Introduction
According
to WHO slogan “Healthy child is a nation wealth”.
India being a third world country contains 40% of
the undernourished children in the world.
Undernutrition occurs mostly because of
insufficient access to adequate food, marriage at
a younger age and early births of children,
thoughtful weaklings, delivery horrors, tallness
and weight of babies, breastfeeding support or
other poverty-related matters (1). The problem of
malnutrition is most pronounced in central India,
including states such as Chhattisgarh and Madhya
Pradesh (2) (Dakshayani and Gangadhar, 2015). A
number of recent studies have shown high levels of
malnutrition in children under the age of five
years in India (3). In pursuance, the Government
of India started on October 2, 1975, to implement
a comprehensive Integrated Child Development
Service (ICDS) scheme in all territories and
States as welfare programmes for children for
better health. The initiative helps control
malnutrition and childhood morbidity, as well as
the generation of mortality among children under 6
years old, turning in this way into the largest
development program for early childhood growth
(4). The Aanganwadi -A word derived from Hindi
which is the language spoken by majority of the
population – it has a enormous in every house
meaning Angan is courtyard and Wadi means to sit;
here children come, have supplementary food
/pre-school education plays and goes back home
(5). One of the services provided by Anganwadi
centres (ADCs) is that they immunize children,
conduct health check-ups and referral services,
and provide health and nutrition education for the
well-being of the children (6). Anganwadi center
is a childcare facility in village level, managed
by Anganwadi (meaning courtyard shelter) worker
who trained to deliver nutrition and other related
service (7). This worker is a community-based,
frontline voluntary worker of the ICDS program
(8). She plays a crucial role in supporting
families, particularly mothers in providing proper
health and nutrition-care capabilities, as well as
timely detection and treatment of diseases (9). In
remote areas the program is dedicated to the
poorest strata while delivering services at local
grass root level with full beneficiaries’
involvement (10).
Good nutrition
provides children with several immeasurable
benefits such as the acquisition of speech,
critical thinking, learning, and relationship
building and adaptation skills. Growth and
development is something that has existed since
conception and will continue until full maturity.
This leads to low nutrition in children which
leads to diseases and eventually malnutrition.
This may lead to irreversible physical and mental
damage (11). There is a range of factors, both
internal and external factors which determines the
nutritional status of children. Internal factors
include such things as age, sex, nutrition,
behavior, physical activity and diseases, whereas
the external factors are food supply, cultural
practices and socio economic factors (12). The
objective of this study is to assess the impact of
Anganwadi centres (under ICDS) on the nutritional
status of the children involved in the program.
Material and Methods
Study
Overview
The study utilized a
cross-sectional method, involving 780 children
aged 2-5 years from 50 anganwadi centres in
Bilaspur, Chhattisgarh, India. A random sample
method was used to get the data.
Data
Collection
Anthropometric
measurements, socio-demographic profiles,
supplementary food, and other basic facilities
provided in ICDS Centres were gathered from
anganwadi workers. The age of the children was
recorded from their “Jaccha-Baccha” cards. An
interview schedule was used as the primary method
for data collection, which was conducted after
obtaining necessary approvals from relevant
authorities.
Evaluation
of the Incidence of Undernutrition
The prevalence of
undernutrition among children in the study was
evaluated applying the WHO (2006) classification
of Z-Scores (13). Among the causes of
undernutrition three main causes were found. The
first one is:
- Stunting (low height-for-age) – This implies a
‘chronic’ type of malnutrition, which results
from deficient caloric intake affecting the
child’s cognitive and physical development.
- Underweight (low weight-for-age) – It refers
to under nutrition as a consequence of
malnutrition that pertains to acute conditions
and greatly increases the chance of death of
children.
- Wasting (BMI-for-age) - This refers to a state
of short-term deficiency disease that is due
mainly to the infection with or malnutrition
caused by other illnesses (14).
Using the cap for
BMI of a population as quoted above Wilson (1995)
provides the following classification of
prevalence if BMI is lower than 18.5kg/m². (15)
- Low prevalence - 5-9%
- Medium - 10-19%
- High - 20-39%
- Very high - 40%
Statistical
Analysis
All statistical
analyses were performed using the Statistical
Package for Social Sciences (SPSS/PC - Version
23), including percentages, frequency analysis,
chi-square tests, and regression analyses. A
statistical significance level was established at
(p < 0.05). Microsoft Office Excel was utilized
for graphical representations of the data.
Sample Size
Calculation
The estimated sample
size of the studied children was calculated using
the formula: n = (z2pq)/d2 (16)
Results
Table 1 summarizes
the descriptive analysis and mean comparisons of
anthropometric data reported and total number of
children in the study. The findings reveal the
presence of a significant positive sex difference
in mean weight for 24 months age children at
t-value 0.022 (df = 148; p = 0.009). Moreover,
there was a greater variation in height (t-value =
-0.427; df = 148; p = 0.001) and BMI (t-value =
0.512; df= 148; p = 0.051) for the same age group.
At 36 months of age also mean weight showed
significant positive difference about sex, with
weight with t-value of 0.896 (df= 187; p= 0.003).
The height difference was statistically almost
significant (t-value = -1.592; df = 187; p =
0.050) and for BMI a statistically significant
difference was recorded (t-value = 0.794; df =187;
p = 0.012).
Table 1: Comparative statistics and
gender specific mean difference in
anthropometric variables among the studied
children
|
Age
|
24 Months
|
36 Months
|
48 Months
|
60 Months
|
Variables
|
Boys (75)
|
Girls (75)
|
T-Test
|
Boys (99)
|
Girls (90)
|
T-Test
|
Boys (125)
|
Girls (113)
|
T-Test
|
Boys (89)
|
Girls (114)
|
T-Test
|
Weight (kg)
|
9.57
|
9.45
|
0.022*
|
10.87
|
11.04
|
0.896*
|
12.98
|
12.61
|
1.743
|
14.46
|
14.26
|
0.765
|
0.93
|
1.25
|
1.13
|
1.49
|
1.65
|
1.65
|
1.967
|
1.773
|
Height (cm)
|
81.13
|
81.48
|
-0.427*
|
85.77
|
86.89
|
-1.592*;
|
94.35
|
94.5
|
-0.187
|
100.01
|
100.1
|
-0.09
|
3.86
|
5.6
|
4.47
|
5.22
|
6.23
|
5.85
|
6.89
|
6.78
|
BMI (kg/m2)
|
14.5
|
14.4
|
0.512*
|
14.76
|
14.6
|
0.794*;
|
14.5
|
14.1
|
2.429
|
14.47
|
14.28
|
0.776
|
1.36
|
1.63
|
1.17
|
1.47
|
1.26
|
1.54
|
1.55
|
1.8
|
Significance At
*=P<0.05, **=P<0.01, ***=P<0.001 |
Table 2 shows the
age and sex-specific prevalence of stunting,
underweight, and wasting among the children under
study. More than two-fifths of the total 780
children were stunted (41.3%). The highest levels
of stunting were seen in 36 months boys (35.3%)
and girls (25.5%) and in the least number of
months for 24 boys (14.6%) and girls (12.0%). In
moderate stunting, it was most marked for 24
months boys (41.3%) and 48 months girls (30.7%),
while it was least marked for 36 months boys
(28.8%) and girls (13.3%). The table shows
significant relationship between Boys to Girls at
ages 36 months (χ2=12.352; df=2;p=0.002 and 48
months (χ2=4.381;df=2;p=0.021 for height-for-age.
Table 2: Prevalence of stunting,
underweight and wasting age and sex wise
relationship among studied children
|
Age (Months)
|
Sex (N)
|
Stunting Status
|
Chi Square
(X2)
|
Severely Stunted
|
Moderately Stunted
|
Normal
|
N
|
%
|
N
|
%
|
N
|
%
|
24
|
Boys (75)
|
11
|
14.6
|
31
|
41.3
|
34
|
45.3
|
2.580
|
Girls (75)
|
09
|
12.0
|
22
|
29.3
|
43
|
57.3
|
36
|
Boys (99)
|
35
|
35.3
|
28
|
28.8
|
36
|
36.3
|
12.352**
|
Girls (90)
|
23
|
25.5
|
12
|
13.3
|
55
|
61.1
|
48
|
Boys (125)
|
31
|
24.8
|
32
|
25.6
|
62
|
49.6
|
4.381**
|
Girls (113)
|
18
|
15.9
|
35
|
30.7
|
60
|
53.0
|
60
|
Boys (89)
|
19
|
21.3
|
29
|
32.3
|
41
|
46.0
|
2.466
|
Girls (114)
|
16
|
14.0
|
29
|
25.4
|
69
|
60.5
|
Age (Months)
|
Sex (N)
|
Underweight Status
|
Chi Square
(X2)
|
Severely Underweight
|
Moderately Underweight
|
Normal
|
N
|
%
|
N
|
%
|
N
|
%
|
24
|
Boys (75)
|
13
|
17.3
|
29
|
38.6
|
33
|
44
|
2.736
|
Girls (75)
|
8
|
10.6
|
26
|
34.6
|
41
|
54.6
|
36
|
Boys (99)
|
21
|
21.2
|
50
|
50.5
|
28
|
28.8
|
6.185*
|
Girls (90)
|
10
|
11.1
|
41
|
45.5
|
39
|
43.3
|
48
|
Boys (125)
|
15
|
12.0
|
31
|
24.8
|
79
|
63.3
|
0.594
|
Girls (113)
|
19
|
16.8
|
32
|
28.3
|
66
|
58.4
|
60
|
Boys (89)
|
10
|
11.3
|
23
|
25.8
|
56
|
62.9
|
7.892
|
Girls (114)
|
09
|
7.8
|
27
|
23.6
|
78
|
67.5
|
Age (Months)
|
Sex (N)
|
Wasting Status
|
Chi Square (X2)
|
Severely Wasted
|
Moderately Wasted
|
Normal
|
Overweight
|
N
|
%
|
N
|
%
|
N
|
%
|
N
|
%
|
|
24
|
Boys (75)
|
13
|
17.3
|
29
|
38.6
|
32
|
41.3
|
1
|
1.3
|
14.056*
|
Girls (75)
|
10
|
13.3
|
27
|
36.0
|
33
|
44.0
|
5
|
6.6
|
36
|
Boys (99)
|
19
|
21.2
|
31
|
31.3
|
43
|
43.3
|
4
|
4.0
|
23.328*
|
Girls (90)
|
4
|
4.4
|
14
|
15.5
|
64
|
71.1
|
8
|
8.8
|
48
|
Boys (125)
|
12
|
9.6
|
14
|
11.2
|
92
|
73.7
|
7
|
5.6
|
10.102*
|
Girls (113)
|
5
|
4.4
|
6
|
5.3
|
97
|
85.6
|
5
|
4.2
|
60
|
Boys (89)
|
7
|
7.8
|
7
|
7.8
|
69
|
77.5
|
6
|
6.7
|
7.169
|
Girls (114)
|
4
|
3.5
|
20
|
17.5
|
86
|
75.6
|
4
|
3.5
|
Significance At
*=P<0.05, **=P<0.01, ***=P<0.001. |
Table 3 reveals that
out of a total of 780 children, 46.3% were
underweight. The highest prevalence of severe
underweight was noted in boys at months (21.2%)
and girls at months (16.8%). Conversely, the
lowest rates were noted in boys at months (12.0%)
and girls at months (7.8%). Moderately underweight
children were predominantly boys at months (50.5%)
and girls at months (45.5%), while the lowest
prevalence was among boys at months (24.8%) and
girls at months (23.6%). There is a significant
relationship between boys and girls at age 36
concerning their weight-for-age, with a chi-square
value of (Χ2=6.18, df =2, p=0.045).
Among the 780
children, 28.8% were found to be wasted. The most
common severe wasting was in boys at age 36 months
(21.2%) and girls at age 24 months (13.3%), while
it is least likely in boys at age 60 months (7.8%)
and girls at age 60 months (3.5%). The highest
prevalence of moderate wasting is in boys at age
24 months (38.6%) and girls at age 24 months
(36.0%) and the lowest in boys at age 60 months
(7.8%) and girls at age 48 months (5.3%). The
prevalence of overweight was highest at age 60
months (6.7%) for boys and at age 36 months (8.8%)
for girls, while the lowest prevalence was noted
in boys at age 24 months (1.3%) and in girls at
age 60 months (3.5%). At ages 24 months (Χ2=14.056,
df=5, p=0.026), 36 months (Χ2=23.328,
df=4, p=0.000), and 48 months (Χ2=10.102,
df=2, p=0.034), there were significant
relationships between BMI-for-age of boys and
girls.
Table 3 also
illustrates the relationship between receiving
supplementary food through the Integrated Child
Development Services (ICDS) and the nutritional
status of children in terms of weight-for-age,
height-for-age, and BMI-for-age. Children not
receiving regular supplementary food showed higher
rates of severe stunting (32.1%) compared to
moderately stunted children (23.9%). Approximately
20.7% of the children were underweight due to
irregular consumption of supplementary food, with
around 16.4% and 19.6% identified as severely and
moderately wasted, respectively. Many parents work
as wage laborers or cultivators, leading children
to accompany them instead of attending the
anganwadi. The data reveals significant
relationships between receiving supplementary food
and height-for-age (x2= 17.57; df=2;
p=0.01), weight-for-age (x2= 20.98;
df=2; p=0.000), and BMI-for-age (x2=
27.90; df=5; p=0.000).
Likewise in table 3
below we see the dependency of supplemental food
from Integrated Child Development Services (ICDS)
and the weight/height-for-age and BMI-for-age of
the children. Children who do not receive
supplementary food regularly: children 32.1% are
under severe stunting. Overall 20.7 % of the
children were moderately stunted (23.9%).
Size-wise, percentage of children was underweight
in terms of normal weight for their age (because
of irregular consumption of supplementary food).
Whereas, about children were severely wasted 16.4%
and % children were moderately 19.6% (See Table
3).The data shows significant relationships
between supplementary food and height-for-age (Χ2=
17.57; df=2;p=0.01), weight-for-age (Χ2=
20.98; df=2; p=0.000), and BMI-for-age (Χ2=
27.90; df=5; p=0.000).
Table 3: Relationship of receiving
supplementary food by ICDS children with
weight-for-age, height-forge and
BMI-for-age among the studied
|
Category
|
Height-For-Age
|
Chi Square
|
Severe Stunting N %
|
Moderate Stunting N %
|
Normal N %
|
Yes
|
100
|
19.0
|
170
|
32.3
|
255
|
48.5
|
17.57*
|
Not Regularly
|
82
|
32.1
|
61
|
23.9
|
112
|
43.9
|
Category
|
Weight-For-Age
|
Chi Square
|
Severe Underweight N %
|
Moderate Underweight N %
|
Normal N %
|
Yes
|
48
|
9.1
|
217
|
41.3
|
260
|
49.5
|
20.98**
|
Not Regularly
|
53
|
20.7
|
97
|
38.0
|
105
|
41.1
|
|
BMI-For Age
|
Category
|
Severe Wasting N %
|
Moderate Wasting N %
|
Normal N %
|
Overweight N %
|
Obese N %
|
Fischer Exact
|
Yes
|
41
|
7.8
|
63
|
12.0
|
391
|
74.4
|
29
|
5.5
|
1
|
0.1
|
27.903***
|
Not Regularly
|
42
|
16.4
|
50
|
19.6
|
152
|
59.6
|
10
|
3.9
|
1
|
0.3
|
Significance at
*=P<0.05, **=P<0.01, ***=P<0.001 |
Discussion
The findings clearly
show that the parents’ job and subsequently their
food instability of the family due to the nature
of their work are the socio-economic factors that
really affect the nutritional outcomes of the
children. Programs that guarantee the constant
provision of supplementary food programs can solve
these issues thus enhancing children's overall
health. At the age of 24 months, boys had a
significantly mean weight difference compared to
girls, and at the age of 36 months, boys again
were the ones who had a positive difference in
mean weight. The age group of 36 months had the
difference that was almost significant at the
height. The highest proportion of stunted growth
was in 36-month boys (35.3%) and girls (25.5%).
The data showed that
children lacking the supplementation food had a
higher rate of severe stunting (32.1%) and
underweight (20.7%). The highest prevalence of
underweight among both boys (21.2%) and girls
(16.8%) is observed at 36 months of age. The
highest prevalence of severe wasting for boys
(21.2%) are noticed at 36 months of age and for
girls (13.3%) is at 24 months of age.
From the analysis on
anthropometric status it can be conceived that
there exist significant differences in nutritional
status between the children when classified
according to their sex as well as with reference
to their age, thus stressing the need for sex-age
specific intervention strategies. Boys have got
higher mean weight than girls at 24 and 36 months
of age which are statistically significant
(p<0.05). Prevalence levels of stunting among
both boys and girls are a cause for concern but it
is more so in case when supplementary food in form
of ICDS is not received.
Conclusion
The present study
brings out alarming levels of malnutrition in the
study children with 48.7% stunting, 46.3%
underweight and 28.8% wasting evident in the
studied population depicting that undernutrition
continues to be a serious problem.9 Regular
nutrition surveillance is required and
vulnerability oriented especially for those
belonging to the poorest of the poor and severe
forms of malnutrition should form the base for
supplementation as far as children attending
anganwadis are concerned. There is a need for
locally available diet feeding programmes being
linked to ICDS using locally available low cost
food stuffs should be given priority on need basis
to preponderantly affected children while who
suffer from moderate grades of undernutrition
attend MTCs along with preschool non-malnourished
beneficiaries. Supervisors and ICDS functionaries
should be adequately trained regarding its best
use, care etc., Delivery system for higher
quantity as well as quality food must strengthened
also ensure higher responsiveness in management of
any adverse incident following immunization by
medical authorities among others so that prompt
care may be provided without making any loss of
time at least two days hazards can occur due
inability to reach health facility due lack /poor
road connectivity during September−April−May
months characterized by rainy seasons being
common.
Conflicting Interests: The authors declared no potential
conflicts of interest.
Funding sources: None
Acknowledgements:
The authors would like to thank all of the
research participants for their tremendous support
during the study. Authors are also grateful to GGV
for logistical support and Financial assistance
has been received by MG from (UGC Letter No.:
688(NET-JUNE 2014) was highly acknowledged.
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