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Weight-for-age z-score as a proxy marker for diarrhoea in epidemiological studies
  1. Wolf-Peter Schmidt1,*,
  2. Sophie Boisson1,
  3. Bernd Genser2,
  4. Mauricio Barreto2,
  5. Kathy Baisley1,
  6. Suzanne Filteau1,
  7. Sandy Cairncross1
  1. 1 London School of Hygiene and Tropical Medicine, United Kingdom;
  2. 2 Instituto de Saúde Coletiva, Federal University of Bahia, Salvador, Brazil
  1. Correspondence to: Wolf Schmidt, London School of Hygiene and Tropical Medicine, Keppel street, London, WC1E 7HT, United Kingdom;{at}


Background: The validity of unblinded randomised trials testing interventions against diarrhoea is severely compromised by the potential bias. Objective proxy markers for diarrhoea not relying on self-report are needed to assess the effect of interventions that cannot be blinded. Short term changes in weight for age z-score (WAZ) may (due to catch-up growth) not be a clinically important marker for nutritional status. However, even a transient decrease in WAZ could indicate recent diarrhoea, and be interpreted as the effect of an intervention.

Methods: Using data from two large Vitamin A trials from Ghana and Brazil, we explored the immediate effect of the cumulative diarrhoea occurrence over 14 and 28 day time windows on WAZ.

Results: We found a very strong linear association between the number of days with diarrhoea over the last 14 to 28 days and WAZ. In both trials, differences in diarrhoea between the trial arms were associated with corresponding differences in WAZ.

Conclusion: Repeated WAZ measures appear to be a suitable proxy marker for diarrhoea in children, but have disadvantages in terms of specificity and study power.

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