Introduction:
Protein energy malnutrition (PEM) is an extensive health and nutritional concern in the developing countries. National Family Health Survey (NFHS) –3 reported a prevalence of 48%, 43% and 20% for stunting, underweight, and wasting respectively. (1) In 2011 census, the proportion of malnutrition was highest in Madhya Pradesh (60%) and least in Sikkim (19.7%). (2)
NFHS- 3 reported, almost half of the children under five years of age were stunted and underweight. Under-nutrition was more rampant in the age group of 12-23 months. Smaller birth spacing children, children belonging to SC and ST’s, large families and also mother’s height, weight, occupation, standard of living had an effect over the nutritional status of children. (3)
Migrant population are non-native population. They are greatly exposed to many health problems. The cause could be, frequent migration, food uncertainty, climate and other environmental risks which has an adverse effect on the health of children, causing child mortality.(4) In India, 307 million or 30% of the total population are migrants who have migrated to within and outside the states. In Karnataka, 4.1% are inter-state migrants. (5)
Proper nutrition is required for the all-round development of the child. It does not only contribute for good health but also for the growth. Malnutrition in initial childhood can lead to grave, long-term concerns which in turn can impede motor, sensory, cognitive, social and emotional development. (6)
This present study aimed to assess the prevalence of malnutrition among under-five children aged six months to five years of the migrant population of Udupi District, Karnataka, India. The study also attempted to do the subgroup prevalence of malnutrition among infants, toddlers and preschoolers.
Materials and Methods:
This was a cross-sectional study conducted among 260 migrant population of Udupi District, Karnataka to examine the prevalence of malnutrition among children between the ages of six months to five years. Udupi District has three taluks namely, Udupi, Karkala, and Kundapur taluk. Udupi taluk was selected randomly for the study. The list of migrant population areas of Udupi taluk was obtained from the District Commissioner’s Office and the Udupi Municipality Office. The migrant population areas namely, Beedinagudde, Perampalli road, and Manipal were selected through simple random sampling. Cluster sampling was used to collect the sample. The migrant population who stay in these areas are from within and outside the states, come in search of employment and education. The sample size was calculated using the estimation of proportion formula and the estimated sample size was 260.
The data was collected using the background information, which included the demographic proforma and the modified Kuppuswamy socioeconomic scale. The nutritional status of under-five children was assessed using the anthropometric measurements which included, height and weight. The study was approved by the Institutional Ethics Committee of Kasturba Hospital, Manipal. Permission was obtained from the Tehsildar of Udupi taluk and informed consent was obtained from the participants after explaining the purpose of the study.
Data collection
A house to house survey using the interview method was conducted to rule out the prevalence of malnutrition. The nutritional status was examined by taking anthropometric measurements. The height of the child above two years and the mother was obtained by making them stand in an upright position. The heels were slightly separated. Heels, buttocks, shoulder blades and back of head were brought in contact with a vertical surface or a wall. The head was positioned in a way that the subject looks forward. The scale was firmly placed over the head to compress the hair. A marking was done and the height was measured using a calibrated inch tape. The length and the weight of children below two years were measured using a calibrated infantometer. The head was firmly held in position against a fixed upright head board by one person. The legs were straightened, keeping the feet at right angles to the legs, with the toe pointing upward. The free foot board is brought into firm contact with the child’s heels. The length of the child was measured from the scale provided in the infantometer.
The weight of the child was measured by making the baby wear minimum clothes and assessing the weight when the baby was still. The weight of the child and the mother was examined by making them wear light clothing and making them stand over the calibrated weighing machine placed on a levelled surface. The weighing machine was corrected for any zero error before the measurement. (4) The data was then compared with the Indian Academy of Pediatrics (IAP) classification and the World Health Organization (WHO) classification. The IAP classification is classified as per weight for age of the standard.
According to the IAP classification, grading of malnutrition is classified as normal if weight for age is above 80%, grade I or mild malnutrition if weight for age is between 71 to 80%, grade II or moderate malnutrition if weight for age is between 61 to 70%, grade III or severe malnutrition if weight for age is between 51 to 60%, and grade IV or very severe malnutrition if weight for age is below 50%. (1)
According to WHO classification, the nutritional status is classified as underweight or weight for age, wasting or weight for height, and stunting or height for age in relation with the Z-score. If the Z-score is below -2SD then the child is said to be stunted. If the Z-score is below -3SD, then the child is severely stunted. The child is said to be underweight if the Z-score is below -2SD, and severely underweight if the Z-score is below -3SD. The child is said to be wasted if the Z-score is below -2SD, and severely underweight if the Z-score is below -3SD. If the Z- score is above 1SD, then the child is said to have a possible risk of overweight, above 2SD the child is said to be overweight, and above 3SD the child is said to be obese. (7)
The statistical analysis was done using SPSS version 20.
Results:
Among a total of 260 migrant children, around 114 (43.8%) children were between the age group of three to five years, 40 (15.4%) children were between six months to one year and 106 (40.8%) children were between one to three years. Majority 142 (54.6%) were male children, 232 (89.2%) children followed Hinduism and 28 (10.8%) belonged to Muslim religion. Table 1 shows that most 217 (83.5%) children belonged to nuclear families, and 132 (50.8%) children were single child, 217 (83.5%) children living in Manipal, and majority 250 (96.2%) children belonged to Karnataka state. The socioeconomic status of the parents of under-five children is depicted in Table 2.
Table 1: Sample Characteristics of the Migrant Children |
Sample characteristics of participants (n= 260) |
Frequency (f) |
Percentage (%) |
Type of family |
Nuclear |
217 |
83.5 |
Joint |
43 |
16.5 |
Number of siblings |
Single child |
132 |
50.8 |
1 to 2 |
110 |
42.3 |
3 to 4 |
18 |
6.9 |
Place of stay |
Manipal |
217 |
83.5 |
Beedinagudde |
10 |
3.8 |
Perampalli Road |
33 |
12.7 |
Native state |
Karnataka |
250 |
96.2 |
Tamil Nadu |
4 |
1.5 |
Andhra Pradesh |
2 |
0.8 |
Kerala |
1 |
0.4 |
Odhisha |
1 |
0.4 |
Bihar |
2 |
0.8 |
The nutritional status of 260 children were analyzed by assessing the height and weight measurements using IAP and WHO classification of malnutrition. The prevalence of malnutrition was 151 (58.07%) children according to Indian Academy of Pediatrics classification for weight for age. Maximum 109 (41.92%) children belonged to the normal category, whereas 86 (33.08%) were in grade I malnutrition, 45 (17.31%) were in grade II malnutrition, 16 (6.15%) were in grade III malnutrition, and only 4 (1.54%) children were in the grade IV malnutrition category. According to WHO classification of malnutrition, the prevalence of underweight was 127 (48.8%), stunting 176 (67.7%) and wasting 51 (19.6%) and is depicted in Table 3.
Table 2: Distribution of sample characteristics related to socioeconomic status |
Sample characteristics (N=260) |
Frequency (f) |
Percentage (%) |
Father’s occupation |
Unemployed |
7 |
2.7 |
Unskilled worker |
206 |
79.2 |
Semi-skilled worker |
22 |
8.5 |
Skilled worker |
5 |
1.9 |
Semi-profession |
10 |
3.8 |
Profession |
10 |
3.8 |
Mother’s occupation |
Unemployed |
136 |
52.3 |
Unskilled worker |
121 |
46.5 |
Skilled worker |
1 |
0.4 |
Profession |
2 |
0.8 |
Father’s education |
Illiterate |
27 |
10.4 |
Primary school certificate |
142 |
54.6 |
Middle school certificate |
43 |
16.5 |
High school certificate |
22 |
8.5 |
Intermediate or post high school diploma |
8 |
3.1 |
Graduate or PG |
18 |
6.9 |
Mother’s education |
Profession or honors |
1 |
0.4 |
Primary school certificate |
108 |
41.5 |
Middle school certificate |
57 |
21.9 |
High school certificate |
26 |
10.0 |
Intermediate or post high school diploma |
9 |
3.5 |
Graduate or PG |
14 |
5.4 |
Family income in rupees |
1866-5546 |
143 |
55.0 |
5547-9248 |
81 |
31.2 |
9249-13873 |
10 |
3.8 |
13874-18497 |
18 |
6.9 |
18498-36996 |
8 |
3.1 |
Socioeconomic status |
Lower Class (V) |
3 |
1.2 |
Upper Lower Class (IV) |
224 |
86.2 |
Lower Middle Class (III) |
9 |
3.5 |
Upper Middle Class (II) |
22 |
8.5 |
Upper Class (I) |
2 |
0.8 |
Table 3: Prevalence of nutritional status in migrant under-five children based on WHO classification |
Nutritional Status (N=260) |
Frequency (f) |
Percentage (%) |
Underweight
At possible risk |
22 |
8.5 |
Normal |
111 |
42.7 |
Underweight |
71 |
27.3 |
Severely underweight |
56 |
21.5 |
Stunting |
|
|
At possible risk |
6 |
2.3 |
Normal |
78 |
30.0 |
Stunted |
90 |
34.6 |
Severely stunted |
86 |
33.1 |
Wasting |
|
|
Obese |
5 |
1.9 |
Overweight |
8 |
3.1 |
Possible risk of overweight |
61 |
23.5 |
Normal |
135 |
51.9 |
Wasted |
31 |
11.9 |
Severely wasted |
20 |
7.7 |
Further analysis was done to describe the grading of malnutrition and the nutritional status of children in different age groups and is presented in Table 4.
Maximum 19 (47.5%) infants were normal in grading of malnutrition, 13 (32.5%) infants were severely stunted, 11 (27.5%) were severely underweight, and 11 (27.5%) infants were at possible risk for overweight. Maximum 32 (30.2%) toddlers were in the Grade I grading of malnutrition. Maximum 48 (45.3%) toddlers were severely stunted, 25 (23.6%) were underweight and severely underweight respectively, and 28 (26.4%) were at possible risk of overweight. Maximum 42 (36.8%) preschooler were in the Grade I category of malnutrition, most 43 (37.7%) were stunted, 39 (34.2%) were underweight, and 15 (13.2%) preschoolers were wasted.
Table 4: Prevalence of grading of malnutrition and the nutritional status in infants, toddlers, and preschoolers based on IAP and WHO classification |
Nutritional Status (N=260) |
Infants
n=40
f (%) |
Toddlers
n=106
f (%) |
Preschooler
n=114
f (%) |
Grading of malnutrition |
Normal |
19(47.5%) |
47(44.3%) |
50(43.9%) |
Grade I |
5(12.5%) |
32(30.2%) |
42(36.8%) |
Grade II |
8(20%) |
16(15.1%) |
20(17.5%) |
Grade III |
6(15%) |
9(8.5%) |
2(1.8%) |
Grade IV |
2(5%) |
2(1.9%) |
0 |
Stunting |
At possible risk |
2(5%) |
3(2.8%) |
1(0.9%) |
Normal |
13(32.5%) |
20(18.9%) |
45(39.5%) |
Stunted |
12(30%) |
35(33%) |
43(37.7%) |
Severely stunted |
13(32.5%) |
48(45.3%) |
25(21.9%) |
Underweight |
At possible risk |
8(20%) |
10(9.4%) |
4(3.5%) |
Normal |
14(35%) |
46(43.4%) |
51(44.7%) |
Underweight |
7(17.5%) |
25(23.6%) |
39(34.2%) |
Severely underweight |
11(27.5%) |
25(23.6%) |
20(17.5%) |
Wasting |
Obese |
2(5%) |
2(1.9%) |
1(0.9%) |
Overweight |
3(7.5%) |
3(2.8%) |
2(1.8%) |
Possible risk of overweight |
11(27.5%) |
28(26.4%) |
22(19.3%) |
Normal |
13(32.5%) |
52(49.1%) |
70(61.4%) |
Wasted |
4(10%) |
12(11.3%) |
15(13.2%) |
Severely wasted |
7(17.5%) |
9(8.5%) |
4(3.5%) |
Discussion:
The present study signified a high prevalence of malnutrition among the under-five children of migrant population. Migrants of Udupi District are people who have moved from different states of our country and different districts of Karnataka to Udupi District in search of work for their daily living and who belong to low income group. They live mainly in the tented houses. The seeking of health care has not become a priority for them. The children are left with the neighbors when the parents go for work. The findings has shown a wide gap to achieve a healthy nutrition status which needs to be addressed.
The findings of this study was supported by a cross-sectional study conducted among 563 children on the prevalence of underweight among under-five children in rural area of Kancheepuram District in Tamil Nadu, India, which showed an estimated prevalence of 52.9%. According to IAP classification, 47.1% were mildly malnourished, and 30.9% were moderately malnourished. About 7% were severely malnourished. (7)
A cross sectional study on the prevalence and risk factors of under nutrition among 133 under five children in a rural community surveyed showed that 84 (63.16%) children were undernourished. There was a higher frequency of grade I malnutrition with an estimation of 42.8%, while the occurrence of grade II malnutrition was 18.7% and grade III malnutrition was 1.5%. (8) The findings of the present study was supported by another epidemiological study conducted by Dhone, Chitnis, Bhawalkar, and Jadhav in 2012 on under nutrition among under five children in an urban slum area. Out of 319 children, 208 (65.2%) children were undernourished. (9) A study on the prevalence of malnutrition among 256 children in rural Karnataka, South India was conducted in the villages of Bengaluru. The results showed that 70% children were malnourished. High prevalence of wasting was seen in 60.4% children while stunting was seen in 38.6% children. (10)
The present study also gives age-wise prevalence of different age groups of under-five children. This can provide a base for the health care professionals to target the under privileged to plan cost effective interventions for the under-five children of the migrant population. Health seeking behavior of the families could be assessed and the efforts can be made to enhance the knowledge of the migrant group about the governmental programmes which are available. Comprehensive nutrition plans can be developed and implemented among the migrant group to enhance their knowledge, practice and healthy living.
Conclusion:
Children of today are inhabitants of tomorrow. Hence, refining the nutritional status of children becomes extremely important. The first six years establish the most crucial period in life, when the fundamentals are laid for cognitive, social and emotional language, physical, motor development and cumulative lifelong learning. The young child under three years of age is most defenceless to the vicious cycles of malnutrition, disease, infection and resultant disability, all of which impact the present condition. India is one among many countries where child malnutrition is a major underlying cause for child mortality in India. Therefore, ruling out the nutritional status of high risk group would help the health care delivery system and the policy makers to identify the root cause for malnutrition and provide intervention for the suppression of malnutrition.
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