An important problem in assessing adult undernutrition during famine is the inability to differentiate between primary and secondary undernutrition. At present, there are no one-off measurements that can do this. In practice admission into selective feeding programmes should be based on the CHANCES criteria, irrespective of whether the adult is suffering from primary or secondary undernutrition. Those with malnutrition secondary to infection (for example, TB or HIV) will fail to respond adequately to treatment. Adult selective feeding programmes must therefore be designed in a way that allows for these people to be referred to other more appropriate support or treatment programmes. The design of these is beyond the scope of this article.
In future, as catabolic hormones produced in response to infection have a greater influence on peripheral energy and protein stores 82 it might be that in secondary undernutrition resulting from infection the MUAC is more depressed than BMI. This might lead to the possibility of using a combination of the two indicators to differentiate between primary and secondary undernutrition. To date, no work has been undertaken to investigate this possibility.
