Anthropometric assessment is used to evaluate nutrition status. It involves measuring body height, weight, and proportions. BMI is calculated from weight and height and used to assess obesity levels. Other measures include mid-upper arm circumference, waist circumference, hip circumference, and skinfold thickness. Guidelines for weight gain during pregnancy vary based on pre-pregnancy BMI. High or low weight gain can impact birth outcomes like birth weight and risk of cesarean delivery. Accurate data monitoring is needed to evaluate nutrition programs and health system performance.

1. Anthropometric assessment of
adults and elderly
Dr. Dewan S. Alam, MBBS, MMedSc, PhD.
Head, Non-communicable Disease Unit
Health System & Infectious Diseases Division
icddr,b

2. Why Anthropometric Assessment?
 Anthropometry is the measurement of body height,
weight & proportions.
 It is an essential component of clinical examination
of infants, children, pregnant women and adults.
 It is used to evaluate both under & over nutrition.

3. Anthropometric Measures
a. Height (cm)
 The subject stands erect & bare footed on a stadiometer with a
movable head piece.
 The head piece is leveled with skull vault & height is recorded
to the nearest 0.5 cm.
b. Weight (kg)
 Use a regularly calibrated electronic or balanced-beam scale.
 Spring scales are less reliable.
 Weigh in light clothes, no shoes
 Read to the nearest 100 gm (0.1kg)

5. BMI measurement and nutritional status
 The international standard for assessing body size in adults is the
body mass index (BMI).also termed Quetlet’s Index
(Gibson, 2005, p 259)
– Formula: BMI = Weight (kg)/ Height (m²)
• Evidence shows that high BMI (obesity level) is associated
with type 2 diabetes & high risk of cardiovascular morbidity
& mortality.

6. BMI (WHO – Classification, 2011)
Source: http://apps.who.int/bmi/index.jsp?introPage=intro_3.html

7. WHO Expert Consultation for Asian
• Proportion of Asian people with a high risk of type 2 diabetes and cardiovascular
disease is substantial at BMI's lower than the existing WHO cut-off point for
overweight (= 25 kg/m2).
• Cut-off point for observed risk varies from 22 kg/m2 to 25 kg/m2 in different Asian
populations and for high risk, it varies from 26 kg/m2 to 31 kg/m2 .
Source: WHO expert consultation, 2004.

8. Indicators: (contd..)
c. % body fat (BIA: Bioelectrical Impedance Analysis)
• Widely used method for estimating body composition.
• Relatively simple, quick, and noninvasive.
• Determines the electrical impedance of body tissues, which provides an
estimate of total body water (TBW).
• Using values of TBW derived from BIA, one can then estimate fat-free
mass (FFM) and body fat (adiposity).
(Macias et al., 2007; NIH, 1994)

9. Indicators: (contd..)
• Skinfold thickness measurements provide an estimate of the
size of the subcutaneous fat depot, which in turn, provides an
estimate of total body fat.
(Gibson, 2005)
• Skinfold thickness and arm circumference are two
measurements that indirectly assess two
important components of a body:
– Fat and fat-free mass.
– Cause, the main storage form of energy and fat-free
mass, usually muscle, is a good indicator of the
protein reserves of a body.

10. Indicators: (contd..)
d. Skinfolds:
– Triceps skinfold:
Measured at the mid point of the back of
the upper arm
– Biceps skinfold:
Measured as the thickness of a vertical
fold on the front of the upper arm,
directly above the center of the cubital
fossa, as the same level as the triceps
skinfold.
(Gibson, 2005)

11. d. Skinfolds: (Contd..)
– Subscapular skinfold
Measured below and laterally to the angle of
the shoulder blade, with the shoulder and
arm relaxed. Placing the subjects arm behind
the back may assist in identification of the
site. The skin fold should angle 45 degree
from horizontal, in the same direction as the
inner border of the scapula.
– Suprailiac skinfold
Measured in the mid axillary line
immediately superior to the illiac crest. The
skinfold is picked up obliquely just posterior
to the mid axillary line and parallel to the
cleavage lines of the skin.
(Gibson, 2005)

12. Indicators: (contd..)
e. Mid Arm Circumference (MAC) (cm) g. Hip Circumference (Hip) (cm)
– Measured at the point of greatest
circumference around hips &
buttocks to the nearest 0.5 cm.
Waist–hip ratio or waist-to-hip ratio
f. Waist Circumference (Wst) (cm) (WHR) is the ratio of the circumference
Waist circumference is measured at the level of the waist to that of the hips.
of the umbilicus to the nearest 0.5 cm. – Formula= Waist:Hip Ratio = Wst/Hip

13. Chronic energy deficiency
• To identifying CED affected individuals involves
– measuring body weight and height,
– then energy intake (or expenditure) and
– basal metabolic rate (BMR).
BMI < 16.0 16.0-16.9 17.0-18.4 > 18.5
CED grade III II I Normal
Source: James et al., 1988; Shetty & James, 1994

14. Over weight & Obesity
• The overweight and obesity group defined overweight as -
– Obesity related to a BMI of 25–29.9 kg/m2 (grade 1),
– With grade 2 overweight commonly termed as obesity specified for a
BMI of 30–39.9 kg/m2,
– Grade 3 or morbid obesity as applying to those with BMI ≥ 40 kg/m2.
(James, 2008)
• Obesity is associated with a rapid increase in health problems
such as CVD and diabetes.
(Engelgau et al., 2011)

15. Weight Gain in Pregnancy - Physiology
• 27.5 lbs (12.5 kg) is “normal” physiologic gain
(Hytten 1991)
• 9 kg (~20 lbs) is made up of fetus, placenta,
amniotic fluid, uterine/breast hypertrophy,
increased blood volume and retained fluid
• 3.5 kg (7.5 lbs) is maternal storage fat

16. Weight Gain in Pregnancy - Physiology
• 27.5 lbs (12.5 kg) is “normal” physiologic gain
(Hytten 1991)
• 9 kg (~20 lbs) is made up of fetus, placenta,
amniotic fluid, uterine/breast hypertrophy,
increased blood volume and retained fluid
• 3.5 kg (7.5 lbs) is maternal storage fat

17. Pregnancy Weight Gain Recommendations in
the U.S. - History
• 19th century - restriction of food intake to
prevent difficult labor
• 1901 - first published study of diet and birth
weight – restricted food intake linked to lower
BW
• 1920’s – more studies associating weight gain
and BW

18. Pregnancy Weight Gain Recommendations in
the U.S. - History
• 1971 – Hytten and Leitch published review of studies from
1950’s and 60’s
• Average gain of 12.5 kg (27.5 lbs) is “physiologic normality” in
healthy young primigravid women
• Association between pre-pregnancy weight, weight gain, and
birth weight noted in literature
• 1970 – National Academy of Sciences Food and Nutrition
Board’s Committee on Maternal Nutrition: 20-25 lbs
recommended
Associated with low weight gain:
– Infant mortality
– Disability
– Mental retardation

19. Pregnancy Weight Gain Recommendations in
the U.S. - History
• 1972 – ACOG also endorsed the 20-25 lb
guideline
• 1981 – FNB’s Nutrition Services in Perinatal
Care: Inadequate gain = 1kg or less/month in
2nd and 3rd trimesters, Excessive gain = 3kg or
more/month

20. What outcomes have been associated with
pregnancy weight gain?
• Birth weight
– SGA/IUGR
– LGA/macrosomia >>maternal morbidities
• Mode of delivery
• Preterm birth
• Postpartum weight retention

21. Weight Gain and Birth Weight
• Well-established relationship, even when
using net weight gain (total weight gain minus
birth weight of infant)
• Relationship seems to be modified by pre-
pregnancy body mass index
• Controversy about relationship between
weight gain and birth weight among obese
women

22. The IOM Report and Guidelines
IOM Recommendations for Weight Gain in Pregnancy (1990)
Pre-pregnancy Body IOM Recommended
Mass Index Gestational Weight
Gain (lbs/kg)
<19.8 (Low) 28-40 / 12.5-18
19.8 - 26.0 (Normal) 25-35 / 11.5 - 16
26.1 - 29.0 (High) 15-25 / 7 – 11.5
>29.0 (Obese) At least 15 / At least 6

23. The IOM Report and Guidelines
• Retrospective, observational data
• First widely-accepted guidelines, BMI-
specific
• Controversy over guidelines: too high,
too low.
• ~ 30 – 40 % of all women
• To date: The range for best outcome of
the infant

24. Weight gain recommendations in Europe &
Asia
 Austria: Max. 15 kg weight gain
 Denmark: IOM guidelines
 Finland: 15 kg for normal weight women
 Germany: No official guidelines
 Switzerland: No official guidelines
 UK: Not weighing during pregnancy
 Hong Kong: BMI specific weight gain
recommendations
 No information available: France, Italy, Spain,
Sweden

25. Weight Gain and Macrosomia
• Strongly associated
• Most cases of macrosomia occur in non-diabetic
women
• Macrosomia is associated not just with infant
trauma, but with multiple increased risks of maternal
morbidity: cesarean birth, severe perineal
lacerations, peripartum infection, and prolonged
hospital stay (even among those delivering vaginally)

26. Weight Gain and Cesarean Birth
• High weight gain is associated with increased
risk of both prolonged labor and cesarean
birth
• This relationship is only partly attributable to
higher birth weight
• Even when birth weight controlled for in
multivariate analysis, high weight gain is an
independent risk factor for cesarean birth

27. Weight Gain and Preterm Birth
• Multiple epidemiologic studies have
associated poor gestational gain with
increased risk of preterm birth
• Obvious confounder of length of gestation as
well as birth weight – most studies have
addressed this
• Most studies have not stratified by pre-
pregnancy BMI, some excluded obese women

28. Weight Gain and Preterm Birth Study -
Results
• Low BMI group gaining below guidelines had PTB
rate of 5.9% vs. 3.5% for those gaining within
guidelines (P< 0.001)
• High BMI group gaining below guidelines had PTB
rate of 8.1% vs. 3.8% for those gaining within
guidelines (P<0.001).
• Normal BMI group gaining below guidelines had PTB
rate of 5.2% vs. 3.4% for those gaining within
guidelines (P<0.001).

29. Gestational Weight Gain – Methodologic
Challenges
• What measure of weight gain to use?
• How reliable are self-reported weights?
• Gestational age assessment
• Race/ethnicity variation
• Limitation of retrospective/epidemiologic data
• Optimal weight gain depends on the outcome one studies

30. What can we do? Do interventions work?
• Historically: guidelines/provider advice can
impact actual weight gain
• Few studies have linked interventions to
outcomes beyond #kg gained

31. Interventions
• By-mail patient education
• Regular clinical meetings for education with
goal-setting
• Phone calls between visits
• Newsletters
• Personal graph of weight gain

32. Goals for Future Research
• Achieve adequate weight gain in pregnancy
• Studies in overweight/obese women
• Qualitative research – patient and provider
attitudes, beliefs
• RCTs of novel interventions – both weight gain
and other outcomes – low glycemic load diet
trial – Janet King PI

33. Why is weight gain important during pregnancy?
• The extra weight during pregnancy provides
– Nourishment to developing baby
– Stored for breastfeeding baby after delivery
Picture Source: (WHO, 2011; p 17)

34. New Recommendations for Total and Rate of Weight Gain During
Pregnancy, by Prepregnancy BMI
The guidelines and supporting recom­mendations are intended to be used in concert with good clinical
judgment and should include a discussion between the woman and her care provider about diet and exercise.
Developed by WHO and adopted by NHLBI.
Source: Rasmussen, & Yaktine, 2009; Rasmussen et al., 2009.

35. Data availability on Information and
Accountability for Woman’s and Children’s Health
WHO, (2011). Monitoring maternal, newborn and child health: understanding key progress indicators. p 15.

36. Strengthening countries’ capacity to monitor and evaluate results
• High quality data are critically needed in order to enable
global assessment of progress on the Commission’s
recommended measures of coverage, impact, financing,
and equity related to women’s and children’s health.
• The availability of accurate, timely, and consistent data at
the national and sub-national levels is crucial for countries
to be able to effectively manage their health systems,
allocate resources according to need, and ensure
accountability for delivering on health commitments.
(WHO, 2011, p 13)

37. ADVANTAGES OF ANTHROPOMETRY
• Objective with high specificity & sensitivity
• Measures many variables of nutritional significance (Ht, Wt,
MAC, HC, skin fold thickness, waist & hip ratio & BMI).
• Readings are numerical & gradable on standard growth
charts.
• Readings are reproducible.
• Non-expensive & need minimal training

38. Limitations of Anthropometry
• Inter-observers errors in measurement
• Limited nutritional diagnosis
• Problems with reference standards, i.e. local
versus international standards.
• Arbitrary statistical cut-off levels for what
considered as abnormal values.