O

riginal Article

Measuring Malnutrition -The Role of Z Scores and the Composite Index

of Anthropometric Failure (CIAF)
N Seetharaman, TV Chacko, SLR Shankar, AC Mathew

ABSTRACT
Background : The current WHO recommendation is to use the Z-Score or SD system to grade undernutrition which allows
us to measure all the three indices and express the results in terms of Z scores or standard deviation units from the median
of the international reference population.
Objectives : To estimate the prevalence of undernutrition among under-ve children in Coimbatore slums, using the Z-Score
system of classication and the recently constructed Composite Index of Anthropometric Failure (CIAF). 2. To compare the
Z-Score system with the Indian Academy of Pediatrics (IAP) classication of undernutrition.
Methods : Nutritional assessment was done using anthropometry and clinical examination. Children were weighed and
measured as per the WHO guidelines on Anthropometry. Epi-Info 2002 software package was used to calculate the Z scores
and for statistical analysis.
Results : Only 31.4% of the children studied were normal; 68.6% were in a state of Anthropometric Failure. As per the Z
score system, 49.6% were underweight (21.7% severely); 48.4% were stunted (20.3% severely) and 20.2% were wasted
(6.9% severely). Whereas, as per IAP criteria, 51.4% were undernourished and 3.2% were severely undernourished. Using
Underweight (low weight-for-age) as the only criterion for identifying undernourished children (as done in the Integrated Child
Development Services currently) may underestimate the true prevalence of undernutrition, by as much as 21.9%.
Conclusions : More widespread use of the Z-Score system is recommended for identifying all the facets of undernutrition.
Estimates of the true prevalence of undernutrition must incorporate a composite index of anthropometric failure.
Keywords : Z-Score Classication, Composite Index of Anthropometric Failure (CIAF),
Anthropometry, Malnutrition, ICDS.
India has the highest percentages of undernourished children
in the world(1). In any community, under-ve children are one
of the most vulnerable groups for nutritional deciencies,
owing to many factors ranging from Low Birth Weight to
maternal ill health to socio-economic and environmental
factors (2). Most of these problems are accentuated and are
highly unfavorable for a child growing in todays slums. It must
be stated here that, although the words undernutrition and
malnutrition are being used interchangeably, malnutrition is a
broader term that includes under-nutrition and over-nutrition.
In this study, the term undernutrition is used.
There have been quite a few attempts at grading the degrees
of undernutrition. Weight-for-age classications (Gomez,
I.A.P) are the most commonly used. Height-for-age and
Weight-for-height classications (McLaren, Waterlows) have
been used less frequently(3). Each of these classications
use different sets of reference data and each system employ
different cut-off points to decide who is normal and who falls
under mild, moderate, or severe undernutrition. The cut-off
points are usually a certain percent of the mean/median or
a percentile, of the reference population. Most of the cut-off
points are admittedly arbitrary and do not carry a prognostic
significance for any given individual child(4). Employing
different reference values and cut-off points has been a
Department of Community Medicine, PSG Institute of Medical
Sciences and Research Peelamedu, Coimbatore. Tamilnadu
Email: seethahere@gmail.com
Received : 19.08.05
Indian Journal of Community Medicine Vol. 32, No.1, January 2007

major hindrance in comparing data across various studies

and countries. In India, the nationwide Integrated Child
Development Services (ICDS) program uses the IAP criteria
to grade undernutrition.
None of these classications address all the three indices of
undernutrition - Stunting, Wasting and Underweight. Stunting
(Low height-for-Age) is an indicator of chronic undernutrition
due to prolonged food deprivation and/or illness; Wasting
(Low weight for height) is an indicator of acute undernutrition,
the result of more recent food deprivation and/or illness;
Underweight (Low weight-for-age) is used as a composite
measure to reect both acute and chronic undernutrition,
although it cannot distinguish between them(4).
The current WHO recommendation is to use the Z-Score
or SD system to grade undernutrition. This system allows
us to measure all the three indices and express the results
in terms of Z scores or standard deviation units from the
median of the international reference population, developed
from anthropometric data collected in the United States by
the National Center for Health Statistics (NCHS). Children
who are more than 2 SD below the reference median (i.e. a
Z-Score of less than -2) are considered to be undernourished
i.e. to be stunted, wasted or to be underweight. Children with
measurements below 3 SD (a Z-Score of less than-3) are
considered to be severely undernourished(4).
Although widely recommended, the Z Scores have not been
widely in use in India, especially in community-based studies.
35

Seetharaman N, et al : Malnutrition by Z Scores and CIAF

This is in spite of the fact that the nationally representative

National Family Health Survey 2 (NFHS 2) uses Z scores
to grade undernutrition(5). The Z score system is not yet
being widely used among researchers, probably because
of the perceived difculty in calculating the Z-Scores. The
Epi-Info 2002 software developed and distributed by the
Center for Disease Control, Atlanta(6) has eliminated this
problem. Besides being sex-specic and able to measure all
the three indices, the main advantage of Z scores is that it
allows comparison across indicators and countries. Another
advantage is that, Z-Scores can be subjected to summary
statistics (such as Mean and SD), which help us to assess
the quality of the data collected.
The three indices stunting, wasting and underweight reect
distinct biological processes and their use is necessary
for determining appropriate interventions (4). It must be
remembered here that these indices overlap i.e. a child
who is underweight may also have wasting and/or be
stunted and other similar combinations. On the one hand,
none of the three indices is able to provide a comprehensive
estimate of the total number of undernourished children in a
community and on the other hand - since they overlap - we
cannot add these three indices to get the overall prevalence.
For a comprehensive measure of the overall prevalence of
undernutrition, what is needed is a single aggregate indicator
that incorporates all undernourished children, be they wasted
and/or stunted and/or underweight.
Such an aggregate indicator the Composite Index of
Anthropometric Failure (CIAF) has been proposed by
Svedberg (7). His original model suggests six sub-groups
of anthropometric failure (labeled A-F); to which one more
sub-group (labeled Y) has been added by Nandy et al(8).
The anthropometric sub-groups of the children are as
follows: A No Failure, B Wasting only, C - Wasting +
Underweight, D - Wasting + stunting + Underweight, E
- Stunting + Underweight, F - Stunting only and nally, Y
Underweight only. The sum of the children in groups B to
F provides the CIAF. As a single indicator, CIAF provides
a single number to the overall estimate of undernourished
children in a population, which none of the current indicators
do. Furthermore, using the CIAF, anthropometric data can
be disaggregated for further analysis, e.g. to analyze the
specic risk factors & correlates or the mortality/morbidity
patterns for the different types of anthropometric failure.
Such disaggregation enables the identication of groups of
children missed by conventional indices.
The current study uses the Z-Score system and the CIAF
to estimate the magnitude of undernutrition among underve children in the slums coming under the eld practice
area of the PSG Urban Health Center, Coimbatore. The
appropriateness of using low weight-for-age as the only
indicator for detecting childhood undernutrition has been
analyzed. The calculations are in reference to the WHO/
NCHS International population.
Material and Methods
Ten slums coming under the field-practice area of the
Urban Health Centre, PSG Institute of Medical Sciences &
Indian Journal of Community Medicine Vol. 32, No.1, January 2007

Research, Coimbatore formed the study area. The Study

population comprised of Children less than ve years of
age residing in the above-mentioned slums. The total
number of under-ve children in these 10 slums was 625.
Sample size for the cross-sectional prevalence study was
calculated using the formula Sample size (n) =4PQ/d2. With
an expected prevalence of undernutrition (P) of 50% and a
relative precision (d) of 10% of P, the required sample size
was calculated as 400.
To arrive at the required sample size of 400, six out of the
ten slums were randomly selected and all the under-ve
children in the six selected slums were included in the study.
The actual number of children in these six slums was 405
and this was taken as the study population (n = 405). All the
children up to 59 months of age living in the selected slums
were included for the study. Children who were not resident
of the slum, but visiting and children of families who had
moved into the slum within the past 1 month were excluded
from the study.
The exact age of the child was computed from the childs
date of birth. When data on the exact date of birth was not
available, the age as told by the mother was used, corrected
to the nearest month. A regional local-events calendar
was used to assist the mothers for better recall. Nutritional
assessment was done using anthropometry and clinical
examination. Children were weighed and measured as per
the WHO guidelines on Anthropometry(4). For children less
than two years, the recumbent length was measured with
the children lying down. Data collection was done over a
period of two months.
Statistical analysis was done using EPI-INFO 2002 software
package, from CDC. The Z-scores for the different nutritional
indices weight-for-age, height-for-age and weight-for-height
were calculated in reference to NCHS International reference
population by using the EPI-NUT component of the software.
The prevalence of underweight (low weight-for-age), stunting
(low height-for-age) and wasting (low weight for height)
were calculated at the cut-off level of < -2 SD (Z-Score <2)
and the prevalence of severe underweight, stunting and
wasting at cut-off level of < -3 SD (Z-Score <-3) of the NCHS
reference median values. Svedberg and later, Nandy et al
have used these indicators to construct the CIAF. This index
provides us with a single number to the overall prevalence
of undernutrition in the community.
Chi-Square test was used to verify the statistical signicance
of the associations. P value of less than 0.05 was considered
statistically signicant.
Results
Majority (93.6%) of the study population were Hindus; 70.8%
were living in nuclear families; 65.2% were practicing openair defecation; 74.8% were living in overcrowded dwellings
and 86.4% had per-capita incomes less than Rs.750 per
month. Table 1 shows the age-sex distribution of the study
population. Female children constituted 54.3% of the study
group. The maximum numbers of children (21.5% each) were
seen in the 24-35 and the 48-59 months age group.
36

Seetharaman N, et al : Malnutrition by Z Scores and CIAF

Table 1: Age-Sex distribution of the study population

(n=405)

Age Group
(months)

Male (%)

Total (%)

0 - 11
12 - 23
24 - 35
36 - 47
48 - 59

36 (19.5)
43 (23.2)
38 (20.5)
39 (21.1)
29 (15.7)

32 (14.6)
37 (16.8)
49 (22.3)
44 (20.0)
58 (26.4)

68 (16.8)
80 (19.8)
87 (21.5)
83 (20.5)
87 (21.5)

Total

185 (100)

220 (100)

405 (100)

Female (%)

undernourished, if we use the popularly used low weightfor-age as the only indicator of undernutrition.
Table 4: Classication of children with anthropometric failure (n=405)

Table 2 presents the distribution of undernutrition among

the children studied. Female infants (0-11 months) had a
signicantly lower prevalence of undernutrition compared to
male infants (p<0.001). The Overall gender difference was
not statistically signicant.
Table 2: Prevalence of undernutrition by sex and age group (n = 405)
Age
(Months)

Male Under
Female Under
N
nourished
N
nourished
n (%)
n (%)

Total Under
N
nourished
n (%)

0 - 11

36

31 (86.1)

32

15 (46.9)

68

46 (67.6)

12 23

43

38 (88.4)

37

21 (56.8)

80

59 (73.8)

24 35

38

16 (42.1)

49

38 (77.6)

87

54 (62.1)

36 47

39

19 (48.7)

44

39 (88.6)

83

58 (69.9)

48 59

29

19 (65.5)

58

42 (72.4)

87

61 (70.1)

Total

185

123 (66.5)

220

155 (70.5)

405

278 (68.6)

Table 3 shows the prevalence of underweight, wasting

and stunting among the children studied. Conventional
growth monitoring activities detect only those children with
underweight (46.7 %). By Using Z scores, we can further
identify children with wasting (20.2 %) and stunting (49.6
%).
Table 3 : Age-wise Prevalence of Indices of Undernutrition
Age
Number % of
(months)
of
Normal
Children Children

Underweight
Wasting
% below
% below
< -2SD < -3SD< -2SD < -3SD

(n = 405)
Stunting
% below
< -2SD < -3SD

0 - 11
12 23
24 35
36 47
48 59

68
80
87
83
87

32.4
26.3
32.9
30.1
29.9

14.7
42.5
50.6
56.6
62.1

7.4
25.0
21.8
28.9
10.3

14.7
17.5
21.5
30.1
16.1

7.4
6.3
10.3
6.0
4.6

60.3
56.3
40.2
39.8
54.0

39.7
12.5
11.5
22.9
25.3

Total

405

31.4

46.7

19.0

20.2

6.9

49.6

21.7

Below-2 SD denotes undernutrition and below-3 SD denotes severe

undernutrition.

CIAF permits us disaggregation of the undernourished

children in to different subgroups, as shown in Table 4.
Overall, only 127 (31.4%, group A) of the children studied
were anthropometrically normal; 278 (68.6%) of the children
were suffering from one or other form of Anthropometric
Failure. That is, summing up the children in groups B to
F provides the CIAF (68.6%). By using low weight-for age
(underweight) as the sole criterion for undernutrition, we can
identify children from groups C, D, E and Y (189 children
in our study) but will be missing those in groups B and
F-children who are stunted or wasted but not underweight.
In the current study, 89 such children (accounting to 21.9%
of the total study population) would be missed out as not
Indian Journal of Community Medicine Vol. 32, No.1, January 2007

Group

Anthropometric statusa, b

A
B
C
D
E
F
Y#

No Failure
Wasting only
Wasting + Underweight
Wasting + Stunting + Underweight
Stunting + Underweight
Stunting only
Underweight only

Number of Children (%)

127 (31.4)
11 (2.7)
48 (11.9)
23 (5.7)
100 (24.7)
78 (19.3)
18 (4.4)

Total

405 (100)

# - Sub-groups A to F as proposed by Peter Svedberg5 and sub-group Y

as suggested by Nandy et al(4).
aAnother theoretical combination would be wasted and stunted, but
this is not physically possible since a child cannot simultaneously
experience stunting and wasting and not be underweight.
bAdding up children in the subgroups B to F gives us the CIAF
(68.6 %)

Table 5 attempts a comparison between the IAP system

and the Z score system of grading undernutrition. As per
IAP criteria, 208 children (51.4%) were undernourished
and 13 (3.2%) were severely undernourished (Grade III
& IV). Compared to this, as per the Z score system 189
children (46.6%) were undernourished and 77 (19%) were
severely undernourished. Although the overall prevalence
of undernutrition is higher (by 4.8%) as per the IAP criteria,
the Z score system identies a much higher prevalence
of severe undernutrition compared to IAP system. In the
present study, 64 out of the 77 children graded as Severely
undernourished (by Z score system) seem to fall under
Grade II (the Moderately undernourished category) of the
IAP system.
Table 5: Comparison of the IAP and the Z-Score Systems

(n = 405)

Z Scores
IAP

Normal Undernutrition Severe

(< -2SD) Undernutrition
(< -3SD)

Normal
Mild (Grade I)
Moderate (Grade II)
Severe (Grades III, IV)
Total (%)

197
19
0
0

0
93
19
0

216 (53.3) 112 (27.7)

Total
(%)

0
0
64
13

197 (48.6)
112 (27.7)
83 (20.5)
13 (3.2)

77 (19.0)

405 (100.0)

Discussion
In India, there is still a paucity of community-based studies on
childhood undernutrition using the Z score system. Using the
Z score classication, Studies from Haryana(9) and Punjab(10)
report comparable prevalence levels. The relatively high
prevalence of wasting observed among the children in the
current study is indicative of a state of acute undernutrition,
indicative of recent food deprivation and/or illness. NFHS
2 uses the Z score system of classification to grade
undernutrition among Indian children. At the national level,
the prevalence of underweight, stunting and wasting were
47%, 45.5 % and 15.5% respectively and the corresponding
values for Tamilnadu were 36.7%, 29.4% and 19.9%.
37

Seetharaman N, et al : Malnutrition by Z Scores and CIAF

Currently the IAP classication based on weight-for-age,

is followed in the anganwadi centers throughout the
country to grade undernutrition at the grass-root level for
the Government of Indias project on the Integrated Child
Development Services (ICDS). As revealed by Table 5 the
IAP system identies 4.8% more children as undernourished,
whereas the Z score system identies signicantly more
children as severely undernourished. These Severely
undernourished children are the ones who get additional
nutritional supplementation under the ICDS. In our study, 64
out of the 77 children graded as Severely undernourished
by Z score system fall under the Grade II Moderately
undernourished category as per the IAP system. This has
high practical signicance, in light of the fact that priorities of
nutritional supplementation through ICDS are inclined towards
the severely undernourished children - Grades III & IV of
the IAP system. A similar study (11) in West Bengal comparing
the IAP and the Z score systems, found comparable results
- 61% of the children were undernourished (3.9% severely)
as per IAP criteria, whereas 46.6% were undernourished
(6.9% severely) as per Z score system.
As seen from Table 4, underweight children form only one
subgroup of the total number of undernourished children
i.e. children who show evidence of anthropometric failure.
Nandy et al have improved on the CIAF (originally proposed
by Svedberg) which they have applied to the entire NFHS 2
dataset. In their study, Children with no failure (Group A)
account for 40.2% while children with Wasting and Stunting
and Underweight (Group D) account for 7.2% and children
with Stunting only (Group F) account for 10.1%. In the
current study, considerably fewer children only 31.4%
were normal or had no anthropometric failure and 5.7%
of children had Wasting and Stunting and Underweight.
The prevalence of Stunting only is relatively high 19.3%
among the slum children studied.
As evidenced by the current study, the use of underweight
(low weight-for-age) as the sole criterion for identifying
undernourished children may be underestimating the true
load of undernutrition. Use of the CIAF helps us to visualize
the extent of underestimation. Nearly 22% of the present
study population 89 undernourished children would
be missed if low weight-for-age is considered as the only
indicator of undernutrition. CIAF provides an overall estimate
on the number of undernourished children in a population,
which none of the conventional indices provide. Attempts
at estimating the overall prevalence of undernutrition in
the population must integrate such an aggregate index of
undernutrition. This could be a tool of considerable interest
to health planners and policy makers - especially considering
the fact that to compute the CIAF, the only additional data that
needs to be collected is the height of the child. Measurement
of the childs height as part of the routine ICDS growth
monitoring is worth considering.
The limitations of this study include- the approximation of
Indian Journal of Community Medicine Vol. 32, No.1, January 2007

childrens weight to the nearest 500 grams, which might have

had an inuence on the prevalence estimates. The date of
birth as told by the mother has been used; crosschecking
with records could not be done for all of the children. There
have been concerns about the appropriateness of using the
NCHS data as the reference population for Indian children(12).
To address this concern, WHO is in the process of developing
a more appropriate reference population, which would be
available soon(13).
Conclusions
Overall, only 31.4% of the under-ve children studied were
anthropometrically normal. In other words, more than two
thirds of the children were undernourished. This is a very
serious problem, by any scale. Under such conditions,
our intervention efforts need to be broader than providing
supplementary nutrition alone.
More widespread use of the Z-Score system of classication,
especially in community-based studies, is recommended.
This system enables us to estimate/express the prevalence
of undernutrition using all the three indices underweight,
stunting and wasting. This also allows meaningful comparisons
with the nationally representative NFHS 2 database. The
process of calculating the Z scores has been made very
simple by the use of Epi-info software package developed
and distributed freely by the CDC.
Current measures of undernutrition are, on their own,
unable to give a reliable estimate of the overall number of
undernourished children in a population. This issue has
been addressed with the construct of the new indicator,
CIAF. Findings from the current study suggest that
conventional measures of undernutrition may be missing
out a considerable proportion of undernourished children
present in the population. The proportion of children identied
as severely undernourished receive additional nutritional
supplementation under the ICDS. Hence, underestimating
this proportion might prevent undernourished children from
receiving the benet of the extra supplementation they
deserve. The dissagregation of undernourished children in to
different sub-groups (as done in CIAF) allows the researcher
to further examine the relationship between particular
combinations of undernutrition and poverty or morbidity/
mortality data (when available). Studies have shown that
children with double or triple failures are more likely to be
from poorer families and also have a higher morbidity risk
than children with single failures(8). Identication of these
children with multiple failures has obvious implications in antipoverty policies. A comprehensive measure of the total load
of undernutrition such as the Use of the Composite Index
of Anthropometric Failure discussed in this paper must be
incorporated in our attempts at quantifying undernutrition.
Acknowledgement
The authors would like to thank Mr.Nanjappan for his help in
data collection, Miss.Narmada for her help in data analysis
38

Seetharaman N, et al : Malnutrition by Z Scores and CIAF

and Dr.YSS.Sivan for his continual efforts in improving the

paper.

8.

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