Introduction

Under 5 years children are generally considered as nutritionally vulnerable segments of any Nation. Malnutrition during childhood can also affect growth potential and the risk of morbidity and mortality in later years of life (1). In developing countries like India, under nutrition is one of the greatest problems among children. According to the Global Hunger Index 2023 (2), India ranks 111^th out of the 125 countries. With a score of 28.7, India has reported a serious level of hunger index. Chronic under nutrition in childhood is linked to slower cognitive development and serious health impairments later in life that reduce the quality of life of individuals (3). Undernourished children are at higher risk of death from infectious diseases due to poor immune response and host defenses (4). It has been well established that under nutrition in childhood is the leading cause of high child mortality rates in developing countries (5).

Anthropometry is a widely accepted, low-cost technology for defining the nutritional status of children (6). Recently, the World Health Organization (WHO) developed age- and sex-specific mid-upper arm circumference (MUAC) cut-off points to determine child under nutrition (7). In community-based studies, mid-upper arm circumference (MUAC) appears to be a superior predictor of childhood under nutrition than many other anthropometric indicators (6). The mid-upper arm circumference (MUAC) is an important measurement that is often used for the assessment among preschool children.

ICDS (Integrated Child Development Services) scheme represents one of the largest and most unique programs in the Globe implemented for early childhood development in India. The scheme was launched in the year 1975 (8). The package of services provided by the ICDS scheme includes supplementary nutrition, immunization, health check-ups, referral services, nutrition and health education, and preschool education (8). Children below six years are the beneficiaries of this scheme.

However, few amounts of literature exist regarding the prevalence of under nutrition based on MUAC among preschool children in West Bengal (9-13), in India (14-17) and outside of India (4, 18-24). After an extensive literature survey, it has been found that, hitherto there is no work done by any researcher having a similar kind of objectives. So, this study aimed to evaluate the nutritional status of children aged 2-5 years using mid-upper arm circumference (MUAC) cut-off values. Following the World Health Organization (7) age and sex-specific cut-off points are used to assess the nutritional status of ICDS children of Jalpaiguri, West Bengal, India.

Material and Methods

A cross-sectional study was carried out in randomly selected 44 ICDS centers from January 2022 to October 2023 in Maynaguri block, Jalpaiguri District, West Bengal, India. Children aged 24 – 60 months (Boys - 499 and Girls - 522) from three (Rajbanshi, Nama Shudra, Nashya Seikh) ethnicities were considered for this study. Date of birth and ethnicity identified by polio vaccination card provided by ICDS workers.

The anthropometric measurement of MUAC was measured by the author (AB) on each subject following the standard technique (25). The MUAC was measured using a non-stretchable plastic measuring tape, to the nearest 1 mm. The MUAC is the circumference of the left upper arm, measured at the mid-point between the tip of the shoulder and the tip of the elbow (acromion and the olecranon process). Small marks were made at the identified points. A tape was placed over those two points, and the midpoint between them was marked. Then the tape was placed around the arm in such a manner that it was touching the skin, but not compressing the soft tissues

Normal children had z-scores between -2SD and +2SD. Children with z-score < -2SD were classified as undernourished. Children having z-scores between – 3SD and -2SD were classified as moderately undernourished and those having < -3SD as severely undernourished.

Age and sex specific mean and standard deviation of Mid upper arm circumference was computed. Student’s t-test was performed to test the sex difference in MUAC. Analysis of variance (ANOVA) was done to analyse the significant age differences in the mean values of MUAC. The Chi-square (χ2) test was also performed to observe the significant difference in the prevalence of under nutrition with various factors. Statistical significance was set at P<0.05. All types of statistical analysis were done on SPSS V 18.

Results

A total of 1021 children, 48.87 % boys and 51.13 % girls, aged 24-60 months old were measured in the present study. Table 1 presents the percentage distribution of the studied children, age and sex-specific mean (SD) Mid-Upper Arm Circumference (MUAC) of the sample. The mean MUAC of boys was higher in every age group except for 24 - 30 months and 37 - 42 months. Age combined mean MUAC value among boys was 14.21 (1.33) cm was greater than girls 14.08 cm (1.27). Significant sex difference in mean MUAC was not found at any age group. One-way ANOVA reveals the mean MUAC increased with age. Significant age differences were found among both sexes for boys (F = 14.777; p< 0.001) and girls (9.465; p< 0.001).

Table 2 describes the age and sex-specific prevalence (%) of under nutrition based on MUAC among the studied preschool children. The overall percentage of moderate and severe undernourished girls (moderate – 25.67 %; severe – 5.75 %) is higher than the boys (moderate – 24.85 %; severe – 5.41%). The highest percentage of moderate under nutrition was found in the age group 24-30 months among boys (30.23 %) and 49-54 months among girls (30.85 %). Whereas, the highest percentage of severe under nutrition was found in the age group 24-30 months among boys (12.79 %) and 43-48 months among girls (13.33 %).

Table 3 shows the sex-combined age-specific under nutrition based on the MUAC cut-off value recommended by WHO 2007. The highest percentage of under nutrition was found in the age group 43-48 months (40.51 %) of children and the lowest percentage of under nutrition was found at 37-42 (24.70%) months of children. Chi-square analysis (χ2-13.345) shows a statistically significant relationship of under nutrition with age groups. Results show that female has a higher percentage of under nutrition 31.42 % than males 30.26 % but there is no statistically significant relationship between under nutrition with gender.

Table 4 shows the association between socio-economic and socio-demographic variables prevalence of mid-upper arm circumference-based under nutrition. Birth weight below 2500 gm, children from Nashyaseikh community, birth order 3^rd and above, number of siblings 2, open type of bath place, crop residue as a fuel for cooking, monthly income level Rs. <7501, maternal BMI level <18.5 having the highest prevalence of undernourished children. The χ2 analysis shows that there were several factors such as birth weight, ethnicity, birth order, number of siblings, bath place, fuel of cooking, income level and Asia-specific maternal BMI level were statistically significant with the prevalence of MUAC-based under nutrition.

Discussion

Childhood malnutrition is an important health problem in developing countries like India. The mean age of children in our study was 42.48 (10.88) months for boys and 43.14 (10.62) months for girls. In the present study, the overall prevalence of under nutrition was 30.85 %. The present study documented that the overall prevalence of under nutrition among girls (31.42 %) is higher than that of boys (30.26 %), with few similar findings reported by several scholars (11,17,24) and contrary to the previous findings (4,10,13). The percentage of moderate under nutrition is higher than severe under nutrition among both genders. The overall age and sex combined prevalence of under nutrition was 30.85 % of which 25.27 % and 5.58 % of children were moderately and severely undernourished, moderate under nutrition was found higher than severe undernourished similar to the previous studies (4,9,10,13,24).

In our study, we found that the nutritional condition of ICDS beneficiaries was serious with high rates of under nutrition. The highest percentage of under nutrition was found among Nashya Seikh children, Rajbanshi children and Nama Shudra children respectively. We suggest that more studies dealing with under nutrition based on MUAC should be undertaken among children of different ethnicities. It was noticed that age, sex, and ethnicity play a significant role in determining the MUAC (4,9,10,13,24,26). Measurement of MUAC is a quick and reliable method for screening children to identify those who are seriously malnourished (10,13). The application of MUAC appears to be a better predictor for the assessment of childhood under nutrition than many other anthropometric indicators (11). The important finding of the study is the significant association of age group and ethnicity found with under nutrition in the present study similar to a study previous study (26).

Fig 1: Comparison of national and international studies on the prevalence of under nutrition based on MUAC

Fig 1. Shows comparison with international studies reveals that the prevalence of under nutrition in the present study is higher than the children of Cameroon (21.60 %), Malaysia (26.80 %), Nepal (17 %), Nigeria (25.70 %) and Pakistan (18.30 %). In the context of India, the present study reported a higher prevalence of under nutrition than the children of Midnapur (18.96 %), South 24 Pargana (25.61 %) of West Bengal, Odisha (29.10 %), Bihar (25 %). Whereas higher prevalence was found than the present study among children of Hooghly (64.50 %), Nadia (35.11 %) North 24 Pargana (69.80 %) of West Bengal, Chhattisgarh (45.20 %), Punjab (38.52 %) in India. International studies from Kenya (47 %), Bangladesh (68.30 %) and Pakistan (76 %) show a higher prevalence of under nutrition than the present study.

Several socio-economic and socio-demographic factors are strongly associated with the prevalence of MUAC-based under nutrition. Studies reported that girls are more affected by under nutrition than boys in rural areas(18,27). Birth Weight below 2500 grams has a significant relationship with under nutrition(28-30). Different ethnic backgrounds have an impact on child under nutrition similar to the previous studies(31,32). Few studies reported that birth order is highly associated with under nutrition(18,27,33,34). A higher number of siblings is also a reason behind child under nutrition(35,36). There is a significantly greater association of under nutrition with children belonging to lower-income groups (27,38,39). Maternal BMI level has an impact on child under nutrition similar to previous finding (37).

The present study reveals that birth weight, ethnicity, birth order, number of siblings, bath place, fuel of cooking, income level and Asia-specific maternal BMI level were important determinants of under nutrition among children.

Conclusion

Assessment of nutritional status by Mid Upper Arm Circumference is a simple, reliable, easy-to-perform, inexpensive, and conventional method for preschool children. Furthermore, research on MUAC representing communities with a larger sample size is essential to monitor health status. Mid-upper arm circumference-based under nutrition becomes more effective for comparing the age and sex-specific regional and ethnic differences of children. Thus regular monitoring of health scenarios among ICDS beneficiaries by MUAC may be helpful to ameliorate the nutritional deficiencies among preschool children. Therefore, the Government should implement the policy of regular surveillance in the form of nutritional surveys and may also utilize the socio-economic and socio-demographic variables as determining factors of child malnutrition.

Acknowledgement

The researchers would like to thank all the concerned ICDS workers and also the parents of the subjects for their cooperation. We thank those children who participated in this research work. Special thanks to the CDPO of Maynaguri for his support. However, the authors assume full responsibility for all data and content presented. Arindam Biswas recipient of a Senior Research Fellowship (SRF-UGC-NET) by the Government of India.

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