Utility of Mid-Upper Arm Circumference in Detection of Maternal Acute Malnutrition

Sir,

The recent publication entitled “Screening Maternal Acute Malnutrition Using Adult Mid-Upper Arm Circumference (MUAC) in Resource-Poor Settings”[1] supported by the UNICEF in your journal was informative and useful. However, few scientific issues need clarification for the benefits of public health practitioners, research scientists, program implementers, and health administrators.

1. The researchers have justified measuring MUAC instead of height to assess acute maternal malnutrition, as the former takes comparatively less time than the latter. According to them, using nonstretchable adult MUAC tape “an average measuring time taken per person for MUAC was 54 s whereas for height using stadiometer was 59 s.” Authors have referred their earlier study in support of this justification. This is an important issue as it raises concern about validity of results obtained in both present and earlier study. Real time consumed in measuring height and MUAC at community-level research study should be much more as it involves many additional steps that need to be addressed. These steps include visiting a house, identifying an indexed subject, self-introduction, obtaining informed consent, taking tools out for measurements and taking measurements, adjustment of clothes/footwear, and recording it in duplicate or triplicate

2. Researchers identified 84% specificity in mothers screened with MUAC <23 cm. This cutoff could detect high proportion of “false-positive” women with acute malnutrition that may pose additional high burden on treatment/interventions for managing malnourished mothers

3. Authors have referred nine studies in to support their results. Out of them, five are unpublished concerning validity of recommendations made in the present study

4. Authors recommended “Care packages for those mothers who have very low MUAC on their nutrition as well as fetal stunting.” Does the study suggest provision of nutrition supplements/therapeutic foods for mothers screened positive for acute malnutrition? If yes, what specific interventions can be given to these identified mothers? If no, then why should mothers screened for acute malnourishment

5. The present study revealed “those with MUAC <23 and <21 cm were 48% and 14%, respectively.” Diagnostic accuracy between MUAC cutoff of <23 cm and body mass index (BMI) of <18.5 kg/m² as the gold standard. It would be more meaningful if BMI <16 kg/m² would be taken as the gold standard as suggested in a previously published data.[2] It recommended BMI <16 kg/m² to assess severe acute malnutrition in adults (nonpregnant and nonpostpartum). It further added that if BMI cannot be assessed, then MUAC <19 cm should be identified[2]

6. A recently completed seven countries study on pregnant women, four from Africa (Democratic Republic of Congo, Ethiopia, Malawi, and South Africa) and three from South Asia (Bangladesh, Nepal, and Pakistan) concluded that based on the wide variability of sensitivity and specificity between studies, it may be difficult to recommend a MUAC cutoff that would be suitable in all settings.[3]

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Conflicts of interest

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