Abstract
Measurement of mid-upper arm circumference (MUAC) was originally proposed in the 1960s to assess the nutritional status of children between the age of 1–5 years. It was based on the assumption that it was closely related to muscle mass and also that it varied little with age, making rapid nutritional assessment possible in populations where age is not known with precision. Development of MUAC growth reference curves later showed that the assumption of age independence was not correct and MUAC was progressively abandoned. Weight-for-height z-score (WHZ), which is determined independently of age, became the gold standard for the assessment of acute malnutrition. However, more recently, results of several community studies comparing anthropometric indices to identify children with highest risk of dying have renewed interest in MUAC. Comparison of the receiver operator characteristic (ROC) curves of different indices showed that MUAC was consistently superior to WHZ in identifying children with a high risk of dying. These studies also showed that correction of MUAC for age or for height did not improve its prognostic value. The superior performance of MUAC to identify high-risk children could be due to its preferential selection of younger and/or more stunted children, or to the close relationship of MUAC with muscle and fat mass. These two explanations are not mutually exclusive as young and stunted children tend to have a low muscle mass in relation to body weight which makes them more vulnerable to malnutrition. The performance of WHZ can also be affected by differences in body shape not linked to wasting, by hydration status or by measurement errors. Following these mortality studies, a paradigm shift has taken place in populations with high malnutrition-related mortality, such as in famine situations. The priority then is to identify high-risk children in need of urgent treatment to prevent short-term death. In this context, identification by WHZ, measuring a statistical deviation from a standard, has less practical relevance. Available evidence also suggests that children with a low MUAC can be rapidly identified by community- or facility-based health workers, or by mothers and that children identified by MUAC put on weight rapidly when treated. They should be the priority target for nutritional programs.
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Abbreviations
- AUC:
-
Area Under the Curve
- BMI:
-
Body mass index
- CMAM:
-
Community-based management of acute malnutrition
- DEXA:
-
Dual-energy X-ray absorptiometry
- MUAC:
-
Mid-upper arm circumference
- ROC:
-
Receiver operating characteristics
- RUTF:
-
Ready-to-use Therapeutic Foods
- SAM:
-
Severe acute malnutrition
- WHO:
-
World Health Organization
- WHZ:
-
Weight-for-height z-score
References
Alam N, Wojtyniak B, Rahaman MM (1989) Anthropometric indicators and risk of death. Am J Clin Nutr 49:884–888
Alé FG, Phelan KP, Issa H et al (2016) Mothers screening for malnutrition by mid-upper arm circumference is non-inferior to community health workers: results from a large-scale pragmatic trial in rural Niger. Arch Public Health 74:38
Bairagi R (1981) On validity of some anthropometric indicators as predictors of mortality. Am J Clin Nutr 34:2592–2594
Berkley J, Mwangi I, Griffiths K et al (2005) Assessment of severe malnutrition among hospitalized children in rural Kenya: comparison of weight for height and mid upper arm circumference. JAMA 294:591–597
Berkley JA, Ngari M, Thitiri J et al (2016) Daily co-trimoxazole prophylaxis to prevent mortality in children with complicated severe acute malnutrition: a multicentre, double-blind, randomised placebo-controlled trial. Lancet Glob Health 4:e464–e473
Bern C, Nathanail L (1995) Is mid-upper-arm circumference a useful tool for screening in emergency settings? Lancet 345:631–633
Binns P, Dale N, Banda T et al (2016) Safety and practicability of using mid-upper arm circumference as a discharge criterion in community based management of severe acute malnutrition in children aged 6 to 59 months programmes. Arch Public Health 74:24. https://doi.org/10.1186/s13690-016-0136-x
Blackwell N, Myatt M, Allafort-Duverger T et al (2015) Mothers Understand And Can do it (MUAC): a comparison of mothers and community health workers determining mid-upper arm circumference in 103 children aged from 6 months to 5 years. Arch Public Health 73:26. https://doi.org/10.1186/s13690-015-0074-z
Bogin B, Varela-Silva MI (2010) Leg length, body proportion, and health: a review with a note on beauty. Int J Environ Res Public Health 7:1047–1075
Briend A, Dykewicz C, Graven K et al (1986) Usefulness of nutritional indices and classifications in predicting death of malnourished children. Brit Med J 293:373–375
Briend A, Wojtyniak B, Rowland MG (1987) Arm circumference and other factors in children at high risk of death in rural Bangladesh. Lancet 2:725–728
Briend A, Garenne M, Maire B et al (1989) Nutritional status, age and survival: the muscle mass hypothesis. Eur J Clin Nutr 43:715–726
Briend A, Khara T, Dolan C (2015) Wasting and stunting – similarities and differences: policy and programmatic implications. Food Nutr Bull 36(1_suppl):S15–S23
Briend A, Maire B, Fontaine O et al (2012) Mid-upper arm circumference and weight-for-height to identify high-risk malnourished under-five children. Matern Child Nutr 8:130–133
Briend A, Zimicki S (1986) Validation of arm circumference as an indicator of risk of death in one to four year old children. Nutr Res 6:249–261
Burgess HJL, Burgess AP (1969) A modified standard for mid-upper arm circumference in young children. J Trop Pediat 15:189–192
Cahill G (2006) Fuel metabolism in starvation. Ann Rev Nutr 26:1–22
Carter EP (1987) Comparison of weight:height ratio and arm circumference in assessment of acute malnutrition. Arch Dis Child 62:833–835
Dale N, Myatt M, Prudhon C et al (2013) Using mid-upper arm circumference to end treatment of severe acute malnutrition leads to higher weight gains in the most malnourished children. PLoS One 8:e55404. https://doi.org/10.1371/journal.pone.0055404
Davis LE (1971) Epidemiology of famine in the Nigerian crisis: rapid evaluation of malnutrition by height and arm circumference in large populations. Am J Clin Nutr 24:358–364
de Onis M, Onyango AW, Borghi E et al (2006) Comparison of the World Health Organization (WHO) Child Growth Standards and the National Center for Health Statistics/WHO international growth reference: implications for child health programmes. Public Health Nutr 9:942–947
Fabiansen C, Phelan K, Cichon B et al (2016) Short children with a low Midupper arm circumference respond to food supplementation: an observational study from Burkina Faso. Am J Clin Nutr 103:415–421
FAO-WHO-UNU Expert Consultation (1985) Energy and protein requirements. World Health Organization, Geneva
Grellety E, Golden M (2016) Weight-for-height and mid-upper-arm circumference should be used independently to diagnose acute malnutrition: policy implications. BMC Nutr. https://doi.org/10.1186/s40795-016-0049-7
Gustafson P, Gomes VF, Vieira CS et al (2007) Clinical predictors for death in HIV-positive and HIV-negative tuberculosis patients in Guinea-Bissau. Infection 35:69–80
Heymsfield SB, McManus C, Stevens V et al (1982) Muscle mass: reliable indicator of protein-energy malnutrition severity and outcome. Am J Clin Nutr 35(5 Suppl):1192–1199
Irena AH, Ross DA, Salama P et al (2013) Anthropometric predictors of mortality in undernourished adults in the Ajiep feeding programme in southern Sudan. Am J Clin Nutr 98:335–339
Jelliffe DB (1966) The assessment of nutritional status of the community, Monograph series, vol 53. WHO, Geneva
Jelliffe EFP, Jelliffe DB (1969) The arm circumference as a public health index of protein-calorie malnutrition of early childhood. J Trop Pediatr 15:179–188
Jensen SM, Mølgaard C, Ejlerskov KT et al (2015) Validity of anthropometric measurements to assess body composition, including muscle mass, in 3-year-old children from the SKOT cohort. Matern Child Nutr 11:398–408
Kerac M, Blencowe H, Grijalva-Eternod C et al (2011) Prevalence of wasting among under 6-month-old infants in developing countries and implications of new case definitions using WHO growth standards: a secondary data analysis. Arch Dis Child 96:1008–1013
Kerr DS, Stevens MC, Robinson HM (1978) Fasting metabolism in infants. I. Effect of severe undernutrition on energy and protein utilization. Metabolism 27:411–435
Lelijveld N, Seal A, Wells JC et al (2016) Chronic disease outcomes after severe acute malnutrition in Malawian children (ChroSAM): a cohort study. Lancet Glob Health 4:654–662
Lindtjørn B (1985) Measuring acute malnutrition: a need to redefine cut-off points for arm circumference? Lancet 2:1229–1230
Miller MD, Crotty M, Giles LC, Bannerman E, Whitehead C, Cobiac L, Daniels LA, Andrews G (2002) Corrected arm muscle area: an independent predictor of long-term mortality in community-dwelling older adults? J Am Geriatr Soc 50:1272–1277
McDowell I, King FS (1982) 1982. Interpretation of arm circumference as an indicator of nutritional status. Arch Dis Child 57:292–296
McNeil BJ, Keller E, Adelstein SJ (1975) Primer on certain elements of medical decision making. N Engl J Med 293:211–215
Mwangome MK, , Martha K, Greg Fegan G, Tony Fulford T et al. Mid-upper arm circumference at age of routine infant vaccination to identify infants at elevated risk of death: a retrospective cohort study in the Gambia. Bull WHO 2012; 90: 887–894
Mwangome MK, Berkley JA (2014) The reliability of weight-for-length/height Z scores in children. Matern Child Nutr 10:474–480
Myatt M, Duffield A, Seal A et al (2009) The effect of body shape on weight-for-height and mid-upper arm circumference based case definitions of acute malnutrition in Ethiopian children. Ann HumBiol 36:5–20
Myatt M, Khara T, Collins S (2006) A review of methods to detect cases of severely malnourished children in the community for their admission into community-based therapeutic care programs. Food Nutr Bull 27(Suppl 3):S7–S23
Pelletier DL (1994) The relationship between child anthropometry and mortality in developing countries: implications for policy, programs and future research. J Nutr 124(10 Suppl):2047S–2081S
Pelletier DL, Low JW, Johnson FC et al (1994) Child anthropometry and mortality in Malawi: testing for effect modification by age and length of follow-up and confounding by socioeconomic factors. J Nutr 124(10 Suppl):2082S–2105S
Post CL, Victora CG (2001) The low prevalence of weight-for-height deficits in Brazilian children is related to body proportions. J Nutr 131:1290–1296
Powell-Tuck J, Hennessy EM (2003) A comparison of mid upper arm circumference, body mass index and weight loss as indices of undernutrition in acutely hospitalized patients. Clin Nutr 22:307–312
Rainer A (1969) The QUAC stick: a field measure used by the Quaker Service team in Nigeria. J Trop Ped 15:243–247
Rasmussen J, Andersen A, Fisker AB et al (2012) Mid-upper-arm-circumference and mid-upper-arm circumference Z-score: the best predictor of mortality? Eur J Clin Nutr 66:998–1003
Reeds PJ, Fjeld CR, Jahoor F (1994) Do the differences between the amino acid compositions of acute-phase and muscle proteins have a bearing on nitrogen loss in traumatic states? J Nutr 124:906–910
Rolland-Cachera MF, Brambilla P, Manzoni P et al (1997) Body composition assessed on the basis of arm circumference and triceps skinfold thickness: a new index validated in children by magnetic resonance imaging. Am J Clin Nutr 65:1709–1713
Sachdeva S, Dewan P, Shah D et al (2016) Mid-upper arm circumference v. Weight-for-height Z-score for predicting mortality in hospitalized children under 5 years of age. Pub Health Nutr 19:2513–2520
Schwinger C, Fadnes LT, den Broeck J (2016) Using growth velocity to predict child mortality. Am J Clin Nutr 103:801–807
Shakir A (1975) Arm circumference in the surveillance of protein-calorie malnutrition in Baghdad. Am J Clin Nutr 28:661–665
Shakir A, Morley D (1974) Measuring malnutrition. Lancet 1:758–759
Soler-Cataluña JJ, Sánchez-Sánchez L, Martínez-García MA et al (2005) Mid-arm muscle area is a better predictor of mortality than body mass index in COPD. Chest 128:2108–2115
Standard KL, Wills VG, Waterlow JC (1959) Indirect indicators of muscle mass in malnourished infants. Am J Clin Nutr 7:271–280
Van den Broeck JR, Eeckels R, Massa G (1996) Validity of single-weight measurements to predict current malnutrition and mortality in children. J Nutr 126:113–120
Van den Broeck J, Eeckels R, Hokken-Koelega A (1998) Fatness and muscularity as risk indicators of child mortality in rural Congo. Int J of Epidemiol 27:840–844
Van Loon H, Saverys V, Vuylsteke JP et al (1987) Screening for marasmus: a discriminant analysis as a guide to choose the anthropometric variables. Am J Clin Nutr 45:488–493
Vella V, Tomkins A, Ndiku J et al (1994) Anthropometry as a predictor for mortality among Ugandan children, allowing for socio-economic variables. Eur J Clin Nutr 48:189–197
Waterlow JC (1992) Protein energy malnutrition. Edward Arnold, London
World Health Organization (1995). Physical status: the use and interpretation of anthropometry. Technical Report Series 854. World Health Organization, Geneva
World Health Organization (2000) The management of nutrition in major emergencies
World Health Organization (2009) WHO child growth standards and the identification of severe acute malnutrition in infants and children: joint statement by the World Health Organization and the United Nations Children’s Fund
Zerfas AJ (1975) The insertion tape: a new circumference tape for use in nutritional assessment. Am J Clin Nutr 28:782–787
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Briend, A., Mwangome, M.K., Berkley, J.A. (2019). Using Mid-Upper Arm Circumference to Detect High-Risk Malnourished Patients in Need of Treatment. In: Preedy, V., Patel, V. (eds) Handbook of Famine, Starvation, and Nutrient Deprivation. Springer, Cham. https://doi.org/10.1007/978-3-319-55387-0_11
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