Globalization and Health ( IF 5.9 ) Pub Date : 2019-11-08 , DOI: 10.1186/s12992-019-0502-x Nima Yaghmaei 1 , Debarati Guha-Sapir 1
Humanitarian crises, such as conflicts and disasters, have devastating impacts on health systems, quickly rendering pre-crisis health data outdated. Without comprehensive assessments, response planning and resource allocation become difficult and can result in ineffective actions. We thank El Bcheraoui and colleagues for their insightful research paper ‘Health in Yemen: losing ground in war time’. The paper provides an analysis into the effects of the war in Yemen on public health, and it will assist planning and resource allocation going forward.
As highlighted by El Bcheraoui and colleagues, humanitarian crises have a large impact on maternal and child health, with malnutrition being a major concern. Therefore, one effective method of health assessment in crises is the monitoring of nutrition status in these vulnerable populations. Commonly used indicators for nutrition status are anthropometric indices, such as weight-for-height (WH)(wasting), height-for-age (HA)(stunting), weight-for-age (WA)(underweight), or mid-upper arm circumference (MUAC) measurements. These indices are used by national surveys, such as the Demographic and Health Surveys (DHS) and UNICEF’s Multiple Cluster Surveys (MICS), or small-scale survey methods, such as the Standardized Monitoring and Assessment of Relief and Transitions (SMART).
In the case of Yemen, rates of malnutrition were demonstrated by El Bcheraoui and colleagues using various indicators of nutritional status for both women 15–49 years old and children < 5 years old [1]. However, we would like to bring into question the use of the terminology “global acute malnutrition (GAM) stunting” and “severe acute malnutrition (SAM) stunting” in the results.
The term “Global acute malnutrition (GAM) stunting” is the incorrect combination of two indicators used for malnutrition: “Global acute malnutrition (GAM)” and “stunting.” Stunting is the terminology used for children < 5 years old who have a HA Z-score (HAZ) < 2.0, and is recognized as chronic malnutrition for the indication of linear growth retardation [2, 3]. On the other hand, global acute malnutrition (GAM) is the terminology used for the combination of severe acute malnutrition (SAM) and moderate acute malnutrition (MAM): WH Z-score (WHZ) < 2.0 (wasting) and/or MUAC < 12.5 cm and/or nutritional oedema [4]. Concurrently, the term “SAM stunting” is incorrect as SAM is indicated by WHZ < 3.0 (severe wasting) and/or MUAC < 11.5 cm and/or nutritional oedema, while severe stunting is indicated by HA Z-score < 3.0 [4]. Despite the evidence of some common causality and positive association between stunting and wasting, they remain separate indicators since they are based on different anthropometric measures [2].
The misuse of terminology may have operational implications since GAM prevalence above 15% is considered critical and regarded as the threshold for an emergency, while this is not the case for stunting, since a stunting prevalence of 15% is considered “low” [5, 6]. Thus, the incorrect labelling of stunting as wasting would likely result in the overestimation of malnutrition rates, while the incorrect labelling of wasting as stunting would likely underestimate malnutrition rates. El Bcheraoui and colleagues indicate a national average of 52.3% for “Global acute malnutrition GAM stunting”, this figure is not indicative of GAM which can be expected to be significantly lower, but it is indicative of stunting, which was at 46.5% prior to the conflict [1]. Additionally, data from more recent small-scale surveys conducted in Yemen by humanitarian organizations have also found similar levels of stunting.
Even with the adjusted labelling, the use of stunting as an indicator for malnutrition in a humanitarian crisis also has operational implications. Firstly, fluctuations in stunting and acute malnutrition are not synonymous, and it is not recommend to use stunting as an independent indicator for nutrition interventions in humanitarian crises [7]. Acute malnutrition is a more appropriate indicator as it rapidly manifests in young children and has a higher risk of mortality than chronic malnutrition, while chronic malnutrition is not indicative of an acute crisis as it reflects long-term conditions [7, 8]. Prior to the war, Yemen was ranked poorly on the Human Development Index, and large proportions of the population faced poverty and nutrition deficiencies [1]. Thus, stunting rates from surveys conducted in 2016 would likely be more indicative of pre-crisis conditions, ultimately giving an inadequate indication of the areas with the highest needs as a result of the crisis. As well, acute malnutrition is easier to measure using either WHZ or MUAC, neither of which are overly susceptible to reporting bias for age, unlike stunting (HAZ). Additionally, acute malnutrition indicators can be used as an individual-level indicator for treatment and as a population-level indicator, while stunting is only appropriate at a population-level [7].
From the perspective of intervention design, stunting does not indicate the nutrition information needed for acute nutrition interventions, since, comparatively, stunting indicates to a lesser degree the nutrition status of a population, and more the general living and welfare of the population [9]. Nutrition interventions in humanitarian crises usually focus on immediate needs and are nutrition specific. These interventions may include infant and young child feeding (IYCF) programs, and distribution of food aid and Ready-To-Use Foods (RUFs). For these interventions, stunting would be an inappropriate indicator since success in these interventions would not necessarily correspond with rapid improvements of linear growth amongst the population [7]. As a result, potentially lifesaving short-term interventions could be deemed unsuccessful having had only minor changes in linear growth retardation and thus, only minor changes in stunting rates.
Therefore, of the potential nutrition indicators, reporting using indicators such as WHZ, MUAC and underweight (WAZ) is recommended. If possible, both chronic and acute malnutrition should be measured, since concurrent stunting and wasting exhibit the highest risk of mortality [5].
As highlighted by El Bcheraoui and colleagues, data sources are limited during humanitarian crises. DHS and MICS surveys are difficult to conduct in real time and are time consuming. This further demonstrates the importance and necessity of small-scale surveys. With improvements in statistical analysis using modelling, researchers can utilize small-scale surveys and report crucial information, such as acute malnutrition levels in the population. El Bcheraoui and colleagues have made this clear in their discussion by recommending rapid health assessment surveys for short-term activities. We believe this is an important recommendation that needs more attention.
The paper by El Bcheraoui and colleagues is a reminder of the challenges faced by health systems in humanitarian crises, and the difficulty of producing comprehensive assessments in such circumstances.
Not applicable
- DHS:
-
Demographic and Health Survey
- GAM:
-
Global Acute Malnutrition
- HA:
-
Height-for-age
- HAZ:
-
Height-for-age Z score
- IYCF:
-
Infant and Young Child Feeding
- MAM:
-
Moderate Acute Malnutrition
- MICS:
-
Multiple Cluster Surveys
- MUAC:
-
Mid-upper Arm Circumference
- RUF:
-
Ready-to-use Foods
- SAM:
-
Severe Acute Malnutrition
- SMART:
-
Standardized Monitoring and Assessment of Relief and Transitions
- WA:
-
Weight-for-age
- WH:
-
Weight-for-height
- WHZ:
-
Weight-for-height Z score
- 1.
El Bcheraoui C, Jumaan AO, Collison ML, Daoud F, Mokdad AH. Health in Yemen: losing ground in war time. Glob Health. 2018;14(1):42.
- 2.
Myatt M, Khara T, Schoenbuchner S, Pietzsch S, Dolan C, Lelijveld N, et al. Children who are both wasted and stunted are also underweight and have a high risk of death: a descriptive epidemiology of multiple anthropometric deficits using data from 51 countries. Arch Public Health. 2018;76(1):28.
- 3.
Young H, Marshak A. Persistent Global Acute Malnutrition. Feinstein Int Cent Publ. 2017;55.
- 4.
The Sphere Project. Humanitarian charter and minimum standards in humanitarian response: the sphere handbook. Rugby: The Sphere Project; 2018.
- 5.
Khara T, Mwangome M, Ngari M, Dolan C. Children concurrently wasted and stunted: a meta-analysis of prevalence data of children 6-59 months from 84 countries. Matern Child Nutr. 2017;14(2):e12516.
- 6.
Akparibo R, Booth A, Lee A. Recovery, relapse, and episodes of default in the Management of Acute Malnutrition in children in humanitarian emergencies: a systematic review. Oxfam: Feinstein International Center; UKAID; 2017.
- 7.
Perumal N, Bassani DG, Roth DE. Use and misuse of stunting as a measure of child health. J Nutr. 2018;148(3):311–5.
- 8.
Briend A, Khara T, Dolan C. Wasting and stunting—similarities and differences: policy and programmatic implications. Food Nutr Bull. 2015;36:S15–23.
- 9.
Leroy JL, Frongillo EA. Perspective: what does stunting really mean? A critical review of the evidence. Adv Nutr. 2019 Mar 1;10(2):196–204.
Not applicable
Ethical approval and consent to participate
Not applicable
Funding
No specific funding was used for this article.
Affiliations
- Centre for Research on the Epidemiology of Disasters, Institute of Health & Society, UCLouvain, Brussels, Belgium
- Nima Yaghmaei
- & Debarati Guha-Sapir
- Search for Nima Yaghmaei in:
- Search for Debarati Guha-Sapir in:
Contributions
NY conceived the topic, and performed the analysis and writing. DGS reviewed and approved the final manuscript. Both authors read and approved the final manuscript.
Corresponding author
Correspondence to Nima Yaghmaei.
Consent for publication
Not applicable
Competing interests
The authors declare that they have no competing interests.
Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
Cite this article
Yaghmaei, N., Guha-Sapir, D. The use of stunting as a nutrition indicator in Yemen civil war. Global Health 15, 63 (2019) doi:10.1186/s12992-019-0502-x
- Received
- Accepted
- Published
- DOI
Keywords
- War
- Conflict
- Malnutrition
- Child health
- Anthropometry
中文翻译：
在也门内战中使用发育迟缓作为营养指标
冲突和灾难等人道主义危机对卫生系统造成毁灭性影响，迅速使危机前的卫生数据过时。如果没有全面的评估，应对计划和资源分配就会变得困难，并可能导致行动无效。我们感谢 El Bcheraoui 及其同事富有洞察力的研究论文“也门的健康：战争时期的失势”。本文分析了也门战争对公共卫生的影响，这将有助于今后的规划和资源分配。
正如 El Bcheraoui 及其同事所强调的，人道主义危机对孕产妇和儿童健康产生巨大影响，其中营养不良是一个主要问题。因此，危机中健康评估的一种有效方法是监测这些弱势群体的营养状况。常用的营养状况指标是人体测量指数，例如身高别体重（WH）（消瘦）、年龄别身高（HA）（发育迟缓）、年龄别体重（WA）（体重不足）或中等体重。 - 上臂围 (MUAC) 测量。这些指数用于国家调查，例如人口与健康调查 (DHS) 和联合国儿童基金会的多类集调查 (MICS)，或小规模调查方法，例如救济和过渡标准化监测和评估 (SMART)。
以也门为例，El Bcheraoui 及其同事使用 15-49 岁妇女和 < 5 岁儿童的各种营养状况指标证明了营养不良率[1 ]。然而，我们对结果中“全球急性营养不良（GAM）发育迟缓”和“严重急性营养不良（SAM）发育迟缓”术语的使用提出质疑。
“全球急性营养不良（GAM）发育迟缓”一词是用于营养不良的两个指标的错误组合：“全球急性营养不良（GAM）”和“发育迟缓”。发育迟缓是指 HA Z 评分 (HAZ) < 2.0 的 < 5 岁儿童的术语，被认为是线性生长迟缓的慢性营养不良 [2 , 3 ]。另一方面，全球急性营养不良 (GAM) 是用于组合严重急性营养不良 (SAM) 和中度急性营养不良 (MAM) 的术语：WH Z 得分 (WHZ) < 2.0（消瘦）和/或 MUAC < 12.5 厘米和/或营养性水肿 [ 4 ]。同时，术语“SAM 发育迟缓”是不正确的，因为 WHZ < 3.0（严重消瘦）和/或 MUAC < 11.5 cm 和/或营养性水肿表示 SAM，而 HA Z 分数 < 3.0 表示严重发育迟缓 [ 4 ] 。尽管有证据表明发育迟缓和消瘦之间存在一些共同的因果关系和正相关关系，但它们仍然是独立的指标，因为它们基于不同的人体测量指标[ 2 ]。
术语的误用可能会产生操作上的影响，因为 GAM 患病率高于 15% 被认为是至关重要的，并被视为紧急情况的阈值，而发育迟缓的情况则不然，因为 15% 的发育迟缓患病率被认为是“低”[ 5，6 ]。因此，将发育迟缓错误地标记为消瘦可能会导致营养不良率的高估，而将消瘦错误地标记为发育迟缓可能会低估营养不良率。El Bcheraoui 及其同事指出，“全球急性营养不良 GAM 发育迟缓”的全国平均比例为 52.3%，这个数字并不代表 GAM 会显着降低，但它表明了发育迟缓，在此之前该比例为 46.5%。冲突[ 1 ]。此外，人道主义组织最近在也门进行的小规模调查的数据也发现了类似程度的发育迟缓。
即使调整了标签，在人道主义危机中使用发育迟缓作为营养不良的指标也具有操作意义。首先，发育迟缓的波动与急性营养不良不是同义词，不建议将发育迟缓作为人道主义危机中营养干预的独立指标[ 7 ]。急性营养不良是一个更合适的指标，因为它在幼儿中迅速表现出来，并且比慢性营养不良具有更高的死亡风险，而慢性营养不良并不表示急性危机，因为它反映了长期状况[7 , 8 ]。战前，也门在人类发展指数上排名较差，很大一部分人口面临贫困和营养不足[ 1 ]。因此，2016 年进行的调查的发育迟缓率可能更能反映危机前的情况，最终无法充分表明危机导致需求最高的地区。此外，使用 WHZ 或 MUAC 更容易测量急性营养不良，与发育迟缓 (HAZ) 不同，这两种方法都不太容易受到年龄报告偏差的影响。此外，急性营养不良指标可作为个体层面的治疗指标和群体层面的指标，而发育迟缓仅适用于群体层面[7 ]。
从干预设计的角度来看，发育迟缓并不代表急性营养干预所需的营养信息，因为相对而言，发育迟缓反映了人群的营养状况，更多地反映了人群的总体生活和福利[9 ]。 。人道主义危机中的营养干预措施通常侧重于眼前的需求，并且针对营养问题。这些干预措施可能包括婴幼儿喂养 (IYCF) 计划以及食品援助和即食食品 (RUF) 的分发。对于这些干预措施，发育迟缓将是一个不合适的指标，因为这些干预措施的成功不一定与人口线性增长的快速改善相对应[ 7 ]。因此，可能挽救生命的短期干预措施可能被认为是不成功的，因为线性生长迟缓只有微小的变化，因此，发育迟缓率也只有微小的变化。
因此，在潜在的营养指标中，建议使用 WHZ、MUAC 和体重不足 (WAZ) 等指标进行报告。如果可能，应测量慢性和急性营养不良，因为同时发生的发育迟缓和消瘦表现出最高的死亡风险[ 5 ]。
正如 El Bcheraoui 及其同事所强调的那样，人道主义危机期间的数据来源是有限的。DHS 和 MICS 调查很难实时进行，而且非常耗时。这进一步说明了小规模调查的重要性和必要性。随着建模统计分析的改进，研究人员可以利用小规模调查并报告重要信息，例如人口中的严重营养不良水平。El Bcheraoui 及其同事在讨论中明确了这一点，建议对短期活动进行快速健康评估调查。我们认为这是一项需要更多关注的重要建议。
El Bcheraoui 及其同事的论文提醒我们卫生系统在人道主义危机中面临的挑战，以及在这种情况下进行全面评估的困难。
不适用
- 国土安全部：
-
人口与健康调查
- 游戏：
-
全球急性营养不良
- 哈：
-
年龄别身高
- 热影响区：
-
年龄别身高 Z 分数
- 国际青年联合会：
-
婴幼儿喂养
- 妈妈：
-
中度急性营养不良
- 多指标调查：
-
多重整群调查
- MUAC：
-
中上臂围
- 联阵：
-
即食食品
- 萨姆：
-
严重急性营养不良
- 聪明的：
-
救济和过渡的标准化监测和评估
- 西澳：
-
年龄别体重
- 身高：
-
身高体重
- WHZ：
-
身高别体重 Z 分数
- 1.
El Bcheraoui C、Jumaan AO、Collison ML、Daoud F、Mokdad AH。也门的健康状况：在战争时期节节败退。全球健康。2018；14(1):42。
- 2.
Myatt M、Khara T、Schoenbuchner S、Pietzsch S、Dolan C、Lelijveld N 等。消瘦和发育迟缓的儿童体重不足且死亡风险很高：使用 51 个国家的数据对多种人体测量缺陷进行描述性流行病学。拱门公共卫生。2018；76(1):28。
- 3.
Young H，Marshak A。持续性全球急性营养不良。范斯坦国际中心出版社。2017；55。
- 4.
球体项目。人道主义宪章和人道主义反应的最低标准：领域手册。橄榄球：球体项目；2018.
- 5.
Khara T、Mwangome M、Ngari M、Dolan C。儿童同时消瘦和发育迟缓：对 84 个国家 6-59 个月儿童患病率数据的荟萃分析。母婴营养品。2017；14(2)：e12516。
- 6.
Akparibo R、Booth A、Lee A。人道主义紧急情况下儿童急性营养不良管理中的恢复、复发和违约事件：系统评价。乐施会：范斯坦国际中心；英国国际开发署；2017年。
- 7.
佩鲁马尔 N、巴萨尼 DG、罗斯 DE。使用和滥用发育迟缓作为儿童健康的衡量标准。J 营养。2018；148(3)：311–5。
- 8.
Briend A、Khara T、Dolan C。消瘦和发育迟缓——相似性和差异：政策和计划影响。食品营养公牛。2015；36：S15–23。
- 9.
勒罗伊 JL，弗龙吉洛 EA。观点：发育迟缓的真正含义是什么？对证据进行批判性审查。高级营养。2019 年 3 月 1 日；10(2):196–204。
不适用
道德批准和同意参与
不适用
资金
本文没有使用任何特定资金。
隶属关系
- 灾害流行病学研究中心，健康与社会研究所，加州大学鲁汶分校，布鲁塞尔，比利时
- 尼玛·雅格迈伊
- & 黛巴拉蒂·古哈-萨皮尔
贡献
NY构思了这个主题，并进行了分析和写作。DGS 审查并批准了最终手稿。两位作者阅读并批准了最终手稿。
通讯作者
同意发表
不适用
利益争夺
作者声明他们没有利益冲突。
出版商备注
施普林格·自然对于已出版的地图和机构隶属关系中的管辖权主张保持中立。
开放获取本文根据知识共享署名 4.0 国际许可证 ( http://creativecommons.org/licenses/by/4.0/ )的条款分发，该许可证允许在任何媒体上不受限制地使用、分发和复制，前提是您提供适当注明原作者和来源，提供知识共享许可的链接，并注明是否进行了更改。除非另有说明，知识共享公共领域奉献豁免 ( http://creativecommons.org/publicdomain/zero/1.0/ ) 适用于本文中提供的数据。
引用这篇文章
Yaghmaei, N.，Guha-Sapir, D. 在也门内战中使用发育迟缓作为营养指标。全球健康 15, 63 (2019) doi:10.1186/s12992-019-0502-x
- 已收到
- 公认
- 已发表
- DOI
关键词
- 战争
- 冲突
- 营养不良
- 儿童健康
- 人体测量学
京公网安备 11010802027423号