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Indian Journal of Community Medicine

Rapid Assessment of Nutritional Status and Dietary Pattern in Municipal Area

Author(s): Sandip Kumar Ray*, Akhil Bandhu Biswas**, Samir Das Gupta***, Dipankar Mukherjee****,

Vol. 25, No. 1 (2000-01 - 2000-03)

*Department of Community Medicine, Medical College, Calcutta. **R.G. Kar Medical College

Abstract:

Research question: What is the nutritional status of the children under five years of age and dietary pattern of the families.

Objective: Rapid assessment of the magnitude of the problem of malnutrition in a municipal area of North Bengal and also to assess dietary pattern and average calorie intake.

Study design: Cross-sectional study based on 30 cluster sampling technique.

Settings: Municipal area of Siliguri.

Participants: 316 underfive children in 30 clusters for assessment of nutritional status and 92 families for assessment of dietary pattern.

Results: Prevalence of malnutrition was observed to be 62.97% and prevalence of severe degree of malnutrition was 6.65%, more so amongst 12-23 months of age and amongst females. Average calorie intake was 2271.7 K.cals and nearly half (47.8%) of the studied families were getting less than 2400 K.cals.

Introduction:

The magnitude of the problem of malnutrition amongst children under 5 years of age is high throughout the country and also in the state of West Bengal. National Family Health Survey data (1992-93) projected that 56.8% children (0-4 years) suffered from malnutrition in West Bengal with 18% having severe grades1. Most of information on the magnitude of the problem of malnutrition was available mainly from the rural areas. Therefore, as per the recommendation of the state level workshop on nutrition2, a survey was undertaken in the Siliguri municipal area with the objective of rapidly assessing the magnitude of the problem of malnutrition as well as dietary pattern of the families. Some epidemiological factors associated with malnutrition were also explored.

Material and Methods:

Siliguri is a sub-divisional town in the Darjeeling district of the state of West Bengal. The then Siliguri Municipal Corporation had 30 wards with a population of 2,15,382. Ward-wise population was obtained from the municipal authorities and formed the sampling frame. 30 cluster sampling technique, as followed in case of UIP evaluation, was followed. The random number and sampling interval were 1397 and 7180 respectively. 30 clusters were identified by using the standard technique3.

Sample size:

For assessment of the nutritional status of the children under 5 years of age, the prevalence of malnutrition in earlier studies in urban areas of West Bengal was considered for sample size calculation. In one urban area, 76% prevalence was observed4,5. It was used for determination of sample size, which was calculated to be 126, based on the formula 4PQ/L2, where P is the prevalence, Q is 1-P and L is the permissible error i.e. 10% in the present study. The sample size was multiplied by design effect on nutrition which was 26.

To study dietary pattern, the sample size was determined based on the data of the lowest magnitude of poor which was around 50% as per Bapna (1990-91)7. Thus, sample size was found to be 400. Considering the average family-size of 5, around 80 families were to be covered to have an adequate sample size of 400. Therefore, in each cluster 2.6 i.e. 3 families were randomly choosen for studying dietary pattern.

Pretested proforma was used for data collection. Weight of the children was recorded by Salter weighing machine. Grading of malnutrition was done as per IAP classification8. Age was assessed either from records or by asking question and comparing it with local events calendar. The diet survey was carried out by oral questionnaire using 24 hours recall method.

Results and Discussion:

A total of 316 under five children and 92 families were studied for observing nutritional status and dietary pattern respectively.

Table I: Age-wise distribution of malnutrition.

Age in Months Nutritional status
Normal Grade I Grade II Grade III Grade IV
No (%) No (%) No (%) No (%) No (%)
0-5 (n=18) 11 (61.1) 4 (22.22) 3 (16.67) - (-) - (-)
6-11 (n=39) 16 (41.03) 12 (30.7) 6 (15.38) 4 (10.26) 1 (2.56)
12-23 (n=62) 16 (25.81) 17 (27.42) 23 (37.09) 6 (9.68) - (-)
24-35 (n=68) 23 (33.82) 23 (33.82) 20 (29.41) 1 (1.47) 1 (1.47)
36-59(n=129) 51 (39.53) 45 (34.88) 25 (19.38) 6 (4.65) 2 (1.55)
Total (n=316) 117 (37.03) 101 (31.96) 77 (24.37) 17 (5.38) 4 (1.27)

Overall prevalence of the malnutrition in children under 5 years was found to be 62.97% and prevalence of severe degree malnutrition (Grade III and IV) was 6.65%. Prevalence of malnutrition in the present study, appeared to be comparatively lower than the earlier studies in Calcutta slums (75.68%) 4,5 and Ausgram tribal community of West Bengal (79.9%)4 while the overall prevalence was more or less same with that of a rural community of Gosaba Block (66%) 4,5. This could be due to better literacy rate in these two areas.

Similarly, the prevalence of severe degree of malnutrition was also found to be highest in tribal area (9.26%) followed by Calcutta urban slum area (8.10%) and lowest at Gosaba rural area (4.33%) 4,5. Findings of the present study as regards severe degree was in between the later two studied areas. ICDS surveys conducted at various areas on different occasions also reported similar types of observations on malnutrition among children aged 1 to 6 years4.

Overall prevalence of malnutrition was highest (74.19%) in the age group 12-23 months, followed by 24-35 months (66.18%) and 36-59 months (60.47%). But the trend was somewhat different in case of severe degree of malnutrition (Grade III and IV) which was highest in 6-11 months of age group (12.82%) followed by 12-23 months (9.68%) age group. Higher prevalence of severe degree in 6-11 months age group could be due to delayed initiation or faulty complementary feeding practices. However, no case of severe degree of malnutrition was observed among the infants aged 0-5 months. The findings of present study corroborated with the findings of the studies carried out in other areas in relation to severe degree of malnutrition amongs children under 2 years of age 4,5. Special attention should be paid to this group of beneficiaries, mainly through ICDS scheme.

Sex-wise distribution:

64.74% males and 61.58% females were malnourished. For overall prevalence of malnutrition, the sex differential was not statistically significant (p >0.05), but statistically significant sex difference (p<0.05) was observed in prevalence of severe degree of malnutrition, which was almost double in female children (8.47%) in comparison to male children (4.3%). Studies at Ausgram block also revealed similar trends4. Similar observations were noted in a number of ICDS surveys carried out in this decade which also showed that prevalence of malnutrition was more in females than in male children4. This could be due to the neglect of female children particularly with respect to intra familial food distribution.

Parental Literacy and Malnutrition:

Table II: Parental literacy and malnutrition.

  Normal No (%) Grade I No (%) Grade II No (%) Grade III No (%) Grade IV No (%)
Father:
Literate (n=213) 91 (42.72) 69 (32.39) 39 (18.31) 11 (5.16) 3 (1.41)
Illiterate (n=103) 26 (25.24) 32 (31.07) 38 (36.89) 6 (5.83) 1 (0.97)
Total (n=316) 117 (37.03) 101 (31.96) 77 (24.37) 17 (5.38) 4 (1.27)
Mother:
Literate (n=142) 64 (45.07) 40 (28.17) 30 (21.13) 6 (4.23) 2 (1.41)
Illiterate (n=174) 53 (30.45) 61 (35.06) 47 (27.01) 11 (6.32) 2 (1.15)
Total (n=316) 117 (37.03) 101 (31.96) 77 (24.37) 17 (5.38) 4  

Substantial differences in the prevalence of malnutrition were observed among children belonging to illiterate fathers (74.76%) and literate fathers (57.28%) which was statistically significant (p<0.05). It was revealed further that the prevalence of malnutrition among the children of literate mothers was comparatively lower (54.93%) than the illiterate mothers (69.55%) and the difference was also statistically significant (p<0.05). Severe malnutrition was also more prevalent in children belonging to illiterate parents. These findings were indicative of a strong association between parental literacy and nutritional status of children.

Number of siblings, sibling interval and nutritional status:

It was observed that 56.07% children with two or less member of siblings, were malnourished. On the contrary 71.33% children were malnourished when number of siblings were 3 or more. The difference was statistically significant (p<0.05). Relationship between sibling interval and nutritional status was also studied. Among the children with sibling interval of less than 36 months, 68.7% children were malnourished. However, the prevalence rate was significantly less (p<0.05) in children with sibling interval of 36 months or more. Earlier, studies by Ray et al at both urban and rural areas also reported higher prevalence of malnutrition in families having more than 3 siblings9-11.

Immunisation status and malnutrition:

A significantly higher (p<0.05) prevalence of malnourished children were observed amongst partially immunised and non-immunised children (81.25% and 88.23% respectively) in comparison to fully immunised children (62.07%). Severe degree of malnutrition was also significantly higher (p<0.05) among partially immunised and non-immunised children (12.5% and 11.76% respectively) in comparison to the fully immunised children (6.89%). This implies that partially and non-immunised children were at higher risk of malnutrition as they were not protected against the vaccine preventable diseases including measles and contributing to the vicious cycle of malnutrition and infection.

Morbidity due to infectious diseases and nutritional status:

Enquiry was made regarding occurrence of some major childhood morbidity over a recall period of 15 days. It was noted that 37.9% children suffered from diarrhoeal episodes. Out of them 75% were having different degrees of malnutrition and it was significantly (p<0.05) higher than the overall prevalence rate (62.97%). Prevalence of severe degree of malnutrition was also more than double (14.58%) in children who suffered from diarrhoea than the overall prevalence of severe degree of malnutrition (6.65%) which was also statistically significant (p<0.05). Among the children with acute respiratory tract infection, 69.98 percent were suffering from malnutrition with 8.32% having severe degree of malnutrition and both were significantly higher than the overall prevalence (p<0.05).

Dietary intake pattern:

Table III: Dietary intake pattern:

Project Area No. of families Cereals Pulses GLV Roots tubers Other veg. Fruit Milk food Flesh Poultry product Sugar/Jaggery Oil
Siliguri (urban) CU=354.7 92 515.5 34.2 33 132 58.2 101.4 105.1 31.7 5.9 32.6 36.1
RDA (Sedentary)   460 40 40 50 60 - 150 - - 30 40

GLV = Green leafy vegetables, CU = Consumption unit, RDA = Recommended daily allowances

Diet survey was undertaken in 92 families which constituted a total of 354.7 consumption units. Average intake of different categories of food-stuff per consumption unit was calculated. Cereals and starchy foods formed the main bulk of their diet. Intake of cereals and roots and tubers were found to be higher than the ICMR recommended daily allowances13. Findings of the present study corroborated with the other studies carried out at Ausgram, Gosaba and Calcutta as regards cereals and starchy foods consumption while it did not corroborate with the findings related to green leafy vegetables consumption4,5.

Average calorie intake per consumption unit (C.U.) was found to be 2271.7 K.cals. which is 94.6% of RDA for a sedentary worker as per ICMR recommendation. It was further observed that almost half (47.8%) of the studied families were deprived of the basic minimum calories requirement (2400 K.cals.) indicating more vulnerability to widespread malnutrition and infection.

Conclusion:

The present study findings amply reveal that problem of malnutrition is multifaceted and has links with various socio-economic and demographic factors. So a multipronged attack involving various departments is of utmost concern in order to reach the goal of reducing malnutrition to half by the end of this century. Therefore, an area specific integrated decentralised planning as well as sensitisation workshop for the peripheral level functionaries on nutrition related issues based on "Triple A" approach should be planned14 and conducted with the above perspective.

Acknowledgement:

Authors deeply acknowledge UNICEF Calcutta for their support and Principal Medical College, Calcutta for kindly permitting authors to carry out the study.

References:

  1. National Family Health Survey: International Institute of Population Sciences, Bombay. 1994, 1-17.
  2. Ray SK: Report of the Nutrition Workshop, Nutrition Sensitisation Workshop - Report submitted to UNICEF, Deptt. of Community Medicine, Medical College, Calcutta, 1995, 1-19.
  3. Govt. of India: Evaluate service coverage, Training Module, 1992, 6-17.
  4. Ray SK, Biswas AB: A strategy development on the basis of nutritional profile and household food security of vulnerable population in West Bengal, Deptt. of Community Medicine, Medical College, Calcutta, 1994, Report submitted to UNICEF, Calcutta, 9-40.
  5. Ray SK, Biswas AB, Kumar S: Comparative study of household food security and nutritional profile of under five children in a rural & urban community of West Bengal. Indian Journal of Public Health, 1997, 42: 136-47.
  6. Wavne W Daniel: Biostatistics - a foundation for analysis in Health Sciences, 5th Edition 1987, 23-60.
  7. Bapna SL: Option for ensuring household food security in India, Article prepared for UNICEF, N. Delhi, 1993, 1-37.
  8. Nutritional sub-committee of IAP, Report of Convenor, Indian Pediatr 1972; 9: 360.
  9. Ray SK, Lahiri A, Mukhopadhya BB: A short communication on some aspects of under 5-year clinic services at Goda peri-urban community, Indian J Community Medicine, 1985, 14: 114-118.
  10. Ray SK, Mukhopadhya BB: Some correlates of nutritional status of under-fives attending a clinic at Rayan village at Burdwan, Ind J Pub H, 1986; 30: 25.
  11. Ray SK, De Sarkar S, Lahiri A, Mukhopadhya BB: A cross-sectional study of undernutrition in 0-5 year age group in an Urban slum Community, Ind J Pub H, 1987; 31: 168.
  12. Gopalan C, Sastri BV, Balasubramanian SC: Nutritive value of Indian foods, National Institute of Nutrition, ICMR, Hyderabad, 1985, 10.
  13. Reddy V, Rao P, Asastri GS, Kashinath K: Nutrition trends in India. National Institute of Nutrition, ICMR, Hyderabad, 1993, 1-32.
  14. UNICEF, The state of the world's children. Oxford University Press, 1998, 40-41.
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