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Indian Journal of Community Medicine

Nutritional Status and Gender Differeces in the Children of less than 5 Years of age Attending ICDS Anganwadis in Vadodara City

Author(s): KD Bhalani, PV Kotecha

Vol. 27, No. 3 (2002-07 - 2002-09)

Deptt. of P.S.M., Government Medical College, Vadodara, Gujarat


Research questions: 1. What is the prevalence of malnutrition in the children of ICDS anganwadies of Vadodara city? 2. In there a gender difference in malnutrition prevalence among the children attending anganwadis? 3. What is the impact of ICDS programme on the nutritional status of children of anganwadis?

Objectives: 1. To measure the prevalence of malnutrition with the gender difference and age trend in the children of less than 5 years of age. 2. To compare the level of malnutrition in the children in the years of 1996 to 1998. 3. To study the pattern of change in the nutritional status of the children from the year 1996 to 1998.

Study design: Cross-sectional study with a cohort data analysis.

Settings: 30 randomly selected anganwadis of Vadodara city.

Participants: 3157 children aged less than 5 years attending ICDS anganwadis of Vadodara city.

Statistical analysis: Simple proportions, Chi square test.

Results: From the total 3157 children 62.9% were found malnourished. The prevalence of moderate to severe malnutrition among girls was 28.4% as against 16.9% in boys (p<0.0001). Nutritional status of the children started worsening in the 2nd year of their life. More than 60% of infants were fond normal as against 37.6% of children of age group of 1 to 2 years, 29.3% of children of 2 to 3 years and 23.5% of children of 3 years and above (p<0.0001). From the children who were normal in 1996, only 44.4% remained normal after attending ICDS anganwadis for two years, while from the children who were malnourished in 1996, 17.8% children deteriorated further, 58.0% remained as malnourished as they were and only 24.2% of them improved.

Conclusion: ICDS programme failed to bring the expected results in the slum children of Vadodara city.

Keywords: Pre-school children, Nutritional status, Gender differences, ICDS


Nutrition is the cornerstone of socio-economic development. The nutritional problems are multifactorial with roots in the sectors of education, demography, agriculture and development. During 1995, more than 28% of the world's children under the age of 5 years were underweight for their age ranging from 2.9% in the developed countries to 31% in developing countries1. Because of the size of the population, almost half of the world's malnourished children are to be found in just 3 countries - India, Pakistan and Bangladesh2.

Integrated Child Development Services (ICDS) scheme is running for the last 25 years all over India with the main objective of improving the nutritional status of the children under 5 years of age. The network of ICDS consists of 3,907 projects and reaches out to 17.8 million children of disadvantaged group3

However, there are studies, which have shown the decline in 'severe' and 'moderate' malnutrition in the pre-school children, the present study measured the prevalence of malnutrition and also the impact of ICDS on the nutritional status of children with special reference to gender among urban anganwadis.

Vadodara is a city with total population of 1.03 million according to 1991 census4. There are 336 slum areas scattered in the 10 different administrative wards of Vadodara Municipal Corporation. in these slums 160 anganwadis (AWs) function, 120 of which are managed by the Vadodara Municipal Corporation, while remaining 40 are managed by Kashiba Children's Hospital.

Material and Methods:

This is a cross-sectional study that was carried out between July 1, 1998 and August 31, 1998.

Initially, a complete list of AWs of urban slums of Vadodara city was obtained from the ICDS office of the Vadodara Municipal Corporation. The permissions of the Chief Medical Officer, Municipal Corporation, Vadodara and ICDS officer, Kashiba Children's Hospital, Vadodara were obtained to conduct a study and field survey.

The schedule was prepared in the computer package Epi-info 6.04b and was pre-tested by visiting one of the selected AW and modified accordingly.

The sample for the study was selected by systematic random sampling method. Out of 160 AWs 30 were selected.

All the selected AWs were visited and list of the children of less than 5 years of age with their age (in months) and sex records were obtained from the register maintained by the anganwadi workers (AWWs). Weight records (in Kgms.) of the children for the months of June 98, June 97 and June 96 were also obtained from the AWs. For classification of malnutrition, Indian Academy of Paediatrics (IAP) classification was used.

Results and Discussion:

From the total of 3157 children studied in 30 AWs, 705(22.4%) were moderate to severely malnourished according to IAP classification (in grade II and III) and 1280(40.5%) were mildly malnourished (in grade I), while only 1172(37.1%) children were not malnourished. There was no child in grade IV in the study population.

Table I: Sex-wise prevalence of malnutrition in the children of less than 5 years of age in 1998.

IAP grades Malnutrition
Male (n=1659) Female (n=1498) Total (n=3157)
No. (%) 95% CI No. (%) 95% CI No. (%) 95% CI
0 696 (42.0) 39.6-44.4 476 (31.8) 29.4-34.2 1172 (37.1) 35.4-38.8
I 683 (41.2) 38.8-43.6 597 (39.8) 37.4-42.4 1280 (40.5) 38.8-42.3
II 264 (15.9) 14.2-17.8 370 (24.7) 22.5-27.0 634 (20.1) 18.7-21.5
IV 16 (1.0) 0.6-1.6 55 (3.7) 2.8-4.8 71 (2.3) 1.8-2.8

x2 = 78.2; p<0.0001.

More girls (68.2%) were malnourished than boys (58%) and the difference was statistically significant. Even in severity of malnutrition this difference persisted (TableI).

There are number of possible explanations for the gender difference like, negligence of girls, poor nutrition, more morbidities and less health care facilities and overall lower social status of the girl child. However, it could also be because the same yardsticks (reference curves) were used in IAP classification for assessing nutritional status in male and female children.

Table II: Age-wise prevalence of malnutrition in the children of less than 5 years of age in 1998.

IAP grades Malnutrition
<6 months (n=293) 6-11 months (n=417) 12-23 months (n=731) 24-35 months
> 35 months
No. (%) No. (%) No. (%) No. (%) No. (%)
0 191 (65.2) 257 (61.6) 275 (37.6) 228 (29.3) 221 (23.5)
I 84 (28.7) 109 (26.1) 302 (41.3) 344 (44.3) 441 (47.0)
II 14 (4.8) 46 (11.0) 133 (18.2) 187 (24.1) 254 (27.1)
III 4 (1.4) 5 (1.2) 21 (2.9) 18 (2.3) 23 (2.4)

x2 = 318.73; p<0.0001.

65.2% of the children under 6 months of age were normal. As the age advanced, the proportion of normal children in the age group decreased. Among the children aged 3 years and above only 23.5% were normal. The shape fall in the proportion was observed in the second year of life. The rise in level of malnutrition continued with increasing age but the rate of rise was much lower after second year. The prevalence of moderate to severe malnutrition were from 6.2% to 29.5% in different age groups (Table II). There was an increased level of malnutrition with increasing age (p<0.0001).

Breastfeeding meets all nutritional needs of the child for the first 6 months of life. Because of the conventionally adopted good practice of breastfeeding, the level of malnutrition in this age group is minimal and often it is similar to the children in Europe and North America as the food the children receive is the best2.

The National Family Health Survey (NFHS) 1992-93 has also shown similar trend. The results of the survey underline the critical period of infancy in the strategies for reducing malnutrition rates. The pooled data from 18 states showed that the malnutrition rate increased sharply in the end of the first year of life. There was a little change in the rates in children of 24 months and above. If fewer children were malnourished at 12 to 23 months of age, it is less likely that the rates will increase further in older age groups5.

Around 6 months of age, all children need other foods, besides breast milk, as it alone is no longer adequate for child's nutritional progress2. After the age of 4 to 6 months, supplementary feeding (weaning) should be started. Late start of weaning or inadequate supplementary food can lead a child to malnourishment. During the weaning process, children are particularly exposed to the deleterious synergistic action of malnutrition and infection. Once the child becomes malnourished, due to weakened immune system, child becomes prone to infections and may fall in the vicious circle of malnutrition to illness and illness to malnutrition.

Sudden rise of malnutrition level in second half of infancy and in the second year of life seen in our study could be because of the poor weaning practices prevalent in the society. In India, Bangladesh and Pakistan, the proportion of breastfed children aged six to nine months receiving complementary foods is less than one third2.

Malnutrition in 1996, 1997 and 1998:

Table III: Prevalence of malnutrition in the years of 1996, 1997 and 1998.

IAP grades Malnutrition
1996 (n=786) 1997 (n=1615) 1998 (n=3157)
no. % no. % no. %
0 250 (31.8) 542 (33.6) 1172 (37.1)
I 343 (43.7) 706 (43.7) 1280 (40.5)
II 176 (22.4) 323 (20.0) 634 (20.1)
III 16 (2.0) 42 (2.6) 71 (2.3)
IV 1 (0.1) 2 (0.1) 0 (0)

Overall there was not much change in the level of moderate to severe malnutrition in the children from 1996 to 1998. 22.4%, 22.7% and 24.5% were the respective figures of the prevalence of moderate to severe malnutrition in the years of 1996, 1997 and 1998. 37.1% of the children were normal in 1998 against 33.6% and 31.8% children in the year of 1997 and 1996 respectively.

It was observed that in many slums, large number of people influxed from the other states are living. Their children had not attended the anganwadis for the whole year, as they didn't live there for the whole year. In some areas because of different reasons (as shown by the people during informal talk e.g. helper was not calling children, snack was not given etc.), some people were not sending their children regularly to take the advantage of ICDS services. Such reasons could neutralize the gain in reduction in level of malnutrition in the children, if any.

Child to child shift (96-98) in nutritional status:

Malnutrition status of children for 3 years was compared where data were available with ICDS anganwadis to see their progress with age and attending anganwadis. The shift (difference of grades) of malnutrition in children from their grades in the year 1996 to their grades in 1998 was studied in those 786 children, whose weight records of the year of 1998 and 1996 were available.

Table IV: Child to child shift of nutritional status in the children (96 to 98).

Sex Child to child shift of nutritional status (96-98)
  -3 (%) -2 (%) -1 (%) 0 (%) +1 (%) +2 (%) +3 (%) +4 (%)
Male (n=413) 0   14 (3.4) 108 (26.1) 224 (54.2) 62 (15.0) 4 (1.0) 0   1 (0.2)
Female (n=373) 1 (0.3) 25 (6.7) 86 (23.0) 198 (53.1) 56 (15.0) 6 (1.6) 1 (0.3) 0  
Female (n=373) 1 (0.1) 39 (5.0) 194 (24.7) 422 (53.7) 118 (15.0) 10 (1.3) 1 (0.1) 1 (0.1)

x2 = 8.89, shift = change in the IAP grade; p=0.261.

422(53.7%) of the total 786 children remained in the same grade of malnutrition and 234(29.8%) worsened (negative shift of malnutrition), while only 130(16.5%) of them improved from their malnutrition status of 1996. There was not much difference in the shift of malnutrition status between male and female children (p=0.261).

But 'no shift' is making confusion here. The child who was malnourished in the year of 96 and remains malnourished in the year of 98 and the child who was normal in the year of 96 and remains normal in the year of 98, both represent entirely different picture of shift in malnutrition. Because the children who are normal i.e. in grade 0 cannot improve further according to IAP grading, which is not the case for the children who were malnourished.

So the children who were Normal (in grade 0) in the year of 96 and who were Not Normal (in grade >0) or Undernourished in the year of 96 represent two different cohorts which should be studied separately.

Table V: Shift of nutritional status in the 'Normal' children.

Sex Child to child shift of
nutritional status (96-98)
-3 (%) -2 (%) -1 (%) 0 (%)
Male (n=160) 0   14 (8.7) 70 (43.8) 76 (47.5)
Female (n=90) 1 (1.1) 22 (24.4) 32 (35.6) 35 (38.9)
Total (n=250) 1 (0.4) 36 (14.4) 102 (40.8) 111 (44.4)

x2 = 13.54; p=0.0036.

250(31.8%) of the total 786 children were normal in 96. Only 44.4% of them could maintain their normal nutritional status in the year 98, while 40.8% shifted down by one grade and 14.4% shifted down by two grades of malnutrition. The removal of confounding effect of 'nutritional status of the children in 1996' brought the difference in the shift between two sex (p=0.0036) to surface in this cohort. 47.5% of the boys remained normal, while only 38.9% of the girls remained normal. Moreover, 24.4% of the girls shifted down by two grades of malnutrition as against only 8.7% of boys.

Thus the large proportion of healthy children in 1996 had shifted to different levels of malnutrition in 1998, showing the retrograde trend. It is important to note that here this shift from healthy to malnourished status is proportionately more in girls than in boys. Possible explanations have been discussed earlier.

Table VI: Shift of nutritional status in the 'Malnourished' children in 1996.

Sex Child to child shift of nutritional status (96-98)
  -2 (%) -1 (%) 0 (%) +1 (%) +2 (%) +3 (%) +4 (%)
Male (n=253) 0 (0) 38 (15.0) 148 (58.5) 62 (24.5) 4 (1.6) 0 (0) 1 (0.4)
Female (n=283) 3 (1.1) 54 (19.1) 163 (57.6) 56 (19.8) 6 (2.1) 1 (0.3) 0 (0)
Total (n=536) 3 (0.6) 92 (17.2) 311 (58.0) 118 (22.0) 10 (1.8) 1 (0.2) 1 (0.2)

As an expected cell value is less than 5, x2 is not valid.

536(68.2%) of the total children, were malnourished in 1996, only 24.2% of them showed improvement in their nutritional status, while 75.8% of them remained either unchanged (0 shift) or shifted in higher grades of malnutrition. This means that 3/4th of the children, who were malnourished in the year 1996, either didn't improve at all or worsened further in two years. This is in contradiction to what ICDS anganwadis result, we would expect.

20.2% of the malnourished girls worsened further as against only 15% of the boys, while 26.5% of the boys improved from their nutritional status of 96 as against 22.2% of the girls, showing privileged position of male gender.

Table VII: Age trend in the shift (96-98) in the children.

Sex Child to child shift of nutritional status (96-98)
-3   -2  -1  0  +1  +2  +3  +4
Mean age (months) 29.0 32.8 36.7 42.4 42.2 39.7 42.0 37.0

Children between the age of 2 and 3 years (as in 1998) worsened more than their elder colleagues. This may be because these children were of around 6 months of age in 1996 and because of the good breastfeeding practices, they were well nourished in 1996. But in 1998, because of the poor weaning practices, they shifted to higher grades of malnutrition.


From the study, it is concluded that,

  1. According to IAP classification, 22.4% of the children of under 5 years of age, registered in the anganwadis of Vadodara city were moderate to severely malnourished (Gr II, III and IV) with a significant difference in its prevalence between male (16.9%) and female (28.4%) children.
  2. The level of moderate to severe malnutrition in the elder children was higher than that in younger children ranging from 6.1% in the age group of under 6 months to 29.5% in the age group of 36 to 59 months, with a steep rise in the level in the second year of life.
  3. There was almost no change in prevalence of malnutrition in the children of under 5 years, registered in the ICDS anganwadis during these two years i.e. from June, 96 to June 98.
  4. A study of child to child shift of malnutrition (according to IAP classification) by cohort analysis from the record data in the children showed that, only 44.4% of the children, who were Normal in the year of 1996 remained Normal, while from the Malnourished (in 1996) children, only 24.2% improved and all others either remained in the same grade of malnutrition or worsened further.
  5. Gender-wise analysis of the shift study revealed a significant difference in the shift between male and female children, who were Normal in 1996 favoring the male children.


ICDS has been by far the best comprehensive nutritional programme and a detailed qualitative study is required to understand the reasons of failure of this programme to improve nutritional status of children attending AWs.


We heartly thank Medical Officers of Vadodara Municipal Corporation and staff members of AWs besides little children attending AWs.


  1. Park K. Park's textbook of Preventive and Social medicine; M/s Banarsidas Bhanot; 1997; 344: 358-369, 416-429
  2. Vulimiri R et al. The Asian enigma; The progress of nations, UNICEF. 1996; 10-17.
  3. Government of India (1995) Integrated child development services.
  4. Government of India (1991) Census 1991, Vadodara district.
  5. International Institute for Population Science (1995) National family health survey 92-93, India.
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