Validation of MUAC Cut-Offs of WHO for Diagnosis of Acute Malnutrition among Children under 5 Years in Karachi, Pakistan


  • Mehreen Qadri APPNA Institute of Public Health, Jinnah Sindh Medical University, Karachi, Pakistan
  • Lubna Ansari Baig APPNA Institute of Public Health, Jinnah Sindh Medical University, Karachi, Pakistan
  • Zaeema Ahmer APPNA Institute of Public Health, Jinnah Sindh Medical University, Karachi, Pakistan
  • Aimen Asim APPNA Institute of Public Health, Jinnah Sindh Medical University, Karachi, Pakistan
  • Syed Moin Aly Institute of Medical Education, Jinnah Sindh Medical University, Karachi, Pakistan



SAM, MAM, MUAC, WHZ-score, children under 5 years, Karachi


Objective: To validate the WHO recommended Mid-Upper Arm Circumference (MUAC) cut-offs for acute malnutrition screening in children younger than five in Karachi, Pakistan.

Methods: A cross-sectional study was conducted, including an anthropometric examination following WHO guidelines. Height was measured using Stadiometer and Infantometer. The link between MUAC and Weight-for-Height-Z score (WHZ) for different cut-offs of MUAC for Moderate Acute Malnutrition (MAM) and Severe Acute Malnutrition (SAM) was shown using Receiver Operator Characteristics (ROC) curves and the Youden index. Sensitivity and specificity of MUAC <11.5 cm and ≥11.5 to <12.5cm were determined using WHZ scores of -3 Standard Deviation (SD) and ≥-3 to <-2 SD for SAM and MAM, respectively.

Results: Among 499 children, as per WHZ score, 9.6% and 27.1% had SAM and MAM, respectively, whereas according to MUAC, 6.4% and 3.6% had MAM and SAM, respectively. At the maximum value of the Youden index of 55.6%, an optimum cut-off of 12.7cm for screening of SAM with MUAC was found compared to the recommended cut-off of 11.5cm. Similarly, at the maximum value of the Youden index of 57.7%, an optimum cut-off of 13.9cm for screening of MAM with MUAC was found compared to the recommended cut-off of 12.5cm.

Conclusion: The current MUAC cut-off of WHO for screening SAM and MAM cases captures only a small percentage of children under five. This needs to be revised to capture children with acute malnutrition for timely treatment in Pakistan.


Black RE, Victora CG, Walker SP, Bhutta ZA, Christian P, De Onis M, et al. Maternal and child undernutrition and overweight in low-income and middle-income countries. The Lancet 2013; 382(9890): 427-51.

Annan R, Webb P, Brown R, Eds. Management of moderate acute malnutrition (MAM): Current knowledge and practice collaborating to improve the management of acute malnutrition worldwide. CMAM Forum 2014.

UNICEF. Government of Pakistan (2019) National Nutrition Survey 2018-Key Findings Report. UNICEF.

Laillou A, Prak S, de Groot R, Whitney S, Conkle J, Horton L, et al. Optimal screening of children with acute malnutrition requires a change in current WHO guidelines as MUAC and WHZ identify different patient groups. PloS One 2014; 9(7): e101159.

Fiorentino M, Sophonneary P, Laillou A, Whitney S, de Groot R, Perignon M, et al. Current MUAC cut-offs to screen for acute malnutrition need to be adapted to gender and age: the example of Cambodia. PLoS One 2016; 11(2): e0146442.

Guideline W. Updates on the management of severe acute malnutrition in infants and children. Geneva: World Health Organization 2013; 2013: 6-54.

Fernández MÁL, Delchevalerie P, Van Herp M. Accuracy of MUAC in the detection of severe wasting with the new WHO growth standards. Pediatrics 2010; 126(1): e195-e201.

Dairo M, Fatokun ME, Kuti M. Reliability of the mid-upper arm circumference for the assessment of wasting among children aged 12-59 months in urban Ibadan, Nigeria. Int J Biomed Sci 2012; 8(2): 140.

Talapalliwar MR, Garg BS. Nutritional status and its correlates among tribal children of Melghat, Central India. Ind J Pediatr 2014; 81(11): 1151-7.

John C, Ocheke I, Diala U, Adah R, Envuladu E. Does mid-upper arm circumference identify all acute malnourished 6–59 month old children, in field and clinical settings in Nigeria? South Afr J Clin Nutr 2017; 30(3).

Tadesse AW, Tadesse E, Berhane Y, Ekström E-C. Comparison of mid-upper arm circumference and weight-for-height to diagnose severe acute malnutrition: A study in Southern Ethiopia. Nutrients 2017; 9(3): 267.

Kapil U, Pandey R, Bansal R, Pant B, Varshney AM, Yadav CP, et al. Mid-upper arm circumference in detection of weight-for-height Z-score below− 3 in children aged 6–59 months. Public Health Nutr 2018; 21(10): 1794-9.

Dukhi N, Sartorius B, Taylor M. Mid-upper arm circumference (MUAC) performance versus weight for height in South African children (0–59 months) with acute malnutrition. South Afr J Clin Nutr 2017; 30(2).

Grellety E, Golden MH. Weight-for-height and mid-upper-arm circumference should be used independently to diagnose acute malnutrition: policy implications. BMC Nutr 2016; 2(1): 1-1.

Mehta N, Bhatt R, Vora H, Parmar B. Comparison of mid-upper arm circumference and weight-for-height z score for assessing acute malnutrition in children aged 6-60 months: An Analytical Study 2019.

Shukla N, Toppo NA, Thakur A, Kasar PK, Sharma B. Study of health care seeking behaviour for illnesses among malnourished children of age 06-59 months in rural and urban areas of Jabalpur district, Madhya Pradesh 2019.

Hossain MI, Ahmed T, Arifeen SE, Billah SM, Faruque A, Islam MM, et al. Comparison of mid-upper arm circumference and weight-for-height z score for assessing acute malnutrition in Bangladeshi children aged 6–60 month: An analytical study. Am J Clin Nutr 2017; 106(5): 1232-7.

Hai TT, Bardosono S, Wiradnyani LAA, Hop LT, Ngan HTD, Phuong HN. The optimal mid-upper-arm circumference cut-offs to screen severe acute malnutrition in Vietnamese children. AIMS Public Health 2020; 7(1): 188.

Bari A, Nazar M, Iftikhar A, Mehreen S. Comparison of Weight-for-Height Z-score and mid-upper arm circumference to diagnose moderate and severe acute malnutrition in children aged 6-59 months. Pak J Med Sci 2019; 35(2): 337.

Ur Rehman M, Bibi S, Imran I, Anwar H, Alam T, Mohammad K. Mid upper arm circumference and weight for height z-score as screening tools for acute malnutrition in underweight children< 5 years of age. Pak J Physiol 2020; 16(1): 6-9.

Sougaijam R, Gupta S, Raut A, Bharambe M, Garg B. Validating the MUAC (Mid-upper arm circumference) Cut-off for Detection of Severe Acute Malnutrition in Children Aged 6–59 Months in Rural Maharashtra. Ind Pediatr 2019; 56(3).

Lamsal KP, Parajuli KR, Pun BK, Adhikari RP, Bashyal M, Dangol B, et al. Accuracy of Using Mid-Upper Arm Circumference to Detect Wasting Among Children Aged 6–59 Months in Nepal. Global Health: Sci Pract 2021; 9(4): 881-9.

Sendaula E. Performance of MUAC and associated factors in the prediction of acute malnutrition among children 6-59 months at Mulago hospital, Kampala: Makerere University 2018.

McLaren S, Steenkamp L, Venter D. Use of Mid Upper-Arm Circumference (MUAC) as screening tool in an urban township in the Eastern Cape: rationale for testing changed cut-off values to identify malnutrition. South Afr J Clin Nutr 2017; 30(4): 118-9.

Adelia S, Susanto JC. Mid-upper arm circumference measurement for severe malnutrition screening in under-fives. Paediatrica Indonesiana 2020; 60(1): 42-52.

Sachdeva S, Dewan P, Shah D, Malhotra RK, Gupta P. Mid-upper arm circumference v. weight-for-height Z-score for predicting mortality in hospitalized children under 5 years of age. Public Health Nutr 2016; 19(14): 2513-20.





General Articles