Concurrent wasting and stunting among children 6-59 months: an analysis using district-level survey data in
Tomás Zaba1, Joel Conkle2, Mara Nyawo3
1United Nations Children's Fund, 1440 Zimbabwe Avenue, Maputo, Mozambique. tomas.zaba@outlook.com.
Insights
Concurrent wasting and stunting (WaSt) in children is a serious mortality risk. Including MUAC measurements in the definition of WaSt identifies more children, especially younger girls, for crucial treatment.
Area of Science:
- Pediatric Nutrition
- Global Health
- Anthropometry
Background:
- Concurrent wasting and stunting (WaSt) was previously thought to be independent but is now known to increase mortality risk.
- Current WaSt definition (WHZ < -2 and HAZ < -2) may not capture all affected children.
- Wasting is measured by WHZ and MUAC, which identify different child populations.
Purpose of the Study:
- To evaluate the impact of incorporating MUAC into the WaSt case definition.
- To assess the prevalence and burden of WaSt with an expanded definition.
- To explore the feasibility of diagnosing WaSt using a single measurement.
Main Methods:
- Analysis of anthropometric surveys from 37 districts in Mozambique (2017-2019).
- Development of a new WaSt case definition including MUAC alongside WHZ.
- Evaluation of WaSt case eligibility for existing treatment programs using True Positive and False Positive values.
- ROC curve analysis to determine optimal MUAC and WAZ cut-offs.
Main Results:
- The expanded WaSt definition identified more children, particularly younger girls, compared to the original definition.
- Combined MUAC and WHZ screening captured most WaSt cases (100% in facilities, 79.4% in community screenings).
- Proposed cut-offs (MUAC ≤133mm, WAZ ≤ -2.145) generated a high number of false positives.
Conclusions:
- The WaSt case definition should integrate MUAC measurements.
- Mozambique should begin reporting and monitoring WaSt in surveys and implement treatment.
- Further research is needed for cost-effective WaSt identification with minimal false positives and optimal treatment outcomes.
Background:
In the past it was believed that wasting and stunting were independent of each other. Recent work has shown that they can occur concurrently in a child and that increases considerably the risk of mortality. Concurrent wasting and stunting (WaSt) is currently defined as WHZ < -2 AND HAZ < -2. Wasting is measured by WHZ and MUAC and evidence shows that they tend to identify different sets of children. Our study aimed to look at the effect of adding MUAC on the prevalence and burden of WaSt, and to assess diagnosis of WaSt with a single measurement.
Methods:
We analyzed population-based anthropometric surveys from 37 districts in Mozambique conducted by the Government of Mozambique between 2017 and 2019. We proposed a new case-definition for WaSt that includes MUAC in acknowledgement of the different children with wasting diagnosed by WHZ and MUAC. We estimated how many WaSt cases are eligible to be included in the existing treatment program in Mozambique by calculating the True Positive and False Positive Values of WaSt using our proposed case-definition against the wasting admission criteria. AUC of ROC curves used for MUAC and WAZ and optimal cut-offs were determined using Youden's Index.
Results:
Including MUAC in the concurrent WaSt case-definition identified more children with WaSt compared to the original case-definition and more younger children and girls were identified. Using both MUAC and WHZ and enrolling severe and moderate wasting is already picking up most of the WaSt cases: 100% in health facilities and 79.40% with MUAC mass screenings at community level. Cut-off values from the ROC curve for the proposed case-definition were MUAC ≤133 mm and WAZ ≤ 2.145 Z-scores, however, they yielded many false positive values.
Conclusion:
WaSt case-definition should include MUAC. WaSt should commence to be reported in surveys and Mozambique should also start monitoring and treating children with WaSt. A cost-effective approach to identify all children with WaSt without adding too many false positive is needed, as well as understanding how to achieve optimal treatment outcomes within existing programs.
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