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James: You are in the unusual position of judging undernutrition on two grounds: one is height, but you do not specify a cut-off point. The other is socio-economic, which could be a problem. Can you distinguish between these? Is the height criterion to be included in a graded way into Grades I-III CED? What is the prevalence of these height or socio-economic categories in your society?
Shetty: Stature is distinctly different in those individuals classified as underweight and those with CED, both having BMI <18.5. The so-called underweights have a normal stature of 1.70-1.74 m, while the undernourished are <1.6m, a clear difference of about 10 cm. We have data from the literature on over 1000 studies over 50 years of normal healthy adults in India. The mean BMI is 19-20 but there are still individuals of <18.5 in these groups of healthy individuals. Many of them have been monitored in a variety of physiological studies and have been assessed as fit, healthy and normal. This may be an effect of age and our cut-off point of 18 years may be too early. Norgan showed that there are correlations in the 30-39 year age group that are very different from the 18-30 year group. The profile of distribution of healthy individuals may change if you eliminate those <20 years of age. Perhaps the inclusion of those <18 years as fully grown is part of the problem.
Waterlow: You indicated that BMR is mostly correlated with weight and BMI adds very little. If you have two people of the same weight, but one is short and stocky and the other is tall and thin and they have different BMIs, will they have the same BMRs? Schofield added height to his weight equations and found that on average it made little difference. But if you compute from his equations individual cases, they are rather different. What is your experience as you seem to think that stature does make a difference to BMR?
Shetty: Their predicted BMRs would be the same, and their measured BMRs would be similar, i.e. within accepted levels of variation. So the shape and the surface area don't seem to make much difference.
James: If you discard height and are left with your socio-economic index you then define these people as healthy because you know they have access to enough food. If that is your method for identifying people with a low BMR, then I am becoming worried. Shetty: The well-fed thin group is small. We need to know what percentage of the population are in this category, and by subtracting them from the calculations we can obtain a better idea of the true numbers in CED. Waterlow: Even in John Durnin's healthy British soldiers there were some <18.5.
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