater equivalence to the WHO/NCHS reference values. However, it will require a shift in paradigm to convince health professionals and nutritionists working in refugee settings to abandon the traditional preference for use of proportion of median in favour of Z-score.
Could clinical examination alone help solve this problem of defining malnutrition in refugee settings? Clinical examination relies on a symptomatic approach. However, the clinical signs of malnutrition, especially under-nutrition, are non-specific and result from deficiencies of more than one nutrient or as a result of factors not related to nutrition such as infectious diseases or metabolic disease (King & Burgess, 1992; Garrow & James, 1993). In addition, in complex emergencies malnourished children presenting symptoms represent a small proportion of the total malnourished child refugee population. Current findings suggest that for every case of malnutrition with symptoms (severe malnutrition) observed in the refugee population, 10 cases of moderate acute malnutrition may exist in that population (WHO et al., 2000). Moderate acute malnutrition may not be diagnosed by clinical examination and consequently, those asymptomatic malnourished children will be more likely to be missed. Therefore, clinical observation alone cannot accurately describe communities' nutritional status. Further evaluation would be needed. However, clinical observation has its own strength. If severely malnourished children are being physically identified within a given community, it is a good indication that that community needs further nutritional evaluation or attention.
The reference standards must be set for different ethnic groups and feeding practices, that is, children fed by either breast-milk or bottle. There is an urgent need to develop new and more accurate methods of assessing malnutrition in refugee children. Current methods of assessing malnutrition using WHO/NCHS references need to be refined and standardized such that the growth reference curve takes into account the health environment in which children were born, socio-economic status, ethnicity and race, and feeding practices. This is the only way to ensure that physiological growth is accounted for and scientifically described. The current growth reference values reflect the growth of readily identifiable children whose public health environment helped them to attain their hereditary growth potential. These reference values did not take into account variations in growth and cannot be accepted as describing normal growth variation. For example the growth pattern is influenced by the feeding pattern and change in the feeding pattern means that change in growth pattern is likely to follow. If the feeding pattern of those children who participated in the Fels Longitudinal Study had changed, then a change in the growth curve would have been observed. This variation in growth in response to variation in feeding patterns is not reflected by the traditional NCHS/WHO reference data and it is this variation in growth that affects public health decision-making. This is particularly worrying for the refugee population since refugees are more likely to face new cuisine, new types of food preparation and new public health environments which consequently impact on both their feeding practices and growth. However, given that the Z-score detects the variation in growth, that is, precisely identifies malnourished children regardless of the height, we recommend that the use of Z-score be promoted in refugee settings. This implies that health professionals, nutritionists and relevant staff from the Ministry of Health involved in catering for the nutritional needs of refugees will need to be trained to acquaint them with the calculation of Z-score and its meaning.
However, considering that the WHO/NCHS growth references are inadequate for assessing the growth of breastfed children and children who grew-up in an impaired public health environment, in the absence of new growth curve references, the current Z-score cut-off points used for decision-making would need to be revisited. Hence, two questions need to be addressed in applied research:
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André Renzaho originally from Zaire, is currently employed at the Centre for Culture Ethnicity and Health as a Research and Evaluation Coordinator and is currently completing his PhD in Public Health Nutrition at Deakin University. After an extensive career in public health nutrition in refugee camps with various UN and Non-Government Organisations, André moved into the area of public health. In Australia, André has been very active in advocating for refugee public health. In 2000, he was contracted to evaluate the Commonwealth's Partners In Culturally Appropriate Aged Care Project. Recently, he completed an evaluation of the DHS's Western Region Refugee Health Model and is currently completing a report examining how primary health care providers identify and prioritise the health and welfare needs of refugees and humanitarian entrants in Victoria. André has also published in journal articles and recently his paper: "Selective Feeding Centres in Refugees Setting: Evaluation Framework Protocol" has been accepted for publication in the Asia Pacific Journal of Clinical Nutrition, Volume 11, Issue 2. André has recently received a prestigious Ian Potter Grant to assess the impact of acculturation on the nutrition and physical activity of sub-Saharan African refugee children living in Victoria.
Cate Burns is currently employed as Lecturer in Public Health Nutrition in the School of Health Sciences at Deakin University. She holds a Science degree, a diploma in Dietetics and a PhD from the University of Sydney. After a long and productive career in the clinical management of obesity at the Metabolism and Obesity Service at Royal Prince Alfred Hospital in Sydney, during which time Cate completed her PhD, she moved into the area of public health. In her current position Cate has undertaken research into dietary acculturation, food security and the nutritional impact of the use of fast and ready-prepared foods as part of obesity prevention strategies in populations who are most vulnerable. Cate has published extensively in peer-reviewed journals and participates in academic debate both nationally and internationally. She is currently leading a project funded by Vichealth to evaluate community-based interventions for food insecurity in Melbourne.
Daniel Reidpath is Senior Lecturer in Social Epidemiology. His main interests are in social inequalities and health and the role of social and cultural context as a determinant of health. His most recent past work included a critique of the Disability Adjusted Life Year as a measure of population health, specifically focusing on its failure to account adequately for variations in the impact of disease across social and cultural contexts. He is currently conducting a Ford Foundation funded, six country, situation analysis of HIV/AIDS related discrimination in the Asia Pacific. Recent publications incude: Reidpath, D. D., Allotey, P., Kouamé A. & Cummins R. A. Social, Environmental and Cultural Contexts and the Measurement of the Burden of Disease: An Exploratory Comparison in the Developed and Developing World. Melbourne: Key Centre for Women's Health in Society, The University of Melbourne (2001) ; Reidpath, D. D., Burns, C., Garrard, J., Mahoney, M., & Townsend, M. "An ecological study of the relationship between socioeconomic status and obesogenic environments" Health and Place 8, (2002), pp.141-145 ; Allotey, P. A., & Reidpath, D. D. "Establishing causes of childhood mortality: the 'spirit child' Social Science and Medicine 52(7)(2001), pp. 1007-1012.
|Paper presented at the International Conference "The Refugee Convention, Where to from Here?" convened by the Centre for Refugee Research (Sydney, December 2001).|