A man's waist is 99 cm and his hip circumference 110 cm. His waist-hip ratio and its interpretation by the WHO threshold are:

0.90, at the threshold of substantially increased risk

0.85, below the threshold for men

0.90, normal because the male threshold is 1.0

0.90, at the threshold of substantially increased risk

Low height-for-age in a child indicates:

Stunting, a sign of chronic undernutrition

Wasting, a sign of acute undernutrition

Which of the following identify severe acute malnutrition in a child aged 6 to 59 months? Select all that apply.

Weight-for-height below −3 SD

Assertion (A): Adolescent girls in India have a high prevalence of anaemia. Reason (R): The growth spurt and the onset of menstruation raise iron requirements in adolescence. Choose the correct option.

Both A and R are true, and R is the correct explanation of A

Both A and R are true, but R is not the correct explanation of A

Which statements about infant feeding are correct? Select all that apply.

Complementary foods should be introduced at about 6 months

Breastfeeding should begin within the first hour after birth

Colostrum should be discarded because it is too thick for the newborn

Complementary foods should be introduced at about 6 months

Breastfeeding should begin within the first hour after birth

Water should be given to exclusively breastfed infants in summer

Nutrition and Dietetics II: Public Health Nutrition, Nutrition through the Life Span, Community, Sports and Emergency Nutrition, and Nutritional Assessment

This chapter covers items 3 to 6 of Unit II. It starts at the population level with public health nutrition: the burden of malnutrition in India as the National Family Health Survey measures it and the causal framework that explains it. It then follows one life from conception to old age, stage by stage, setting out the physiological changes, the nutritional needs and the concerns of each. Community, sports and emergency nutrition come next, three settings with very different goals. The chapter closes with nutritional assessment, the toolkit of anthropometric, biochemical, clinical and dietary methods, with the formulas worked through: body mass index against both the WHO and the Asian-Indian cut-offs, waist-hip ratio, and z-scores.

1. Public health nutrition

Public health nutrition applies nutrition science to promote health and prevent disease in whole populations, through surveillance, policy, programmes and education rather than individual treatment. India carries a double burden of malnutrition: persistent undernutrition and micronutrient deficiency alongside rising overweight, obesity and diet-related non-communicable disease, sometimes within the same household. When micronutrient deficiency is counted separately, this is called the triple burden.

Indicator (NFHS-5, 2019-21)	Per cent
Children under 5 who are stunted (low height-for-age)	35.5
Children under 5 who are wasted (low weight-for-height)	19.3
Children under 5 who are underweight (low weight-for-age)	32.1
Children aged 6 to 59 months who are anaemic	67.1
Women aged 15 to 49 who are anaemic	57.0

The UNICEF conceptual framework of the causes of malnutrition, first set out in 1990, remains the standard way to think about causes. Immediate causes are inadequate dietary intake and disease, which feed each other. Underlying causes are household food insecurity, inadequate care and feeding practices for women and children, and an unhealthy environment with poor water, sanitation and health services. Basic causes lie in the distribution of resources, income, education, gender relations and political and economic structures. Programmes that treat only the immediate causes tend not to last.

⚠️ Stunting, wasting and underweight measure different things

Stunting (height-for-age) reflects chronic, long-term undernutrition; wasting (weight-for-height) reflects acute, recent weight loss; underweight (weight-for-age) is a composite that cannot tell the two apart. A child can be stunted without being wasted.

2. Nutrition through the life span

Stage	Physiological changes	Key nutritional needs and concerns
Pregnancy	Expanded blood volume, growth of foetus, placenta and maternal tissues; haemodilution	Extra energy and protein in later trimesters, iron and folic acid, iodine, calcium; low birth weight and anaemia as concerns
Lactation	Milk secretion under prolactin, let-down under oxytocin	The highest energy demand of adult female life, fluids, calcium
Infancy (0 to 12 months)	Fastest growth after birth: birth weight roughly doubles by about 5 months and triples by one year	Early initiation of breastfeeding within an hour, colostrum, exclusive breastfeeding for 6 months, complementary foods from 6 months with continued breastfeeding to 2 years or beyond
Preschool (1 to 6 years)	Slower growth, rising activity, small stomach	Frequent energy-dense meals; the peak age of undernutrition and infection
School age (6 to 12 years)	Steady growth, laying down reserves before puberty	Breakfast, school meals, iron; junk food and early obesity
Adolescence (10 to 19 years)	Growth spurt, puberty, menarche in girls	High energy, protein, calcium and iron needs; anaemia in girls, eating disorders, early marriage and pregnancy
Adulthood	Maintenance; gradual gain of fat and loss of lean mass	Energy balance, fibre, limiting salt, sugar and fat; prevention of non-communicable disease
Old age	Lower basal metabolic rate, loss of muscle (sarcopenia) and bone, weaker taste, smell, thirst and teeth, lower B12 absorption	Nutrient-dense soft foods, protein, calcium and vitamin D, fluids, fibre; social isolation and poverty as risks

Low birth weight is a birth weight below 2,500 grams, whatever the length of gestation; it may follow preterm birth (before 37 completed weeks) or intrauterine growth restriction, and maternal undernutrition, anaemia and short birth spacing are major causes in India. The first 1,000 days, from conception to a child's second birthday, are the window in which nutrition has the largest and least reversible effect on growth, brain development and later disease risk.

🎯 Why colostrum matters

Colostrum, the thick yellow milk of the first days, is rich in secretory IgA and other anti-infective factors, vitamin A and protein. Discarding it, a practice still met in parts of India, removes the newborn's first protection; giving pre-lacteal feeds such as honey or water adds a risk of infection.

3. Community, sports and emergency nutrition

Community nutrition works with groups in their own setting: diagnosing the community's nutrition problems, planning with local people, and acting through anganwadi centres, schools, self-help groups and health workers. Its tools are nutrition education, growth monitoring and promotion, kitchen gardens, take-home rations, demonstrations of low-cost recipes and referral.

Sports nutrition fits intake to training. Carbohydrate is the main fuel for intense exercise, stored as limited muscle and liver glycogen; endurance athletes may carbohydrate-load for events lasting more than about 90 minutes. Protein needs of athletes are commonly put at about 1.2 to 2.0 grams per kilogram a day, above the allowance for sedentary adults, and are best spread across meals. Hydration is monitored by weighing before and after training; each kilogram lost is replaced with roughly 1.25 to 1.5 litres of fluid. A pre-event meal is eaten about 3 to 4 hours before, high in carbohydrate and low in fat and fibre.

In emergencies and disasters, nutrition work moves from general food distribution to targeted care. The humanitarian Sphere standards use 2,100 kcal per person per day as the planning figure for a general ration. Children with moderate acute malnutrition receive supplementary feeding; those with severe acute malnutrition are managed in the community with ready-to-use therapeutic food if they have appetite and no complications, and in inpatient care (in India, Nutrition Rehabilitation Centres) with the therapeutic milks F-75 and then F-100 if they have complications. Breastfeeding is protected, and unsolicited donations of infant formula are discouraged because they displace breastfeeding where clean water is scarce.

Acute malnutrition, children 6 to 59 months (WHO)	Criteria
Severe acute malnutrition	Weight-for-height below −3 SD, or MUAC below 115 mm, or bilateral pitting oedema
Moderate acute malnutrition	Weight-for-height from −3 to below −2 SD, or MUAC from 115 to below 125 mm

4. Nutritional assessment: methods and techniques

Nutritional status is assessed by the ABCD methods: Anthropometry, Biochemical tests, Clinical examination and Dietary assessment, often with a fifth, Ecological factors, covering vital statistics (infant and maternal mortality, morbidity), food availability and socio-economic conditions. Each method sees a different stage: dietary methods detect inadequate intake before anything else, biochemical tests detect depleted stores, and anthropometry and clinical signs detect established deficiency.

Asian Indians carry more body fat and cardiometabolic risk at a given BMI, hence the lower cut-offs used in Indian studies
BMI (kg/m²)	WHO international classification	Asian-Indian cut-offs (WHO expert consultation 2004; Indian consensus guidelines 2009)
Below 18.5	Underweight	Underweight
18.5 to 22.9	Normal	Normal
23.0 to 24.9	Normal	Overweight
25.0 to 29.9	Overweight (pre-obese)	Obese
30.0 and above	Obese	Obese

Worked: an adult weighs 70 kg and is 1.65 m tall. BMI = 70 / (1.65 × 1.65) = 70 / 2.7225 = 25.7 kg/m², overweight (pre-obese) by the WHO classification and obese by the Asian-Indian cut-offs. Central obesity is judged by waist circumference (Indian cut-offs of 90 cm for men and 80 cm for women) and by waist-hip ratio; the WHO treats a ratio of 0.90 or more in men and 0.85 or more in women as substantially increased risk. A man with a waist of 99 cm and hips of 110 cm has a ratio of 99 / 110 = 0.90, at the risk threshold.

Children are compared with the WHO Child Growth Standards (2006) as z-scores: z = (observed value − reference median) / reference SD. Below −2 is moderate and below −3 severe. Older classifications still asked are Gomez (weight-for-age as a percentage of the reference: grade I 75 to 90, grade II 60 to 75, grade III below 60) and the Indian Academy of Paediatrics grades.
Biochemical: haemoglobin and serum ferritin for iron, serum retinol for vitamin A, urinary iodine for iodine status (a population median of 100 to 199 micrograms per litre is adequate), serum albumin for protein status.
Clinical: signs such as pallor, Bitot's spots, angular stomatitis, goitre, the "flag sign" in the hair and oedema of kwashiorkor, the wasted "old man" face of marasmus.
Dietary: the 24-hour recall (quick, memory-dependent, one day is not usual intake, so it is repeated), the food frequency questionnaire (habitual intake over weeks or months), the diet history, the weighed food record (most accurate, most burdensome) and, nationally, food balance sheets of food available per head.

🧠 BMI uses metres squared

Convert centimetres to metres before squaring: 165 cm is 1.65 m and its square is 2.7225, not 272. A BMI in the hundreds or below 5 means the conversion was skipped.

Key takeaways

NFHS-5 (2019-21) found 35.5 per cent of under-fives stunted, 19.3 per cent wasted and 32.1 per cent underweight, with anaemia in 67.1 per cent of young children and 57.0 per cent of women.
The UNICEF framework sorts causes into immediate (intake, disease), underlying (food insecurity, care, environment and services) and basic (resources and structures).
Exclusive breastfeeding to 6 months, complementary feeding from 6 months and the first 1,000 days are the core of life-cycle nutrition; low birth weight is below 2,500 g.
SAM in children 6 to 59 months is weight-for-height below −3 SD, MUAC below 115 mm or bilateral pitting oedema; Sphere plans general rations at 2,100 kcal per person per day.
BMI is kg/m²; WHO calls 25 overweight and 30 obese, while Asian-Indian cut-offs call 23 overweight and 25 obese; WHO flags waist-hip ratios of 0.90 (men) and 0.85 (women).

Practice questions (10)

Attempt each one before opening the answer. Every explanation names the tempting wrong option as well as the right one, because that is where marks are lost.

An adult weighs 70 kg and is 1.65 m tall. What is the BMI, rounded to the nearest whole number? Type the number.
Numerical answer — type the value.
Show answer
Answer: 26
BMI = 70 / 1.65² = 70 / 2.7225 = 25.7, which rounds to 26. This is overweight by the WHO classification and obese by the Asian-Indian cut-offs, which place obesity at 25.
A woman has a BMI of 24.0 kg/m². How is she classified by the WHO international cut-offs and by the Asian-Indian cut-offs respectively?
1. Overweight; overweight
2. Overweight; obese
3. Normal; overweight
4. Normal; normal
Show answer
Answer: C — Normal; overweight
WHO's normal range runs from 18.5 to 24.9, so 24.0 is normal internationally. The Asian-Indian cut-offs place 23.0 to 24.9 in the overweight band, reflecting higher risk at lower BMI in Asian Indians.
A man's waist is 99 cm and his hip circumference 110 cm. His waist-hip ratio and its interpretation by the WHO threshold are:
1. 0.85, below the threshold for men
2. 0.90, normal because the male threshold is 1.0
3. 0.90, at the threshold of substantially increased risk
4. 1.11, low risk
Show answer
Answer: C — 0.90, at the threshold of substantially increased risk
WHR = waist / hip = 99 / 110 = 0.90. The WHO treats 0.90 or more in men (0.85 in women) as substantially increased metabolic risk. Dividing hip by waist gives the wrong ratio of 1.11.
Low height-for-age in a child indicates:
1. Overweight
2. Stunting, a sign of chronic undernutrition
3. Wasting, a sign of acute undernutrition
4. Oedematous malnutrition
Show answer
Answer: B — Stunting, a sign of chronic undernutrition
Height-for-age falls behind only after long periods of inadequate nutrition and repeated infection, so it measures stunting. Wasting is low weight-for-height, and oedema is a clinical sign, not an anthropometric index.
Which of the following identify severe acute malnutrition in a child aged 6 to 59 months? Select all that apply.
1. MUAC below 115 mm
2. Weight-for-height below −3 SD
3. Height-for-age below −2 SD
4. Bilateral pitting oedema
Show answer
Answer: A — MUAC below 115 mm; B — Weight-for-height below −3 SD; D — Bilateral pitting oedema
Any one of weight-for-height below −3 SD, MUAC below 115 mm or bilateral pitting oedema defines SAM. Height-for-age below −2 SD is moderate stunting, a chronic measure that does not define acute malnutrition.
A child's weight is 7.4 kg. For the child's age and sex the reference median is 9.6 kg and the reference standard deviation 1.1 kg. What is the weight-for-age z-score? Type the answer as a signed whole number.
Numerical answer — type the value.
Show answer
Answer: -2
z = (7.4 − 9.6) / 1.1 = −2.2 / 1.1 = −2. A z-score of −2 is the boundary of moderate underweight; below −3 would be severe.
Which dietary assessment method best captures a person's habitual intake over several months?
1. Food balance sheet
2. A single 24-hour recall
3. Serum retinol estimation
4. Food frequency questionnaire
Show answer
Answer: D — Food frequency questionnaire
The food frequency questionnaire asks how often foods are eaten over weeks or months, so it reflects habitual intake. One 24-hour recall captures a single day, a food balance sheet measures national availability, and serum retinol is a biochemical, not a dietary, method.
Assertion (A): Adolescent girls in India have a high prevalence of anaemia. Reason (R): The growth spurt and the onset of menstruation raise iron requirements in adolescence. Choose the correct option.
1. Both A and R are true, and R is the correct explanation of A
2. Both A and R are true, but R is not the correct explanation of A
3. A is true, but R is false
4. A is false, but R is true
Show answer
Answer: A — Both A and R are true, and R is the correct explanation of A
Both are true and R explains A. Rapid growth expands blood volume and muscle mass, and menstrual losses begin, so iron needs rise just when diets are often poor in bioavailable iron; this is why weekly iron-folic acid supplementation targets adolescents.
Which statements about infant feeding are correct? Select all that apply.
1. Colostrum should be discarded because it is too thick for the newborn
2. Complementary foods should be introduced at about 6 months
3. Breastfeeding should begin within the first hour after birth
4. Water should be given to exclusively breastfed infants in summer
Show answer
Answer: B — Complementary foods should be introduced at about 6 months; C — Breastfeeding should begin within the first hour after birth
Early initiation within an hour and complementary feeding from about 6 months are the recommendations. Colostrum is the most protective milk of all, and breast milk meets an exclusively breastfed infant's water needs even in hot weather, so extra water only adds infection risk.
By the Gomez classification, a child whose weight is 70 per cent of the reference weight-for-age has:
1. Grade II malnutrition
2. Grade III malnutrition
3. Normal nutrition
4. Grade I malnutrition
Show answer
Answer: A — Grade II malnutrition
Gomez places 75 to 90 per cent of the reference in grade I, 60 to 75 per cent in grade II and below 60 per cent in grade III, so 70 per cent is grade II. Normal nutrition is above 90 per cent.