LETTERS

Composite index of anthropometric failure (CIAF) classification: is it more useful?

Amiya Kumar Bhattacharyya¹

Formerly Professor of Nutritional and Metabolic Diseases and Director, School of Tropical Medicine, Kolkata, India

Editor – The paper published by Nandy et al. in the Bulletin on the composite index of anthropometric failure (CIAF) is welcome in view of the paucity of recent attempts to classify undernourished children satisfactorily.¹ However, the usefulness of the CIAF classification has to be considered vis-à-vis Waterlow's widely used stunting–wasting classification.²

In addition to height for age (HA) and weight for height (WH), the CIAF classification uses weight for age (WA) — a measure that does not differentiate acute, chronic, and past (recent or remote) undernutrition. The CIAF classification introduces two new groups of children (group B and group C). Group B (2.6%) has normal HA and WA but low WH, an improbable anthropometric combination; group C (6.1%), with higher HA but low WH and WA, is of little immediate concern and can be considered "healthy", presumably growing up to become thin tall adults.³ Other groups, A, D, E, F and Y in the CIAF classification are covered by the Waterlow classification.⁴

The CIAF classification does not address the limitations of the Waterlow classification.² Firstly, it does not satisfy the long-felt need for a combined clinical and anthropometric classification that would be useful for clinical as well as community health work. The classification proposed by the Wellcome Trust Working Party in 1970⁵ and the one used in a WHO monograph in 19996 are inadequate because their coverage of syndromes is incomplete and predetermined, and inappropriate anthropometric criteria are assigned to the syndromes. Personally, I prefer to use a composite classification in which a syndrome is first diagnosed clinically and the anthropometric status (criteria not predetermined) of stunting–wasting is then applied to it.^7,8

Secondly, although children with Z-scores of less than –3 are considered to be severely undernourished, the lower limit of severity remains undefined. I have observed children aged 3–5 years suffering from prolonged or repeated nutritional assaults with extremely low Z-scores (HA: –6 to –7;WA: –5 to –6; and WH –3 to –4) and identified a very severe type, the nutritionally battered child.^7–9 Possibly such cases are flagged as improbable in National Family Health Surveys (NFHS) and hence excluded.¹ The severe cases of stunting–wasting in the absence of kwashiorkor or marasmus reported by Indian workers may resemble these.⁸

Lastly, although in the Waterlow classification² wasting means low WH, as a clinical sign it means visible loss of subcutaneous fat and skeletal muscles. Low WH is observed with clinical wasting in cases of acute undernutrition and in chronic undernutrition of marasmic but not mild-to-moderate or severe (florid kwashiorkor) types where fat masks muscle wasting, if present. Hence, low WH may or may not be associated with clinical wasting, and wasting in the Waterlow classification2 should be differentiated as anthropometric wasting. In their paper, Nandy et al. do not seem to have appreciated this difference and have incorrectly stated that "wasting is an indicator of acute undernutrition".¹

NFHS data are not always reliable,¹ and the reliability of the CIAF model needs to be tested using carefully collected data. However, the associations exhibited between the types of anthropometric failure and morbidities are interesting.

Competing interests: none declared.

1. Nandy S, Irving M, Gordon D, Subramanian SV, Smith GD. Poverty, child undernutrition and morbidity: new evidence from India. Bull World Health Organ 2005;83:210-6.

2. Waterlow JC. Some aspects of childhood malnutrition as a public health problem. Br Med J 1974;5936: 88-90.

3. Physical status: the use and interpretation of anthropometry, Geneva: World Health Organization; 1995. Report of a WHO Expert Committee. Technical Report Series, No. 854.

4. Waterlow JC, Buzina R, Keller W, Lane JM, Nichaman MZ. The presentation and use of height and weight data for comparing the nutritional status of groups of children under the age of 10 years. Bull World Health Organ 1977;55:489-95.

5. Wellcome Trust Working Party. Classification of infantile malnutrition. Lancet 1970;2:302-3.

6. Management of severe malnutrition: a manual for physicians and other senior health workers. Geneva: World Health Organization; 1999.

7. Bhattacharyya AK. Protein-energy malnutrition (kwashiorkor–marasmus syndrome): terminology, classification and evolution. World Rev Nutr Diet 1986;47:80-133.

8. Bhattacharyya AK. Assessment of growth and nutritional status in Indian population. J Indian Anthropol Soc 2000;49:69-102.

9. Bhattacharyya AK. Child abuse in India and nutritionally battered child. Child Abuse and Neglect: the International Journal 1979;3:607-14.

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1 Correspondence to Professor Bhattacharyya at the following address: Surendranath Co-op. Housing Estate, 201, Maniktala Main Road, Flat No. 19, Kolkata 700 054, India (email: mailtobhattacharyya@yahoo.com)