Malnutrition and disability: unexplored opportunities for collaboration.

There is increasing international interest in the links between malnutrition and disability: both are major global public health problems, both are key human rights concerns, and both are currently prominent within the global health agenda. In this review, interactions between the two fields are explored and it is argued that strengthening links would lead to important mutual benefits and synergies. At numerous points throughout the life-cycle, malnutrition can cause or contribute to an individual's physical, sensory, intellectual or mental health disability. By working more closely together, these problems can be transformed into opportunities: nutrition services and programmes for children and adults can act as entry points to address and, in some cases, avoid or mitigate disability; disability programmes can improve nutrition for the children and adults they serve. For this to happen, however, political commitment and resources are needed, as are better data.

Effectiveness of weekly vitamin A (10,000 IU) and iron (60 mg) supplementation for adolescent boys and girls through schools in rural and urban East Java, Indonesia.

OBJECTIVE: High prevalences of vitamin A deficiency and anaemia among adolescents warrant interventions. This study evaluated the effectiveness of school-based supplementation to reduce anaemia and improve vitamin A status. DESIGN: School-based, grade-randomized, intervention. SUBJECTS AND SETTING: In all, 1757 girls and 1859 boys, aged 12-15 y, in 24 Junior High Schools. INTERVENTIONS: Weekly supplementation for 14 weeks with 60 mg iron and 250 microg folate (Fe group; n=978), 10 000 IU vitamin A (VA group; n=970) or both (VAFe group; n=1042) to subjects in 15 schools, compared to subjects in nine other schools not receiving supplements (control; n=626). RESULTS: The baseline anaemia prevalence (Hb <120 g/l) in girls was 20% (prepubertal) and 26% (pubertal), and in boys 24% (pre-pubertal) and 11% (pubertal). Serum retinol concentrations were low (<1.05 micromol/l) in 41% of boys and 45% of girls. The interventions did not increase haemoglobin concentrations. Serum retinol concentration of boys, but not girls, in the VA group increased (0.33 vs 0.07 micromol/l in controls; P<0.01). The risk factors for low serum retinol concentration were lower baseline serum retinol concentration (OR 0.02-0.03) with, for girls, nightblindness at baseline (OR 5.88), and for boys, not receiving vitamin A (OR control: 1.00; VA: 0.37; Fe: 0.77; VAFe: 0.34) and maternal illiteracy (OR mother never attended school 1.00, mother received any formal education 0.17-0.33). CONCLUSIONS: Supplementation with vitamin A increased serum retinol concentration of boys. Iron supplementation did not change Hb. This appeared to be due to poor compliance, and partly related to side effects.

Determinants of weight and length of Indonesian neonates.

OBJECTIVE: To investigate the determinants of neonatal weight and length. DESIGN: From 16-20 week of pregnancy, 366 mothers of the neonates had participated in the community-based study to investigate the effect of weekly supplementation during pregnancy with iron and vitamin A on infant growth. Women from five villages were allocated randomly to receive two tablets each containing 60 mg iron as ferrous sulphate and 250 micro g folic acid (n=121) or two tablets each containing 2400 RE vitamin A in addition to the same amount of ferrous sulphate and folic acid (n=122). A third ('daily') group (n=123) participating in the national iron supplementation programme was recruited from four neighbouring villages. RESULTS: Neonatal weight and length did not differ between the two weekly groups and between the weekly iron group and the 'daily' group. Iron and vitamin A status during pregnancy did not influence neonatal weight and length significantly. Boys were 100 g heavier and 0.53 cm longer than girls (P<0.05). First born neonates were lighter (P<0.01) and tended to be shorter (P=0.070) than neonates of higher birth order. Maternal age and education as well as other socioeconomic determinants were not associated with neonatal weight and length. Neonatal weight was 32% explained by gestational age, maternal weight, postnatal measurement, gender and parity, while neonatal length was 28% explained by gestational age, maternal weight, postnatal measurement, gender and maternal height. CONCLUSIONS: Gestational age, maternal weight at second trimester and infant gender were the main predictors of neonatal weight and length. SPONSORSHIP: The study was supported by The Netherlands Organization for Scientific Research-Netherlands Foundation for the Advancement of Tropical Research (NWO-WOTRO; WV 93-280) and Neys-van Hoogstraten Foundation (IN 114), The Netherlands, and German Agency for Technical Cooperation (GTZ)/South East Asian Ministers of Education Organization (SEAMEO), Indonesia.

Randomised double-blind trial of the effect of vitamin A supplementation of Indonesian pregnant women on morbidity and growth of their infants during the first year of life.

OBJECTIVE: To investigate whether supplementation with vitamin A together with iron of Indonesian pregnant women decreases morbidity and improves growth of their infants during the first year of life. DESIGN: Women from a rural area in West Java, Indonesia, were randomly assigned on an individual basis to double-blind supplementation once weekly from approximately 18 weeks of pregnancy until delivery. Supplementation comprised 120 mg iron and 500 microg folic acid with or without 4800 RE vitamin A. Their newborn infants were followed up during the first year of life: weight, length, morbidity and food intake were assessed monthly. RESULTS: Infants whose mothers had taken vitamin A supplements during pregnancy had similar weight, length, weight gain and growth as their counterparts during the follow-up period. The proportions of infants with reported symptoms of morbidity were similar in the vitamin A plus iron group and the iron group. In addition immunisation coverage and feeding mode did not differ between the groups. All infants were breast-fed, but exclusive breast-feeding rapidly declined at 4 months of age. Infants with serum retinol concentrations >0.70 micromol/l increased their weight and length more during the first 6 months of life and had higher weight-for-age Z-scores during the first year of life than infants with serum retinol concentrations

Vitamin A and iron supplementation of Indonesian pregnant women benefits vitamin A status of their infants.

Many Indonesian infants have an inadequate nutritional status, which may be due in part to inadequate maternal nutrition during pregnancy. This study was designed to investigate whether infant nutritional status could be improved by maternal vitamin A and Fe supplementation during gestation. Mothers of these infants from five villages had been randomly assigned on an individual basis, supervised and double-blind, to receive supplementation once weekly from approximately 18 weeks of pregnancy until delivery. Supplementation comprised 120 mg Fe and 500 microg folic acid with or without 4800 retinol equivalent vitamin A. Mothers of infants from four other villages who participated in the national Fe and folic acid supplementation programme were also recruited; intake of tablets was not supervised. Anthropometric and biochemical parameters of infants and their mothers were assessed approximately 4 months after delivery. Infants of mothers supplemented with vitamin A plus Fe had higher serum retinol concentrations than infants of mothers supplemented with Fe alone. However, the proportion of infants with serum retinol concentrations <0.70 micromol/l was >70 % in all groups. Maternal and infant serum retinol concentrations were correlated. Fe status, weight and length of infants were similar in all groups. Fe status of girls was better than that of boys, but boys were heavier and longer. We conclude that supplementation with vitamin A in conjunction with Fe supplementation of women during pregnancy benefits vitamin A status of their infants. However, considering the large proportion of infants with marginal serum retinol concentrations, it may still be necessary to increase their vitamin A intake.

Temporary stability of urban food and nutrition security: the East Jakarta study.

The food and nutrition situation in households of East Jakarta was assessed in 1993/1994 and 1998/1999 with the aim of identifying the determinants of potential problems and the dynamics of change. In 1993/1994, the nutritional status of approximately 73% of children under 5 years of age and 60% of mothers was within the normal range, although underweight and overweight were prevalent in almost all households. Between 1998 and 1999, there was a sharp increase in fathers reporting unemployment. The consumption of animal food sources decreased, whereas the consumption of food derivatives such as oils and sugar remained high. Approximately 90% of the population obtained drinking water from wells. By 1998, the public garbage collection system had almost completely collapsed in East Jakarta. Between 1993 and 1998, the prevalence of diarrhoea and acute respiratory infections in children aged under 5 years increased dramatically, from 8 and 44% to 24 and 70%, respectively. The urban environment has undergone significant changes. In Indonesia, as a whole, many achievements in the improvement of household food security and care have been lost due to the economic and political crisis. The statistical association between mothers' and fathers' education and the nutritional status of their children that was observed in 1993/94 did not appear in the 1998 survey. It seems that the education-related coping mechanisms of the parents were inadequate to deal with the rapid deterioration in the economic and political situation.

Weekly vitamin A and iron supplementation during pregnancy increases vitamin A concentration of breast milk but not iron status in Indonesian lactating women.

Studies on the effect of vitamin A and iron supplementation during pregnancy on maternal iron and vitamin A status postpartum are scarce. We investigated whether retinol and iron variables in breast milk and in serum postpartum were enhanced more with weekly vitamin A and iron supplementation during pregnancy than with weekly iron supplementation. During pregnancy, subjects were randomly allocated to two groups and received either (n = 88) a weekly supplement of iron (120 mg Fe as FeSO(4)) and folic acid (500 microg) or (n = 82) the same amount of iron and folic acid plus vitamin A [4800 retinol equivalents (RE)]. Transitional milk (4-7 d postpartum) had higher (P < 0.001) concentrations of retinol and iron than mature milk (3 mo postpartum). Compared with the weekly iron group, the weekly vitamin A and iron group had a greater (P < 0.05) concentration of retinol in transitional milk (as micromol/L) and in mature milk (as micromol/g fat). Although serum retinol concentrations approximately 4 mo postpartum did not differ significantly, the weekly vitamin A and iron group had significantly fewer (P < 0.01) subjects with serum retinol concentrations < or = 0.70 micromol/L than the weekly iron group. Iron status and concentrations of iron in transitional and mature milk did not differ between groups. We have shown that weekly vitamin A and iron supplementation during pregnancy enhanced concentrations of retinol in breast milk although not in serum by approximately 4 mo postpartum. However, no positive effects were observed on iron status and iron concentration in breast milk.

Effect of iron-fortified candies on the iron status of children aged 4-6 y in East Jakarta, Indonesia.

BACKGROUND: Iron deficiency anemia is the most prevalent nutrition problem in young children. One possible strategy to prevent iron deficiency anemia in this population group is the fortification of affordable food. OBJECTIVE: This study was designed to assess whether iron-fortified candies can improve iron status and are acceptable to children aged 4-6 y. DESIGN: A double-blind, placebo-controlled intervention study was conducted in Jakarta, INDONESIA: The children were randomly assigned to 1 of 2 treatment groups: a fortified group (n = 57) and a placebo group (n = 60). Every week for 12 wk, 30 g (10 pieces) candy was given to the children. The candy given to the fortified group contained 1 mg elemental Fe/g and very small amounts of other vitamins and minerals. RESULTS: The hemoglobin concentration of the fortified group increased by 10.2 g/L (95% CI: 8.3, 12 g/L) whereas that of the placebo group increased by 4.0 g/L (2.0, 6.0 g/L; P < 0.001). Anemia prevalence decreased from 50.9% at the start of the intervention to 8.8% after 12 wk of intervention in the fortified group (P < 0.001) and from 43.3% to 26.7% in the placebo group (P < 0.05). After 12 wk of intervention, the serum ferritin concentration was 71% higher than at baseline in the fortified group and 28% higher in the placebo group (P < 0.001). Acceptability of the iron-fortified candies was good. The per capita cost of the supplement was approximately US$0.96-1.20 for the 12 wk of intervention. CONCLUSION: Iron-fortified candies were effective for improving the iron status of young children and might be an affordable way to combat iron deficiency in children of low-to-middle income groups.

Weekly supplementation with iron and vitamin A during pregnancy increases hemoglobin concentration but decreases serum ferritin concentration in Indonesian pregnant women.

We investigated whether weekly iron supplementation was as effective as the national daily iron supplementation program in Indonesia in improving iron status at near term in pregnancy. In addition, we examined whether weekly vitamin A and iron supplementation was more efficacious than weekly supplementation with iron alone. One group of pregnant women (n = 122)was supplemented weekly with iron (120 mg Fe as FeSO4) and folic acid (500 microg); another group (n = 121) received the same amount of iron and folic acid plus vitamin A [4800 retinol equivalents (RE)]. A third ("daily") group (n = 123), participating in the national iron plus folic acid supplementation program, was also recruited. Data on subjects with complete biochemical data are reported (n = 190). At near term, hemoglobin concentrations increased, whereas serum ferritin concentrations decreased significantly in the weekly vitamin A and iron group, suggesting that vitamin A improved utilization of iron for hematopoiesis. Iron status in the weekly iron group was not different from that of the "daily" group. However, iron status decreased with daily supplementation if <50 iron tablets were ingested. Serum transferrin receptor concentrations increased in all groups (P < 0.01). Serum retinol concentrations were maintained in the weekly vitamin A and iron group, but decreased in the other two groups (P < 0.01). Thus, delivery of iron supplements on a weekly basis can be as effective as ona daily basis if compliance can be ensured. Addition of vitamin A to the supplement improved hemoglobin concentration.

Poor micronutrient status of active pulmonary tuberculosis patients in Indonesia.

Malnutrition is observed frequently in patients with pulmonary tuberculosis (TB), but their nutritional status, especially of micronutrients, is still poorly documented. The objective of this study was to investigate the nutritional status of patients with active TB compared with that of healthy controls in Jakarta, Indonesia. In a case-control study, 41 out-patients aged 15-55 y with untreated active pulmonary TB were compared with 41 healthy controls selected from neighbors of the patients and matched for age and sex. Cases had clinical and radiographic abnormalities consistent with pulmonary TB and at least two sputum specimens showing acid-fast bacilli. Anthropometric and micronutrient status data were collected. Compared with the controls, TB patients had significantly lower body mass index, skinfold thicknesses (triceps, biceps, subscapular, suprailiac), mid-upper arm circumference, proportion of fat, and concentrations of serum albumin, blood hemoglobin, plasma retinol and plasma zinc, whereas plasma zinc protoporphyrin concentration, as a measure of free erythrocyte protoporphyrin concentration, was greater. When patients and controls were subdivided on the basis of nutritional status, concentrations of serum albumin, blood hemoglobin, and zinc and retinol in plasma were lower in malnourished TB patients than in well-nourished healthy controls, well-nourished TB patients and malnourished healthy controls. In conclusion, the nutritional status of patients with active pulmonary TB was poor compared with healthy subjects, i.e., significantly more patients were anemic and more had low plasma concentrations of retinol and zinc. Low concentrations of hemoglobin, and of retinol and zinc in plasma were more pronounced in malnourished TB patients.

Premature complementary feeding is associated with poorer growth of vietnamese children.

The objective of this longitudinal study was to investigate the association between the premature initiation of complementary feeding and physical growth of children. Four cohorts of newborn children were included, consisting of 90 infants born in 1981, 90 in 1982, 60 infants in 1983 and 60 in 1984. The weights and heights of children were measured monthly up to 1 y, then every 3 mo for y 2 and 3, and once every 6 mo in y 4. Information on feeding practices and diseases of the children was obtained by interviewing the mothers at each home visit. All but three children (98.6%) were breast-fed. Although 87.1% of the mothers breast-fed their children for at least 1 y, only 3.3% of the infants were breast-fed exclusively at the age of 4 mo. In the analyses of growth, care was taken to address the biases of reverse causality, regression to the mean and confounding. There was little association between feeding pattern at 15 d and growth in length in mo 1. However, partially breast-fed and weaned infants gained weight more slowly than those exclusively or predominantly breast-fed. From 1 to 3 mo, exclusively breast-fed infants grew more quickly in both weight and length, followed by predominantly breast-fed infants. From 3 to 6 mo, exclusively breast-fed infants gained more weight compared with the other groups, but there was a slight difference (P = 0.047) in length gain only between exclusively and partially breast-fed infants. In the older period (6-12 mo), exclusively and predominantly breast-fed infants grew in length more quickly than partially breast-fed and weaned groups. However, there was no difference in weight gain among groups. Morbidity from diarrhea and acute respiratory infections was significantly lower for the >/=3 mo exclusively breast-fed group (chi(2) and Fisher-Exact Test). Over nearly the whole age range from 1 mo to 4 y, Z-scores for all indices (weight-for-age, height-for-age and weight-for-height) of the children who received complementary food were significantly lower than those of children who were exclusively breast-fed for at least 3 mo (repeated measures ANOVA, adjusted for sex, family size, maternal education and family income). These results show a long-term deterioration of physical growth in infants who received premature complementary feeding and confirm the importance of exclusive breast-feeding for infants for at least 3 mo.

Polio as a platform: using national immunization days to deliver vitamin A supplements.

In 1988 the 41st World Health Assembly committed WHO to the goal of global eradication of poliomyelitis by 2000 "in ways which strengthen national immunization programmes and health infrastructure". The successful use of polio National Immunization Days (NIDs) to deliver vitamin A is an example of how polio eradication can serve as a platform to address other problems of child health. Importantly, this integration is helping to achieve the World Summit for Children goal of eliminating vitamin A deficiency by the year 2000. It is estimated that between 140 million and 250 million preschool children are at risk of subclinical vitamin A deficiency. In 1998 more than 60 million children at risk received vitamin A supplements during polio national immunization days (NIDs). While food fortification and dietary approaches are fundamental to combating vitamin A deficiency, the administration of vitamin A supplements during NIDs helps raise awareness, enhance technical capacity, improve assessment and establish a reporting system. Moreover, polio NIDs provide an entry point for the sustainable provision of vitamin A supplements with routine immunization services and demonstrate how immunization campaigns can be used for the delivery of other preventive health services.

World Health Organization hemoglobin cut-off points for the detection of anemia are valid for an Indonesian population.

The study was designed to determine whether population-specific hemoglobin cut-off values for detection of iron deficiency are needed for Indonesia by comparing the hemoglobin distribution of healthy young Indonesians with that of an American population. This was a cross-sectional study in 203 males and 170 females recruited through a convenience sampling procedure. Hemoglobin, iron biochemistry tests and key infection indicators that can influence iron metabolism were analyzed. The hemoglobin distributions, based on individuals without evidence of clear iron deficiency and infectious process, were compared with the National Health and Nutrition Survey (NHANES) II population of the United States. Twenty percent of the Indonesian females had iron deficiency, but no male subjects were iron deficient. The mean hemoglobin of Indonesian males was similar to the American reference population at 152 g/L with comparable hemoglobin distribution. The mean hemoglobin of the Indonesian females was 2 g/L lower than that of the American reference population, which may be the result of incomplete exclusion of subjects with milder form of iron deficiency. When the WHO cutoff (Hb < 120 g/L) was applied to female subjects, the sensitivity of 34.2% and specificity of 89.4% were more comparable to the test performance for white American women, in contrast to those of the lower cut-off. On the basis of the finding of hemoglobin distribution of men and the test performance of anemia (Hb < 120 g/L) for detecting iron deficiency for women, it is concluded that there is no need to develop different cut-off points for anemia as a tool for iron-deficiency screening in this population.

Thiamine deficiency is prevalent in a selected group of urban Indonesian elderly people.

This cross-sectional study involved 204 elderly individuals (93 males and 111 females). Subjects were randomly recruited using a list on which all 60-75 y-old-people living in seven sub-villages in Jakarta were included. The usual food intake was estimated using semiquantitative food frequency questionnaires. Hemoglobin, plasma retinol, vitamin B-12, red blood cell folate and the percentage stimulation of erythrocyte transketolase (ETK), as an indicator of thiamine status, were analyzed. Median energy intake was below the assessed requirement. More than 75% of the subjects had iron and thiamine intakes of approximately 2/3 of the recommended daily intake, and 20.2% of the study population had folate intake of approximately 2/3 of the recommended daily intake. Intakes of vitamins A and B-12 were adequate. Biochemical assessments demonstrated that 36.6% of the subjects had low thiamine levels (ETK stimulation > 25%). The elderly men tended to have lower thiamine levels than the elderly women. The overall prevalence of anemia was 28.9%, and the elderly women were affected more than the elderly men. Low biochemical status of vitamins A, B-12 and RBC folate was found in 5.4%, 8.8 % and 2.9% of the subjects, respectively. Dietary intakes of thiamine and folate were associated with ETK stimulation and plasma vitamin B-12 concentration (r = 0.176, P = 0.012 and r = 0.77, P = 0.001), respectively. Results of this study suggest that anemia, thiamine and possibly vitamin B-12 deficiency are prevalent in the elderly living in Indonesia. Clearly, micronutrient supplementation may be beneficial for the Indonesian elderly population living in underprivileged areas.

Effect of daily and weekly micronutrient supplementation on micronutrient deficiencies and growth in young Vietnamese children.

BACKGROUND: Micronutrient deficiencies remain common in preschool children in developing countries. Interventions focus on single micronutrients and often lack effectiveness. Weekly instead of daily supplementation may improve effectiveness. OBJECTIVE: The efficacy of weekly and daily supplementation in reducing anemia prevalence and in improving the zinc, vitamin A, and growth status of 6-24-mo-old Vietnamese children was investigated. DESIGN: In this double-blind, placebo-controlled trial, the daily group (n = 55) received 8 mg elemental Fe (as iron sulfate), 5 mg elemental Zn (as zinc sulfate), 333 microg retinol, and 20 mg vitamin C 5 d/wk for 3 mo. The weekly group (n = 54) received 20 mg Fe, 17 mg Zn, 1700 microg retinol, and 20 mg vitamin C once a week. A third group (n = 54) received a placebo only. Venous blood samples were collected at the start and end of the supplementation period and anthropometric measurements were taken at the start and 3 mo after the end of supplementation. RESULTS: At baseline, 45.6% of subjects had hemoglobin concentrations < 110 g/L, 36.3% had zinc concentrations < 10.71 micromol/L, and 45.6% had retinol concentrations <0.70 micromol/L. Hemoglobin, retinol, and zinc concentrations of both the weekly and daily groups increased similarly compared with the placebo group (P < 0.001). There was no significant difference in growth between the supplemented groups and the placebo group. However, the height-for-age of subjects stunted at baseline increased with z scores of 0.48 (P < 0.001) and 0.37 (P < 0.001) for the daily and weekly groups, respectively. CONCLUSIONS: Weekly and daily supplementation improved hemoglobin, zinc, and retinol concentrations similarly. Neither intervention affected growth of the overall population, but growth of children stunted at baseline was improved through both types of supplementation.

Validation of predicted total body water and extracellular water by multi-frequency impedance in young Indonesian adults.

To investigate the validity of the prediction of body water compartments by multi-frequency impedance in Indonesians, 42 adults (19 males and 23 females) were recruited in Jakarta, the capital of Indonesia. Extracellular water (ECW) and total body water (TBW) were measured with dilution techniques and predicted from body impedance at 1 and 100 kHz, respectively, using prediction formulas developed in a Dutch population. Furthermore, body weight, body height and body density were measured and as a measure of body build TBW/height and ECW/height were calculated. Percent ECW of body weight in both males (26 +/- 3%) and females (23 +/- 2%) was higher compared to the Dutch reference population, and also the body water distribution (ECW/TBW) was higher (0.46 +/- 0.04) compared to the reference population. TBW/height and ECW/height appeared to be considerably lower in the Indonesian group compared to the reference group, indicating a more slender body shape. TBW was overestimated by 1.8 +/- 2.4 and 2.5 +/- 1.3 kg in males and females, respectively. ECW was underestimated in males by 0.1 +/- 1.2 kg and slightly overestimated in females (0.1 +/- 1.0 kg). After corrections for differences in body build and body water distribution the bias of the predicted TBW was markedly reduced from 2.2 +/- 1.9 to 1.3 +/- 1.8 kg (males and females combined). For ECW the bias after correction for body water distribution and body build was 0.3 +/- 0.6 kg (males and females combined). It is concluded that multi-frequency impedance is suitable for the prediction of body water compartments at the population level but, due to differences in body build and body water distribution, validation in a larger group of Indonesian subjects is needed to avoid systematic prediction errors.

The association between BMI and haemoglobin and work productivity among Indonesian female factory workers.

OBJECTIVE: To investigate the relationship between body mass index (BMI), haemoglobin (Hb) concentration and work productivity in Indonesian female industrial workers engaged in cigarette rolling. DESIGN: Randomized-stratified, cross-sectional study. SETTING: A clove cigarette factory in Central Java Province, Indonesia. SUBJECTS: Two-hundred and thirty female cigarette-rollers. METHODS: Anthropometric variables (height, weight, mid-upper arm circumference, BMI), body composition (lean body mass and fat mass from skinfolds thicknesses), Hb, work productivity (cigarettes/hour) were determined. RESULTS: Of the 230 selected subjects 40.4% were anaemic and 41.3% had BMI < 18.5. Average production was 620 +/- 86 cigarettes/h. Productivity was positively correlated with work experience (r = 0.214, P < 0.01), lean body mass (r = 0.183, P < 0.01), height (r = 0.150, P < 0.05), Hb (r = 0.141, P < 0.05), and arm muscle area (r = 0.120, P < 0.05). Anaemic subjects produced 4.9% less (P < 0.01) than the non-anaemic ones. No linear relationship existed between BMI and productivity, but subjects with a BMI < 18.5, or < 17.0, produced respectively 5.1% (P < 0.05) and 6.8% (P <0.05) less than subjects with BMI between 18.5-22.5. CONCLUSIONS: Work productivity of persons with low BMI and Hb may be reduced. However, BMI was not a good screening tool to detect low producers. When using BMI < 18.5 and a production < 550 cigarettes/h as cut-offs sensitivity (64.7%) and specificity (55.5%) were low.