CHAPTER 13

Anthropometric failure among Santal preschoolchildren of Purulia, West Bengal, India

Subal Das1, Sudip Datta Banik2 and Kaushik Bose3†

AbstractThe present ethnic group based cross-sectional study was undertaken

to evaluate the prevalence of anthropometric failure (Composite Index ofAnthropometric Failure or CIAF) following Nandy et al. (2005) among Santalpreschool children of Purulia District, West Bengal, India. The 514preschoolers (259 boys, 255 girls) aged 2-6 years were measured for weightand height. Stunting, underweight and wasting were used to evaluate theanthropometric failure of the subjects following the reference of United StatesNational Center for Health Statistics (NCHS). Results showed that overall(age and sex combined) prevalence of stunting, underweight and wastingwere 29.8 %, 24.5% and 8.2%, respectively. Age specific anthropometricfailure (CIAF [B-Y]) rates demonstrated that boys aged 3 years had the highestprevalence of anthropometric failure (CIAF [B-Y]) (56.1 %) while girls of 3years of age had the highest (49.2 %) prevalence. Age combined prevalenceof undernutrition based on CIAF (B-Y) showed that boys (40.4 %) had higherprevalence of undernutrition than girls (37.0 %). The overall age-sexcombined prevalence of undernutrition was 38.7 %. Among the studiedchildren, 61.3 % showed no anthropometric failure. There was no significant

1 Department of Anthropology and Tribal Development, GGV, Bilaspur, C.G., India.2 Department of Human Ecology, Somatology Laboratory, Cinvestav-IPN, Merida,

Yucatan, Mexico.3 Dept. of Anthropology, Vidyasagar University, West Bengal, India.

†corresponding author

244 Human Growth: The Mirror of the Society

age group difference (χ2 = 0.733; df = 1) between no failure (A) and CIAF(B–Y). These findings will help to identify population specific nutritionaldeprivation and ultimately aid in formulating nutritional supplementationpolicies and programmes to reduce undernutrition.

Key words: Stunting, underweight, wasting, CIAF, z-score.

Introduction

India is unique with its diversified ethnicity. About 645 (approximately)tribes reside in this country. With a total population of 84,326,240, tribalsconstitute 8.2 % of the total population of our nation. Out of the totalpopulation, 15.9 % are preschoolers below 6 years of age (Census, 2011). Arecent analysis by the maternal and child undernutrition study group estimatedthat stunting, severe wasting and intrauterine growth restriction together wereresponsible for 2.2 million deaths annually and most of these mortalitieswere found in underprivileged communities (Black et al., 2008). Regardingnutritional status of preschool children in India, it was seen that 35.7 %children were underweight and 40.7 % are stunted whereas 0.5 % wereoverweight and 2.7 % were tall (Bharati et al., 2012). Children are the futureof society and mothers are the guardian of that future. Hence to ensure soundfoundation and secure future of any society, health and nutrition of theirchildren need protection. Children in preschool stage require most attention,as this is the period of rapid growth and development, which makes themhighly vulnerable to malnutrition (WHO, 2005a). In rural India includingWest Bengal, undernutrition among preschool children was creating animportant public health problem (Mustaphi and Dobe, 2005). In West Bengal,half of the children suffer from different types of undernutrition (Bose et al.,2008).

Anthropometry refers to body measurements. The basic measurementstaken from children include weight, length, and height, which arethen compared to the sex-specific National Centre for Health Statistics(NCHS) and WHO-guided international reference population as a way toassess the level of undernutrition. Evidence has shown that growth patternsof well-fed, healthy children are the same for all races and ethnicities, so thisreference population is used for all areas of the world (CDC, 2005).Widespread anthropometric indicators combine measurements with age. In

Anthropometric failure among Santal preschool children of Purulia... 245

particular, stunting symbolizes low height-for-age, wasting represents lowweight-for-height, and underweight signify low weight-for-age. Stuntingprovides an indicator of chronic undernutrition since it quantifies growthpotential restricted; wasting is an indicator of acute undernutrition since itquantifies weight loss; the degree of underweight is an indicator of bothwasting and stunting, combining measures of “the current status of bodyproportion and linear growth (Marriott et al., 2009; WHO, 2005b).

The present study utilizes z-score as the indicator to describe theprevalence of anthropometric failure among Santal tribal preschool childrenof Purulia, West Bengal, India.

Materials and Methods

Present cross-sectional study was conducted in Santal dominated (innumbers) villages of Purulia District, West Bengal, which were situated about270 km from Kolkata, the capital of West Bengal, India. The Santals are oneof the largest indigenous communities in India. They occupy primarily theChotanagpur Plateau, with their settlements distributed over an area of 350miles, from the Ganges to the Baitarani. The Santal Parganas district isconsidered to be the heart of the Santal area. Beyond this region, the Santalsare found widely in India as agricultural and industrial laborers.

The Santal language, Santali, belongs to the Munda (or Mundari) branchof the Austro-Asiatic language family (http://www.joshuaproject.net/people-profile.php? Peo3=14743 and rog3=IN). Scheduled tribe constitutes 5.5%of total population of our state. The Santals comprised more than half (51.8%) of the tribal population of West Bengal (Census of India, 2001).

The present study was carried out during January to September 2010. Atotal of 514 (259 boys and 255 girls) preschoolers (aged 2-6 years) weremeasured. Data were collected after obtaining necessary approval from theuniversity ethical committee, guardians, villagers and members of thePanchayat Samiti (statutory body of the local Government). Parents wereinformed about the objectives of present study prior to taking themeasurements. Information on age, sex, weight and height was collected ona pre-tested questionnaire by house-to-house visit, following interview andmeasurements.

246 Human Growth: The Mirror of the Society

Anthropometry can be used for various purposes, depending on theanthropometric indicators selected. Height and weight measurements weretaken for each participant by the first author (S.D.) following standardtechniques (Lohman et al., 1988). Technical errors of measurement werefound to be within reference values (Ulijaszek and Kerr, 1999) and thus notincorporated in statistical analyses. Standard growth charts of the NationalCenter for Health Statistics (NCHS) (Hamill et al., 1979) were used asreference data for anthropometric measurements and derived indices. Thethree most commonly used internationally recommended anthropometricindicators: stunting (low height-for-age), underweight (low weight-for-age)and wasting (low weight-for-height) were used as indices of nutritional statusor undernutrition among children (WHO, 1995) and composite index ofanthropometric failure (CIAF) ( Table 13.1) was also calculated using thesame indicators for the children (Nandy et al., 2005). Composite index ofanthropometric failure (CIAF) is a single measure with which we can estimatethe overall prevalence of anthropometric failure (Nandy et al., 2005). Thatparticular study (Nandy et al., 2005) modified Svedberg’s (2000) modelidentifying an additional sub­group – one that includes children who areonly underweight – group Y). These groups included (Table 13.1) childrenwith height and weight appropriate for their age (i.e., above –2SD z-scores)who were not in “anthropometric failure”, and those children whose heightand weight for their age were below the norm (i.e., below–2SD z-scores)and thus experiencing one or more forms of “anthropometric failure”. TheCIAF excluded those children not in anthropometric failure (group A) andincludes all children who were wasted, stunted, or underweight, and theircombinations (groups B–Y).

Table 13.1 CIAF classification (B-Y) of children with “anthropometric failure”(Nandy et al., 2005)

Group Description Wasting Stunting Underweight

A No failure No No NoB Wasting only Yes No NoC Wasting and underweight Yes No YesD Wasting, stunting & underweight Yes Yes YesE Stunting & underweight No Yes YesF Stunting only NO Yes NOY Underweight only No No Yes

Anthropometric failure among Santal preschool children of Purulia... 247

The following formula was used to calculate the z-score of the studiedpreschooler:

Z-score = (observed value) - (median reference value)Standard deviation of reference population

Stunting: <-2 HAZ (z-score for height-for-age);Underweight: <-2 WAZ (z-score for weight-for-age);Wasting: <-2 WHZ (z-score for weight -for- height).Student’s independent sample t-test was performed to ensure the sex

difference in anthropometric variables and indicators. One way ANOVA (Ftest) was undertaken to test for age differences in mean height, weight, HAZ,WAZ and WHZ. Chi-square tests were done to test significant age groupdifference between CIAF and no failure. All statistical analyses wereundertaken using the Statistical Package for Social Science (SPSS, 14) andEmergency Nutrition Assessment program (ENA) for windows.

Figure 13.1 Prevalence of anthropometric failure (using CIAF) age and sex wiseamong the preschoolers

Results

Table 13.2 shows mean weight, height, height-for-age (HAZ), weight-for-age (WAZ) and weight-for-height (WHZ) of Santal preschool childrenby age and sex. Overall mean weight and height of boys were 13.7 kg and96.6 cm, respectively. Similarly for Santal girls, mean weight and heightwere 13.4 kg and 96.3 cm, respectively. It is clear from the table that for

248 Human Growth: The Mirror of the Society

weight, boys at the age of 5 years (16.08 kg) and girls at 6 years (15.71 kg)were heavier than other ages. For height, at 6 years, both boys (106.37 cm)and girls (105.66 cm) were taller than other ages. Significant sex differencein mean weight was observed at the age of 2 years. Significant sex differencein weight-for-age was observed at the age of 5 and 6 years. Significance wasobserved at (p< 0.01) level. Significant age differences were also observedfor weight, height and weight-for-age for both boys and girls.

Table 13.3 and figure 13.1 describe the proportions of Santal childrenwith anthropometric failure in each of the subgroups. Out of those sixsubgroups with undernourished children, group E (containing children whoare stunted and underweight) was the highest (17.3 %). In group E boys weremore (18.1 %) undernourished than their female (16.5 %) counterpart. Ageand sex specific prevalence of CIAF (group E) was highest among boys(23.8 %) at age 2 years and among girls (28.1%) at age 3 years. Age specificCIAF (B-Y) describes those boys of age 3 years have the highest prevalenceof CIAF (B-Y) (56.1 %) and the girls of age 3 years have highest (49.2 %)prevalence. Age combined prevalence of undernutrition based on CIAF (B-Y) showed boys (40.4 %) having high prevalence of undernutrition thangirls (37.0 %). The overall age-sex combined prevalence of undernutritionwas (38.7 %). Among the studied children only (61.3 %) showed no failure.There was no significant age group difference (χ2 = 0.733; df =1) betweenno failure (A) and CIAF (B–Y).Table 13.2 Descriptive statistics with t-value and F (ANOVA) value among the studied Santal

preschool children

Age(Years) Sex (n) Weight(kg) Height(cm) HAZ WAZ WHZ

2 Boys (63) 11.25 (1.68) 85.73 (6.48) -0.69 (1.96) -0.87 (1.26) -0.62 (1.14)Girls (47) 10.39 (1.84) 84.37 (7.76) -0.75 (2.33) -1.15 (1.41) -0.93 (0.94)

t 2.558** 0.977 0.617 1.091 0.2703 Boys (41) 11.96 (1.98) 89.50 (7.24) -1.64 (1.81) -1.54 (1.25) -0.68 (1.17)

Girls (57) 11.57 (1.96) 88.84 (8.13) -1.46 (2.05) -1.47 (1.31) -0.70 (1.02)t 0.977 0.420 -0.467 -0.255 0.073

4 Boys (57) 13.78 (1.92) 98.24 (7.10) -1.21 (1.57) -1.43 (1.11) -0.95 (1.07)Girls (47) 13.53 (2.19) 97.87 (7.74) -1.03 (1.73) -1.35 (1.24) -0.97 (0.91)

t 0.617 0.254 -0.561 -0.383 0.0975 Boys (61) 16.08 (2.61) 105.28 (8.53) -1.00 (1.68) -1.11 (1.08) -0.51 (0.90)

Girls (76) 15.61 (2.42) 104.94 (8.87) -0.90 (1.82) -0.60 (0.96) -0.64 (0.83)t 1.091 0.226 -0.325 -2.903** 0.880

Anthropometric failure among Santal preschool children of Purulia... 249

6 Boys (37) 15.88 (2.58) 106.37 (8.90) -1.47 (1.87) -1.37 (0.88) -0.59 (0.73)Girls (28) 15.71 (2.21) 105.66 (8.85) -1.41 (1.85) -0.71 (0.71) -0.57 (0.51)

t 0.270 0.321 -0.125 -3.246** -0.066

Overall Boys (259) F= 54.853*** F= 76.652*** F= 2.269 F= 3.044* F= 1.561

Girls (255) F= 61.370*** F= 65.633*** F= 1.226 F= 6.059*** F= 1.847

Where; kg= kilogram, cm= centimeter, HAZ= Height-for-age; WAZ= Weight-for-age &WHZ= Weight-for-height; Number of individuals (n) and Standard deviations are presentedin parentheses; Significance at *=p<0.05, **=p<0.01, ***=p<0.001.

Discussion

It is evident from the current study as well previous similar studiesdone by several researchers (Figure 13.2) that use of CIAF as an indicator ofundernutrition is wiser then the sole use of stunting or underweight or wastingas the criterion for identifying undernourished preschool children because itmay undervalue the clear depiction of undernu­trition. The CIAF facilitateshealth investigators to envisage the degree of complete anthropometric failure(undernutrition). The CIAF provides an overall approximation of the figureof undernourished children within a community, which is not possible byany of the conventional indicators. Thus, attempts at estimating the overallprevalence of anthropometric failure in a ethnic group must integrate suchan aggregate index of undernutri­tion (Seetharaman et al. 2007).

Figure 13.2 Comparative prevalence of anthropometric failure (CIAF based) with National,Regional and International studied populations.

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Figure 13.2 represented the comparative prevalence of undernutritionusing composite index of anthropometric failure (CIAF) with otherinternational, national and regional studies undertaken by researchers. It wasclear from the figure that very few studies had been conducted so far usingCIIAF. Overall highest prevalence of anthropometric failure was observedamong the Bengalee children (69.1 %) (Mukhopadhyay and Biswas, 2011)and the least prevalence was observed among the Kashmiri children (25.6%) (Anjum et al., 2012). It was also clear from the figure that out of the fournational studies, South Indian children (68.6 %) (Seetharaman et al., 2007)had the highest and Kashmiri (Anjum et al., 2012) children (25.6 %) hadlowest prevalence of anthropometric failure using CIAF. Out of all four studiesso far conducted in West Bengal, children of Bankura (69.1 %),(Mukhopadhyay and Biswas, 2011) had the highest and ICDS (IntegratedChild Development Schemes of Government) children of Madhyamgram,West Bengal (59.8 %) (Mandal and Bose, 2009) had the lowest frequency ofanthropometric failure using CIAF. Anthropometric failure among the studiedSantal preschool children showed lower percentage than other studied samplesshown in figure 2, except the Kashmiri children (25.58 %) (Anjum et al.,2012). Nevertheless, it is very high (critical situation) prevalence (38.7 %).It is advisable to conduct similar kind of community specific descriptivestudies to understand the gravity of the nutritional situation. Effective policiescan be formulated to curb the menace of undernutrition, not only regionally,but also nationally as well as globally. Prioritization of nutritionalsupplementation programmes can be undertaken based on the results of suchstudies involving CIAF.

Table 13.3 Prevalence of anthropometric failure (using CIAF) age and sex wiseamong the preschoolers

Group Age (Years) Overall Total

2 3 4 5 6 Boys GirlsBoys Girls Boys Girls Boys Girls Boys Girls Boys Girls

A 60.2 55.3 43.9 50.9 61.4 57.4 68.9 76.3 56.8 75.0 59.5 63.1 61.3B 4.8 4.3 2.4 3.5 7.0 4.3 3.3 1.3 2.7 0.0 4.2 2.7 3.5C 4.8 4.3 4.9 3.5 3.5 2.1 4.9 0.0 0.0 0.0 3.9 2.0 2.9D 0.0 2.1 7.3 1.8 0.0 6.4 0.0 0.0 2.7 0.0 1.5 2.0 1.8E 23.8 17.0 22.0 28.1 17.5 23.4 13.1 6.6 13.5 7.1 18.1 16.5 17.3F 3.2 8.5 14.6 10.5 8.8 4.3 8.2 15.8 21.6 17.9 10.0 11.4 10.7Y 3.2 8.5 4.9 1.8 1.8 2.1 1.6 0.0 2.7 0.0 2.7 2.4 2.5CIAF (B-Y) 39.8 44.7 56.1 49.2 38.6 42.6 31.1 23.7 43.2 25.0 40.4 37.0 38.7

Chi-square, χ2=0.733, df =1; Computed only for a 2x2 table.

Anthropometric failure among Santal preschool children of Purulia... 251

The relevance and uniqueness of the present study comes from the factthat, it is the first to utilize CIAF anthropometric data in any tribal preschoolchildren from India. One lacuna of the present study is that it is limited tosingle ethnic group, being from one area (district) of West Bengal, India.These results may therefore only be informative for a community and notrepresentative of the whole district. To obtain a broader representation, wesuggest that more studies involving CIAF among preschool children fromdifferent ethnic groups be undertaken not only from West Bengal but alsoother parts of our country. Similar research will let us not only to comparethe rates of three conventional measures of undernutrition with CIAF, butalso help to articulate the enhanced efficacy and use of CIAF. Since theoverwhelming majority of the Indian populations reside in rural areas wherethe rates of childhood undernutrition are very high, such studies should focuson rural/tribal preschool children. Important health and nutritional policyand promotion programs can be formulated based on findings of such datawith the ultimate objective of decreasing childhood undernutrition in ruraland tribal preschoolers.

Acknowledgement

Santal preschool children participating and cooperating during datacollection, their care takers, parents, villagers and members of panchayatsamiti are gratefully ac­knowledged for their permission beforecommencement of study. However, the authors assume full responsibilityfor all data and content pre­sented. Subal Das received financial assistancein the form of Research Fellowship from University Grants Commission,Government of India for his Ph.D.

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