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1.  Assessment of Malnutrition Among Adolescents:Can BMI be Replaced by MUAC 
Objectives:
To find out the magnitude of malnutrition among the adolescents of an urban slum of Kolkata study population. To compare the middle upper arm circumference (MUAC) with that of body mass index (BMI) for determination of nutritional status of the study population.
Materials and Methods:
This was a school-based descriptive epidemiological study done among adolescent male students aged 10–19 years in the service area of Urban Health Centre, Chetla. The school is an all boy’s government aided school and all the students reside in the Chetla slum, the largest slum of Kolkata. Anthropometric measurements of the students of one section selected from each class i.e. class V to XII were recorded.
Results:
Results showed 47.93% of study population as per BMI and 60.30% as per MUAC were malnourished. Evaluation of screening test showed MUAC as a marker was 94.6% sensitive and 71.2% specific. A correlation between measurements of MUAC and BMI was demonstrated (r=0.822; SE=0.035; 95% CI; P=0.000000; r2=0.74).
doi:10.4103/0970-0218.66892
PMCID: PMC2940185  PMID: 20922106
Body mass index; middle upper arm circumference; sensitivity; specificity
2.  Effect of mother’s education on child’s nutritional status in the slums of Nairobi 
BMC Pediatrics  2012;12:80.
Background
Malnutrition continues to be a critical public health problem in sub-Saharan Africa. For example, in East Africa, 48 % of children under-five are stunted while 36 % are underweight. Poor health and poor nutrition are now more a characteristic of children living in the urban areas than of children in the rural areas. This is because the protective mechanism offered by the urban advantage in the past; that is, the health benefits that historically accrued to residents of cities as compared to residents in rural settings is being eroded due to increasing proportion of urban residents living in slum settings. This study sought to determine effect of mother’s education on child nutritional status of children living in slum settings.
Methods
Data are from a maternal and child health project nested within the Nairobi Urban Health and Demographic Surveillance System (NUHDSS). The study involves 5156 children aged 0–42 months. Data on nutritional status used were collected between October 2009 and January 2010. We used binomial and multiple logistic regression to estimate the effect of education in the univariable and multivariable models respectively.
Results
Results show that close to 40 % of children in the study are stunted. Maternal education is a strong predictor of child stunting with some minimal attenuation of the association by other factors at maternal, household and community level. Other factors including at child level: child birth weight and gender; maternal level: marital status, parity, pregnancy intentions, and health seeking behaviour; and household level: social economic status are also independently significantly associated with stunting.
Conclusion
Overall, mothers’ education persists as a strong predictor of child’s nutritional status in urban slum settings, even after controlling for other factors. Given that stunting is a strong predictor of human capital, emphasis on girl-child education may contribute to breaking the poverty cycle in urban poor settings.
doi:10.1186/1471-2431-12-80
PMCID: PMC3444953  PMID: 22721431
Education; Child stunting; Health; Urban slum; Kenya
3.  All Slums are Not Equal: Maternal Health Conditions Among Two Urban Slum Dwellers 
Background:
Pregnant women inhabiting urban slums are a “high risk” group with limited access to health facilities. Hazardous maternal health practices are rampant in slum areas. Barriers to utilization of health services are well documented. Slums in the same city may differ from one another in their health indicators and service utilization rates. The study examines whether hazardous maternal care practices exist in and whether there are differences in the utilization rates of health services in two different slums.
Materials and Methods:
A cross-sectional study was carried out in two urban slums of Aligarh city (Uttar Pradesh, India). House-to-house survey was conducted and 200 mothers having live births in the study period were interviewed. The outcome measures were utilization of antenatal care, natal care, postnatal care, and early infant feeding practices. Rates of hazardous health practices and reasons for these practices were elicited.
Results:
Hazardous maternal health practices were common. At least one antenatal visit was accepted by a little more than half the mothers, but delivery was predominantly home based carried out under unsafe conditions. Important barriers to utilization included family tradition, financial constraints, and rude behavior of health personnel in hospitals. Significant differences existed between the two slums.
Conclusion:
The fact that barriers to utilization at a local level may differ significantly between slums must be recognized, identified, and addressed in the district level planning for health. Empowerment of slum communities as one of the stakeholders can lend them a stronger voice and help improve access to services.
doi:10.4103/0970-0218.94027
PMCID: PMC3326809  PMID: 22529541
Barriers to utilization; hazardous delivery practices; maternal health; urban slums
4.  Poor nutritional status of schoolchildren in urban and peri-urban areas of Ouagadougou (Burkina Faso) 
Nutrition Journal  2011;10:34.
Background
Malnutrition is still highly prevalent in developing countries. Schoolchildren may also be at high nutritional risk, not only under-five children. However, their nutritional status is poorly documented, particularly in urban areas. The paucity of information hinders the development of relevant nutrition programs for schoolchildren. The aim of this study carried out in Ouagadougou was to assess the nutritional status of schoolchildren attending public and private schools.
Methods
The study was carried out to provide baseline data for the implementation and evaluation of the Nutrition Friendly School Initiative of WHO. Six intervention schools and six matched control schools were selected and a sample of 649 schoolchildren (48% boys) aged 7-14 years old from 8 public and 4 private schools were studied. Anthropometric and haemoglobin measurements, along with thyroid palpation, were performed. Serum retinol was measured in a random sub-sample of children (N = 173). WHO criteria were used to assess nutritional status. Chi square and independent t-test were used for proportions and mean comparisons between groups.
Results
Mean age of the children (48% boys) was 11.5 ± 1.2 years. Micronutrient malnutrition was highly prevalent, with 38.7% low serum retinol and 40.4% anaemia. The prevalence of stunting was 8.8% and that of thinness, 13.7%. The prevalence of anaemia (p = 0.001) and vitamin A deficiency (p < 0.001) was significantly higher in public than private schools. Goitre was not detected. Overweight/obesity was low (2.3%) and affected significantly more children in private schools (p = 0.009) and younger children (7-9 y) (p < 0.05). Thinness and stunting were significantly higher in peri-urban compared to urban schools (p < 0.05 and p = 0.004 respectively). Almost 15% of the children presented at least two nutritional deficiencies.
Conclusion
This study shows that malnutrition and micronutrient deficiencies are also widely prevalent in schoolchildren in cities, and it underlines the need for nutrition interventions to target them.
doi:10.1186/1475-2891-10-34
PMCID: PMC3103411  PMID: 21504619
5.  Gender inequality and bio-social factors in nutritional status among under five children attending anganwadis in an urban slum of a town in Western Maharashtra, India 
Nutrition for under-5 children is of great importance as the foundation for life-time health, strength, and intellectual vitality is laid during this period. Globally, more than one-third of the child deaths are attributable to under-nutrition. The discriminatory attitudes against female children vary from being implicit to those that are quite explicit. So, the present cross-sectional study aims to assess the nutritional status (gender differences) of 146 under-5 children attending Anganwadis and also to study the bio-socio-demographic factors associated with malnutrition attending three Anganwadis of Adopted Urban slum area, involving anthropometric examination using standardized techniques and interview using predesigned semi-structured questionnaire for the mothers in September-October 2011. Nutritional status grading was done based on weight for age as per Indian Academy of Pediatrics (IAP) Classification and using height for age as per Vishveshwara Rao's Classification. 51.4% were males, majority in age group of 2-3 years. 63% children were malnourished, majority in Grade I malnutrition. Out of the total females, 72% were stunted and 43% were severely malnourished having mid arm circumference <12.5 cm. Birth order (P < 0.05), education status of the mother (P < 0.001), socio-economic status (P < 0.05) and type of family (P < 0.05) were found to be significantly associated with malnutrition.
PMCID: PMC3793383  PMID: 24124435
Nutritional status; under-5 children; urban slum; Western Maharashtra
6.  Burden of childhood diseases and malnutrition in a semi-urban slum in southern India 
BMC Public Health  2013;13:87.
Background
India has seen rapid unorganized urbanization in the past few decades. However, the burden of childhood diseases and malnutrition in such populations is difficult to quantify. The morbidity experience of children living in semi-urban slums of a southern Indian city is described.
Methods
A total of 176 children were recruited pre-weaning from four geographically adjacent, semi-urban slums located in the western outskirts of Vellore, Tamil Nadu for a study on water safety and enteric infections and received either bottled or municipal drinking water based on their area of residence. Children were visited weekly at home and had anthropometry measured monthly until their second birthday.
Results
A total of 3932 episodes of illness were recorded during the follow-up period, resulting in an incidence of 12.5 illnesses/child-year, with more illness during infancy than in the second year of life. Respiratory, mostly upper respiratory infections, and gastrointestinal illnesses were most common. Approximately one-third of children were stunted at two years of age, and two-thirds had at least one episode of growth failure during the two years of follow up. No differences in morbidity were seen between children who received bottled and municipal water.
Conclusions
Our study found a high burden of childhood diseases and malnutrition among urban slum dwellers in southern India. Frequent illnesses may adversely impact children’s health and development, besides placing an additional burden on families who need to seek healthcare and find resources to manage illness.
doi:10.1186/1471-2458-13-87
PMCID: PMC3577473  PMID: 23360429
Children; Morbidity; Incidence; Slum; Longitudinal study; India
7.  Contribution of Enteric Infection, Altered Intestinal Barrier Function, and Maternal Malnutrition to Infant Malnutrition in Bangladesh 
Children born malnourished had more infections with Entamoeba histolytica, enterotoxigenic Escherichia coli, and Cryptosporidium. Conversely, malnutrition was preceded by prolonged diarrhea and altered intestinal barrier function. These studies demonstrate the potential for nutritional interventions based on treatment or prevention of enteric infections.
Background. Malnourished children are at increased risk for death due to diarrhea. Our goal was to determine the contribution of specific enteric infections to malnutrition-associated diarrhea and to determine the role of enteric infections in the development of malnutrition.
Methods. Children from an urban slum in Bangladesh were followed for the first year of life by every-other-day home visits. Enteropathogens were identified in diarrheal and monthly surveillance stools; intestinal barrier function was measured by serum endocab antibodies; and nutritional status was measured by anthropometry.
Results. Diarrhea occurred 4.69 ± 0.19 times per child per year, with the most common infections caused by enteric protozoa (amebiasis, cryptosporidiosis, and giardiasis), rotavirus, astrovirus, and enterotoxigenic Escherichia coli (ETEC). Malnutrition was present in 16.3% of children at birth and 42.4% at 12 months of age. Children malnourished at birth had increased Entamoeba histolytica, Cryptosporidium, and ETEC infections and more severe diarrhea. Children who became malnourished by 12 months of age were more likely to have prolonged diarrhea, intestinal barrier dysfunction, a mother without education, and low family expenditure.
Conclusions. Prospective observation of infants in an urban slum demonstrated that diarrheal diseases were associated with the development of malnutrition that was in turn linked to intestinal barrier disruption and that diarrhea was more severe in already malnourished children. The enteric protozoa were unexpectedly important causes of diarrhea in this setting. This study demonstrates the complex interrelationship of malnutrition and diarrhea in infants in low-income settings and points to the potential for infectious disease interventions in the prevention and treatment of malnutrition.
doi:10.1093/cid/cir807
PMCID: PMC3245731  PMID: 22109945
8.  A Study on Consciousness of Adolescent Girls About Their Body Image 
Background:
Perceived body image is an important potential predictor of nutritional status. Body image misconception during adolescence is unexplored field in Indian girls.
Objectives:
To study the consciousness of adolescent girls about their body image.
Materials and Methods:
This multistage observational study was conducted on 586 adolescent girls of age 10–19 years in Lucknow district (151 from rural, 150 from slum, and 286 from urban area) of Uttar Pradesh, India. Information on desired and actual body size was collected with the help of predesigned questionnaire.
Results:
20.5% of studied girls show aspiration to become thin, who already perceived their body image as too thin. 73.4% adolescent girls were satisfied with their body image, while 26.6% were dissatisfied. The dissatisfaction was higher among girls of urban (30.2%) and slum (40.0%) areas in comparison to rural (22.5%) area. Percentage of satisfied girls was less in the 13–15 years (69.9%) age groups in comparison to 10–12 years (76.5%) and 16–19 years (76.4%). Among girls satisfied with their body image, 32.8% girls were found underweight, and 38.4% were stunted. Underweight girls (42.1%) and stunted girls (64.9%) were higher in number within satisfied girls of slum area. Among all of these adolescent girls, 32.8% of girls had overestimated their weight, while only 4.9% of girls had underestimated their weight.
Conclusions:
This study concludes that desire to become thin is higher in adolescent girls, even in those who already perceived their body image as too thin.
doi:10.4103/0970-0218.86520
PMCID: PMC3214444  PMID: 22090673
Adolescence; body image satisfaction; perceived body image; stunting; underweight
9.  Anthropometrically determined nutritional status of urban primary schoolchildren in Makurdi, Nigeria 
BMC Public Health  2011;11:769.
Background
No information exists on the nutritional status of primary school children residing in Makurdi, Nigeria. It is envisaged that the data could serve as baseline data for future studies, as well as inform public health policy. The aim of this study was to assess the prevalence of malnutrition among urban school children in Makurdi, Nigeria.
Methods
Height and weight of 2015 (979 boys and 1036 girls), aged 9-12 years, attending public primary school in Makurdi were measured and the body mass index (BMI) calculated. Anthropometric indices of weight-for-age (WA) and height-for-age (HA) were used to estimate the children's nutritional status. The BMI thinness classification was also calculated.
Results
Underweight (WAZ < -2) and stunting (HAZ < -2) occurred in 43.4% and 52.7%, respectively. WAZ and HAZ mean scores of the children were -0.91(SD = 0.43) and -0.83 (SD = 0.54), respectively. Boys were more underweight (48.8%) than girls (38.5%), and the difference was statistically significant (p = 0.024; p < 0.05). Conversely, girls tend to be more stunted (56.8%) compared to boys (48.4%) (p = 0.004; p < 0.05). Normal WAZ and HAZ occurred in 54.6% and 44.2% of the children, respectively. Using the 2007 World Health Organisation BMI thinness classification, majority of the children exhibited Grade 1 thinness (77.3%), which was predominant at all ages (9-12 years) in both boys and girls. Gender wise, 79.8% boys and 75.0% girls fall within the Grade I thinness category. Based on the WHO classification, severe malnutrition occurred in 31.3% of the children.
Conclusions
There is severe malnutrition among the school children living in Makurdi. Most of the children are underweight, stunted and thinned. As such, providing community education on environmental sanitation and personal hygienic practices, proper child rearing, breast-feeding and weaning practices would possibly reverse the trends.
doi:10.1186/1471-2458-11-769
PMCID: PMC3198944  PMID: 21974827
10.  Anthropometric and Micronutrient Status of School-Children in an Urban West Africa Setting: A Cross-Sectional Study in Dakar (Senegal) 
PLoS ONE  2013;8(12):e84328.
Background
Urban areas in West Africa are not immune to undernutrition with recent urbanization and high food prices being important factors. School children often have a poor nutritional status, potentially affecting their health and schooling performance. Yet, generally school children do not benefit from nutrition programs. The objective of the study was to assess the anthropometric and micronutrient status of children from state schools in the Dakar area.
Methods
School children (n = 604) aged from 5 to 17 y (52.5% girls, 47.5% ≥10 y) were selected through a two-stage random cluster sample of children attending urban primary state schools in the Dakar area (30 schools × 20 children). The prevalence of stunting (height-for-age<−2 z-scores) and thinness (BMI-for-age<−2 z-scores, WHO 2006, and three grades of thinness corresponding to BMI of 18.5, 17.0 and 16.0 kg/m2 in adults) were calculated from weight and height. Hemoglobin, plasma concentrations of ferritin (FER), transferrin receptors (TfR), retinol binding protein (RBP), and zinc, and urinary iodine concentrations were measured. Correction factors were used for FER and RBP in subjects with inflammation determined with C-reactive protein and α1-acid-glycoprotein.
Results
4.9% of children were stunted, 18.4% were thin, 5.6% had severe thinness (BMI-for-age<−3 z-scores). Only one child had a BMI-for-age>2 z-scores. Prevalence of anemia, iron deficiency and iron deficiency anemia was 14.4%, 39.1% and 10.6% respectively. 3.0% had vitamin A deficiency, 35.9% a marginal vitamin A status, and 25.9% zinc deficiency. Urinary iodine was <50 µg/L in 7.3% of children and ≥200 µg/L in 22.3%. The prevalence of marginal vitamin A, zinc deficiency, high TfR was significantly higher in boys than in girls (P<0.05). Height-for-age and retinol were significantly lower in participants ≥10 y and <10 y respectively.
Conclusion
Undernutrition, especially thinness, iron and zinc deficiencies in school children in the Dakar area requires special targeted nutrition interventions.
doi:10.1371/journal.pone.0084328
PMCID: PMC3877263  PMID: 24391938
11.  Chronic growth faltering amongst a birth cohort of Indian children begins prior to weaning and is highly prevalent at three years of age 
Nutrition Journal  2009;8:44.
Background
Poor growth of children in developing countries is a major public health problem associated with mortality, morbidity and developmental delay. We describe growth up to three years of age and investigate factors related to stunting (low height-for-age) at three years of age in a birth cohort from an urban slum.
Methods
452 children born between March 2002 and August 2003 were followed until their third birthday in three neighbouring slums in Vellore, South India. Field workers visited homes to collect details of morbidity twice a week. Height and weight were measured monthly from one month of age in a study-run clinic. For analysis, standardised z-scores were generated using the 2006 WHO child growth standards. Risk factors for stunting at three years of age were analysed in logistic regression models. A sensitivity analysis was conducted to examine the effect of missing values.
Results
At age three years, of 186 boys and 187 girls still under follow-up, 109 (66%, 95% Confidence interval 58-73%) boys and 93 (56%, 95% CI 49-64%) girls were stunted, 14 (8%, 95% CI 4-13%) boys and 12 (7%, 95% CI 3-11%) girls were wasted (low weight-for-height) and 72 (43%, 95% CI 36-51) boys and 66 (39%, 95% CI 31-47%) girls were underweight (low weight-for-age). In total 224/331 (68%) children at three years had at least one growth deficiency (were stunted and/or underweight and/or wasted); even as early as one month of age 186/377 (49%) children had at least one growth deficiency. Factors associated with stunting at three years were birth weight less than 2.5 kg (OR 3.63, 95% CI 1.36-9.70) 'beedi-making' (manual production of cigarettes for a daily wage) in the household (OR 1.74, 95% CI 1.05-2.86), maternal height less than 150 cm (OR 2.02, 95% CI 1.12-3.62), being stunted, wasted or underweight at six months of age (OR 1.75, 95% CI 1.05-2.93) and having at least one older sibling (OR 2.00, 95% CI 1.14-3.51).
Conclusion
A high proportion of urban slum dwelling children had poor growth throughout the first three years of life. Interventions are needed urgently during pregnancy, early breastfeeding and weaning in this population.
doi:10.1186/1475-2891-8-44
PMCID: PMC2761939  PMID: 19788734
12.  Performance of a Community-based Health and Nutrition-education Intervention in the Management of Diarrhoea in a Slum of Delhi, India 
Diarrhoeal infections are the fifth leading cause of death worldwide and continue to take a high toll on child health. Mushrooming of slums due to continuous urbanization has made diarrhoea one of the biggest public-health challenges in metropolitan cities in India. The objective of the study was to carry out a community-based health and nutrition-education intervention, focusing on several factors influencing child health with special emphasis on diarrhoea, in a slum of Delhi, India. Mothers (n=370) of children, aged >12–71 months, identified by a door-to-door survey from a large urban slum, were enrolled in the study in two groups, i.e. control and intervention. To ensure minimal group interaction, enrollment for the control and intervention groups was done purposively from two extreme ends of the slum cluster. Baseline assessment of knowledge, attitudes, and practices on diarrhoea-related issues, such as oral rehydration therapy (ORT), oral rehydration salt (ORS), and continuation of breastfeeding during diarrhoea, was carried out using a pretested questionnaire. Thereafter, mothers (n=195) from the intervention area were provided health and nutrition education through fortnightly contacts achieved by two approaches developed for the study—‘personal discussion sessions’ and ‘lane approach’. The mothers (n=175) from the control area were not contacted. After the intervention, there was a significant (p=0.000) improvement in acquaintance to the term ‘ORS’ (65–98%), along with its method of reconstitution from packets (13–69%); preparation of home-made sugar-salt solution (10–74%); role of both in the prevention of dehydration (30–74%) and importance of their daily preparation (74–96%); and continuation of breastfeeding during diarrhoea (47–90%) in the intervention area. Sensitivity about age-specific feeding of ORS also improved significantly (p=0.000) from 13% to 88%. The reported usage of ORS packets and sugar-salt solution improved significantly from 12% to 65% (p=0.000) and 12% to 75% (p=0.005) respectively. The results showed that health and nutrition-education intervention improved the knowledge and attitudes of mothers. The results indicate a need for intensive programmes, especially directed towards urban slums to further improve the usage of oral rehydration therapy.
PMCID: PMC2995023  PMID: 21261200
Community health; Diarrhoea; Interventions; Nutrition education; Oral rehydration solutions; Slums; India
13.  A case-control study of maternal knowledge of malnutrition and health-care-seeking attitudes in rural South India. 
INTRODUCTION: In India, approximately 20 percent of children under the age of four suffer from severe malnutrition, while half of all the children suffer from undernutrition. The contributions of knowledge and attitudes of nutrition-conscious behaviors of the mothers to childhood malnutrition has been unclear. The purpose of this study was to explore maternal knowledge of the causes of malnutrition, health-care-seeking attitudes and socioeconomic risk factors in relation to children's nutritional status in rural south India. METHODS: A case-controlled study was conducted in a rural area in Tamil Nadu, India. Thirty-four cases and 34 controls were selected from the population of approximately 97,000 by using the local hospital's list of young children. A case was defined as a mother of a severely malnourished child under four years of age. Severe malnutrition was defined as having less than 60 percent of expected median weight-for-age. A control had a well-nourished child and was matched by the location and the age of the child. Interviews obtained: (1) socioeconomic information on the family, (2) knowledge of the cause of malnutrition and (3) health-care-seeking attitudes for common childhood illnesses, including malnutrition. RESULTS: Poor nutritional status was associated with socioeconomic variables such as sex of the child and father's occupation. Female gender (OR = 3.44, p = .02) and father's occupation as a laborer (OR = 2.98, p = .05) were significant risk factors for severe malnutrition. The two groups showed a significant difference in nutrition-related knowledge of mild mixed malnutrition (OR = 2.62, p = .05). No significant difference was apparent in health-care-seeking attitudes. Based on their traditional beliefs, the mothers did not believe that medical care was an appropriate intervention for childhood illnesses such as malnutrition or measles. DISCUSSION: The results suggested that the gender of the child and socioeconomic factors were stronger risk factors for malnutrition than health-care availability and health-care-seeking attitudes. The father's occupation was a more accurate indicator for malnutrition than household income. These results suggest a need for intensive nutritional programs targeted toward poor female children and their mothers.
PMCID: PMC2589065  PMID: 9493847
14.  Relationship of Personal Hygiene with Nutrition and Morbidity Profile: A Study Among Primary School Children in South Kolkata 
Background:
Majority of the health problems affecting school children are preventable by promotion of hygienic practices through proper health education by the teachers, who are the first contacts.
Objectives:
The study was undertaken to find out the status of nutrition and personal hygiene among primary school children and their association with their varied morbidity profiles.
Materials and Methods:
A descriptive, observational, cross-sectional study was conducted in a primary school situated in the largest slum of Kolkata.
Results:
The participants included 103 boys and 81 girls, with a mean age of 6.2 years. The mean personal hygiene score of the girls (4.15 ± 0.98) was significantly higher than that of boys (3.2 ± 1.4) [P<0.05]. Most of the boys (54.37%) and girls (74.07%) were normally nourished as per the CDC growth chart. Over 70% of the children were suffering from one or more morbidities, the most common morbidity in both the sexes being pallor, followed by worm infestation. Personal hygiene scores were significantly higher (P<0.05) among those children who were normally nourished as well as those who did not suffer from any morbidity in the last 15 days.
Conclusions:
Care should be taken to improve the pitiable state of personal hygiene and poor sanitary practices of these school children through coordinated and concerted health education measures by teachers as well as parents.
doi:10.4103/0970-0218.66894
PMCID: PMC2940186  PMID: 20922107
Morbidity; personal hygiene; school children
15.  High Malnutrition Rate in Venezuelan Yanomami Compared to Warao Amerindians and Creoles: Significant Associations WITH Intestinal Parasites and Anemia 
PLoS ONE  2013;8(10):e77581.
Background
Children in rural areas experience the interrelated problems of poor growth, anemia and parasitic infections. We investigated the prevalence of and associations between intestinal helminth and protozoan infections, malnutrition and anemia in school-age Venezuelan children.
Methods
This cross-sectional study was conducted in 390 children aged 4-16 years from three rural areas of Venezuela: the Amazon Region, Orinoco Delta and Carabobo State. Stool samples were collected for direct parasitic examinations. Anthropometric indicators of chronic (height-for-age Z score) and acute (weight-for-height and Body Mass Index (BMI)-for-age Z score in respectively children under 5 years of age and children aged 5 years and above) malnutrition were calculated. Multivariate linear and logistic regression models were built to determine factors associated with nutritional status and polyparasitism.
Results
Hookworm and Strongyloides stercoralis prevalences were highest in children from the Amazon rainforest (respectively 72% and 18%) while children from the Orinoco Delta and Carabobo State showed higher rates of Ascaris lumbricoides (respectively 28% and 37%) and Trichuris trichiura (40% in both regions). The prevalence of Giardia lamblia infection was not significantly different between regions (average: 18%). Anemia prevalence was highest in the Amazon Region (24%). Hemoglobin levels were significantly decreased in children with a hookworm infection. Malnutrition was present in respectively 84%, 30% and 13% of children from the Amazon Region, Orinoco Delta and Carabobo State. In multivariate analysis including all regions, G. lamblia and helminth infections were significantly and negatively associated with respectively height-for-age and weight-for-height/BMI-for-age Z scores. Furthermore, hemoglobin levels were positively associated with the height-for-age Z score (0.11, 95% CI 0.02 - 0.20).
Conclusions
In rural populations in Venezuela helminthiasis and giardiasis were associated with acute and chronic nutritional status respectively. These data highlight the need for an integrated approach to control transmission of parasites and improve the health status of rural Venezuelan children.
doi:10.1371/journal.pone.0077581
PMCID: PMC3797096  PMID: 24143243
16.  The unseen face of humanitarian crisis in Eastern Democratic Republic of Congo: was nutritional relief properly targeted? 
STUDY OBJECTIVE—Comparison of children's nutritional status in refugee populations with that of local host populations, one year after outbreak refugee crisis in the North Kivu region of Democratic Republic of Congo.
DESIGN—Cross sectional surveys.
SETTING—Temporary and other settlements, in the town of Goma and surrounding rural areas.
SUBJECTS—Anthropometric indicators of nutritional status and presence or absence of oedema were measured among 5121 children aged 6 to 59 months recruited by cluster sampling with probability proportional to size, between June and August 1995.
RESULTS—Children in all locations demonstrated a typical pattern of growth deficit relative to international reference. Prevalence of acute malnutrition (wt/ht < −2 Z score) was higher among children in the rural non-refugee populations (3.8 and 5.8%) than among those in the urban non-refugee populations (1.4%) or in the refugee population living in temporary settlements (1.7%). Presence of oedema was scarcely noticed in camps (0.4%) while it was a common observation at least in the most remote rural areas (10.1%). As compared with baseline data collected in 1989, there is evidence that nutritional status was worsening in rural non-refugee populations.
CONCLUSIONS—Children living in the main town or in the refugee camps benefited the most from nutritional relief while those in the rural non-refugee areas were ignored. This is a worrying case of inequity in nutritional relief.


Keywords: malnutrition; disasters; equity
doi:10.1136/jech.54.1.6
PMCID: PMC1731539  PMID: 10692955
17.  To assess the effects of nutritional intervention based on advocacy approach on malnutrition status among school-aged children in Shiraz 
Background:
The present study was carried out to assess the effects of community nutrition intervention based on advocacy approach on malnutrition status among school-aged children in Shiraz, Iran.
Materials and Methods:
This case-control nutritional intervention has been done between 2008 and 2009 on 2897 primary and secondary school boys and girls (7-13 years old) based on advocacy approach in Shiraz, Iran. The project provided nutritious snacks in public schools over a 2-year period along with advocacy oriented actions in order to implement and promote nutritional intervention. For evaluation of effectiveness of the intervention growth monitoring indices of pre- and post-intervention were statistically compared.
Results:
The frequency of subjects with body mass index lower than 5% decreased significantly after intervention among girls (P = 0.02). However, there were no significant changes among boys or total population. The mean of all anthropometric indices changed significantly after intervention both among girls and boys as well as in total population. The pre- and post-test education assessment in both groups showed that the student's average knowledge score has been significantly increased from 12.5 ± 3.2 to 16.8 ± 4.3 (P < 0.0001).
Conclusion:
This study demonstrates the potential success and scalability of school feeding programs in Iran. Community nutrition intervention based on the advocacy process model is effective on reducing the prevalence of underweight specifically among female school aged children.
PMCID: PMC3872579  PMID: 24381614
Malnutrition; public health advocacy; school age children
18.  Malnutrition: Missed Opportunities for Diagnosis 
Ghana Medical Journal  2008;42(3):101-104.
Summary
Introduction
Malnutrition is a serious public health problem particularly in developing countries where it is responsible for 54% of under 5s mortality. Anthropometric measurements are key tools for the assessment of nutritional status and diagnosis of malnutrition. Height and weight measurements are not routinely done in most clinics and hospitals in Ghana. Children therefore miss the opportunity for accurate nutritional assessment and detection of malnutrition.
Objectives
To determine the prevalence of wasting among children <5 years and to document extent of under-diagnosis.
Method
From June to August 2004, children aged >3 months to <5 years attending the outpatient clinic of Komfo Anokye Teaching Hospital were systematically assessed for wasting using weight-for-height standard deviation score (Z-score).
Results
Of 1182 children (mean age 24.9 months), 251 (21.2%) were wasted, 48 (4.1%) of them severely. Only 15 (5.9%) of the 251 children with wasting were so identified by the attending physician.
Conclusion
Malnutrition is widespread yet under-diagnosed. Anthropometric measurements should be promoted in all child health clinics.
PMCID: PMC2643431  PMID: 19274107
wasting; malnutrition; weight-for-height; Z-score; missed opportunities
19.  Nutritional status of young children in Mumbai slums: a follow-up anthropometric study 
Nutrition Journal  2012;11:100.
Background
Chronic childhood malnutrition remains common in India. As part of an initiative to improve maternal and child health in urban slums, we collected anthropometric data from a sample of children followed up from birth. We described the proportions of underweight, stunting, and wasting in young children, and examined their relationships with age.
Methods
We used two linked datasets: one based on institutional birth weight records for 17 318 infants, collected prospectively, and one based on follow-up of a subsample of 1941 children under five, collected in early 2010.
Results
Mean birth weight was 2736 g (SD 530 g), with a low birth weight (<2500 g) proportion of 22%. 21% of infants had low weight for age standard deviation (z) scores at birth (<−2 SD). At follow-up, 35% of young children had low weight for age, 17% low weight for height, and 47% low height for age. Downward change in weight for age was greater in children who had been born with higher z scores.
Discussion
Our data support the idea that much of growth faltering was explained by faltering in height for age, rather than by wasting. Stunting appeared to be established early and the subsequent decline in height for age was limited. Our findings suggest a focus on a younger age-group than the children over the age of three who are prioritized by existing support systems.
Funding
The trial during which the birth weight data were collected was funded by the ICICI Foundation for Inclusive Growth (Centre for Child Health and Nutrition), and The Wellcome Trust (081052/Z/06/Z). Subsequent collection, analysis and development of the manuscript was funded by a Wellcome Trust Strategic Award: Population Science of Maternal and Child Survival (085417ma/Z/08/Z). D Osrin is funded by The Wellcome Trust (091561/Z/10/Z).
doi:10.1186/1475-2891-11-100
PMCID: PMC3546020  PMID: 23173787
20.  Women’s Reproductive Health in Slum Populations in India: Evidence From NFHS-3 
The urban population in India is one of the largest in the world. Its unprecedented growth has resulted in a large section of the population living in abject poverty in overcrowded slums. There have been limited efforts to capture the health of people in urban slums. In the present study, we have used data collected during the National Family Health Survey-3 to provide a national representation of women’s reproductive health in the slum population in India. We examined a sample of 4,827 women in the age group of 15–49 years to assess the association of the variable slum with selected reproductive health services. We have also tried to identify the sociodemographic factors that influence the utilization of these services among women in the slum communities. All analyses were stratified by slum/non-slum residence, and multivariate logistic regression was used to analyze the strength of association between key reproductive health services and relevant sociodemographic factors. We found that less than half of the women from the slum areas were currently using any contraceptive methods, and discontinuation rate was higher among these women. Sterilization was the most common method of contraception (25%). Use of contraceptives depended on the age, level of education, parity, and the knowledge of contraceptive methods (p < 0.05). There were significant differences in the two populations based on the timing and frequency of antenatal visits. The probability of ANC visits depended significantly on the level of education and economic status (p < 0.05). We found that among slum women, the proportion of deliveries conducted by skilled attendants was low, and the percentage of home deliveries was high. The use of skilled delivery care was found to be significantly associated with age, level of education, economic status, parity, and prior antenatal visits (p < 0.05). We found that women from slum areas depended on the government facilities for reproductive health services. Our findings suggest that significant differences in reproductive health outcomes exist among women from slum and non-slum communities in India. Efforts to progress towards the health MDGs and other national or international health targets may not be achieved without a focus on the urban slum population.
doi:10.1007/s11524-009-9421-0
PMCID: PMC2845837  PMID: 20148311
Slum; India; National Family Health Survey-3; Contraception; Antenatal care; Skilled delivery care
21.  Nutritional status of children in India: household socio-economic condition as the contextual determinant 
Background
Despite recent achievement in economic progress in India, the fruit of development has failed to secure a better nutritional status among all children of the country. Growing evidence suggest there exists a socio-economic gradient of childhood malnutrition in India. The present paper is an attempt to measure the extent of socio-economic inequality in chronic childhood malnutrition across major states of India and to realize the role of household socio-economic status (SES) as the contextual determinant of nutritional status of children.
Methods
Using National Family Health Survey-3 data, an attempt is made to estimate socio-economic inequality in childhood stunting at the state level through Concentration Index (CI). Multi-level models; random-coefficient and random-slope are employed to study the impact of SES on long-term nutritional status among children, keeping in view the hierarchical nature of data.
Main findings
Across the states, a disproportionate burden of stunting is observed among the children from poor SES, more so in urban areas. The state having lower prevalence of chronic childhood malnutrition shows much higher burden among the poor. Though a negative correlation (r = -0.603, p < .001) is established between Net State Domestic Product (NSDP) and CI values for stunting; the development indicator is not always linearly correlated with intra-state inequality in malnutrition prevalence. Results from multi-level models however show children from highest SES quintile posses 50 percent better nutritional status than those from the poorest quintile.
Conclusion
In spite of the declining trend of chronic childhood malnutrition in India, the concerns remain for its disproportionate burden on the poor. The socio-economic gradient of long-term nutritional status among children needs special focus, more so in the states where chronic malnutrition among children apparently demonstrates a lower prevalence. The paper calls for state specific policies which are designed and implemented on a priority basis, keeping in view the nature of inequality in childhood malnutrition in the country and its differential characteristics across the states.
doi:10.1186/1475-9276-9-19
PMCID: PMC2931515  PMID: 20701758
22.  Effectiveness of personalised, home-based nutritional counselling on infant feeding practices, morbidity and nutritional outcomes among infants in Nairobi slums: study protocol for a cluster randomised controlled trial 
Trials  2013;14:445.
Background
Nutrition in the first 1,000 days of life (during pregnancy and the first two years) is critical for child growth and survival. Poor maternal, infant and young child nutrition (MIYCN) practices are widely documented in Kenya, with potential detrimental effects on child growth and survival. This is particularly a problem in slums, where most urban residents live. For example, exclusive breastfeeding for the first six months is only about two per cent. Innovative strategies to reach slum residents are therefore needed. Strategies like the Baby Friendly Hospital Initiative have proven effective in some settings but their effectiveness in resource-limited settings, including slums where many women do not deliver in hospital, is questionable. We propose to test the effectiveness of a home-based intervention on infant feeding practices, nutrition and health outcomes of infants born in two slums in Nairobi, Kenya.
Methods/Design
The study, employing a cluster-randomised study design, will be conducted in two slums in Nairobi: Korogocho and Viwandani where 14 community units (defined by the Government’s health care system) will form the unit of randomization. A total of 780 pregnant women and their respective child will be recruited into the study. The mother-child pair will be followed up until the child is one year old. Recruitment will last approximately one year and three months from September 2012 to December 2013. The mothers will receive regular, personalised, home-based counselling by trained Community Health Workers on MIYCN. Regular assessment of knowledge, attitudes and practices on MIYCN will be done, coupled with assessments of nutritional status of the mother-child pairs and diarrhea morbidity for the children. Statistical methods will include analysis of covariance and multinomial logistic regression. Additionally, cost-effectiveness analysis will be done. The study is funded by the Wellcome Trust and will run from March 2012 to February 2015.
Discussion
Interventions aimed at promoting optimal breastfeeding and complementary feeding practices are considered to have high impact and could prevent a fifth of the under-five deaths in countries with high mortality rates. This study will inform policy and practice in Kenya and similar settings regarding delivery mechanisms for such high-impact interventions, particularly among urban poor populations.
Trial registration
ISRCTN83692672
doi:10.1186/1745-6215-14-445
PMCID: PMC3879433  PMID: 24370263
Breastfeeding; Infant feeding practices; Child nutrition; Cluster randomised controlled trials; Kenya; Sub-Saharan Africa; Urban slums
23.  Does maternal autonomy influence feeding practices and infant growth in rural India? 
Social science & medicine (1982)  2011;73(3):447-455.
The high prevalence of child under-nutrition remains a profound challenge in the developing world. Maternal autonomy was examined as a determinant of breast feeding and infant growth in children 3 to 5 months of age. Cross-sectional baseline data on 600 mother-infant pairs were collected in 60 villages in rural Andhra Pradesh, India. The mothers were enrolled in a longitudinal randomized behavioral intervention trial. In addition to anthropometric and demographic measures, an autonomy questionnaire was administered to measure different dimensions of autonomy (e.g. decision-making, freedom of movement, financial autonomy, and acceptance of domestic violence). We conducted confirmatory factor analysis on maternal autonomy items and regression analyses on infant breast feeding and growth after adjusting for socioeconomic and demographic variables, and accounting for infant birth weight, infant morbidity, and maternal nutritional status. Results indicated that mothers with higher financial autonomy were more likely to breastfeed 3–5 month old infants. Mothers with higher participation in decision-making in households had infants that were less underweight and less wasted. These results suggest that improving maternal financial and decision-making autonomy could have a positive impact on infant feeding and growth outcomes.
doi:10.1016/j.socscimed.2011.05.040
PMCID: PMC3164576  PMID: 21742425
infant feeding; infant growth; maternal autonomy; confirmatory factor analysis; India; nutrition; mothers
24.  Effects of weaning biscuits on the nutritional profile and the cognitive development in preschool children 
Aim
To study the effect of weaning biscuits supplementation of the nutritional parameters and cognitive performance of the selected children.
Methods
Three primary schools situated in Salem District, Tamilnadu, India were selected. A total number of 150 school children, 61 from primary school I, 46 from primary school II and 43 from primary school III comprised the study sample. About 80 primary school children with Grade II malnutrition were selected for the experimental study. Home diet without any supplementation was followed by Group I (n = 20, control group), potato flour biscuit was supplemented to Group II (n = 20), wheat biscuits was given to Group III (n = 20) and ragi biscuits were given to Group IV (n = 20) for the period of 3 months. Parameters like anthropometric measurements, hemoglobin content clinical picture and cognitive performance were analyzed before and after supplementation.
Results
Results about Group I (control group) showed no significant difference in height, weight and clinical picture and cognitive performance after three months on their home diet. In Group II, III and IV significant increase in all the above parameters was noticed. More increase was found in Group II children supplemented with potato flour biscuits for a period of 3 months. About cognitive performance better results was obtained in Group II followed by Group III (supplemented with wheat biscuits) and Group IV (supplemented with ragi biscuits). Least was obtained by control group children who are in their home diet.
Conclusion
All these observations evident that if such weaning biscuits made with potato flour, wheat and Ragi can form a daily ingredient in their diets, it will bring out better all round development of the children.
doi:10.1186/1824-7288-36-18
PMCID: PMC2830220  PMID: 20167064
25.  Community Based Maternal and Child Health Nutrition Project, Uttar Pradesh: An Innovative Strategy Focusing on “At Risk” Families 
Research Question:
Use of community based volunteers, frequently reaching and counseling a selected group of prioritized families, can make a substantial difference in improving maternal and child care practices and in reducing child undernutrition.
Setting:
Program Rural Uttar Pradesh, India.
Study Design:
A comparison of baseline and endline surveys following 4 years of community based project intervention
Participants:
“At risk” undernutrition families comprising mothers of under twos, newlyweds, and severely undernourished children below 6 years.
Intervention:
Mapping and counseling of “at risk” families. Measuring impact on maternal-child care practices, underweight status.
Results:
Trained community mobilizers identified and counseled selected “at risk” families. Following 4 years of implementation in 907 villages of 8 blocks of four districts, significant improvement was noted in practices of early initiation of breastfeeding, feeding colostrum, timely introduction of complementary feeding, and washing the hands after defecation. Percentage of mothers exclusively breastfeeding at 6 months was only 2.1% with 78% receiving prelacteal feeds. A small increase in normal and mild malnutrition and a significant reduction of 43% in severe malnutrition was noted.
Conclusion:
Frequently counseling by accredited social health activists by focusing on selected defined “at risk” families of under twos and those with severe malnourished children could result in increasing acceptability of correct child health, feeding, and care practices and in contributing to improving nutritional status scenario.
doi:10.4103/0970-0218.120159
PMCID: PMC3831694  PMID: 24302825
Accredited social health activists; at risk families; child feeding practices; community volunteers; inter-personal counseling; severe malnutrition; undernutrition

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