International Journal of Public Health and Epidemiology ISSN: 2169-303X Vol. 2 (4), pp. 078-084, July, 2013.

Available online at © International Scholars Journals

Full Length Research Paper

Malnutrition among rural Indian children: An
assessment using web of indices
Fahmina Anwar1, Manoj Kumar Gupta2, C.Prabha3 and R.K.Srivastava4
Research fellow, Department of Community Medicine Institute of Medical sciences, Banaras Hindu University,
Varanasi, India.
Assistant professor, Institute of Health Management Research, Bangalore, India.
Professor, Department of Community Medicine Institute of Medical sciences, Banaras Hindu University, Varanasi,
Accepted 9 April, 2013

Childhood malnutrition is an enduring problem in developing countries. Cases with mild-to-moderate
malnutrition are likely to remain unrecognized because conventional measures of under nutrition may be
missing out a considerable proportion of undernourished children present in the population. With this
background, a community based study was conducted to estimate the prevalence of under nutrition
among children by using various available indicators. It is a community based on cross sectional study
carried out in the rural area of Varanasi, India. A total of 483 children aged 0-36 months were examined that
were selected by adopting appropriate sampling methodology. They were subjected to anthropometry
(weight, height and Mid Upper Arm Circumference (MUAC)) measurements following standard
technique.BMI and other parameters were also assessed, the data thus obtained was analysed using
SPSSv16.0. Prevalence of stunting, underweight and wasting were 43.1%, 35.2% and 31.5%, respectively.
The Composite Index of Anthropometric Failure (CIAF) shows 62.5% of children suffering from
anthropometric failure. As much as 88 (42.9%) children were suffering from malnutrition according to
MUAC criteria (< 13.5 cm). Nearly two thirds of the children were in the zone of anthropometric failure.
There is a need and scope to construct an alternative indicator to provide a single, aggregated figure of the
number of undernourished children in a population.

Key words: Anthropometric measurements, stunting, underweight, wasting, anthropometric failure.


Malnutrition is widely recognized as a major health for individuals as well as families, community work, health
problem in developing countries. Growing children in care delivery systems and other underlying determinants,
particular are most vulnerable to its consequences. including poverty (Bhutta ZA, et al 2008). Childhood
Cases with mild-to-moderate malnutrition are likely to under nutrition can be evaluated anthropometrically
remain unrecognized because clinical criteria for their (Bose K, 2007; Lee RD & Nieman DC. 2003). It is
diagnosis are imprecise and are difficult to interpret an important tool in the study and understanding of
accurately. Studies have suggested that there is a need human biological variability, including, of course,
to focus on the youngest children in nutrition programmes morphological variation as universally applicable, non
to prevent long-term effects (Victora CG et al 2008). invasive and inexpensive methods (WHO, 1995). There
Undernourished children are also more likely to come are many anthropometric indicators in use, such as Mid-
from poorer backgrounds (WHO, 1997; Wagstaff A, Upper Arm Circumference (MUAC), MUAC for height,
watanabe 2000), where they do not get enough food and weight for age, height for-age, weight for height, and
are exposed to poor living conditions (for example, lack of body mass index of Quetlet. Most of these indicators
proper sanitation or clean drinking water), which in turn need to be used along with specific reference tables, for
leads to disease and further under nutrition. So, example. National Centre for Health Statistics (NCHS)
nutritional programmes should focus on sufficient feeding tables or WHO growth standards, for interpreting data
(Hamill PV et al 1979) this might not be possible in over-
crowded outpatient departments of common tertiary care
*Corresponding author E-mail: hospitals. Therefore, to estimate the expected weight or

nutrition among young children (Svedberg P. However. Underweight thus cannot distinguish programming and outcomes. Nandy et al. be they wasted and/or stunted and/or not have any unit. a new aggregate indicator is CIAF. using age as a variable anthropometric failure. because of their overlapping none is able to anthropometric indicators of under nutrition among provide a comprehensive estimate of the number of children (Bhattacharya AK 2000). Nandy et al (2005) had utilised the CIAF good so that the government resources and facilities on Indian data and recommended its use in preference to meant for malnourished population may reach only those the three conventional measures (ST.Anwar et al. one that incorporates all undernourished Wasting Index (WI) = Wasting / CIAF.e. the result of prolonged food deprivation or profound implications on prevalence reporting. The CIAF on the other hand indicates total identifies six groups of children.Development economist peter (Mahgoub S. 078 height of a child rapidly.age) and wasting (low weight-for-height). It therefore provides a single disadvantages. underweight and wasting relative to the total wasting. At the same time.Based on Svedberg’s should have a high sensitivity to detect malnutrition model (who suggested six subgroups of anthropometric accurately. nutrition disease/illness. stunting or who are underweight are all prevalence of under nutrition (Boss K. but this is not physically possible since a child chronological age. (2005) identified an for. Silo L & Fields-Gardner C 2009) and Svedberg. it would be useful for clinical as well as community health misses some children who are considered work. He proposes constructing a composite stunting. so producing an have a proposition which deals with the problem of underestimate Svedberg suggests that if children with stunting. Reporting of accurate between a child that is small in weight relative to his/her prevalence data and targeting highest risk populations for height and a child that is low in height relative to his/her appropriate interventions using CIAF may help to improve (13) age. An ideal anthropometric indicator under nutrition (Svedberg P. Another theoretical combination would be ‘wasted and underweight reveals low body mass relative to stunted’. sufficient for measuring the overall prevalence of under Bhattacharyya (2006) has explained its drawbacks too.e. UW and WS) of in need of them. underweight (low weight paper. Groups B to F). The three most commonly used under nutrition. et al 2005). South Asia and Sub-Saharan also have wasting or become stunted and some children Africa (Harttgen and Misselhorn 2006). due to suboptimal health or nutritional conditions. the result of more recent food deprivation or mutually exclusive categories to identify both prevalence illness.e. 2000). many field workers and clinicians use the first the norm and thus are experiencing one or more forms of formulae introduced by Weech. a child’s cannot simultaneously experience stunting and wasting height and weight. The CIAF excludes those children (Bose K. its specificity should be failure (A to F). it does not satisfy the long felt need for Since being underweight (having low weight for age) is a a combined clinical and anthropometric classification that product of stunting and wasting and not the sum. 2000). Underweight Index (UI) = Underweight / CIAF and needed. Traditionally. China (Dang SN who have wasting will also be stunted and/or underweight & Yan H 2007). While additional subgroup: one that includes children who are stunting reflects a failure to reach linear growth potential only underweight but not stunted or wasted (group-Y). India (Seetharaman et al 2007). underweight and wasting have been used as However. Nandy and Miranda (2008) have further internationally recommended anthropometric indicators supported and validated the use of CIAF in a more recent are stunting (low height-for-age). cannot distinguish between them (WHO. These indices do children. some children who are underweight will (Berger M et al 2006). underweight and wasting which are absolute index of anthropometric failure (CIAF). These groups include under nutrition and does not provide any information on children with height and weight appropriate for their age the prevalence of stunting. although it failures (Svedberg P. some children evaluating childhood nutritional status. On the the quality and outcomes of global nutrition efforts . Mandal GC 2010). stunting. Group A) and counts all formulae in clinical practice (Behrman RE. Paediatricians now widely use these not in anthropometric failure (i. This is in contrast to the rates of underweight. 2000). underweight is used as a composite indicator to and higher nutritional risk with multiple anthropometric reflect both acute and chronic under nutrition. or to be in a state of These three indices are: Stunting Index (SI) = Stunting / “anthropometric failure”. Nevertheless. wasting is an indicator of acute under of CIAF methods clearly identified risk levels with nutrition. Accordingly these three . in studies undernourished children in a population. or are underweight Each of the above indicators has advantages and (i. Svedberg’s model measures. The use of CIAF may have under nutrition. Three new indices of childhood under nutrition undernourished by the other indices. but who may be normal in weight-for-height. which is influenced by both. et al 2007). especially in emergency children whose height and weight for their age are below situations. Stunting is an indicator of chronic and not be underweight. CIAF has also who are stunting will also have wasting or be been utilised and validated by investigations from Kenya underweight. some have high sensitivity while others measure with which to estimate the overall prevalence of have high specificity.Use other hand. stunting. considered undernourished. However. According to him. Botswan (Nandy S M. children who have wasting. underweight and wasting (i. 1995). who are not in anthropometric failure) and also relative to total under nutrition. et al 2000). argues that conventional indices are not Cameroon (Emina JBO 2009).

a higher value of UI Where.5 cm. All demonstrated a prevalence of 45% undernutrition. Children whose age available indicators. z= 1. Briend A. Effective health promotion and nutritional z 2 pq interventional programmes can be formulated based on n 2 these indices.5 cm) can (PPS) sampling technique. mid‐upper arm was done. Based measurements were taken thrice and averaged for the . the total sample size was round up and fixed to such as in emergency situations of famine or a refugee 480. 079 Int. This study was interview and examination of the child. SI.One Community Development Block (i. q= 100-p. could not be accurately known were excluded from the study. subjects (480). and non-stretchable tape made Community Development Block on non study samples.96  45  55 additional information on the prevalence of different forms n  469. Public Health Epidemiol. Key operational advantages of prepare a sampling frame. low MUAC. a higher value of SI would L indicate enhanced level of chronic under nutrition relative to total under nutrition necessitating increased long-term nutritional intervention. p= Assumed prevalence (45% requiring increased immediate intervention. In the selected village total the proposal of MUAC as an additional screening tool in enumeration of children age 0-36 months was done to non-emergency situations.1986). shows that these are poorly Development Blocks of Varanasi was found nearly similar correlated (Gayle HD. of plastic (WHO 1976 and WHO 1983). Trowbridge FL. new indices. 1980). The ages of carried out to estimate the prevalence of under nutrition children were recorded using birth/delivery records or among children aged 0-36 months by using various aanganwadi/ school/crèche records. Weight data collection was carried out for a period of one year of children was taken using a stand-on scale and infant (February 2010 to January 2011). This study was approved by the ethical circumference (MUAC) appears to be a superior predictor committee of Banaras Hindu University and prior consent of childhood under nutrition than many other was taken by parents/guardian of the children before anthropometric indicators (WHO 1995). The required study subjects MUAC include the portability of measuring-tapes. This led to Bariasanpur and Rustampur. Recumbent length was taken for children under 85 study was devoted to extensive literature search. Heights of children were measured to the nearest millimetre using a This study was conducted for a period of one and half right-angled head-plate non-stretchable tape fixed to the years (December 2009 to July 2011). The cm and standing height for children over 85 cm. MUAC has been proposed as an alternative index for nutritional status for use where the collection of height and weight is difficult. They provide 1. such as 12. As per established on a daily basis.5) 2 nutrition in a particular population. Chiraigaon) crisis. has been used as a proxy of Varanasi District by simple random sampling method for low weight-for-height. Similarly. and the were selected adopting probability proportion to size fact that a single cut-off value (12. The selected villages were (Bairagi R. underweight and calculated using the formula: wasting with respect to and relative to total under nutrition.96. In order to get required study be used for children aged less than five years. based on a fixed was selected from eight Community Development Blocks cut-off point. the sample size for this study was significance of the problems of stunting. taken as 10% (10% of 45 = replace the conventional measures of under nutrition. systemic (every third) random sampling in community based studies. L= permissible level of error in must be pointed out that these three new indices cannot the estimated prevalence. it in this study). appears to be a blocks. A comparison of these two as socio demographic milieu of all eight Community indicators.e. No other inclusion or exclusion criteria were applied.5) Rather they should supplement them in order to get a The required sample size was calculated to be: more comprehensive picture of the nutritional stress being experienced by a population. J. In these situations.weight sampling method. MUAC. From the Chiraigaon Community Development superior predictor of childhood mortality compared to Block two villages were selected by simple random anthropometric indicators based on height for. Initial period of the wall. Thus. MUAC was measured to the extensive literature search and a pilot study on 30 nearest millimetre at the exact midpoint of the left arm children (aged 0-36 months) conducted in Chiraigaon using a narrow.1981.3 of under nutrition relative to the total level of under (4. Moreover. Zimicki S. flexible.5 cm or al 1988. However.96 1. The ages of children was estimated to the most METHODOLOGY recently attained month (Gorstein J. 4. UI and WI provide information on the on this value. however. the accuracy of which was cross sectional design was adopted for this study. however. A community based weighing machine. For example. as per data collection from BDO offices of the respected Staehling N. would indicate greater level of current under nutrition n= Sample size. 1989).

weight for height and BMI for age. For assessing the RESULTS CIAF.Anwar et al.77 months. All data and indices were compared with Necessary tables were generated and for inferential 2 the WHO growth standard tables for weight for age. undernutrition.3% infants and .81 months groups are defined in greater detail in Table 1.99 + 8. indices are: 35. stunted and underweight and lastly stunted. decisions x test was applied. Three new (male 10. The CIAF shows a higher prevalence of th Microsoft excel 2007 and SPSS version 16 software.86 months). (2005). Svedberg’s (2000) model of six groups (stunted only. These three According to the data. under-weight only.5% of children (58. underweight and wasting relative to rate of under nutrition as measured by the CIAF. wasting and asses childhood under nutrition which deals with the underweight in all studied children. final reading. wasting and A total of 483 children (aged 0-36 months) were underweight. wasted and underweight) of children was used. indices proposed by Bose K et al. 080 Table 1. Classification of children with anthropometric failure (CIAF). the total prevalence of under nutrition. underweight and stunting. 43.02 + 8.* Group Name Description Wasting Stunting Underweight A No Failure No No No B Wasting Only Yes No No C Wasting and Underweight Yes No Yes D Wasting and Stunting and Underweight Yes Yes Yes E Stunting and Underweight No Yes Yes F Stunting only No Yes No Y Underweight only No No Yes * Classification following Nandy et al. height for age..5% had wasting.97 + 8.2% were underweight and 31. wasted only. examined of which 242 were boys and 241 were girls. It also showed the problem of stunting. A value of mean –2SD was taken as the cut-off point for detection of wasting. with 62. 2010 were used to (Figure 1) Table 2 presents rates of stunting.1% of children were stunted. female 11. Stunting Index (SI) = Stunting / CIAF Stunting was found significantly more among children >1 Underweight Index (UI) =Underweight / CIAF year age group while wasting was significantly more Wasting Index (WI) = Wasting / CIAF among infantile age group as compared to their Data thus generated were analysed with the help of counterparts. These Mean age of the study subjects was 10.

Subgroups of anthropometric failure among children. UI and WI among the studied children.603 0.2%) 208 (100. group F (containing children underweight (i.0%) Table 4.686 208/302 = 0.7%) 82 (40.1% of the children in the sample (14.8% boys and combined values of the three new indices.5%) 10. Group Name Description Boys Girls Number (%) A No Failure 74 (30.9%) 331 (100.5%) Table 3.5%) 126 (61.3% >1 year age group) suffering from anthropometric among girls largest group was group E (stunting and failure.4%) 181 (37.0%) 4.2%) 3.1%) 170 (100.563 WI = Wasting / CIAF 86/168 = 0.058 CIAF 162 (58. accounting for 16.0%) 26 (10.9% of girls. Prevalence of under nutrition among children aged 0–3 years (n = 242). . Table 2.4%) 152 (31.2%) 275 (100.536 80/134 = 0.6%) 38 (7.4%) Total 242 (100. of the six subgroups with simultaneously have wasting.5%) F Stunting only 48 (19.9%) 154 (100.1%) 175 (52.0%) 02 (0.8%) 02 (0.001 Underweight 88 (31.1%) 66 (42.597 170/302 = 0.0%) 170 (35.9%) 80 (47.4%) Underweight E Stunting and Underweight 34 (14.3%) 140 (68.503 Table 5.0%) BMI for Age < 2SD 88 (57.1%) 16 (6.9%) 70 (14. Public Health Epidemiol.358 > 2SD 152 (48.481 0. accounting for 19.0%) 36 (14.034 > 2SD 154 (46.1%) Y Underweight only 0 (0. those in group D) accounted for 12.6%) 66 (43.5%) 208 (43.689 UI = Underweight / CIAF 90/168 = 0. UI and WI.8%) 149 (54.0%) Height for Age < 2SD (Stunted) 116 (55. Table 4 presents the sex-specific as well as sex- group F (stunting only).1%) 49.01 Wasted 104 (37. 081 Int.4%) 313 (100.2%) C Wasting and Underweight 22 (9.8%) 175 (53.0%) Weight for Height < 2SD (Wasted) 86 (56. 2 Parameters Boys Girls Total x P value Weight for Age < 2SD (Underweight) 90 (52.8%) 30 (12.9%) D Wasting and Stunting and 34 (14.6%) 161 (51.691 0.4% who are stunted only) is the largest.4%) 152 (100. Boys Girls Overall (sex combined) Index CIAF = 168 CIAF = 134 CIAF = 302 SI = Stunting / CIAF 116/168 = 0. J. stunting and are undernourished children.8%) 92 (44.492 152/302 = 0.690 92/134 = 0.0%) 0.0% boys and 10.8%) 60 (12.0%) 483 (100.9%) 54 (11. Nutritional status of children according to their anthropometric measurements.054 > 2SD 156 (47. Children who each of the subgroups.0%) Total 242 (50.512 66/134 = 0. 2 Group Infants > 1 year Number (%) x p value Stunted 82 (29.0%) 4.4%) 48 (23.030 > 2SD 126 (45.720 0.4%) 78 (16.176 <0.0%) 3.8% children in the sample.0%) 483 (100.2%) 329 (100. Values of SI.6%) 107 (44.0%) 68.0%) 241 (50.3%) 302 (62. Among boys largest group was girls).845 0. Table 3 shows the proportions of children in underweight) accounting for 14.e.5%) B Wasting Only 30 (12.4%) 24 (9.716 0. SI.0%) 241 (100.

to see which type of anthropometric failure girls they were 0. Undernutrition is closely associated with a correction for age or height is substantially better and large proportion of child deaths (Gillespie S. df= 2. Measurement of the child's height as part of the from severe malnutrition (21. As much as would be missed if low weight-for-age is considered as 31. by Seetharaman et al.0%) estimate of the number of undernourished children in a 2 x = 22.1%) 117 (57.5 cm). respectively.2% were suffering the child. the use of underweight (low weight-for-age) as the sole criterion for identifying undernourished children may be underestimating the true These sex-combined overall values of SI. UI and WI are Malnutrition is a fairly wide-spread and complex problem concerned Nandy et al. 1986.4% girls) were found the only indicator of under nutrition.2%) children (37. This can be health-care.5% children (35. 2010. Nutritional status of children (1-3 year) according to their (35%) is much lower than the findings of Bose K et al MUAC.5 . Attempts at wasted. This statement is supported by a lot of children more likely to suffer ill-health than well nourished evidences (Biswas S et al. Stunting was present in of undernourished children are not identified by current 43.2% girls) Disaggregating the data in this way enables the were found underweight (<2SD according to their weight identification of groups of children that are missed by for age). SI.536 and 0.9%).4% boys and 20% girls).563 and 0.5%) was higher among girls (59.8%) 22 (21.8%) 72 (35.686.05) more prevalent value of CIAF in the present study (62. Nearly 132 (27. Briend A. children were found stunted which is higher than the findings of Bose K et al (2010) and NFHS-3 India but CONCLUSION lower than the figure given by Seetharaman et al (2007). The findings of nutritional status reflects future outcomes in terms of their health and based on MUAC shows that arm circumference without development. children (Biswas S. Since undernutrition is a Though infant mortality rates have fallen and life function of both food deprivation and disease.9%) were found significantly (p methods.9%) 50 (49. The current nutritional status of children not only K et al. Three new indices. This could be a tool of considerable developing malnutrition compared to girls (27.0%) Girls 10 (9. (2010). It demonstrates that large numbers wasting between both sexes. than the findings of Nandy et al. (2010) found lower SI than present study but UI reflects their well being of the present time but also and WI were higher.2%) 76 (73. While percentage of underweight children in the study Overall. The corresponding nutrition can be disaggregated for further analyses.05) at higher risk of under nutrition. Briend A et al. anthropometric high rates of malnutrition and mortality especially among indices can serve only as proxies for evaluating the women and children and a widespread lack of access to prevalence of undernutrition among children. 0. The Malnutrition was significantly (p <0.503. health indicators still point to in turn the consequences of poverty. Out additional data that needs to be collected is the height of of these malnourished children 18. that poses a serious threat to life and India is home to the (2007) found higher SIs and UIs than the present study largest number of underweight and stunted children in the but WIs were very low compared to present study.4%).597 and 0. (2005). Seetharaman et al. (2010) were comparatively higher.512. No significant difference was observed in conventional indices. which are expectancy has been rising.The CIAF provides an overall Total 16 (7. As far as SI. 0. Zimicki S. Anwar et al. something conventional indices do not. 2006.1% children. p = <0.1%) 104 (100. UI and WI provide information on the significance of the DISCUSSION problems of ST.5% of the studied children were anthro- . easy to use indicator at community level than classical 2003.1986). the only malnutrition according to MUAC criteria (< 13.689. for values among boys were 0. respectively.32.1%) 205 (100. 2010).01 population. Eighty five (35.5 cm 12. Bose world. As evidenced by the current study.4%) as compared to boys (26. (2007) and NFHS-3 (India). routine ICDS growth monitoring is worth considering. (Table interest to health planners and policy makers .492. Nyirandutiye DH et al.9%) estimating the overall prevalence of under nutrition in the children were found underweight (<2SD) and boys population must integrate such an aggregate index of (36. 0.6%) 101 (100. with undernourished nutritional indices. (2005) and Seetharaman et al.3%) undernourished children - <0.5% boys and 27. (2007) and NFHS-3 <12.4%) were significantly (p <0.especially 5) As much as 88 (42. but CIAFs found (Table 6). Using the CIAF. UW and WS with respect to and relative to total under nutrition. Seetharaman N et al 2007). When BMI for age was used 154 (31. In the present study nearly 4 out of the ten considered as a limitation of the study. 082 Table 6. (2007) and Bose K et al. carries the greatest risk of morbidity or mortality. haddad L.2% girls). only 37. UI and WI were load of under nutrition. Percentage figure for wasted children is higher than MUAC Sex Total findings from Seetharaman et al. data on under 0.5%) 41 (40.5 cm report but lower than the figures from Bose K et al (2010) Boys 6 (5. Among example.9%) children were suffering from considering the fact that to compute the CIAF.0%) and Joseph B (2002) .05) more stunted than girls (38.<13.690.5 >13. Boys (47.2% boys and 33.

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