HelpAge International


Assessment of adults and older people in emergencies: Approaches, Issues and priorities

A presentation for a USAID SMART Workshop

Washington, DC, 23-26 July 2002

  By Dolline Busolo



1          HelpAge International


HelpAge International is a global network of over 70 not-for-profit organisations with a mission to work with and for disadvantaged older people worldwide to achieve a lasting improvement in the quality of their lives.


HelpAge International would like to express their gratitude to the conference organisers for inviting us to participate in the conference on Standardised Monitoring and Assessment of Relief and Transition. 


Participation in the conference would not have been possible without financial support from Food and Nutrition Technical Assistance (FANTA) supported the participation of Dolline Busolo the Regional Nutritionist as a resource person to the conference.

2          Introduction


Experience over the past few years has revealed clear difficulties in arriving at an agreed protocol for the measurement of malnutrition in adults and older people in emergencies. This has in turn produced widely differing criteria for inclusion in dry ration distribution and selective feeding programmes.


Although the use of MUAC and BMI have been used for assessments and intervention,  to date there is no agreement about:


(a)   which methodologies should be used to assess the nutritional status of older people in emergencies

(b)   the sampling approach to arrive at the required representative sample size for older persons

(c)   the cut-off points that should be used to categorise the nutritional status of adults and older people. 


This lack of agreement is reflected in the exclusion of older people from international standards, such as Sphere, that guide best practice in emergencies.


3          Approaches to the measurement of adults and older people


At present, there are a number of approaches being discussed in international nutrition circles, with proponents of BMI, MUAC, the Cormic index and knee height to name a few.  Each approach has its own strengths and weaknesses. However, the present lack of consensus is resulting in poor targeting, widely differing outcomes and, in many cases, the exclusion of the most vulnerable.


Despite the lack of standards, the difficulties with MUAC and BMI cut off points and the lack of agreement regarding sampling, there are several organisations that are involved in targeting adults and older people for assessment and intervention in emergencies.  Some of the approaches used and results gained are outlined below.




4          Assessments and Interventions


a)      Case Study – Ethiopia, 2000


The emergency in south eastern Ethiopia in 2000 highlighted the problems associated with a lack of consensus and a lack of an agreed protocol. Various approaches were used, and widely divergent survey outcomes recorded.


HelpAge International, in conjunction with the Al-Nejah Charity organisation, SOS-Sahel and Goal Ethiopia,undertook a supplementary feeding programme forchildren under five years of age, lactating, pregnant mothers andolder people in Somali region 5[1].  The admission criteria for older people was MUAC <21cm combined with at least one of the following social/economic risk factors:


ü      those living alone

ü      those who had lost livestock

ü      those who had no food in the house

ü      those who were immobile

ü      those who had no relatives, nochildrenand no caregivers.


The discharge criterion was a MUAC of 23cm or above and consistent weight gain for two consecutive sessions.


The admission cut off point cut off point of 21cm was arrived at by consensus among the organisations who were implementing the project and reflected the screening cut off for supplementary feeding programme for adults in emergencies (mainly lactating and pregnant women). In this case the team saw no need to have separate cut off points for adults and older people. The discharge cut off point of 23cm was similar to the WHO recommended sex specific cut off points for men for Chronic Energy Deficiency.


Oxfam-GB targeted internally displaced people in Bolosso Sore in Oromia region for a supplementary feeding programme[2].  The admission criteria for older people was those aged over 50 years with a MUAC<18.5 cm. 


Assessment using BMI showed that none of the admissions had aBMI <17.0 Kg/m2.  An assessment of the causes of malnutrition of the older people admitted showed that many of the beneficiaries were widows with no access to land.  Poor food intake was exacerbated by physiological problems, especially poor sight and dentition difficulties as well as chronic illness. They had no source of income and depended on begging for their survival.  Community support was notably poorer for older people separated from their families.  Older people were clearly chronically vulnerable.


Concern International, implementing an emergency nutrition program in Damot-Weyde, Ethiopia, used MUAC, BMI and Cormic Index adjusted for adults of 18 years and above2.  The prevalence of malnutrition was reported for observed BMI and adjusted BMI (Cormic Index) for adults of 18 to 49 years and those above 49 years. There were large differences between the prevalence rates reported for observed BMI and adjusted BMI.  Using a BMI cut-off of <17 Kg/m2 , the prevalence of malnutrition among younger adults (18-49) was 1.7% (adjusted Cormic Index) and 10.7% (unadjusted).  The prevalence among older people (over 49 years) was 2.0% and 24.5% for adjusted and unadjusted prevalence rates respectively.   MUAC cut-off of 180mm identified a similar proportion of adults with global malnutrition to that using a BMI of <16 Kg/m2.  Mean BMI and mean MUAC significantly decreased with age.



During the same period, GOAL implemented a programme in Yabello Wareda, Oromiyia region, targeting under fives, adults and older people.  In this case, the recorded levels of global malnutrition varied widely depending on the cut-off points used.  Using a cut-off point of 18cms, global malnutrition was 3.4% for older people, whilst a cut-off point of 23cms gave 62.9%.


b)     Case Study – Sudan 2000/01

 The case of Action Contre La Faim[3] illustrates how adults and older people were selected and for inclusion in a therapeutic Feeding programme in Juba Sudan.  BMI was used as the conventional selection indicator.  The programme took place from October 2000 to February 2001, targeting 103 adults and older people with BMI <16 Kg/m2 and those with oedema.  The nutritional treatment of severe malnutrition in adults and elders was based on the same formula used to treat children (F75, F100 or HEM[4], porridge, family meal and fruits/vegetables), with added minerals and vitamins.  However, the amount of milk given per kilograms body weight was much less for adults than children since adult daily energy needs  were assumed to decrease with age. Systematic medical treatment included vitamin A, Folic Acid, Amoxycillin, Mebendazole, Ferrous sulphate and Chloroquine.  Health Education wasas given to the beneficiaries on a daily basis.


 The discharge criteria are shown below:



Older People

BMI equal or above 17.5 kg/m2 for 8 days

BMI equal or above 16.5 kg/m2 for 8 days

No oedema for 15 days

No oedema for 15 days

Ability to  walk

Ability to walk


At the end of the programme the number of adults and elders who had defaulted were 5.4%.  This was very satisfactory according to the ACF defaulting rate (<15%).  The average weight gain for adults and elders was 6.6g/kg/day and the average length of stay for both adults and elders was 42.1 days. Treatment of severe malnutrition in adults and elders took longer than for children.


c)      Case Study – Kenya, 2001


In October 2001, HelpAge International undertook a survey of older people in Turkana, a drought affected district of northern Kenya.  The objectives of the survey were to examine the situation of older people with special focus on nutritional status and social economic status.


The survey was undertaken in collaboration with Oxfam GB who were assessing the nutritional status of children under five. The survey employed a two stage 30 by 30 cluster sampling method, which was modified to 30 by 15 given that the population of older people is about half that of children under five.  Different households from those targeted for children were assessed.  457 older people were assessed.


Anthropometric measurements assessed entailed weight, height and MUAC.  Oedema and dehydration were observed. 


Focus group discussions and household survey methods were used to assess risk factors for older people.  The nutrition vulnerability framework for older people[5] was used.  This entailed discussion and assessment of factors such as:


ü      access to food

ü      functional ability (dependency)

ü      socio-economic status

ü      psychological/emotional assessment

ü      health

ü      care given to and given by older people to other family members

ü      intra household food distribution

ü      the food rations in terms of appropriateness and access


Older people were also involved as key respondents to the wider issues of food security, coping mechanisms, assessment of the community resources and the identification of the longer term and short-term strategies based on the livelihoods of the community.


Household data was entered and analysed using EPI Info version6.04 and SPSS version 10. The results were interpreted based on the WHO/CDC benchmarks for children that outline the prevalence levels and the corresponding recommended action.  


The global acute malnutrition level for older people based on BMI <17 Kg/m2 were 22.9% for older men and 20.5% for older women. The severe acute malnutrition  (BMI less than 16 Kg/m2) was 15.2% and 12.55% respectively.  Based on MUAC, the prevalence of global acute malnutrition was 19.5% for older men and 17.7% for older women based on MUAC of  less than 21 cm.


Other factors that were found to negatively affect the nutritional status of older people based on MUAC assessment were loss of caregiver and mental disability. There was a significant negative correlation (p<0.05%) between MUAC and oedema, immobility, extreme weakness, dehydration and living alone. The most important social risk factors associated with malnutrition in this community were living alone and the loss of caregivers.  Frequently reported diseases among older people were joint pains (53.8%), back pains (44.6%), poor eyesight (42.9%), and fever and malaria (37.6%).


Indicators from the child assessment showed that global acute malnutrition was 19.4% for girls and 17.6% for boys.  Overall, the nutritional situation of older people and children under five were considered to be serious in Turkana. The crude mortality was 2.0 and the under five mortality was 3.1.   Based on weight for height assessment for children, BMI and MUAC  for older people, the nutritional status of  both children and older people were both classified as poor.


Regression analysis was undertaken to establish the correlation between the different risk factors and the MUAC and BMI values for the population.


d)     Case Study – Sierra Leone 2002


Current Evangelism Ministries, a local NGO in Sierra Leone, used basic community indicators to assess the vulnerability of internally displaced older people in war affected Kenema region.  The indicators included visible malnutrition, (according to the assessment of community workers), low physical strength, trauma, poor health, lack of resources,  lack of support  in the care for war-orphans and young children, lack of carers, use of walking sticks/crutches (immobility), displaced/returnees rape victims that have no  access to medical attention, isolated older persons staying in non-supporting families and lack of basic needs.  With this approach, a target group of 200 was selected for emergency relief from a population of 1,300 older people.


5          Issues arising


From the above case studies, it is clear that several issues and problems have yet to be resolved.


ü      In most cases, anthropometric measurements have been used in combination with social/economic risk factors.  This approach has the advantage of looking at nutrition within a wider perspective and helps generate understanding of the nutritional environment of the individual.


ü      From the case studies presented, there appears to be a relationship between certain MUAC cut off points and certain BMI cut off points.  However, they do not always seem to be consistent.  It may be that there is no correlation or that variances are as a result of differences in population groups or in the way the assessments have been carried out.


ü      Whatever the choice of nutrition indicator, the same indicator should be used to monitor change at both assessment and intervention stages.  In cases where MUAC is used as a rapid assessment tool, BMI can be used to verify, and then either tool used to monitor and eventually assess purposes of discharging from feeding programmes.


ü       There is lack of consistency in the sampling method and interpretation of results of surveys in  the cases.  Most of the assessments and interventions have been based on the practises for adults and children. Is there a need to have separate cut off for  screening  for admission into supplementary and therapeutic feeding programmes for older people and adults in emergencies?


ü      Community indicators provide a basic means of assessment that do not require technical staff to administer and which may be appropriate in acute emergencies, especially in the absence of trained nutritionists and with limited resources.


In almost all case studies, there has been extensive use of BMI and MUAC.  However, there are unresolved issues about both tools.


BMI, for instance, has problems that relate to the loss in height and muscle with ageing.  Issues include:


ü      Kyphosis makes it difficult to assess the true height of older people.  However some studies have shown that age related loss of height does not significantly affect height calculations. 

ü      There are problems in relation to the phenotype where the body size varies between ethnic groups.  There is a lack of data on ethnic groups to help standardise BMI to take into account differences in body shape (Cormic Index, standing height/sitting height SH/S ratio) between populations.

ü      Armspan and knee height could be used as proxies for height, but their relationships with height have not been established for different ethic groups.

ü      Although it is recommended to apply a correction factor for the population under study, the use of the Cormic index is not approved by WHO, and there is a limited number of people who have the skill to undertake the calculation. Those that have attempted to calculate found it tedious and time consuming and therefore not suitable for emergencies.

ü      Suitability, acceptability and availability of equipment is a problem which is aggravated by the fact that in emergencies it is often difficult to find hard vertical surfaces to support stadiometers and against which to place scales.


Although MUAC is easily usedin the assessmentofmortality and morbidity in children, there is no universally accepted cut off point for assessing the prevalence of acute malnutrition in adults and older people in emergencies. Issues arising for MUAC include:


ü      WHO  recommends the use of sex specific MUAC cut off points of 22cm for female and 23cm for men for chronic energy deficiency

ü      Although MUAC, in conjunction with clinical criteria, is often proposed as a tool for rapid assessment for adults and older people, the outcomes of the various MUAC cut off points in relation to mortality and morbidity is not known.

ü      There is little information about how the BMI and MUAC change with ageing in Africa.


6          The Way Forward


Whilst some progress has been made towards increasing awareness and understanding of adults and older people’s nutrition needs in emergencies, the lack of agreed standards for assessment has resulted in frustration among many practitioners.  As a result, adults and older people are frequently excluded from nutritional assessments and interventions. In this context, urgent action is needed to promote constructive debate within a framework that will result in consensus.


Ø      For purposes of assessment and surveillance, data on MUAC and BMI should be collected and analysed.   Due to the lack of information in this area, every opportunity should be taken to use programme data to contribute to ongoing operational research.  Specifically we need:


·         indices and cut-off points for defining acute malnutrition

·         performance indicators for assessing effectiveness of selective programmes for adults and older people


Ø      Where feasible, the nutritional status of adults and older people should be assessed using rapid nutrition surveys modified from the CDC/WHO cluster sampling methods to reflect the population of older people to meet statistical rigor.  Older people population could be estimated using census data if available or estimated as half that of children (10% of population).


Ø      When designing programme interventions at a population level, nutritionists should examine risk factors for older people at household and community levels. 


Ø      Some of the underlying causes (at household and community level) and basic causes (at a population level) that may influence older people’s vulnerability should be considered.


Ø      Qualitative information should be collected on what the community perceives as indicators for nutritional vulnerability such as those in the Sierra Leone case.  Qualitative information should include:


·         food security in terms of the typical diets eaten by adults and older people, the food and income source and use and the extent to which they have changed and differ from the general population. 

·         normal community support structures, coping mechanisms specifically those that aim to take care of older people, and the extent to which they have broken down.


Risk factors for individual older people should include:


·         clinical signs including kyphosis

·         socio-economic risk factors, (specifically living alone), presence of care givers, older people that care for children, income source, disability and immobility.


Ø      Since medical complications are common in older people, an assessment of particular underlying chronic illnesses and heart problems is recommended


Ø      Agreement on guidelines/criteria for the inclusion/exclusion of older people in assessments must be discussed at the start of an assessment. Joint assessments of older people along with other age groups are recommended.  There is also need for a separate questionnaire for those caring for older people who are unable to express themselves.


Ø      Training in how to work with older people and adults should be included as part of any nutritional response in an emergency.  Specific training in the use of nutritional assessment tools is also required.


7          Conclusion


Great progress has been made in recent years in understanding and measuring the nutritional needs of adults and older people in emergencies. However, the lack of an agreed criterion for measurement leads to widely differing interpretations and possibly the exclusion of the most vulnerable in emergencies.


In light of the international aid community’s commitment to acceptable standards of service provision in emergencies, and an adherence to best practice, a consensus should be arrived at, and protocols agreed, for inclusion in Sphere and other standards in the near future.



[1] Relief Project for Drought Affected Older People in Borena and Warder Zones, Ethiopia.  Report by HelpAge International, Ethiopia, 2002.

[2]  Report of the workshop  on Addressing the Nutritional Needs of older People in Emergencies: The Issues and challenges, Ghion Hotel  Ethiopia ( HAI  November 2000)

[3] Case study of nutrition intervention for older people by Action Contra La Faim and HAI in Juba

[4] High Energy Milk formula is Dry Skimmed Milk + Oil + Sugar + Complex of minerals and vitamins.

[5]  Better  Nutrition for older people : Assessment by  Action by Suraiya  a Ismail and Mary Manandar

[6] World Health Organization (1995): Adults 60 years of age and older. In Physical Status: The Use and Interpretation of Anthropometry. Report of a WHO Expert Committee. Technical Report Series No. 854. Ch. 9. Geneva: world Health Organization.