Nutritional assessment of under ve children in a rural belt of southern Rajasthan, India

Nutritional assessment of under ve children in a rural belt of southern Rajasthan, India Kumar L. D.1, Mangal N.2*, Varghese K A.3, Chand Salvi T.4, Prakash Salvi P.5, Singh Udawat V.6 DOI: https://doi.org/10.17511/ijphr.2019.i6.03 1 Dilip Kumar L., Associate Professor, Department of Community Medicine, Pacific Institute of Medical Sciences, Udaipur, Rajasthan, India. 2* Nitesh Mangal, Assistant Professor, Department of Community Medicine, Pacific Institute of Medical Sciences, Udaipur, Rajasthan, India. 3 Varghese K A, Statistician, Department of Community Medicine, Pacific Institute of Medical Sciences, Udaipur, Rajasthan, India. 4 Tara Chand Salvi, Medical Social Worker, Department of Community Medicine, Pacific Institute of Medical Sciences, Udaipur, Rajasthan, India. 5 Prem Prakash Salvi, Medical Social Worker, Department of Community Medicine, Pacific Institute of Medical Sciences, Udaipur, Rajasthan, India. 6 Vijaypal Singh Udawat, Health Inspector, Department of Community Medicine, Pacific Institute of Medical Sciences, Udaipur, Rajasthan, India.


Introduction
There has been paradigm shift in priorities of food sector from food self-sufficiency at national level to food security at household level and nutritional security at individual level in India ever since our independence. Eradication of malnutrition of children has been an agenda of topmost priority at global and national level. The WHO guidelines to assess malnutrition in terms of weight for age (underweight), height for age (stunting)and weight for height (wasting) made it possible to quantify the extent of malnutrition at country, state, regional and community level [4].
The National Family Health Survey-4 (2015- 16) reported that 35 The increase in production of food at national level does not ensure equitable distribution of food commodities across states and even between communities in the same state. There is a wide gap between the rural and urban pattern of consumption of food items.
Children under five form a vulnerable group of our population. Children (0-4) constitute about 9.30% of Indian population and 10.70% of Rajasthan's population as per 2011 census. Proper nutritional intake at this age not only keeps them healthy but also makes them fit for work as they grow. Hence the assessment of nutritional intake of children in rural areas in general and tribal areas in particular assumes great significance.
The reasons behind underweight, stunting and wasting of under five children are generally different. Stunting which is linear growth retardation is attributable to adverse economic conditions, poor sanitation and its associated effect with poor intake of energy sources. Similarly, low weight for age in children which is also termed as underweight problems in children is attributable to repeated illness and starvation.
The low weight for height which is termed as wasting is due to recent or current illness and its adverse consequences to gain weight by children. In general stunting, underweight and wasting which are interlaced to a great extent are commonly used by individual and institutional researchers to assess the magnitude of nutritional imbalances in children in different regions [10].
Stunting and Wasting are the two main nutritional indicators according to the ICMR scientists. Wasting as a measure of malnutrition has the distinct advantage to overcome the errors in reported age of children which depends on the stunting and underweight as indictors of malnutrition [11]. The widely used indicator to assess the disproportionate growth is BMI which is the ratio of weight in kg to height in meter square.

Objectives
The objectives of the present study are;

Type of study:
A cross-sectional descriptive study. Also the food intake including liquid and solid taken by the children above 24 months of age was recorded in the questionnaire using dietary recall method for the previous day of interview of each child.
The weight in kilograms was taken with the weighing scale to assess their growth and nutritional status using the standard technique to the nearest 0.5 kg. Also the height was taken of selected children using stadiometer / infantometer to the nearest 0.1cm using the standard technique [12].
The length of children up to two years was measured and beyond that their height was taken to work out BMI. With release of WHO child growth standards in 2006, the trajectory of malnutrition can be studied in terms of weight for age (underweight), height for age (stunting) and weight for height The indices such as weight for age to assess underweight, height/length for age to assess stunting and weight for height to assess wasting problems were used to classify the malnutrition.

Results
In   It is worth mentioning that there has not been any significant gender effect in relative share of children having moderately stunting problem.
The shares of normal children according to stunting in tribal and non-tribal groups have been statistically significant and also the shares for moderately stunting problems between these two social classes. However, the shares of severely stunting classes did not show any significant differences (Table 2).  Remarkably, the hospital delivery was found a nondeciding factor on nutritional level of under five children as the incentive for hospital delivery seems to have no significant impact on post-delivery growth and development of children (Table 4).   The energy intake of the children between 24 months and 60months was found to increase with increase in age for both tribal and non-tribal children. The average calorie intake of male children was more than that of female children for tribal and non-tribal communities. The combined calorie intake of non-tribal children was higher over that of tribal children in the age group of 24 to 60 months.
The relatively high values of Coefficient of Variation in calorie intake for tribal children compared to nontribal children and also the increase in CV values of calorie intake with increase in age is a matter of concern. In both the classes the CV values of calorie intake for girls were higher over boys (Table 5).

Discussion
Nutritional imbalance of children is a global problem of varying magnitude across different countries as well as between urban and rural regions of the same country. The National Nutritional Strategy reported that the problem of under nutrition of under five children is a grave problem in India despite improvement over the years [13].
As per NFHS-3 and NFHS-4 the prevalence of stunting has declined from 48.00% to 38.40% and that for underweight has declined from 42.5% to 35.7% while that of wasting has marginally gone up from 19.8% to 21.00% [14]. As per the National Nutrition Mission the targets of child stunting is to reduce the prevalence up to 25% by 2022 and also to 2 percentage point reduction in prevalence annually in child underweight from 2017 to 2022 [15,16].
Also the WHO and UNICEF 2030 targets to achieve prevalence of child wasting to less than 3% by 2030 [17]. It is felt that concerted efforts are needed to overcome this grave situation. Underweight among children is an indicator of malnutrition posing more risk for morbidity and mortality in children. In the present study, the prevalence of underweight among tribal children was 40.12% and that of nontribal was 28.82%.

In a study conducted by Stanly AM et al (2015) [18]
found the prevalence of underweight among 385 children residing in the rural area of Chennai was 42.9%. In another study done by Yadav SS (2016) [19] et al revealed that the prevalence of underweight was 41.3% in a rural area of Haryana.
Similar findings were observed by other studies conducted by Sukla P et al [20] at Chhattisgarh, Mamulwar MS et al [21] in Pune and Islam S et al [22] in a tribal area of Dibrugarh district of Assam which found the prevalence rate of underweight between 29.00% to 36.00% respectively. While in contrast, the study done by Radhamani KV et al [23] showed the prevalence rate of underweight as 14.60% at North Kerala. The higher prevalence of underweight in the present study could be due to low literacy level of the mothers.
The stunting (height for age) is another indicator widely used to assess level of malnutrition among children. In other words, stunting is attributable to long term deprivation of required nutrition for growth and development of children. The prevalence of stunting problem among tribal and non-tribal children in the present study was 35.62% and 26.78% respectively.
The prevalence of stunting was reported as 31.6% among 224 under five children in a rural area of Pondicherry [24]. knowledge were also important to determine the child's nutritional status [30]. Of these mothers education was the key element considered in the present study.
In the present study, various factors such as mix farming, mother's education and household income were found to be significantly associated with undernutrition. Similar findings were reported in a study conducted by Laxmikant Purohit et al [31] in Maharashtra and Patel P [32] in Gujarat.
Mother's educational status was significantly associated with under-nutrition in the study done at Kalaburagi District of Karnataka [25]. Various studies done by Tiwari SR et al [33] in Mumbai, Sarkar S et al [34] in West Bengal and Upadhyay et al [35] in Puducherry showed that household income was significantly associated with malnutrition.
Balanced growth of under five children implies appropriate weight and height for age and normal Body Mass Index (BMI). Maintaining the same is a tedious task, the onus of which lies on mothers.
Development of a balanced diet schedule for under five children with locally available food stuff and educating mothers for its adherence can solve the problem of malnutrition (underweight, stunting and wasting) to a great extent.
Here it is to be pointed out that a large number of centrally funded schemes including the Poshan Abiyaan which was implemented in the year 2018 are in vogue in various states of the country. The current level of malnutrition at national level as well in the study area is a matter of serious consideration.
However the current scenario may change in the near future with the implementation of Poshan Abhiyaan keeping Anganwadi as the focal point as it aims to ensure holistic development and adequate nutrition for pregnant women, mothers and children [36].

Conclusion
The children below five years are the most vulnerable to under nutrition and its adverse effects.
Nutrition, health education and good access, and utilization of healthcare can be very effective interventions which could result in substantial reduction in under nutrition prevalent in rural children.

Recommendations
The families from both the communities should be encouraged for diversified home-based food production activities to improve the nutritional status of children as large chunk of food intake is dependent on home production or local availability.
Severely malnourished children should be surveyed on regular basis and home visits should be made to monitor as well as to improve their food intake.
Parents of the malnourished children should be What the study adds to the existing knowledge The present study was aimed to compare the level and factors related to malnutrition among the tribal and the non-tribal under-five children in the same rural area. The finding throw light on the need to have separate strategic intervention for tribal and non-tribal families to overcome the problem of malnutrition.

Author's contributions
Dr. Dilip Kumar L: The selection of the topic, methodology and manuscript writing were done by the principal author.

Dr. Nitesh Mangal:
The work related to the questionnaire framing and interpretations of the results were done by the corresponding author.

Dr. K.A. Varghese:
The data analysis as well as the appropriate statistical tests were applied by the statistician. Also, the final proof reading was done.

Mr. Tarachand & Mr. Prem Prakash Salvi:
The preparation of household lists for tribal and nontribal families and the collection of data from selected households were done by both the Medical Social Workers.

Mr. Vijaypal Singh Udawat:
The collected data was entered on MS excel sheet by Health Inspector.