Extent of Nutritional failure among under-five children from an urban slum in South India: A cross-sectional assessment using Composite index of Anthropometric failure

doi:10.21203/rs.3.rs-2433822/v1

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Extent of Nutritional failure among under-five children from an urban slum in South India: A cross-sectional assessment using Composite index of Anthropometric failure

https://doi.org/10.21203/rs.3.rs-2433822/v1

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Introduction

NFHS-5 Telangana statistics reports underweight, stunting, and wasting among under 5 children to be 31.8%, 33.1%, and 21.7% respectively.Nutritional assessment is done by several methods. Composite Index of Anthropometric Failure(CIAF) is an aggregate indicator that excludes children with anthropometric failure and includes children who are wasted, stunted, or underweight, and their combinations. Only a few published research regarding the prevalence of under nutrition have utilized CIAF and explored the association between food intake with anthropometric failures in urban slums of Telangana.

Objectives

To determine the prevalence of anthropometric nutritional failures and to find the determinants among under-five children in an urban slum area of Hyderabad

Methodology

A cross sectional community based study was conducted among 309 under 5 children residing in the urban-slum area of Hyderabad. Sampling of anganwadis was done by probability proportionate to size and children were randomly selected within anganwadis. Using questionnaire and standard operating procedures, socio-demographic profile, health details and nutritional assessment was done. Statistical analysis was done using SPSS version 26.

Results

The prevalence of under nutrition as per CIAF is noted to be 39.6%. The prevalence of stunting, underweight and wasting were found to be 20.7%, 26.8% and 12%, respectively. The illiteracy of father[AOR:2.94(CI: 1.31–6.62);p value = 0.009],low birth weight[AOR:2.024(CI: 1.253–3.26);p value = 0.004], not exclusively breastfed[AOR:4.291(CI: 1.55-11.904);p value = 0.005] and deficient calorie intake[AOR:2.079(CI:1.103–3.906);p value = 0.023]were found to be the significant predictors of Anthropometric failure.

Conclusion

Under nutrition is an important public health problem with 40% prevalence in urban slum of Telangana. CIAF provides a single, aggregated assessment of under nutrition in the community. Enhancing the literacy level of fathers, reduction in low birth weight through better nutrition of mothers during pregnancy, better IYCF practices and providing children with a calorie adequate diet will aid in enhancing children's nutritional status.

Composite Index of Anthropometric failure

CIAF

Under 5 years

Urban slum

malnutrition

underweight

stunting

wasting

Nutrition is a fundamental pillar of human life. Sustainable development goals target 2.2 aims to end all forms of malnutrition by 2030. Under-nutrition is a major contributor to mortality among children younger than 5 years in developing countries including India and has major effects on the realm of public health. (1, 2) According to the National Family Health Survey-5, the children under 5 years who are underweight, stunted, and wasted are 31.8%, 33.1%, and 21.7% respectively in the state of Telangana. In urban areas of Telangana underweight, stunting and wasting is reported as 25.8%, 28.1% and 20% respectively (3). Hence, addressing the challenge of under-nutrition in children is essential to ensure optimal growth, development, overall health, and disease prevention.

Nutritional assessment is done by several methods like anthropometric measurements, dietary assessments, clinical examination, functional assessment, vital statistics, and ecological studies. Through ICDS, in Anganwadis, under-nutrition is conventionally determined through weight-for-age charts: WHO growth standards. Weight for age estimation reflects both acute and chronic malnutrition but misses out on children who are stunted & wasted (4, 5). An aggregate indicator, the Composite Index of Anthropometric Failure (CIAF), can help in addressing this concern. The CIAF excludes those children who aren't in anthropometric failure and includes all children who are wasted, stunted, or underweight, and their combinations, therefore providing us a single measure with which the overall prevalence of under-nutrition can be estimated. (6, 7, 8)

Although there are many studies regarding the prevalence of under nutrition among under-five children, only a few have utilized CIAF to quantify under nutrition among children in Telangana, especially in an urban slum population. With this background, the study will aim to find the prevalence of anthropometric failure along with its determinants among under-five children in the urban slum of Hyderabad.

A cross-sectional study was conducted in the urban slum area of Hyderabad over a period of 6 months starting from June 2022. Study population included all under-five children residing in the urban-slum area of Hyderabad. Children of unwilling mothers & children in the absence of their mother during data collection were excluded from the study.

Sample Size: Considering the prevalence of Anthropometric failure as 56% as per the study conducted by Junaid Khan and Sumit Kumar Das in 2020 (10) with 10% relative precision at a 95% confidence interval, the sample size was calculated as 309 using the formula N = Z²Q/Pe²

Sampling Procedure: A list of all Anganwadis in the area with their population covered were made. Probability Proportionate to size technique was utilized for sampling of anganwadis. Simple random sampling was used to sample children from each anganwadi till the sample size of 310 was reached.

Study Tools: Predesigned pretested semi-structured questionnaire was used to collect data on socio-demographic profile, immunization details, and disease details. Anthropometric measurements like weight, height, mid-upper arm circumference were obtained using standard procedure using properly calibrated portable weighing machine, baby weighing machine, non-stretchable measuring tape and infantometer. Weight was measured to the nearest 0.1 kg using a standard weighing scale. Height and MUAC were calibrated using non-stretchable tape, wherein height was measured fixed to a vertical wall, with the participant standing on a firm/level surface, and it was measured to the nearest 0.1 cm. Recumbent length in infants was measured using an infantometer. WHO-ANTHRO software v3.2.2 was used to calculate Weight-for-Height Z-score (WHZ), Height-for-Age Z-score (HAZ), and Weight-for-Age Z-score(WAZ).

Ethical Considerations: Approval was taken from the Institutional Ethics Committee-Biomedical Research before commencing data collection. All information collected during the study was kept confidential. Case record forms were coded. Written informed consent was taken from mothers of each under-5 child before the interview.

Data collection: Face-to-face interviews of the mothers of the under-five children were done with the help of a pre-designed, pretested, semi-structured questionnaire. For assessing nutritional status, clinical examination, dietary assessment & anthropometric measurements were carried out following standard operating procedures.

Standard definitions:

Wasting (acute malnutrition) is defined as a WHZ of < -2. Severe wasting is considered if WHZ is < -3 OR if MUAC < 11.5 cm.

Stunting (chronic malnutrition) is defined as a HAZ of < -2. Severe stunting is considered if HAZ is < -3.

Underweight (acute and chronic malnutrition) is defined as WAZ of < -2. Severe underweight is considered if WAZ is < -3.

Mid-upper arm circumference (MUAC) (23): Meaured value more than 12.5 were considered normal ; 11.5-12.5cm were considered moderate acute malnutrition and those with mid upper arm sircumference less tha 11.5cm were categorized as severe acute malnutrition

Socio-demographic details: Mean age of the study participants is 30.7 months (SD = 16.213months). Majority of children (57.4%) included in the study were males. Majority of parents of children included in the study are literate, 94.2% of mothers and 90.3% of fathers. Among the mothers of the study participants, 137 (44.2%) acquired education till intermediate and above. Regarding occupational status of father, majority ie. 59.7% (185) were involved in Unskilled labor. Majority (80.3%) of mothers were Homemakers. The Mean monthly income of the family is Rs. 21,811.29 (SD = Rs.11,921.43) and it ranged from Rs. 7500 to Rs. 60000. The majority (76.8%) of the study participants belong to the Upper middle class according to the Modified Kuppuswamy Scale. Majority of the children belonged to nuclear families (88%) with a mean family size of 4.42 (SD = 1.37).

Delivery, Health care details: Majority (44.8%) of the study participants were 1st born children. Among the children included in our study 43.9% were born with low birth weight and 1.6% were very low birth weight. Some proportion of children (7.7%) had neonatal ICU admissions at the time of birth due to conditions including jaundice, premature birth, neonatal pneumonia, etc. In the two weeks preceding to sample collection, 52.6% of the study sample had respiratory infections, while 13.9% of all participants had gastrointestinal disorders. A large majority (95.5%) of the study sample had no prior history of worm infestation and 89% of the subjects hadn't had a deworming in the previous six months. 92.9% of the participants in our study were not detected of any nutritional deficiencies in the past.

Feeding practices: Initiation of breastfeeding occurred within an hour of birth in 96.8% of the study participants. Among 310 children, 290 (93.5%) was breastfed exclusively until they were 6 months old. The majority of the study participants (48.7%) had started complementary feeding at 6 months, followed by more than 7 months (45.5%). In our study, mean duration of breast feeding in months was 18.16 ± 8.31 months and the mean age of initiation of complementary feeding was 6.82 ± 1.83 months. According to the 25 hour recall method, 79.7% of the participants had calorie deficit in their dietary intake. While fat and protein was present among 70.3% and 35.8% of the study participants respectively.

Nutritional status of study participants(Table No.1): In this study, we’ve found that 27.8% of study participants were underweight and 2.3% were severely underweight. The study participants with stunting which represents chronic under-nutrition included 20.7% and 4.2% were severely stunted. 12% of the participants had wasting and 1% was severe wasted. Assessed by MUAC, 9% of the study participants had moderate acute malnutrition, while 0.6% had severe acute malnutrition.

Table 1

Anthropometric Details of study participants as per WHO Growth Standards
Variables	Categories	Frequency	Percentage
Weight for Age	Normal	227	73.2%
	Underweight	76	24.5%
	Severe Underweight	7	2.3%
Height for Age	Normal	246	79.4%
	Stunting	51	16.5%
	Severe Stunting	13	4.2%
Weight for Height	Normal	273	88.1%
	Wasting	34	11%
	Severe Wasting	3	1%
Mid Upper Arm Circumference	Normal (> 12.5cm)	299	96.5%
	Moderate Acute Malnutrition (11.5-12.5cm)	9	2.9%
	Severe Acute Malnutrition (< 11.5cm)	2	0.6%

Composite Index of Anthropometric failure (Figure No.1 & Table No. 2): According to CIAF, almost 40% of study participants have anthropometric failure. Among those children with anthropometric failure, Undwerweight, stunting and wasting alone was present among 9.7%, 11.3%, 1.9% of the study participants respectively. 7.7% had wasting and underweight. 7.1% were stunted and underweight. Among the children included in our study, 2.3% had all three components of anthropometric failure i.e., they were wasted, stunted and underweight.

Table 2

The proportion of various groups of anthropometric failure among study participants
Groups	Description	Frequency	Percentage
Group A	No failure	186	60%
Group B	Wasting only	6	1.9%
Group C	Wasting and underweight	24	7.7%
Group D	Wasting, stunting, and underweight.	7	2.3%
Group E	Stunting and underweight	22	7.1%
Group F	Stunting only	35	11.3%
Group Y	Underweight only	30	9.7%
	Total	310	100%

The determinants of anthropometric failure among under-five children (Table No.3): Among the socio demographic factors in this study, we discovered a strong association between the father's educational background and line of work and the anthropometric failure of the children. Compared to literate fathers, higher proportion of anthropometric failure was observed among illiterate with a p value of 0.017. And when considering the occupation of fathers, those doing skilled and professional labor had higher proportion of children with anthropometric failure compared to unemployed and unskilled labor (p value = 0.009).Among the health related factors, birth weight was found to have statistically significant association with higher proportion i.e. 47.5% among low birth weight compared to children born with normal birth weight (33.1%) with p value 0.010. Among the feeding practices, a statistically significant association was found between anthropometric failure and exclusive breast feeding till 6 months of age (p value < 0.05). Higher proportion of anthropometric failure was found among children who were not exclusively breast fed compared to the rest with p value 0.004. An association was found between calorie and protein deficit in the diet and anthropometric failure, with p = 0.04 and 0.016 respectively. Compared to children on adequate calorie diet as per RDA (28.6%) higher proportion of anthropometric failure (42.5%) was found among calorie deficit group. Similarly, higher proportion of anthropometric failure (48.6%) was found among children having a protein deficit in diet (p value = 0.016) compared to those taking adequate protein.

Table 3

The association between socio-demographic factors, feeding practices, health and disease related factors with anthropometric failure
Variables		Anthropometric Failure		Chi square	Df	p value
		Failure	No Failure
Age	< 12months	24 (42.1%)	33 (57.9%)	0.578	2	0.749
	13–35 months	48 (37.2%)	81 (62.8%)
	36-59months	51 (41.1%)	73 (58.9%)
Gender	Males	69(38.8%)	109(61.2%)	0.146	1	0.703
	Females	54(40.9%)	78 (59.1%)
Father’s Education	Illiterate	18 (60%)	12 (40%)	5.731	1	0.017
	Literate	105 (37.5%)	175(62.5%)
Mother’s Education	Illiterate	7(38.9%)	11(61.1%)	0.005	1	0.944
	Literate	116(39.7%)	176(60.3%)
Father’s Occupation	Skilled & Professional	86(45.5%)	103(54.5%)	6.865	1	0.009
	Unemployed & Unskilled	37(30.7%)	84(69.4%)
Mother’s Occupation	Homemakers	104(41.6%)	146(58.4%)	1.995	1	0.158
	Employed	19(31.7%)	41(68.3%)
SES	Upper	18(34%)	35(66%)	0.872	1	0.350
	Middle	105(40.9%)	152(59.1%)
Type of family	Nuclear	107(39.2%)	166(60.8%)	0.223	1	0.637
	Joint	16(43.2%)	21(56.8%)
Baby cried immediately after birth	No	1(50%)	1(50%)	0.090	1	0.765
	Yes	122(39.6%)	186(60.4%)
Birth Weight	Normal	56 (33.1%)	113 (66.9%)	6.643	1	0.010
	Low Birth Weight	67 (47.5%)	74 (52.5%)
Any neonatal admission	No	110(38.5%)	176(61.5%)	2.282	1	0.131
	Yes	13(54.2%)	11(45.8%)
Child immunized for age	No	5(55.6%)	4(44.4%)	0.976	1	0.323
	Yes	118(39.2%)	183(60.8%)
Respiratory illness in the past 2 weeks	No	55(37.4%)	92(62.6%)	0.598	1	0.439
	Yes	68(41.7%)	95(58.3%)
Gastrointestinal illness in the past 2 weeks	No	108(40.4%)	159(59.6%)	0479	1	0.489
	Yes	15(34.9%)	28(65.1%)
History of worm infestation	No	117(39.5%)	179(60.5%)	0.062	1	0.803
	Yes	6(42.9%)	8(57.1%)
Early initiation of breast feeding (within 1 hour)	Yes	3(30%)	7(70%)	0.404	1	0.525
	No	120(40%)	180(60%)
Exclusive breastfeeding till 6months of age	Yes	109(37.6%)	181(62.4%)	8.213	1	0.004
	No	14(70%)	6(30%)
Age of initiation of Complementary feeding	< 6 months	11(61.1%)	7(38.9%)	3.668	1	0.055
	≥ 6months	112(38.4%)	180(61.6%)
Calorie	Deficit	105(42.5%)	142 (57.5%)	4.075	1	0.044
	Adequate	18(28.6%)	45 (71.4%)

Multivariate analysis to find predictors of anthropometric failure (Table No.4): To find the predictors of anthropometric failure among under five children considering the confounding factors multivariate logistic regression was done. All the variables that came significant in univariate analysis as well as variables which gave a p value < 0.25 along with age and gender of the study participants were included in model. Forward stepwise method was used to run the logistic regression command. Out of 13 variables included, i.e. Age, sex, father’s education and occupation, mother’s education and occupation, birth weight, neonatal hospital admissions, exclusive breast feeding, age of initiation of complementary feeding, continuation of breast feeding for 2 years, mid upper arm circumference, calorie intake and protein intake, 4 variable came to be significant predictors of anthropometric failure (p value < 0.05). Exclusive breast feeding not being provided for 6 months (p value = 0.005), Father’s being illiterate (p value = 0.009 ), calorie intake being less that RDA (p value = 0.023) and Birth weight being < 2.5 kg (p value = 0.004) were significant predictors of Anthropometric failure.It was found that those children who were not exclusive breast fed till 6 months of age were found to be having 4.291(1.55-11.904) times higher odds of having anthropometric failure compared to their counterparts. Similarly, uneducated fathers were having 2.94 (1.31–6.62) times higher odds of having children with anthropometric failure compared to educated fathers. Children with deficient calorie intake were 2.079 (1.103–3.906) times having higher odds of having anthropometric failure compared to those on adequate calorie diet. Children born low birth weight(< 2.5Kg) were found to have 2.024 (1.253–3.26) times higher odds of having anthropometric failure compared to those born with normal birth weight.

Table 4

Predictors of Anthropometric failure through multivariate logistic regression
Variables	Reference Category	OR (CI)	P value
Birth Weight	Normal (0)	2.024 (1.253–3.26)	0.004
Birth Weight	Low Birth Weight (1)	2.024 (1.253–3.26)	0.004
Father’s Education	Literate(0)	2.94 (1.31–6.62)	0.009
Father’s Education	Illiterate (1)	2.94 (1.31–6.62)	0.009
Calorie Intake	Adequate (0)	2.079 (1.103–3.906)	0.023
Calorie Intake	Deficit (1)	2.079 (1.103–3.906)	0.023
Exclusive Breast Feeding till 6 months of age	Yes (0)	4.291 (1.55-11.904)	0.005
Exclusive Breast Feeding till 6 months of age	No (1)	4.291 (1.55-11.904)	0.005

The present study has applied the CIAF scale for estimating the overall burden of child under nutrition and identifying its covariates. CIAF excluded those children who aren't in anthropometric failure and included all children who were wasted, stunted, or underweight, and their combinations, therefore provided us a single measure with which the overall prevalence of under-nutrition could be estimated. Anthropometric failure in children is often seen to comprehend the impact of nutritional deprivation, which depends on a variety of circumstances, with inadequate food, both in terms of consumption and composition, standing to be a significant underlying determinant.

According to the current study, 40% of children suffer from anthropometric failure. The prevalence of stunting, representing chronic malnutrition was found to be 20.7%, while underweight and wasting representing acute malnutrition were found to be 26.8% and 12%, respectively. These rates were consistent with studies conducted by Aparajita Dasgupta et al(7). According to the National Family Health Survey (NFHS)-5, Telangana reported rates of under-nutrition of 25.8%, for underweight, 28.1% for stunting, and 20% for wasting for children under the age of five in urban areas, which are similar to our study. Similar prevalence rates were noted in Bangladesh(19), Ethiopia(21) and Pakistan(18) as well. The studies by Sabu Ulahannan Kochupurackal et al(13), Angeline Jeyakumar et al(10), Waleed Rasheed et al(14), Garima Guptaet et al (8), Subhadeep Shit et al (17) reported higher prevalence rates. Higher prevalence was also noted in a community-based cross-sectional study conducted by Aida H Al-Sadeeq et al(20) in South Yemen. The variations with other research that have been identified could be caused by the different methodologies. The sampling of under 5 children in the present study was done from registered children from Anganwadis of an urban slum, while majority of other studies had done the sampling through house to house survey. One of the major functions of anganwadis under ICDS is growth monitoring, finding malnutrition using weight for age criteria and taking corrective measures like providing the extra nutritional requirements as supplementary nutrition. Hence, our study summaries the prevalence of undernourishment among registered anganwadi children in an urban slum.

Under-5 children evaluated for anthropometric failure using the CIAF, allowed us to divide the undernourished children into other subgroups with combination of acute and chronic malnutrition. We see that 39.6% of the kids had anthropometric failures of one kind or another. Among those children with anthropometric failure, 14.8% had dual anthropometric failure (Category C & E) and 2.3% had all three components of anthropometric failure i.e., they were wasted, stunted and underweight (Category D). Among those with anthropometric failure, 11.3% and 9.7% participants were stunted (Group F) and underweight (Group Y) respectively. We can identify 26.8% of the children from subgroups C, D, E, and Y by using low weight for age (underweight) as the only criterion for under nutrition (as in anganwadis), but miss out identifying the children in subgroups B and F who were stunted and wasted but not underweight. Because of this, 12.8% of these kids would have been wrongly categorized as normally nourished.

The determinants of composite index of anthropometric failure among urban slum children in the present study were exclusive breast feeding not being provided for 6 months, fathers being illiterate, Calorie intake being deficient as per RDA and birth weight being < 2.5kgs. According to the study's findings, infants who are exclusively breastfed have a lower risk of developing anthropometric failure which coincides with other studies such as Itishree Pradhan et al(26). The author analysed the feeding practices and their associations with under nutrition among children aged 6–23 months in the 124 districts of India and stated that appropriate breastfeeding lowered the odds of children being undernourished. Additionally, in a community-based cross-sectional study conducted in rural West Bengal, lesser duration of breast-feeding was found to be an independent predictor of anthropometric failure (7). Among the limited existing literature of the determinants of CIAF, a cross-sectional community based study done by Deepika Dewan(16) in urban Jammu identified early weaning as a significant predictor. Calorie intake being deficient as per RDA was found to be a significant predictor of anthropometric failure in our study. Contrary to this, a study by William Joe et al (9) examined the association between anthropometric based and food based nutritional failure among children in India and noted weak to null correlation between anthropometric failures and food failures. A prospective observational study conducted by Shailendra Meena et al(15) with a nutritional education intervention in the urban and rural ICDS projects of Bhopal district, Madhya Pradesh using audio-visual aids noted almost 6% reduction in moderate underweight upon nutritional intervention and 4% reduction in severe underweight in urban areas.

A community-based, cross-sectional study was carried out in ten states of India by Indrapal I Meshram et al(27) where children with birth weight less than 2.5 kg had Anthropometric failure in 47.5% of cases. Similar finding was observed in a study conducted in Palghar district of Maharashtra, India among tribal children less than 5 Years of age conducted by Angeline Jeyakumar et al(10). Author noted that children who had birth weight > 2.5 kg had lesser odds [AOR: 0.63(0.4–0.9] of anthropometric failure. Similarly, Aparajita Dasgupta et al. found low birth weight to be an independent predictor of anthropometric failure (7). Another community based cross sectional study done in a rural district of Ethiopia by Lamirot Abera et al(28) further identified birth weight as a determining factor of anthropometric failure which was in consonance with our results.

Mother’s education(10–12, 18) was found to be significant predictor in many studies conducted in India. According to authors, mothers' knowledge of children's nutritional needs and skill in conducting growth assessments was protective against the anthropometric failure. In our study, fathers education came out to be a significant predictor of CIAF. It was observed that uneducated fathers were having higher odds of having children with anthropometric failure compared to educated fathers. The rationale for this finding may be that educated fathers are better able to provide for the family's nutritional needs since they may be more aware of what their children need in terms of nutrition. Many studies found age of child, mother’s age, unimmunized kids, high birth order, large family size, nuclear family, low SES,, early initiation of breast feeding, maternal early marriage, domestic violence and morbidities to be predictors of CIAF which have not been found in our study (10–13, 16–18).

Under nutrition is an important public health problem in India. The prevalence of under nutrition as per CIAF in the urban slum of Hyderabad is noted to be 39.6% and is associated with illiteracy of father, low birth weight, exclusive breastfeeding and calorie deficient diet. Enhancing the literacy level of fathers, reduction in low birth weight through improved nutrition of mothers during pregnancy, bettering mothers' awareness on IYCF practices and providing children with a calorie adequate diet as per RDA will aid in enhancing children's nutritional status. Composite Index of Anthropometric Failure (CIAF) provides a single, aggregated assessment of under nutrition in the community which would otherwise be underestimated if conventional indices were solely relied upon. The use of this tool by field-level workers like ASHAs and anganwadi workers under supportive supervision of auxillary nurse midwives will improve the diagnosis of under nutrition and help in the early initiation of treatment. The public health experts and policy makers can more effectively quantify the burden of undernutrition at the national level by using the CIAF as a tool.

Ethics Approval and consent to participate: Approval was taken from the Institutional Ethics Committee-Biomedical Research before commencing data collection. All information collected during the study was kept confidential. Case record forms were coded. Written informed consent was taken from mothers of each under-5 child before the interview.

Availability of data and materials : The collected data was coded and entered in MS Excel and analysis was done using SPSS software. The enetrerd data as well as hard copies of the data collected are not publicly available and is maintained with confidentiality by the corresponding author which can be provided on reasonable request.

Competing interests: The authors declare that they have no competing interests

Funding: Nil

Authors Contribution: Dr. Anu Mohandas (AM); Dr. Hamsa Priya (HP); Dr. Pavani Varma (PV); Dr. Snigdha Pattnaik (SP)

AM and HP conceptualized the study topic. The protocol drafting was done by AM, HP under supervision of PV and SP. Data was collected by HP under supervision of AM. The statistical analysis was done by AM. Drafting of the manuscript was done by AM under supervision of PV and SP

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Extent of Nutritional failure among under-five children from an urban slum in South India: A cross-sectional assessment using Composite index of Anthropometric failure

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