2.4.2. Factors contributing to anaemia prevalence in children five years and below.
2.5. Anaemia in Adolescent girls.
2.5.1. Prevalence of anaemia among adolescent girls.
2.5.2. Factors contributing to the prevalence of anaemia in adolescent girls.
2.6. Anaemia in Pregnant women.
2.6.1. Prevalence of anaemia in pregnant women.
2.6.2. Maternal consequences of anaemia
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2.1 .Nutritional status of children
Malnutrition is high in India especially with micronutrient deficiency prevailing consistently over the decades. Among the vulnerable groups are children, adolescents and women with the major deficient nutrients being iron, vitamin A, iodine and zinc (Singh, 2007). A deficiency of these nutrients remains a major public health problem throughout the developing world and is an underlying factor in over 50 per cent of the child deaths under 5 years occuring due to preventable causes (Rice et al., 2000., Black
et al., 2003., Pelletier and Frongillo, 2003 and Caulfield et al., 2004).
Approximately 9 per cent of sub-Saharan African and 16 per cent South Asian children suffer from moderate acute malnutrition and approximately 2 per cent of children living in developing countries suffer from severe acute malnutrition (UNICEF and WHO, 2012).This is equivalent to approximately 60 million children suffering from moderate malnutrition and 13 million suffering from severe acute malnutrition at any one time. In India approximately 20 per cent of children under five years, are severely wasted (IIPS and Macro, 2007).Estimates from a most recent nationally representative survey indicate that 6.4 per cent of children below 60 months of age have weight-for- height below third standard deviation. Presently, with an Indian population of approximately 1.2 billion, there are about 132 million children under five years (12 % of population), of which 6.4 percent, or roughly 8 million are assumed to be suffering from severe acute malnutrition.
Children are the most important assets of our country. Childhood and maternal under-nutrition is currently the single leading cause of the global burden of under- nutrition. One in every three malnourished children of the world lives in India (UNICEF, 2013). India also contributes to the highest number of deaths among under- fives in South East Asia region and one-fifth of under five deaths worldwide (UNICEF, 2008). Atleast 50 percent of Indian infant deaths are related to malnutrition often associated with infectious diseases, some of which being mostly vaccine preventable diseases (VPDs). It has been estimated that approximately one out of every three Under- five children are chronically malnourished and thereby subjected to a pattern of ill health and poor development in early life (UNICEF, 1998), with malnutrition being associated with more than half of all deaths of children worldwide (Sobo and Oguntona, 2006).
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Nutritional problems like Protein Energy Malnutrition (PEM), Anaemia, and Vitamin-A deficiency continue to be major problems in Indian children. These nutritional deficiencies adversely affect the health and development of children and contribute to high level of morbidity and mortality in the developing countries like India (Gosh and Shah, 2004).
Despite the many national programmes in India like Reproductive and Child Health (RCH) programme, Integrated Management of Neonatal & Childhood Illnesses (IMNCI), Integrated Child Development services (ICDS) scheme, Midday Meal programme and many such programmes, which aim to reduce malnutrition in this sector of the population, 47 percent of children under-five years in India are malnourished (IIPS and Macro, 2007).
2.1.1. Indicators
The indicators of nutritional status used in most cases are weight –for-age, height-
for-age and weight–for-height, MUAC (Mid Upper Arm Circumference) and Head circumference (HC) in children. Several standards have been adopted but the most frequently used and adopted one is WHO growth standards which were released on April 27, 2006. These standards were adopted by UNICEF, FAO and other agencies involved in research of child malnutrition (United Nations System Standing Committee on Nutrition). These parameters are used to calculate and categorise stunting, wasting and underweight among infants and children as a means of assessing growth of a child. Assessment of growth thus not only serves as a means for evaluating the health and nutritional status of children but also provides an indirect assessment of the quality of life of an entire population.
Height –for-age measures linear growth retardation, primarily reflecting chronic (long-term) malnutrition which could be due to prolonged food deprivation and/ or illness which is referred to as stunting (low height-for- age). Weight-for-height measures body mass in relation to height, primarily reflecting acute (short term) under- nutrition (malnutrition) which is a result of more recent food deprivation and /or illness. It is referred to as wasting (low weight-for-height). Weight-for-age is used as a composite measure to reflect both acute and chronic under-nutrition, although it cannot distinguish between them. It is referred to as Under-weight (low weight-for-age).
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The three indices are expressed in terms of standard deviations from the median for an international reference population specified by the WHO. The current WHO recommendation is to use the Z-Score or Standard Deviation (SD) measures to grade under nutrition. Children who are less than 2 SD below the reference median (i.e. a Z- Score of less than 2) are considered to be undernourished i.e. to be stunted, wasted or underweight. Children with measurements below 3 SD (a Z-Score of less than 3) are considered to be severely undernourished. Although widely recommended, the Z Scores have not been widely in use in India, especially in community based studies (Seetharaman et al., 2007).
2.1.2. Forms of malnutrition
Several reports have documented data on the several forms of malnutrition which children below five are predisposed to due to several contributing factors. A double burden of malnutrition has been defined as the emerging growth of both under-nutrition and over-nutrition co-existing in children and their mothers in both developing countries as well as developed countries. This clearly stratifies the problem of poor nutrition due to availability of poor quality food (not balanced in all nutrients) i.e excess of carbohydrates among the rural and urban poor and consumption of fatty foods among the urban rich all of which lead to obesity and other non-communicable diseases like high blood pressure, diabetes, cardiovascular diseases, which are on the rise in this century and claiming more lives than attention given towards their control.
Considerable investments have been made on under-nutrition of children neglecting another deadly sector of nutrition, which is over nutrition, both in terms of money and research, thereby resulting in paucity of information on over-nutrition in children below five. However, the most recent estimates reported in 2013 by UNICEF show that overweight in children is on the rise and likely to continue. It can therefore be predicted that more children are likely to die of NCD‘s in the future or suffer from them at an early age. Listed below are some examples of the different forms of malnutrition that have been documented to occur in children.
Under-nutrition: Insufficient food intake over an extended period of time. For
example, PEM in the form of kwashiorkor and marasmus or both, vitamin A deficiency and anaemia.
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Over-nutrition: Excessive intake of food over a period of time. For-example, over-
weight and obesity.
Imbalance: Disproportion among essential nutrients with or without absolute
deficiency of any nutrient.
Specific deficiency: Relative or absolute lack of an individual nutrient. This can be a
genetic defect or due to presence of particular diseases which hinder digestion of some food and absorption of some nutrients.
2.1.3. Types of malnutrition occurring in children.
Children are a vulnerable sector of the population facing a double burden of malnutrition in which they suffer both under-nutrition and over-nutrition. These two states have resulted in compromised nutritional status of children to the extent of causing increased levels of morbidity and mortality. However, documented facts place under nutrition (PEM, VAD and IDA) as the most prevalent type of malnutrition with over-nutrition in the form of overweight and obesity as a new emerging problem with lesser number of reports available in literature (UNICEF-WHO and World Bank, 2014).
Prior to 2006, the nutritional status of preschool children was most often assessed in relation to an international growth reference population established by the U.S National Centre for Health Statistics (NCHS, 1997) which was endorsed by WHO. However the 2006 WHO Growth standards were also adopted by the government of India and when the two are compared for malnutrition among children under five years in India based on data from NFHS-3, the new WHO growth standards estimate that a higher proportion of children are stunted (48 %), wasted (20 %) and a lower proportion are underweight (43 %) while the old NCHS standards estimate that a lower proportion of children are stunted (42 %),wasted (17 %) and a higher proportion are underweight (48 %). However both standards report remarkably high levels of malnutrition (Arnold
et al., 2009).
2.1.3.1. Prevalence of under-nutrition in children.
This section covers reports from earlier studies to the most recent studies that show the extent and direction of malnutrition over the years in children below five years, both within and outside India which will explain the significance of the study. Documented literature indicates a high prevalence of malnutrition among children in the form of stunting, wasting and underweight in India and elsewhere over the years. There
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are also other forms of malnutrition which are prevalent besides the above mentioned ones like micro-nutrient deficiencies, especially vitamin A, IDD (Iodine deficiency disorder), IDA (Iron deficiency Anaemia).
2.1.3.1.1. Out-side India.
Several studies in Ethiopia have indicated a higher prevalence of chronic under- nutrition as represented by stunting and underweight, as compared to acute under- nutrition reported by wasting prevalence. A cross sectional study conducted in Aynalem village in Tigray region, Ethiopia indicated the overall prevalence of stunting, underweight and wasting as 45 percent, 43.1 percent and 7.1 percent respectively (Taffesse and Goitom ,1997). Another cross sectional survey conducted in rural communities of Tigray region also revealed that the levels of stunting, under weight and wasting were 42.7 percent 38.3 percent and 13.4 percent respectively (Mulugeta et al., 2005).
A community based cross-sectional survey conducted in West Gojam zone revealed that 49.2 percent children were under-weight, 43.2 percent of the children under age five were suffering from chronic malnutrition (stunting) and 14.8 percent acutely malnourished (wasted) (Teshome et al., 2006). According to research conducted in Gimbi district Oromia region, 32.4 percent were stunted, 23.5 percent underweight and 15.9 percent of the children were wasted. Prevalence of severe stunting, severe underweight and severe wasting were 15.7 percent, 8.0 percent and 5.7 percent respectively (Kebede, 2007).
Amonsu et al. (2011) in Nigeria in a cross-sectional descriptive study among 304 males and 296 female children aged 6 – 59 months indicated that malnutrition was prevalent inform of underweight (82.13 %), stunting (33.52 %) and wasting (85.15 %) among the children.
A study in rural kebeles of Haramaya district reported the prevalence of stunting, underweight and wasting as 42.2 percent, 36.6 percent and 14.1 percent respectively. In addition, the proportion of the prevalence of malnutrition by its level of severity indicated that 19.9 percent were severely stunted, 16.6 percent were severely underweight and 3.9 percent were severely wasted (Zewdu, 2012).
Mengistu et al. (2013) in a study in Ethiopia revealed that 47.6 percent, 30.9 percent and 16.7 percent of children were stunted, underweight and wasted, respectively.
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2.1.3.1.2. Indian Scenario.
Malnutrition in India still remains high among children under five with the highest mortality globally. This has been confirmed by several studies conducted in India despite numerous programmes in operation to try and curb this problem. It is because of the magnitude of this problem that India is still placed among the developing countries despite its fast economic growth.
In a study conducted in a rural area in Faridabad district, malnutrition was detected in 27.2 percent of the children by using mid-arm circumference. The sensitivity and specificity was found to be 34.1 percent and 80.8 percent and the authors concluded that this criterion detected moderately severe cases of malnutrition (Sood and Kapril, 1984).
A cross sectional study conducted in the urban slums of Jamnagar, India reported the prevalence of malnutrition at 54 percent of which half of them belonged to grade-I and grade-II. Grade-I (26.22 %), followed by grade-II (21.33 %) and grade-III (6.45 %). It was also observed that prevalence of malnutrition was higher in female children compared to male children. This difference was found statistically significant (Dwivedi
et al., 1992). In studies conducted in urban slums of Delhi and Jabalpur which aimed at
evaluating the prevalence of underweight, stunting and severe underweight, it was observed that the prevalence of stunting was more than that of wasting and severe wasting (Saxena et al., 1997 and Bloss et al., 2004).
Bhalani and Kotecha (2002) reported the prevalence of malnutrition to be 41.00 percent in grade I, grade II (20.00 %) and grade III (0.200 %) in their study.
In another study involving Integrated Child Development Services (ICDS) in Indian Anganwadis, the prevalence of malnutrition according to Indian Academy of Paediatrics (IAP) classification of underweight, stunting and wasting, was 40.5 percent, 20.1 percent and 2.3 percent respectively. Severe degree (below -3 SD) of underweight, stunting and wasting was prevalent in 27.8 percent, 30.3 percent and 6.5 percent respectively (Rao et al., 2005). According to this study, severe malnutrition was prevalent in Anganwandi children, which could possibly mean that the ICDS services needed close monitoring and improvement to meet their target goals.
Damon et al. (2013) evaluated risk factors associated with under nutrition and reported a prevalence of 54 percent malnutrition in children out of which half of them belonged to grade I (26.22 %), grade II (21.33 %) and grade III (6.45 %) malnutrition.
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A significantly higher prevalence of malnutrition was also reported in female children compared to male children.
Anwar et al. (2013) examined 483 children aged 0-36 months in Varanasi, India and reported a prevalence of stunting, underweight and wasting of 43.1 percent, 35.2 percent and 31.5 percent respectively. The composite index of anthropometric failure (CIAF) showed that 2.5 percent of the children were suffering from anthropometric failure and 42.9 percent of the children were suffering from malnutrition according to MUAC criteria (<13.5cm). The study also indicated a high prevalence of malnutrition in children ≥1 year which is line with another study by Joseph et al. (2002). In Madhya Pradesh, prevalence of underweight, wasting and stunting as 46.8 percent, 38.6 percent and 40.6 percent respectively (Shahjada et al., 2014).
It is evident from the above studies, that chronic malnutrition is more prevalent than acute malnutrition which is seen as wasting. However, a study conducted in Nigeria showed a very high prevalence of wasting (acute) and underweight (chronic) under-nutrition. This could be due to regional differences in terms of geographical location and also cultural differences as one study is from western Africa while the others are from eastern Africa and the rest were from India.
2.1.4. Factors affecting the nutritional status of children under-five.
There are several factors which contribute to malnutrition in children and they are given below in different categories such as health status of the child and mother, nutritional factors, socio-economic factors, literacy, sanitation, mental health of care takers and environmental factors/ natural disasters.
The causes of malnutrition are numerous and multifaceted. These causes intertwine with each other and are hierarchically related. The most immediate determinants are poor diet and disease which are themselves caused by a set of underlying factors; household food insecurity, maternal/ child caring practices and access to health services and healthy environment. These underlying factors themselves are influenced by the basic socio-economic and political environment.
2.1.4.1. Personal factors of the child
2.1.4.1.1. Age
The age of the child is crucial to his/her survival. At a tender age, the risk of mortality is high as the child is just getting acquitted to the new surroundings. A few
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days after birth, the child faces several risks due to low immunity as compared to children who have lived for a few years and built their immunity by acquisition (acquired immunity) or through immunization. Stunting, wasting and underweight are most common in the first two years of a child‘s life but also prevalent throughout in children below five years, though the extent varies with age of the child. More frequent infections like cold, cough, diarrhoea episodes, measles and pneumonia, which drain on the body‘s nutrient reserves leading to ill health and malnutrition in the form of PEM, anaemia and VAD, are also age dependent.
Because children are breastfed at their tender age, some studies found that malnutrition was more common as the child grows up i.e. when weaning (complementary feeding) is introduced after 11 months of age. Vinod and Retherford (2000) in analysis of NFHS-1 data, found that infants less than six months old were less likely to be malnourished than older children, which they attributed to breast feeding. This supports the documented fact that breast milk is the best food for children as it contains all nutrients in their balanced form, enough to support the proper growth of a child. However, proper feeding of the mother is necessary to sustain the quality of nutrients in the milk, especially the micronutrients like vitamins (WHO, 2014).
Results from Mengistu et al. (2013) indicated that malnutrition is associated with the age of the child. Children in the age group 13-24 months were reported to be 7 times more likely to be stunted than children aged 6-11 months (AOR = 7.15; 95 %; CI = 2.33, 21.90). The highest prevalence of underweight was reported in children aged 48- 59 months with prevalence of 8 percent. The lowest prevalence of underweight was seen in children aged 6-11 months with prevalence of 1.7 percent, while the highest prevalence of wasting was seen in children aged 48-59 months at Hidabu Abote district, Ethiopia with 5 percent prevalence. The lowest prevalence of wasting was seen in children aged 6-11 months. Several studies have reported similar findings where malnutrition is reported to increase with age of the children under five, especially stunting and wasting (Mulegeta et al., 2005.,Teshome et al.,2006., Asres and Eidelman, 2011). According to a study conducted in Kenya, stunting was maximum in 12-24 months age group children and was statistically significant (Bloss, 2004)).
A study in Varanasi, India by Anwar et al. (2013) in which malnutrition among rural Indian children was assessed using web indices revealed stunting as being
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significant among children ≥ 1year of age, while wasting was significantly more among infantile age group. Additionally, the Composite Index of Anthropometric Failure (CIAF) showed a higher prevalence of under nutrition (62.5 %) of children (58.3 %) in infants and (68.3 added space %) ≥ 1 year age group. It is at this stage (≥ 1 year) that complementary feeding is introduced and if it does not contain nutrients in a balanced formed to support the spurt growth of child, then their bodies fall deficient and it interferes with growth. Similar results were reported in a study conducted in Coimbatore slums among under-fives where the prevalence of wasting was seen among 0-11, 12-23, 24-35, 36-47 and 48-59 months age group as 32.1 percent, 23.8 percent, 31.8 percent, 36.1 percent and 20.7 percent respectively (Joseph et al., 2002).
From the above studies, it is clear that the form of malnutrition is age dependent with chronic under-nutrition increasing as the child grows whereas acute malnutrition was common in the younger children especially due to recurrent infections and improper feeding practices.
2.1.4.1.2. Gender.
Both female and male children are affected by malnutrition globally with high values of malnutrition still being reported in developing countries beyond 40 percent as per WHO standards making malnutrition in children under-five a public health problem. However in countries like India, the female children are reported with higher prevalence in malnutrition than the male children. This could be an impact of societal and cultural