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Length Screens Better than Weight in Stunted Populations^1,2,3,

Marie T. Ruel⁴, Juan Rivera^* and Jean-Pierre Habicht

Institute of Nutrition of Central America and Panama/Pan American Health Organization (INCAP/PAHO), Carretera Roosevelt, Z. 11, P.O. Box 1188, Guatemala, Guatemala, Central America ^* National Institute of Public Health, Av. Universidad No. 655, Col. Sta. Maria Ahuacatitlan CP 62508, Cuernavaca Morelos, Mexico Division of Nutritional Sciences, Cornell University, Ithaca, NY 14853

Stunting (low length-for-age) is the most widespread manifestation of growth retardation worldwide. Yet, most nutrition programs use weight-for-age for screening of at-risk children. This study tested whether weight-for-age was an effective screening tool in a severely stunted rural Guatemalan population, using data from the INCAP longitudinal supplementation trial (n = 400). Stunting was defined as length-for-age <-2 SD of the National Center for Health Statistics standards at 3 y of age. Sensitivity and specificity analyses and receiver operating characteristics curves were used to compare weight indicators (weight-for-age, weight velocity and weight-for-length) with length (length-for-age and length velocity) and arm and head circumferences measured during early infancy. Length indicators were clearly superior to weight in predicting stunting (Z_da test), and velocities were consistently worse than attained growth. Length-for-age at 6 mo had the best performance, followed by length-for-age at 3 mo, and weight-for-age at 6 and at 3 mo. Velocities, weight-for-length and circumferences were all poor predictors of stunting. Using the cutoff of <-1 SD, length-for-age at 3 mo was the best screening indicator for the early detection of growth faltering. Thus, the current use of weight-for-age, which results in large proportions of atrisk children being missed by screening, greatly limits the potential for impact of nutrition interventions.

KEY WORDS: • nutrition assessment • anthropometry • Guatemala • humans • malnutrition

¹ Presented in part at Experimental Biology 93, April 1993, New Orleans, LA [Ruel, M. T. & Rivera, J. (1993) Length at 3 months of age: the best screening indicator for the early detection of malnutrition in stunted populations. FASEB J. 7: A283 (abs.)].

² Financial support for data analyses was provided by NIH grant HD22440. The study was a collaborative effort between R. Martorell (principal investigator, currently at Emory University), J. Rivera (currently at the National Institute of Public Health, Cuernavaca, Mexico), E. Pollitt (University of California at Davis) and J. Haas (Cornell University). Additional funding was provided by grant #92-02716-000 from the Pew Charitable Trust.

³ The costs of publication of this article were defrayed in part by the payment of page charges. This article must therefore be hereby marked "advertisement" in accordance with 18 USC section 1734 solely to indicate this fact.

⁴ To whom correspondence should be addressed.

Manuscript received 11 July 1994. Revision accepted 2 November 1994.

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