Postscript on older people, nutrition in emergencies in Ethiopia

Bradley A.Woodruff, MD MPH, Medical Epidemiologist International Emergency and Refugee Health Branch U.S. Centers for Disease Control and Prevention

This field article from HelpAge Ethiopia is an excellent example of what can be accomplished in emergency situations by dedicated, skilled professionals. Their description illustrates the difficulty in bringing the previously neglected topic of nutritional status in older persons to the attention of responsible authorities. The authors are to be commended for sharing their experience in order that we may all learn more about this important subject.

This article reiterates many of the recommendations regarding the nutrition assessment of adults which were made by the SCN Working Group on Emergencies during a workshop in Nairobi in April 2001¹. Among the most important recommendations are that nutrition surveys should never be carried out as the only method of nutrition assessment, without clear objectives, or without the will and ability to act on the findings. Especially for adults, a population group which is not often considered to be the most vulnerable, clear and specific reasons to conduct a survey should exist before allocating the necessary money, time, manpower, and other resources. Moreover, to maximize the usefulness of data collected, survey results must be complemented by qualitative and quantitative information derived from other sources. A simple estimate of the prevalence of undernutrition may demonstrate the existence of a problem, but usually provides little information about how to attack the problem.

The HelpAge authors point out many of the constraints to assessing and addressing undernutrition in adults and older persons, including existing policies, customary practices, and widely held assumptions of governments and international organisations. Overcoming such barriers often requires hard data, and gathering such data should be an important component of any emergency response. According to the old adage, what gets measured, gets noticed.

Although substantial technical gaps exist regarding assessment of undernutrition in adults and older people, the HelpAge article provides excellent examples of field data collection and analysis which can serve to expand our ability to accurately assess nutritional status. One survey cited in the article demonstrates the substantial effect on undernutrition prevalence of adjusting body mass index (BMI) for cormic index. Similar results have been reported by others². In addition, this survey identified a MUAC cutoff point corresponding to a BMI <16, indicating severe malnutrition, by comparing the prevalence rates of undernutrition derived from BMI and MUAC.

Nonetheless, comparison of various anthropometric indices is insufficient. As recommended by both the HelpAge article and the SCN Working Group on Emergencies, further research needs to be done to validate the utility of various anthropometric indices, especially BMI and mid-upper arm circumference (MUAC), in assessing acute undernutrition in adults and older people. Such validation should include measurement of the correlation between anthropometric indices and health outcomes and functional capacity, and the ability of these indices to identify persons in greatest need of nutritional support programmes.

The HelpAge article also points out some of the difficulties with use of BMI in field assessment surveys. Although use of BMI, especially when adjusting for cormic index, is more complex than use of other anthropometric indices such as MUAC, many of us remember only a few years ago when humanitarian aid workers routinely rejected as impractical for field surveys the measurement of weight and height in children < 5 years of age and the calculation of Z-scores. Nevertheless, with training and exposure of personnel to new techniques and the availability of computers, this methodology has become standard. In the future, measurement of adult stature, sitting height, and weight, as well as the performance of the cormic index adjustment of BMI, will become routine as personnel become more familiar with these methods. These new techniques have the potential to provide much more accurate and detailed nutritional information on adults and older persons. Standardising and validating these techniques will help remove the barriers which currently sustain the nutritional neglect of members of these age groups.

View the article that this postscript relates to

¹SCN Working Group on Emergencies. Assessment of adult undernutrition in emergencies: a report of an SCN Working Group on Emergencies special meeting, April 2001. Nairobi, Kenya; 2001.

²Salama, P, Assefa, F, Talley, L, Spiegel, P, van Der Veen, A and Gotway, CA, Malnutrition, measles, mortality, and the humanitarian response during a famine in Ethiopia. Jama 2001;286: 563-71.