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Discussion

In the present communication an attempt is made to examine the available data from the Indian population to find out the association between the grades of CED (defined in terms of BMI) and physical and functional impairments. Growth retardation of young children of preschool age in terms of a weight-for-age deficit and of wasting (i.e. weight-for-height status), was used as an indicator of morbidity while the incidences of LBW and mortality were used as proxies for functional impairment.

Since the data on food consumption and nutritional status (anthropometric) are obtained from the same households in NNMB surveys, the adult HH BMI on its own can be expected to serve as an index of the energy intake of the household. This is not to imply that diet surveys, despite their methodological difficulties, are unnecessary in assessing the energy status nor that their role in evaluating nutritional status is insignificant. Despite the tediousness and inherent large variations in the estimates of energy intake, diet surveys provide valuable clues when applying appropriate dietary corrective measures. Since the purpose of this discussion is not to highlight the merit or demerit of food consumption surveys, we turn to the main observations made in this communication.

The BMI index proved to be useful in ascertaining the change in nutritional status over a period of time, when dietary indicators could not be relied on to reflect the change (s) because of their large variations (NNMB surveys, 1991). Adult BMI can be a reasonably good substitute not only for assessing energy status of the household but also for evaluating the nutriture of the preschool child in that household. The adult BMI also appears to be a useful index for assessing the socio-economic level of the household in terms of the occupational and income status. Adult BMI was closely associated with the weight rather than the height of the individual because weight is the responsive variable to energy balance. Maternal BMI can also serve on its own as a significant risk factor for LBW. In under

Table 14. The -2 SD, mean and +2 SD limits from various populations studied and reported in literature

Variables Place	Group	Reference	Sex	Age (years)	Mean BMI	SD	Mean -2 SD
Britain	Army	James et al. (1988)	Men	20-24	23.4	2.8	17.8
			Men	25-29	24.2	3.0	18.2
			Men	30-34	24.8	2.9	19.0
			Men	35-39	24.9	3.0	18.9
			Women	20-24	22.8	2.8	17.2
			Women	25-29	22.5	2.9	16.7
			Women	30-34	22.9	2.3	18.3
India	Urban affluent	Gopalan (1989)	Men	3554	24.6	3.4	17.8
			Women	30-49	23.8	2.9	18.0
India	Normal nutrition		Men	21-26	20.91	1.67	17.6
			Women	20-25	20.75	1.44	17 9

Table 15. The percentage distribution of CED based on BMI in males according to age

	Age (years)
BMI class	20-29	30-39	40-49	50-59	>60
Males
<16	6.7	6.5	9.1	11.0	17.5
16-18.4	44.8	39.6	37.5	36.7	35.1
18.5-24.9	47.9	51.2	49.1	47.3	43.0
>25	0.6	2.7	4.3	5.0	3.4
Females
<16	8.6	11.3	12.7	12.0	20.9
16-18.4	41.2	37.9	34.7	32.7	35.5
18.5-24.9	48.2	46.9	45.9	47.0	38.3
>25	2.0	3.9	6.7	8.3	5.3

References

Ferro-Luzzi A, Sette S. Franklin M & James WPT (1992): A simplified approach of assessing adult chronic energy deficiency. Eur J. Clin. Nutr. 46, 173-186.

Gomez F. Ramos GR, Frank S. Cravioto J. Chavez R & Varquez J (1956): Mortality in second and third degree malnutrition. J. Trop. Pediat. 2, 77-83.

Gopalan C (1989): Growth of affluent Indian girls during adolescence. NFI Scientific Paper No. 10, pp. 22-23

James WPT, Ferro-Luzzi A & Waterlow JC (1988): Definition of chronic energy deficiency in adults. Report of working party to the International Dietary Consultation Group. Eur. J. Clin. Nutr 42, 968.

Naidu AN, Neela J & Rao NP (1991): Maternal body mass index and birth weight. Nutr News 12 (2). Hyderabad: National Institute of Nutrition.

NIN Report (1989-90): Body mass index and mortality rates - a 10 year retrospective study. National Institute of Nutrition, Annual Report, 1989-90, pp. 10.

NNMB surveys (1991): National Institute of Nutrition, Report of Repeat Surveys, 1991.

Norgan NG (1990): Body mass index and body energy stores in developing countries. Eur. J. Clin. Nutr. 44, Suppl. 1, 79-84.

Seoane N & Latham MC (1971): Nutritional anthropometry in the identification of malnutrition in childhood. J. Trop. Paediat. Environ. Child Hlth 17, 98-104.

Test K (1990): Using maternal anthropometry to identify risk in pregnancy WHO/MCH/90.3. Geneva: WHO.

WHO (1983): Measuring change in nutritional status. Guidelines for assessing the nutritional impact of supplementary feeding programmes for vulnerable groups. Geneva: WHO. in a household predict that of females in the same household?

Discussion

Waterlow: I am anxious that we are putting too much stress on 18.5 as a cut-off point. I think we should think of a BMI <18.5 as an index of increased risk but not necessarily of CED.

Kennedy: Your comparisons of the 1970s and 1980s are very interesting. Can you comment on reasons for the more marked shift of BMI in males than in females? Would the BMI of males nourished countries where CED is rampant, height (which was shown to be influencing the BMI least), in this analysis has turned out to be a significant confounding factor for LOW in addition to age and parity.

Acknowledgements - The authors express their gratitude to Dr Vinodini Reddy, Director, National Institute of Nutrition, Hyderabad for her keen interest in the investigation. They acknowledge Mr Kashinath, Research Officer for computer analysis. Their sincere thanks are also due to NNMB Central Reference Laboratory staff for providing the data. Invaluable secretarial help was provided by Mrs R Prashanthi and Mrs K. Sailaja.

Naidu: We found no correlation between the BMI of males and females in the same household. But the rank correlation for men and women is significant.

Durnin: The absolute energy intake seems low, but related to body weight it seems to be 1.8 x BMR, which is quite high.

Naidu: I consider the intakes to be quite low.

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