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1.  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
2.  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
3.  Undernutrition and Its Correlates among Children of 3–9 Years of Age Residing in Slum Areas of Bhubaneswar, India 
The Scientific World Journal  2014;2014:719673.
Undernutrition among children is a major public health concern worldwide, more prevalent in Asia and Africa. It manifests itself in various forms such as wasting or stunting or underweight and retards physical and mental development, increases susceptibility to infection, and reduces educational attainment and productivity. The present study was undertaken to assess the level of wasting, stunting, and underweight and determine its associates among slum children of 3–9 years of age, residing in Bhubaneswar city, India. After obtaining informed consent, a total of 249 children from 249 households were studied and their parents/guardians were interviewed to collect all relevant information. 23.3%, 57.4%, and 45.4% of children were found to have wasting, stunting, and underweight, respectively. Variables like birth order of child, period of initiation of breastfeeding and mother's education were found to be strong predictors of wasting, whereas toilet facility in household and practice of drinking water storage were significantly associated with stunting among slum children as revealed in multiple regression analysis. Thus, a multipronged approach is needed such as giving priority to improve education for slum community especially for women, creating awareness regarding benefits of early initiation of breastfeeding, small family size, and proper storage of drinking water, and providing toilet facility in slum households which could improve the nutritional status of slum children.
doi:10.1155/2014/719673
PMCID: PMC4280492  PMID: 25580460
4.  The Double Burden of Obesity and Malnutrition in a Protracted Emergency Setting: A Cross-Sectional Study of Western Sahara Refugees 
PLoS Medicine  2012;9(10):e1001320.
Surveying women and children from refugee camps in Algeria, Carlos Grijalva-Eternod and colleagues find high rates of obesity among women as well as many undernourished children, and that almost a quarter of households are affected by both undernutrition and obesity.
Background
Households from vulnerable groups experiencing epidemiological transitions are known to be affected concomitantly by under-nutrition and obesity. Yet, it is unknown to what extent this double burden affects refugee populations dependent on food assistance. We assessed the double burden of malnutrition among Western Sahara refugees living in a protracted emergency.
Methods and Findings
We implemented a stratified nutrition survey in October–November 2010 in the four Western Sahara refugee camps in Algeria. We sampled 2,005 households, collecting anthropometric measurements (weight, height, and waist circumference) in 1,608 children (6–59 mo) and 1,781 women (15–49 y). We estimated the prevalence of global acute malnutrition (GAM), stunting, underweight, and overweight in children; and stunting, underweight, overweight, and central obesity in women. To assess the burden of malnutrition within households, households were first classified according to the presence of each type of malnutrition. Households were then classified as undernourished, overweight, or affected by the double burden if they presented members with under-nutrition, overweight, or both, respectively.
The prevalence of GAM in children was 9.1%, 29.1% were stunted, 18.6% were underweight, and 2.4% were overweight; among the women, 14.8% were stunted, 53.7% were overweight or obese, and 71.4% had central obesity. Central obesity (47.2%) and overweight (38.8%) in women affected a higher proportion of households than did GAM (7.0%), stunting (19.5%), or underweight (13.3%) in children. Overall, households classified as overweight (31.5%) were most common, followed by undernourished (25.8%), and then double burden–affected (24.7%).
Conclusions
The double burden of obesity and under-nutrition is highly prevalent in households among Western Sahara refugees. The results highlight the need to focus more attention on non-communicable diseases in this population and balance obesity prevention and management with interventions to tackle under-nutrition.
Please see later in the article for the Editors' Summary
Editors' Summary
Background
Good nutrition is essential for human health and survival. Insufficient food intake causes under-nutrition, which increases susceptibility to infections; intake of too much or inappropriate food, in particular in interaction with sedentary behaviour, can lead to obesity, which increases the risk of non-communicable diseases such as diabetes. During the past 30 years, the prevalence (the proportion of a population affected by a condition) of obesity has greatly increased, initially among adults in industrialized countries, but more recently among children and in less-affluent populations. Now, worldwide, overweight people outnumber under-nourished people. Furthermore, some populations are affected by both under-nutrition and obesity, forms of malnutrition that occur when the diet is suboptimal for health. So, for example, a child can be both stunted (short for his or her age, an indicator of long-term under-nutrition) and overweight (too heavy for his or her age). The emergence of this double burden of malnutrition has been attributed to the nutrition transition—the rapid move because of migration or urbanization to a lifestyle characterized by low levels of physical activity and high consumption of refined, energy-dense foods—without complete elimination of under-nutrition.
Why Was This Study Done?
Refugees are one group of people in whom under-nutrition and obesity sometimes coexist. Worldwide, in 2010, 15.4 million refugees were dependent on host governments and international humanitarian agencies for their food security and well-being. It is essential that these governments and organizations provide appropriate food assistance programs to refugees—policies that are appropriate during acute emergencies may not be appropriate in protracted emergencies and may contribute to the emergence of the double burden of malnutrition among refugees. Unfortunately, the extent to which the double burden of malnutrition affects refugees in protracted emergencies is unknown. In this cross-sectional study (an investigation that looks at the characteristics of a population at a single time), the researchers assessed the double burden of malnutrition among people from Western Sahara who have been living in four refugee camps near Tindouf city, Algeria, since 1975.
What Did the Researchers Do and Find?
The researchers used data from a 2010 survey that measured the height and weight of children and the height, weight, and waist circumference of women living in 2,005 households in the Algerian refugee camps. For the children, they estimated the prevalence of global acute malnutrition (which includes thin, “wasted” children, as indicated by a low weight for height based on the World Health Organization growth standards, and those with nutritional oedema), stunting, and underweight and overweight (low and high weight for age and gender, respectively). For the women, they estimated the prevalence of stunting, underweight (body mass index less than 18.5 kg/m2), overweight (body mass index greater than 25 kg/m2), and central obesity (a waist circumference of more than 80 cm). Among the children, 9.1% had global acute malnutrition, 29.1% were stunted, 8.6% were underweight, and 2.4% were overweight. Among the women, 14.8% were stunted, 53.7% were overweight, and 71.4% had central obesity. Notably, central obesity and overweight in women affected more households than global acute malnutrition, stunting, and underweight in children. Finally, based on whether a household included members with under-nutrition or overweight, alone or in combination, the researchers classified a third of households as overweight, a quarter as undernourished, and a quarter as affected by the double burden of malnutrition.
What Do These Findings Mean?
These findings indicate that there is a high prevalence of the double burden of malnutrition among households in Western Saharan refugee camps in Algeria. Although this study provides no information on men and does not investigate whether the obesity seen in these camps leads to an increased risk of diabetes and other non-communicable diseases, these findings have several important implications for the provision of food assistance and care for protracted humanitarian emergencies. For example, they highlight the need to promote long-term food security and to improve nutrition adequacy and food diversity in protracted emergencies. In addition, they suggest that current food assistance programs that are suitable for acute emergencies may not be suitable for extended emergencies. They also highlight the need to focus more attention on non-communicable diseases in refugee camps and to develop innovative ways to provide obesity prevention and management in these settings. However, as the researchers stress, careful policy and advocacy work is essential to ensure that efforts to deal with the threat of obesity among refugees do not jeopardize support for life-saving food assistance programs for refugees.
Additional Information
Please access these websites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1001320.
Wikipedia provides background information about the Western Sahara refugee camps near Tindouf, Algeria (note that Wikipedia is a free online encyclopedia that anyone can edit)
The World Health Organization provides information on all aspects of nutrition and obesity (in several languages)
The United Nations World Food Programme is the world's largest humanitarian agency fighting hunger worldwide; its website provides detailed information about hunger and information about its work in the Western Sahara refugee camps in Algeria, including personal stories and photographs of food distribution
The United Nations High Commissioner for Refugees is the United Nations body mandated to lead and coordinate international action to protect refugees and resolve refugee problems worldwide; its website provides detailed information about its work in the Western Sahara refugee camps in Algeria
Oxfam also provides detailed information about its work in the Algerian refugee camps, a description of the camps, and personal stories from people living in the camps
An article published by the Food and Agriculture Organization of the United Nations explains the double burden of malnutrition
doi:10.1371/journal.pmed.1001320
PMCID: PMC3462761  PMID: 23055833
5.  Is Economic Growth Associated with Reduction in Child Undernutrition in India? 
PLoS Medicine  2011;8(3):e1000424.
An analysis of cross-sectional data from repeated household surveys in India, combined with data on economic growth, fails to find strong evidence that recent economic growth in India is associated with a reduction in child undernutrition.
Background
Economic growth is widely perceived as a major policy instrument in reducing childhood undernutrition in India. We assessed the association between changes in state per capita income and the risk of undernutrition among children in India.
Methods and Findings
Data for this analysis came from three cross-sectional waves of the National Family Health Survey (NFHS) conducted in 1992–93, 1998–99, and 2005–06 in India. The sample sizes in the three waves were 33,816, 30,383, and 28,876 children, respectively. After excluding observations missing on the child anthropometric measures and the independent variables included in the study, the analytic sample size was 28,066, 26,121, and 23,139, respectively, with a pooled sample size of 77,326 children. The proportion of missing data was 12%–20%. The outcomes were underweight, stunting, and wasting, defined as more than two standard deviations below the World Health Organization–determined median scores by age and gender. We also examined severe underweight, severe stunting, and severe wasting. The main exposure of interest was per capita income at the state level at each survey period measured as per capita net state domestic product measured in 2008 prices. We estimated fixed and random effects logistic models that accounted for the clustering of the data. In models that did not account for survey-period effects, there appeared to be an inverse association between state economic growth and risk of undernutrition among children. However, in models accounting for data structure related to repeated cross-sectional design through survey period effects, state economic growth was not associated with the risk of underweight (OR 1.01, 95% CI 0.98, 1.04), stunting (OR 1.02, 95% CI 0.99, 1.05), and wasting (OR 0.99, 95% CI 0.96, 1.02). Adjustment for demographic and socioeconomic covariates did not alter these estimates. Similar patterns were observed for severe undernutrition outcomes.
Conclusions
We failed to find consistent evidence that economic growth leads to reduction in childhood undernutrition in India. Direct investments in appropriate health interventions may be necessary to reduce childhood undernutrition in India.
Please see later in the article for the Editors' Summary
Editors' Summary
Background
Good nutrition during childhood is essential for health and survival. Undernourished children are more susceptible to infections and more likely to die from common ailments such as diarrhea than well-nourished children. Thus, globally, undernutrition contributes to more than a third of deaths among children under 5 years old. Experts use three physical measurements to determine whether a child is undernourished. An "underweight" child has a low weight for his or her age and gender when compared to the World Health Organization Child Growth Standards, which chart the growth of a reference population. A "stunted" child has a low height for his or her age; stunting is an indicator of chronic undernutrition. A "wasted" child has a low weight for his or her height; wasting is an indicator of acute undernutrition and often follows an earthquake, flood, or other emergency. The prevalence (how often a condition occurs within a population) of undernutrition is particularly high in India. Here, almost half of children under the age of 3 are underweight, about half are stunted, and a quarter are wasted.
Why Was This Study Done?
Although the prevalence of undernutrition in India is decreasing, progress is slow. Economic growth is widely regarded as the major way to reduce child undernutrition in India. Economic growth, the argument goes, will increase incomes, reduce poverty, and increase access to health services and nutrition. But some experts believe that better education for women and reduced household sizes might have a greater influence on child undernutrition than economic growth. And others believe that healthier, better fed populations lead to increased economic growth rather than the other way around. In this study, the researchers assess the association between economic growth and child undernutrition in India by analyzing the relationship between changes in per capita income in individual Indian states and the individual risk of undernutrition among children in India.
What Did the Researchers Do and Find?
For their analyses, the researchers used data on 77,326 Indian children that were collected in the 1992–93, 1998–99, and 2005–06 National Family Health Surveys; these surveys are part of the Demographic and Health Surveys, a project that collects health data in developing countries to aid health-system development. The researchers used eight "ecological" statistical models to investigate whether there was an association between underweight, stunting, or wasting and per capita income at the state level in each survey period; these ecological models assumed that the risk of undernutrition was the same for every child in a state. They also used 10 "multilevel" models to quantify the association between state-level growth and the individual-level risk of undernutrition. The multilevel models also took account of various combinations of additional factors likely to affect undernutrition (for example, mother's education and marital status). In five of the ecological models, there was no statistically significant association between state economic growth and average levels of child undernutrition at the state level (statistically significant associations are unlikely to have arisen by chance). Similarly, in eight of the multilevel models, there was no statistical evidence for an association between economic growth and undernutrition.
What Do These Findings Mean?
These findings provide little statistical support for the widely held assumption that there is an association between the risk of child undernutrition and economic growth in India. By contrast, a previous study that used data from 63 countries collected over 26 years did find evidence that national economic growth was inversely associated with the risk of child undernutrition. However, this study was an ecological study and did not, therefore, allow for the possibility that the risk of undernutrition might vary between children in one state and between states. Further, the target of inference in this study was "explaining" between-country differences, while the target of inference in this analysis was explaining within country differences over time. The researchers suggest several reasons why there might not be a clear association between economic growth and undernutrition in India. For example, they suggest, economic growth in India might have only benefitted privileged sections of society. Whether this or an alternative explanation accounts for the lack of an association, it seems likely that further reductions in the prevalence of child undernutrition in India (and possibly in other developing countries) will require direct investment in health and health-related programs; expecting economic growth to improve child undernutrition might not be a viable option after all.
Additional Information
Please access these websites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1000424.
The charity UNICEF, which protects the rights of children and young people around the world, provides detailed statistics on child undernutrition and on child nutrition and undernutrition in India
The WHO Child Growth Standards are available (in several languages)
More information on the Demographic and Health Surveys and on the Indian National Family Health Surveys is available
The United Nations Millennium Development Goals website provides information on ongoing world efforts to reduce hunger and child mortality
doi:10.1371/journal.pmed.1000424
PMCID: PMC3050933  PMID: 21408084
6.  Protein Energy Malnutrition in India: The Plight of Our Under Five Children 
Protein energy malnutrition (PEM) is a major public health problem in India. This affects the child at the most crucial period of time of development, which can lead to permanent impairment in later life. PEM is measured in terms of underweight (low weight for age), stunting (low height for age) and wasting (low weight for height). The prevalence of stunting among under five is 48% and wasting is 19.8% and with an underweight prevalence of 42.5%, it is the highest in the world. Undernutrition predisposes the child to infection and complements its effect in contributing to child mortality. Lalonde model (1974) is used to look into the various determinants of PEM in under five children and its interrelation in causation of PEM. The determinants of PEM are broadly classified under four distinct categories: Environmental factors including the physical and social environment, behavioral factors, health-care service related and biological factors. The socio-cultural factors play an important role wherein, it affects the attitude of the care giver in feeding and care practices. Faulty feeding practice in addition to poor nutritional status of the mother further worsens the situation. The vicious cycle of poor nutritional status of the mother leading to low birth weight child further exposes the child to susceptibility to infections which aggravates the situation. However, it is seen that percapita income of the family did not have much bearing on the poor nutritional status of the child rather lack of proper health-care services adversely contributed to poor nutritional status of the child. PEM is a critical problem with many determinants playing a role in causing this vicious cycle of undernutrition. With almost half of under five children undernourished in India, the Millennium Development Goal (MDG) of halving the prevalence of underweight by 2015 seems a distant dream.
doi:10.4103/2249-4863.130279
PMCID: PMC4005205  PMID: 24791240
India; protein energy malnutrition; under five children; undernutrition
7.  Community Mobilization in Mumbai Slums to Improve Perinatal Care and Outcomes: A Cluster Randomized Controlled Trial 
PLoS Medicine  2012;9(7):e1001257.
David Osrin and colleagues report findings from a cluster-randomized trial conducted in Mumbai slums; the trial aimed to evaluate whether facilitator-supported women's groups could improve perinatal outcomes.
Introduction
Improving maternal and newborn health in low-income settings requires both health service and community action. Previous community initiatives have been predominantly rural, but India is urbanizing. While working to improve health service quality, we tested an intervention in which urban slum-dweller women's groups worked to improve local perinatal health.
Methods and Findings
A cluster randomized controlled trial in 24 intervention and 24 control settlements covered a population of 283,000. In each intervention cluster, a facilitator supported women's groups through an action learning cycle in which they discussed perinatal experiences, improved their knowledge, and took local action. We monitored births, stillbirths, and neonatal deaths, and interviewed mothers at 6 weeks postpartum. The primary outcomes described perinatal care, maternal morbidity, and extended perinatal mortality. The analysis included 18,197 births over 3 years from 2006 to 2009. We found no differences between trial arms in uptake of antenatal care, reported work, rest, and diet in later pregnancy, institutional delivery, early and exclusive breastfeeding, or care-seeking. The stillbirth rate was non-significantly lower in the intervention arm (odds ratio 0.86, 95% CI 0.60–1.22), and the neonatal mortality rate higher (1.48, 1.06–2.08). The extended perinatal mortality rate did not differ between arms (1.19, 0.90–1.57). We have no evidence that these differences could be explained by the intervention.
Conclusions
Facilitating urban community groups was feasible, and there was evidence of behaviour change, but we did not see population-level effects on health care or mortality. In cities with multiple sources of health care, but inequitable access to services, community mobilization should be integrated with attempts to deliver services for the poorest and most vulnerable, and with initiatives to improve quality of care in both public and private sectors.
Trial registration
Current Controlled Trials ISRCTN96256793
Please see later in the article for the Editors' Summary
Editors' Summary
Background
Substantial progress is being made to reduce global child mortality (deaths of children before the age of 5 years) and maternal mortality (deaths among women because of complications of pregnancy and childbirth)—two of the Millennium Development Goals agreed by world leaders in 2000 to end extreme poverty. Even so, worldwide, in 2010, 7.6 million children died before their fifth birthday and there were nearly 360,000 maternal deaths. Almost all child and maternal deaths occur in developing countries—a fifth of under-five deaths and more than a quarter of neonatal deaths (deaths during the first month of life, which account for two-fifths of all child deaths) occur in India alone. Moreover, most child and maternal deaths are caused by avoidable conditions. Specifically, the major causes of neonatal death—complications of preterm delivery, breathing problems during or after delivery, and infections of the blood (sepsis) and lungs (pneumonia)—and of maternal deaths—hemorrhage (abnormal bleeding), sepsis, unsafe abortion, obstructed labor, and hypertensive diseases of pregnancy—could all be largely prevented by improved access to reproductive health services and skilled health care workers.
Why Was This Study Done?
Experts believe that improvements to maternal and newborn health in low-income settings require both health service strengthening and community action. That is, the demand for better services, driven by improved knowledge about maternal and newborn health (perinatal issues), has to be increased in parallel with the supply of those services. To date, community mobilization around perinatal issues has largely been undertaken in rural settings but populations in developing countries are becoming increasingly urban. In India, for example, 30% of the population now lives in cities. In this cluster randomized controlled trial (a study in which groups of people are randomly assigned to receive alternative interventions and the outcomes in the differently treated “clusters” are compared), City Initiative for Newborn Health (CINH) researchers investigate the effect of an intervention designed to help women's groups in the slums of Mumbai work towards improving local perinatal health. The CINH aims to improve maternal and newborn health in slum communities by improving public health care provision and by working with community members to improve maternal and newborn care practices and care-seeking behaviors.
What Did the Researchers Do and Find?
The researchers enrolled 48 Mumbai slum communities of at least 1,000 households into their trial. In each of the 24 intervention clusters, a facilitator supported local women's groups through a 36-meeting learning cycle during which group members discussed their perinatal experiences, improved their knowledge, and took action. To measure the effect of the intervention, the researchers monitored births, stillbirths, and neonatal deaths in all the clusters and interviewed mothers 6 weeks after delivery. During the 3-year trial, there were 18,197 births in the participating settlements. The women in the intervention clusters were enthusiastic about acquiring new knowledge and made substantial efforts to reach out to other women but were less successful in undertaking collective action such as negotiations with civic authorities for more amenities. There were no differences between the intervention and control communities in the uptake of antenatal care, reported work, rest, and diet in late pregnancy, institutional delivery, or in breast feeding and care-seeking behavior. Finally, the combined rate of stillbirths and neonatal deaths (the extended perinatal mortality rate) was the same in both arms of the trial, as was maternal mortality.
What Do These Findings Mean?
These findings indicate that it is possible to facilitate the discussion of perinatal health care by urban women's groups in the challenging conditions that exist in the slums of Mumbai. However, they fail to show any measureable effect of community mobilization through the facilitation of women's groups on perinatal health at the population level. The researchers acknowledge that more intensive community activities that target the poorest, most vulnerable slum dwellers might produce measurable effects on perinatal mortality, and they conclude that, in cities with multiple sources of health care and inequitable access to services, it remains important to integrate community mobilization with attempts to deliver services to the poorest and most vulnerable, and with initiatives to improve the quality of health care in both the public and private sector.
Additional Information
Please access these Web sites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1001257.
The United Nations Childrens Fund (UNICEF) works for children's rights, survival, development, and protection around the world; it provides information on the reduction of child mortality (Millennium Development Goal 4); its Childinfo website provides information about all the Millennium Development Goals and detailed statistics about on child survival and health, newborn care, and maternal health (some information in several languages)
The World Health Organization also has information about Millennium Development Goal 4 and Millennium Development Goal 5, the reduction of maternal mortality, provides information on newborn infants, and provides estimates of child mortality rates (some information in several languages)
Further information about the Millennium Development Goals is available
Information on the City Initiative for Newborn Health and its partners and a detailed description of its trial of community mobilization in Mumbai slums to improve care during pregnancy, delivery, postnatally and for the newborn are available
Further information about the Society for Nutrition, Education and Health Action (SNEHA) is available
doi:10.1371/journal.pmed.1001257
PMCID: PMC3389036  PMID: 22802737
8.  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
9.  Burden of Giardia duodenalis Infection and Its Adverse Effects on Growth of Schoolchildren in Rural Malaysia 
Background
Giardia duodenalis infection and malnutrition are still considered as public health problems in many developing countries especially among children in rural communities. This study was carried out among Aboriginal (Orang Asli) primary schoolchildren in rural peninsular Malaysia to investigate the burden and the effects of Giardia infection on growth (weight and height) of the children.
Methods/Findings
Weight and height of 374 children aged 7–12 years were assessed before and after treatment of Giardia infection. The children were screened for Giardia parasite using trichrome staining technique. Demographic and socioeconomic data were collected via face-to-face interviews using a pre-tested questionnaire. Overall, 22.2% (83/374) of the children were found to be infected with Giardia. Nutritional status of children was assessed and the results showed that the mean weight and height were 23.9 kg (95% CI = 23.3, 24.5) and 126.6 cm (95% CI = 125.6, 127.5), respectively. Overall, the prevalence of severe underweight, stunting and wasting were 28.3%, 23.8% and 21.0%, respectively. Multiple linear regression analyses showed sex, Giardia infection and household monthly income as the significant determinants of weight while sex and level of mother's education were the significant determinants of height. Weight and height were assessed at 3 and 6 months after treatment of Giardia infection. It was found that Giardia infection has a significant association with the weight of children but not with height.
Conclusions/Significance
This study reveals high prevalence of Giardia infection and malnutrition among Aboriginal children in rural Malaysia and clearly highlights an urgent need to identify integrated measures to control these health problems in the rural communities. Essentially, proper attention should be given to the control of Giardia infection in Aboriginal communities as this constitutes one of the strategies to improve the nutritional status of Aboriginal children.
Author Summary
Giardia infection, a neglected infection caused by the protozoan parasite Giardia duodenalis is prevalent worldwide especially among young children in rural areas of the tropics and subtropics. In Malaysia, Giardia infection and protein-energy malnutrition coexist in Aboriginal (Orang Asli) communities with high prevalence among school-aged children. We screened 374 schoolchildren in Lipis and Raub districts, Pahang, Malaysia for the presence of Giardia infection and investigated the effects of this infection on the growth of children. Overall, 22.2% of the children studied were infected with Giardia. Nutritional status of children was assessed and we found that the prevalence of severe underweight, stunting and wasting were 28.3%, 23.8% and 21.0%, respectively. Giardia infection was identified as a significant determinant of weight among these children. Moreover, it was found that Giardia infection has a significant association with the weight of children but not with height. The control of Giardia infection should be given prominence as it is one of the strategies to enhance the nutritional status of Aboriginal children.
doi:10.1371/journal.pntd.0002516
PMCID: PMC3814875  PMID: 24205426
10.  The Effect of Adding Ready-to-Use Supplementary Food to a General Food Distribution on Child Nutritional Status and Morbidity: A Cluster-Randomized Controlled Trial 
PLoS Medicine  2012;9(9):e1001313.
Lieven Huybregts and colleagues investigate how supplementing a general food distribution with a fortified lipid-based spread during a seasonal hunger gap in Chad affects anthropometric and morbidity outcomes for children aged 6 to 36 months.
Background
Recently, operational organizations active in child nutrition in developing countries have suggested that blanket feeding strategies be adopted to enable the prevention of child wasting. A new range of nutritional supplements is now available, with claims that they can prevent wasting in populations at risk of periodic food shortages. Evidence is lacking as to the effectiveness of such preventive interventions. This study examined the effect of a ready-to-use supplementary food (RUSF) on the prevention of wasting in 6- to 36-mo-old children within the framework of a general food distribution program.
Methods and Findings
We conducted a two-arm cluster-randomized controlled pragmatic intervention study in a sample of 1,038 children aged 6 to 36 mo in the city of Abeche, Chad. Both arms were included in a general food distribution program providing staple foods. The intervention group was given a daily 46 g of RUSF for 4 mo. Anthropometric measurements and morbidity were recorded monthly. Adding RUSF to a package of monthly household food rations for households containing a child assigned to the intervention group did not result in a reduction in cumulative incidence of wasting (incidence risk ratio: 0.86; 95% CI: 0.67, 1.11; p = 0.25). However, the intervention group had a modestly higher gain in height-for-age (+0.03 Z-score/mo; 95% CI: 0.01, 0.04; p<0.001). In addition, children in the intervention group had a significantly higher hemoglobin concentration at the end of the study than children in the control group (+3.8 g/l; 95% CI: 0.6, 7.0; p = 0.02), thereby reducing the odds of anemia (odds ratio: 0.52; 95% CI: 0.34, 0.82; p = 0.004). Adding RUSF also resulted in a significantly lower risk of self-reported diarrhea (−29.3%; 95% CI: 20.5, 37.2; p<0.001) and fever episodes (−22.5%; 95% CI: 14.0, 30.2; p<0.001). Limitations of this study include that the projected sample size was not fully attained and that significantly fewer children from the control group were present at follow-up sessions.
Conclusions
Providing RUSF as part of a general food distribution resulted in improvements in hemoglobin status and small improvements in linear growth, accompanied by an apparent reduction in morbidity.
Trial registration
ClinicalTrials.gov NCT01154595
Please see later in the article for the Editors' Summary.
Editors' Summary
Background
Good nutrition during childhood is essential for health and survival. Undernourished children are more susceptible to infections and are more likely to die from common ailments such as diarrhea than well-nourished children. Globally, undernutrition contributes to about a third of deaths among children under five years old. Experts use three physical measurements to determine whether a child is undernourished. An “underweight” child has a low weight for his or her age and gender when compared to the World Health Organization Child Growth Standards, which chart the growth of a reference population. A “stunted” child has a low height for his or her age; stunting indicates chronic undernutrition. A “wasted” child has a low weight for his or her height; wasting indicates acute undernutrition and can be caused by disasters or seasonal food shortages. Recent estimates indicate that about a fifth of young children in developing countries are underweight, and one third are stunted; in south Asia and west/central Africa, more than one tenth of children are wasted, a condition that markedly increases the risk of death.
Why Was This Study Done?
In emergency situations, international organizations support affected populations by providing “general food distributions.” Recently, there have been claims that the provision of targeted nutritional supplements within a general food distribution framework effectively prevents child wasting, but there is little evidence to support these claims. In this cluster-randomized controlled trial, the researchers investigate the effect of a targeted daily dose of a “ready-to-use supplementary food” (RUSF; a lipid-based nutrient supplement) on indicators of undernutrition in 6- to 36-month-old, non-wasted children in Chad, a country beset by a severe food crisis. Political instability in this central African country has severely reduced the nutritional status of children, and annual droughts, which affect crop production, cause a “hunger gap” between June and October. In a recent survey, one fifth of children in Chad were wasted at the beginning of this hunger gap. A cluster-randomized trial randomly assigns groups of people to receive alternative interventions and compares the outcomes in the differently treated “clusters.”
What Did the Researchers Do and Find?
The researchers randomly assigned fourteen household clusters in the city of Abeche, Chad, to the trial's intervention or control arm. All the households received a general food distribution that included staple foods; eligible children in the intervention households were also given a daily RUSF ration between June and September 2010. The researchers regularly measured the children's weights and heights, recorded illnesses reported by caregivers, and measured each child's blood hemoglobin level before and after the intervention to assess their risk of anemia, an indicator of poor nutrition. The addition of RUSF to the household food rations did not significantly reduce the cumulative incidence of wasting. That is, although fewer children in the intervention group became wasted during the trial than in the control group, this difference was not statistically significant—it could have happened by chance. However, compared to the children in the control group, those in the intervention group had a significantly greater gain in height-for-age (equivalent to a difference in height gain of 0.09 cm/month), slightly higher hemoglobin levels at the end of the study, which significantly reduced their anemia risk, and a significantly lower risk of self-reported diarrhea and fever.
What Do These Findings Mean?
Although targeted RUSF provided as part of a general food distribution had no significant effect on wasting in young children in Abeche, Chad, the intervention improved their hemoglobin status and linear growth, and reduced illness among them. Why didn't targeted RUSF prevent wasting effectively in this trial? Maybe the effect of RUSF was diluted out by the effect of the general food distribution or maybe the trial was too short to see a clear effect. Most importantly, though, the trial may have been too small to see a clear effect—the researchers were unable to enroll as many children into their trial as they had planned because of political instability in Chad, and this probably limited the trial's ability to detect small differences between the control and intervention groups. Nevertheless, because these findings provide no clear evidence that adding RUSF to a household food ration effectively prevents wasting, alternative ways to prevent acute malnutrition in Chad and other vulnerable regions of the world should be investigated.
Additional Information
Please access these websites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1001313.
This study is further discussed in a PLOS Medicine Perspective by Kathryn Dewey and Mary Arimond
Action Contra la Faim–France has a web page that describes the situation in Chad
The United Nations Childrens Fund, which protects the rights of children and young people around the world, provides detailed statistics on child undernutrition; it has detailed information, including videos, about the current food crisis in Chad and the Sahel
The WHO Child Growth Standards are available (in several languages)
The United Nations provides information on ongoing world efforts to reduce hunger and child mortality
The World Food Programme is the world's largest humanitarian agency fighting hunger worldwide; its website provides detailed information about malnutrition in Chad, including a video of the current food crisis in the country
Starved for Attention is an international multimedia campaign launched in 2010 by Médecins Sans Frontiéres (MSF) and the VII Photo agency to rewrite the story of childhood malnutrition; information about MSFs work in Chad to tackle malnutrition is available
doi:10.1371/journal.pmed.1001313
PMCID: PMC3445445  PMID: 23028263
11.  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
12.  Nutritional Status of Under-five Children Living in an Informal Urban Settlement in Nairobi, Kenya 
Malnutrition in sub-Saharan Africa contributes to high rates of childhood morbidity and mortality. However, little information on the nutritional status of children is available from informal settlements. During the period of post-election violence in Kenya during December 2007–March 2008, food shortages were widespread within informal settlements in Nairobi. To investigate whether food insecurity due to post-election violence resulted in high prevalence of acute and chronic malnutrition in children, a nutritional survey was undertaken among children aged 6-59 months within two villages in Kibera, where the Kenya Medical Research Institute/Centers for Disease Control and Prevention conducts population-based surveillance for infectious disease syndromes. During 25 March–4 April 2008, a structured questionnaire was administered to caregivers of 1,310 children identified through surveillance system databases to obtain information on household demographics, food availability, and child-feeding practices. Anthropometric measurements were recorded on all participating children. Indices were reported in z-scores and compared with the World Health Organization (WHO) 2005 reference population to determine the nutritional status of children. Data were analyzed using the Anthro software of WHO and the SAS. Stunting was found in 47.0% of the children; 11.8% were underweight, and 2.6% were wasted. Severe stunting was found in 23.4% of the children; severe underweight in 3.1%, and severe wasting in 0.6%. Children aged 36-47 months had the highest prevalence (58.0%) of stunting while the highest prevalence (4.1%) of wasting was in children aged 6-11 months. Boys were more stunted than girls (p<0.01), and older children were significantly (p<0.0001) stunted compared to younger children. In the third year of life, girls were more likely than boys to be wasted (p<0.01). The high prevalence of chronic malnutrition suggests that stunting is a sustained problem within this urban informal settlement, not specifically resulting from the relatively brief political crisis. The predominance of stunting in older children indicates failure in growth and development during the first two years of life. Food programmes in Kenya have traditionally focused on rural areas and refugee camps. The findings of the study suggest that tackling childhood stunting is a high priority, and there should be fostered efforts to ensure that malnutrition-prevention strategies include the urban poor.
PMCID: PMC3190366  PMID: 21957674
Child nutrition; Child nutrition disorders; Child nutritional status; Cross-sectional studies; Food security; Informal settlement; Slums; Kenya
13.  Socioeconomic Inequalities in Childhood Undernutrition in India: Analyzing Trends between 1992 and 2005 
PLoS ONE  2010;5(6):e11392.
Background
India experienced a rapid economic boom between 1991 and 2007. However, this economic growth has not translated into improved nutritional status among young Indian children. Additionally, no study has assessed the trends in social disparities in childhood undernutrition in the Indian context. We examined the trends in social disparities in underweight and stunting among Indian children aged less than three years using nationally representative data.
Methods
We analyzed data from the three cross-sectional rounds of National Family Health Survey of India from 1992, 1998 and 2005. The social factors of interest were: household wealth, maternal education, caste, and urban residence. Using multilevel modeling to account for the nested structure and clustering of data, we fit multivariable logistic regression models to quantify the association between the social factors and the binary outcome variables. The final models additionally included age, gender, birth order of child, religion, and age of mother. We analyzed the trend by testing for interaction of the social factor and survey year in a dataset pooled from all three surveys.
Results
While the overall prevalence rates of undernutrition among Indian children less than three decreased over the 1992–2005 period, social disparities in undernutrition over these 14 years either widened or stayed the same. The absolute rates of undernutrition decreased for everyone regardless of their social status. The disparities by household wealth were greater than the disparities by maternal education. There were no disparities in undernutrition by caste, gender or rural residence.
Conclusions
There was a steady decrease in the rates of stunting in the 1992–2005 period, while the decline in underweight was greater between 1992 and 1998 than between 1998 and 2005. Social disparities in childhood undernutrition in India either widened or stayed the same during a time of major economic growth. While the advantages of economic growth might be reaching everyone, children from better-off households, with better educated mothers appear to have benefited to a greater extent than less privileged children. The high rates of undernutrition (even among the socially advantaged groups) and the persistent social disparities need to be addressed in an urgent and comprehensive manner.
doi:10.1371/journal.pone.0011392
PMCID: PMC2894973  PMID: 20617192
14.  Prevalence and correlates of smoking among urban adult men in Bangladesh: slum versus non-slum comparison 
BMC Public Health  2009;9:149.
Background
Smoking is one of the leading causes of premature death particularly in developing countries. The prevalence of smoking is high among the general male population in Bangladesh. Unfortunately smoking information including correlates of smoking in the cities especially in the urban slums is very scarce, although urbanization is rapid in Bangladesh and slums are growing quickly in its major cities. Therefore this study reported prevalences of cigarette and bidi smoking and their correlates separately by urban slums and non-slums in Bangladesh.
Methods
We used secondary data which was collected by the 2006 Urban Health Survey. The data were representative for the urban areas in Bangladesh. Both slums and non-slums located in the six City Corporations were considered. Slums in the cities were identified by two steps, first by using the satellite images and secondly by ground truthing. At the next stage, several clusters of households were selected by using proportional sampling. Then from each of the selected clusters, about 25 households were randomly selected. Information of a total of 12,155 adult men, aged 15–59 years, was analyzed by stratifying them into slum (= 6,488) and non-slum (= 5,667) groups. Simple frequency, bivariable and multivariable logistic regression analyses were performed using SPSS.
Results
Overall smoking prevalence for the total sample was 53.6% with significantly higher prevalences among men in slums (59.8%) than non-slums (46.4%). Respondents living in slums reported a significantly (P < 0.001) higher prevalence of smoking cigarettes (53.3%) as compared to those living in non-slums (44.6%). A similar pattern was found for bidis (slums = 11.4% and non-slums = 3.2%, P < 0.001). Multivariable logistic regression revealed significantly higher odds ratio (OR) of smoking cigarettes (OR = 1.12, 95% CI = 1.03–1.22), bidis (OR = 1.90, 95% CI = 1.58–2.29) and any of the two (OR = 1.23, 95% CI = 1.13–1.34) among men living in slums as compared to those living in non-slums when controlled for age, division, education, marital status, religion, birth place and types of work. Division, education and types of work were the common significant correlates for both cigarette and bidi smoking in slums and non-slums by multivariable logistic regressions. Other significant correlates of smoking cigarettes were marital status (both areas), birth place (slums), and religion (non-slums). Similarly significant factors for smoking bidis were age (both areas), marital status (slums), religion (non-slums), and birth place (both areas).
Conclusion
The men living in the urban slums reported higher rates of smoking cigarettes and bidis as compared to men living in the urban non-slums. Some of the significant correlates of smoking e.g. education and division should be considered for prevention activities. Our findings clearly underscore the necessity of interventions and preventions by policy makers, public health experts and other stakeholders in slums because smoking was more prevalent in the slum communities with detrimental health sequelae.
doi:10.1186/1471-2458-9-149
PMCID: PMC2705350  PMID: 19463157
15.  Mapping the Risk of Anaemia in Preschool-Age Children: The Contribution of Malnutrition, Malaria, and Helminth Infections in West Africa 
PLoS Medicine  2011;8(6):e1000438.
Ricardo Soares Magalhães and colleagues used national cross-sectional household-based demographic health surveys to map the distribution of anemia risk in preschool children in Burkina Faso, Ghana, and Mali.
Background
Childhood anaemia is considered a severe public health problem in most countries of sub-Saharan Africa. We investigated the geographical distribution of prevalence of anaemia and mean haemoglobin concentration (Hb) in children aged 1–4 y (preschool children) in West Africa. The aim was to estimate the geographical risk profile of anaemia accounting for malnutrition, malaria, and helminth infections, the risk of anaemia attributable to these factors, and the number of anaemia cases in preschool children for 2011.
Methods and Findings
National cross-sectional household-based demographic health surveys were conducted in 7,147 children aged 1–4 y in Burkina Faso, Ghana, and Mali in 2003–2006. Bayesian geostatistical models were developed to predict the geographical distribution of mean Hb and anaemia risk, adjusting for the nutritional status of preschool children, the location of their residence, predicted Plasmodium falciparum parasite rate in the 2- to 10-y age group (Pf PR2–10), and predicted prevalence of Schistosoma haematobium and hookworm infections. In the four countries, prevalence of mild, moderate, and severe anaemia was 21%, 66%, and 13% in Burkina Faso; 28%, 65%, and 7% in Ghana, and 26%, 62%, and 12% in Mali. The mean Hb was lowest in Burkina Faso (89 g/l), in males (93 g/l), and for children 1–2 y (88 g/l). In West Africa, severe malnutrition, Pf PR2–10, and biological synergisms between S. haematobium and hookworm infections were significantly associated with anaemia risk; an estimated 36.8%, 14.9%, 3.7%, 4.2%, and 0.9% of anaemia cases could be averted by treating malnutrition, malaria, S. haematobium infections, hookworm infections, and S. haematobium/hookworm coinfections, respectively. A large spatial cluster of low mean Hb (<80 g/l) and maximal risk of anaemia (>95%) was predicted for an area shared by Burkina Faso and Mali. We estimate that in 2011, approximately 6.7 million children aged 1–4 y are anaemic in the three study countries.
Conclusions
By mapping the distribution of anaemia risk in preschool children adjusted for malnutrition and parasitic infections, we provide a means to identify the geographical limits of anaemia burden and the contribution that malnutrition and parasites make to anaemia. Spatial targeting of ancillary micronutrient supplementation and control of other anaemia causes, such as malaria and helminth infection, can contribute to efficiently reducing the burden of anaemia in preschool children in Africa.
Please see later in the article for the Editors' Summary
Editors' Summary
Background
Global estimates for the time period 1993–2005 suggest that that worldwide, nearly 300 million children had anemia, that is, hemoglobin levels less than 110 g/l. In sub-Saharan Africa, two-thirds of all children were anemic, representing 83.5 million children. These statistics are important because anemia in infancy and childhood is associated with poor cognitive development, reduced growth, problems with immune function—and ultimately, decreased survival. Malnutrition (including micronutrient deficiency, especially of iron, vitamin A, vitamin C, and folate), undernutrition, and infectious diseases, particularly HIV, malaria, and helminth infections (caused by hookworm and Schistosoma haematobium—which causes urinary schistosomiasis), are major causes of anemia in children. Although iron supplementation can often correct anemia, in some circumstances, iron deficiency can protect against common infectious agents, and giving iron can, on occasion, increase the severity of infectious disease in some children. Focusing on the treatment and prevention of infectious diseases that cause anemia is therefore an important alternative strategy in the treatment of anemia.
Why Was This Study Done?
Control tools for targeting interventions for malaria and helminth infection in sub-Saharan Africa include modern spatial risk prediction methods that combine statistical models with geographical information systems (similar to those used in car navigation systems). However, to date no studies have used these tools to spatially predict the risk of anemia. Furthermore, the contribution that malnutrition and infections make to the overall anemia burden in Africa is largely unknown. In this study the researchers used these tools to predict the prevalence of anemia in three West African countries and to estimate the attributable risk of anemia due to malnutrition, malaria, and helminth infections.
What Did the Researchers Do and Find?
The researchers used geographically linked data from the most recent Demographic and Health Surveys (DHS) in Burkina Faso (2003), Ghana (2003), and Mali (2006), which included capillary blood sampling and testing and detailed anthropometric (height and weight) measurements. A total of 7,147 children aged 1–4 years (3,477 girls and 3,670 boys) in the three countries were included in the analysis. The researchers mapped DHS survey locations in the three study countries using DHS cluster coordinates in a geographic information system. Using data from the Malaria Atlas Project, the researchers extracted spatially predicted values of Plasmodium falciparum parasite rate for each DHS cluster using a geographical information system and used previously reported parasitological survey data of hookworm and S. haematobium infections to predict helminth infection risk across the region. Then the researchers developed spatial prediction models using Bayesian statistics to estimate of the population attributable fraction for specific predictors for anemia. Data from the DHS showed that the prevalence of mild, moderate, and severe anemia was 21%, 66%, and 13% in Burkina Faso; 28%, 65%, and 7% in Ghana, and 26%, 62%, and 12% in Mali. The prevalence of stunting, wasting, and being underweight in the study area was 87.8%, 89.7%, and 71.2%, respectively, and the mean P. falciparum parasite rate, and rates of S. haematobium infection, hookworm infection, and S. haematobium/hookworm coinfection for the study area were 52.0%, 26.8%, 8.2%, and 3.6%, respectively. The overall results indicate that in the three countries, approximately 6.7 million children aged 1–4 years have anemia. Severe malnutrition, P. falciparum infection, hookworm infection, S. haematobium infection, and hookworm/S. haematobium coinfection were responsible for an estimated 2.5 million, 1.0 million, 250,000, 285,000, and 61,000 anemia cases, respectively. Central Burkina Faso and southern Ghana had the highest number of anemic children.
What Do These Findings Mean?
These results add insight and detail to anemia prevalence and anemia severity within different geographical areas in three West African countries. The combination of anemia and mean hemoglobin predictive maps identifies communities in West Africa where preschool-age children are at increased risk of morbidity. The use of anemia maps has important practical implications for targeted control in these countries, such as guiding the efficient allocation of nutrient supplements and fortified foods, and enabling risk assessment of anemia due to different causes, which would in turn constitute an evidence base to calculate the best balance between interventions.
Additional Information
Please access these Web sites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1000438.
This study is further discussed in a PLoS Medicine Perspective by Abdisalan Noor
The WHO Web site has comprehensive information on the worldwide prevalence of anemia
More information on Demographic Health Surveys is available
More information on global predictions of malaria is available
doi:10.1371/journal.pmed.1000438
PMCID: PMC3110251  PMID: 21687688
16.  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
17.  A matching decomposition of the rural–urban difference in malnutrition in Malawi 
Background
Child malnutrition remains widespread in many developing countries. Malnutrition during infancy may substantially increase vulnerability to infection and disease, and the risk of premature death. Malnutrition in children may also lead to permanent effects and to their having diminished health capital later in life as adults. These negative consequences of child malnutrition entail that the reduction of child malnutrition is vital for the social-economic development of countries. Urban children generally have better nutritional status than rural children. Malawi is no exception in this regard. The objective of this paper is to explore how much of the rural-urban nutrition gap in Malawi is explained and how much is unexplained by differences in characteristics.
Method
Using data from the 2006 multiple indicator cluster survey (MICS), the paper used the Nopo decomposition method to decompose the rural-urban malnutrition gap. This nonparametric method takes into account the fact that the supports of the distributions of characteristics between the two areas can be different.
Results
The results show that 90% and 89% of the stunting and underweight gaps respectively would be eliminated if there were no urban children with combinations of characteristics which positively influence child nutrition that remain entirely unmatched by rural children. Further to that, 4% and 6% of the stunting and underweight gaps respectively would disappear if there were no rural children with combinations of characteristics which negatively affect child nutrition that remain entirely unmatched by urban children.
Conclusions
These findings suggest that the characteristics which negatively affect child nutrition in rural areas play a small role in the gap, and that most of the gap is largely due to the favourable characteristics such as better parental education and better household economic status among others that urban children have. The findings imply that in order to reduce the malnutrition gap policy interventions should focus more on ensuring that the favourable characteristics that urban children have such as better parental education, better household economic status among others are also available to rural children.
doi:10.1186/s13561-014-0011-9
PMCID: PMC4160003  PMID: 25302140
Matching; Decomposition; Malnutrition; Malawi
18.  Prevalence of undernutrition and associated factors among children aged between six to fifty nine months in Bule Hora district, South Ethiopia 
BMC Public Health  2015;15:41.
Background
More than one-third of deaths during the first five years of life are attributed to undernutrition, which are mostly preventable through economic development and public health measures. To alleviate this problem, it is necessary to determine the nature, magnitude and determinants of undernutrition. However, there is lack of evidence in agro-pastoralist communities like Bule Hora district. Therefore, this study assessed magnitude and factors associated with undernutrition in children who are 6–59 months of age in agro-pastoral community of Bule Hora District, South Ethiopia.
Methods
A community based cross-sectional study design was used to assess the magnitude and factors associated with undernutrition in children between 6–59 months. A structured questionnaire was used to collect data from 796 children paired with their mothers. Anthropometric measurements and determinant factors were collected. SPSS version 16.0 statistical software was used for analysis. Bivariate and multivariate logistic regression analyses were conducted to identify factors associated to nutritional status of the children Statistical association was declared significant if p-value was less than 0.05.
Results
Among study participants, 47.6%, 29.2% and 13.4% of them were stunted, underweight, and wasted respectively. Presence of diarrhea in the past two weeks, male sex, uneducated fathers and > 4 children ever born to a mother were significantly associated with being underweight. Presence of diarrhea in the past two weeks, male sex and pre–lacteal feeding were significantly associated with stunting. Similarly, presence of diarrhea in the past two weeks, age at complementary feed was started and not using family planning methods were associated to wasting.
Conclusion
Undernutrition is very common in under-five children of Bule Hora district. Factors associated to nutritional status of children in agro-pastoralist are similar to the agrarian community. Diarrheal morbidity was associated with all forms of Protein energy malnutrition. Family planning utilization decreases the risk of stunting and underweight. Feeding practices (pre-lacteal feeding and complementary feeding practice) were also related to undernutrition. Thus, nutritional intervention program in Bule Hora district in Ethiopia should focus on these factors.
doi:10.1186/s12889-015-1370-9
PMCID: PMC4314803  PMID: 25636688
Children; Undernutrition; Stunting; Wasting and underweight
19.  Methane production and small intestinal bacterial overgrowth in children living in a slum 
AIM: To analyze small intestinal bacterial overgrowth in school-aged children and the relationship between hydrogen and methane production in breath tests.
METHODS: This transversal study included 85 children residing in a slum and 43 children from a private school, all aged between 6 and 10 years, in Osasco, Brazil. For characterization of the groups, data regarding the socioeconomic status and basic housing sanitary conditions were collected. Anthropometric data was obtained in children from both groups. All children completed the hydrogen (H2) and methane (CH4) breath test in order to assess small intestinal bacterial overgrowth (SIBO). SIBO was diagnosed when there was an increase in H2 ≥ 20 ppm or CH4 ≥ 10 ppm with regard to the fasting value until 60 min after lactulose ingestion.
RESULTS: Children from the slum group had worse living conditions and lower nutritional indices than children from the private school. SIBO was found in 30.9% (26/84) of the children from the slum group and in 2.4% (1/41) from the private school group (P = 0.0007). Greater hydrogen production in the small intestine was observed in children from the slum group when compared to children from the private school (P = 0.007). A higher concentration of hydrogen in the small intestine (P < 0.001) and in the colon (P < 0.001) was observed among the children from the slum group with SIBO when compared to children from the slum group without SIBO. Methane production was observed in 63.1% (53/84) of the children from the slum group and in 19.5% (8/41) of the children from the private school group (P < 0.0001). Methane production was observed in 38/58 (65.5%) of the children without SIBO and in 15/26 (57.7%) of the children with SIBO from the slum. Colonic production of hydrogen was lower in methane-producing children (P = 0.017).
CONCLUSION: Children who live in inadequate environmental conditions are at risk of bacterial overgrowth and methane production. Hydrogen is a substrate for methane production in the colon.
doi:10.3748/wjg.v18.i41.5932
PMCID: PMC3491601  PMID: 23139610
Bacterial overgrowth; Breath test; Children; Colon; Hydrogen; Methane; Small intestine
20.  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
21.  Nutrition: Basis for Healthy Children and Mothers in Bangladesh 
Recent data from the World Health Organization showed that about 60% of all deaths, occurring among children aged less than five years (under-five children) in developing countries, could be attributed to malnutrition. It has been estimated that nearly 50.6 million under-five children are malnourished, and almost 90% of these children are from developing countries. Bangladesh is one of the countries with the highest rate of malnutrition. The recent baseline survey by the National Nutrition Programme (NNP) showed high rates of stunting, underweight, and wasting. However, data from the nutrition surveillance at the ICDDR, B hospital showed that the proportion of children with stunting, underweight, and wasting has actually reduced during 1984–2005. Inappropriate infant and young child-feeding practices (breastfeeding and complementary feeding) have been identified as a major cause of malnutrition. In Bangladesh, although the median duration of breastfeeding is about 30 months, the rate of exclusive breastfeeding until the first six months of life is low, and practice of appropriate complementary feeding is not satisfactory. Different surveys done by the Bangladesh Demographic and Health Survey, United Nations Children's Fund (UNICEF), and Bangladesh Breastfeeding Foundation (BBF) showed a rate of exclusive breastfeeding to be around 32-52%, which have actually remained same or declined over time. The NNP baseline survey using a strict definition of exclusive breastfeeding showed a rate of exclusive breastfeeding (12.8%) until six months of age. Another study from the Abhoynagar field site of ICDDR, B reported the prevalence of exclusive breastfeeding to be 15% only. Considerable efforts have been made to improve the rates of exclusive breastfeeding. Nationally, initiation of breastfeeding within one hour of birth, feeding colostrum, and exclusive breastfeeding have been promoted through the Baby-Friendly Hospital Initiative (BFHI) implemented and supported by BBF and UNICEF respectively. Since most (87-91%) deliveries take place in home, the BFHI has a limited impact on the breastfeeding practices. Results of a few studies done at ICDDR, B and elsewhere in developing countries showed that the breastfeeding peer-counselling method could substantially increase the rates of exclusive breastfeeding. Results of a study in urban Dhaka showed that the rate of exclusive breastfeeding was 70% among mothers who were counselled compared to only 6% who were not counselled. Results of another study in rural Bangladesh showed that peer-counselling given either individually or in a group improved the rate of exclusive breastfeeding from 89% to 81% compared to those mothers who received regular health messages only. This implies that scaling up peer-counselling methods and incorporation of breastfeeding counselling in the existing maternal and child heath programme is needed to achieve the Millennium Development Goal of improving child survival. The recent data showed that the prevalence of starting complementary food among infants aged 6-9 months had increased substantially with 76% in the current dataset. However, the adequacy, frequency, and energy density of the complementary food are in question. Remarkable advances have been made in the hospital management of severely-malnourished children. The protocolized management of severe protein-energy malnutrition at the Dhaka hospital of ICDDR, B has reduced the rate of hospital mortality by 50%. A recent study at ICDDR, B has also documented that home-based management of severe protein-energy malnutrition without follow-up was comparable with a hospital-based protocolized management. Although the community nutrition centres of the NNP have been providing food supplementation and performing growth monitoring of children with protein-energy malnutrition, the referral system and management of complicated severely-malnourished children are still not in place.
PMCID: PMC2740711  PMID: 18831228
Child nutrition; Maternal nutrition; Nutrition disorders; Nutritional status; Protein-energy malnutrition; Bangladesh
22.  Household and community HIV/AIDS status and child malnutrition in sub-Saharan Africa: Evidence from the demographic and health surveys 
Social Science & Medicine (1982)  2011;73(3):436-446.
This paper examines the extent to which under five children in households or communities adversely affected by HIV/AIDS are disadvantaged, in comparison with other children in less affected households/communities. The study is based on secondary analysis of the Demographic and Health Survey (DHS) data collected during 2003–2008 from 18 countries in sub-Saharan Africa, where the DHS has included HIV test data for adults of reproductive age. We apply multilevel logistic regression models that take into account the effect of contextual community/country level HIV/AIDS factors on child malnutrition. The outcome variable of interest is child undernutrition: stunting, wasting and underweight. The results suggest that across countries in sub-Saharan Africa, children whose mothers are infected with HIV are significantly more likely to be stunted, wasted or underweight compared to their counterparts of similar demographic and socio-economic background whose mothers are not infected. However, the nutritional status of children who are paternal orphans or in households where other adults are HIV positive are not significantly different from non-orphaned children or those in households where no adult is infected with HIV. Other adult household members being HIV positive is, however, associated with higher malnutrition among younger children below the age of one. Further analysis reveals that the effect of mothers’ HIV status on child nutritional status (underweight) varies significantly across communities within countries, the effect being lower in communities with generally higher levels of malnutrition. Overall, the findings have important implications for policy and programme efforts towards improved integration of HIV/AIDS and child nutrition services in affected communities and other sub-groups of the population made vulnerable by HIV/AIDS. In particular, children whose mothers are infected with HIV deserve special attention.
doi:10.1016/j.socscimed.2011.05.042
PMCID: PMC3242166  PMID: 21729821
Sub-saharan Africa; Child malnutrition; HIV/AIDS risk factors; Orphaned children; Vulnerable children; Demographic and health surveys; Contextual factors
23.  Evidence of a Double Burden of Malnutrition in Urban Poor Settings in Nairobi, Kenya 
PLoS ONE  2015;10(6):e0129943.
Background
Many low- and middle-income countries are undergoing a nutrition transition associated with rapid social and economic transitions. We explore the coexistence of over and under- nutrition at the neighborhood and household level, in an urban poor setting in Nairobi, Kenya.
Methods
Data were collected in 2010 on a cohort of children aged under five years born between 2006 and 2010. Anthropometric measurements of the children and their mothers were taken. Additionally, dietary intake, physical activity, and anthropometric measurements were collected from a stratified random sample of adults aged 18 years and older through a separate cross-sectional study conducted between 2008 and 2009 in the same setting. Proportions of stunting, underweight, wasting and overweight/obesity were dettermined in children, while proportions of underweight and overweight/obesity were determined in adults.
Results
Of the 3335 children included in the analyses with a total of 6750 visits, 46% (51% boys, 40% girls) were stunted, 11% (13% boys, 9% girls) were underweight, 2.5% (3% boys, 2% girls) were wasted, while 9% of boys and girls were overweight/obese respectively. Among their mothers, 7.5% were underweight while 32% were overweight/obese. A large proportion (43% and 37%%) of overweight and obese mothers respectively had stunted children. Among the 5190 adults included in the analyses, 9% (6% female, 11% male) were underweight, and 22% (35% female, 13% male) were overweight/obese.
Conclusion
The findings confirm an existing double burden of malnutrition in this setting, characterized by a high prevalence of undernutrition particularly stunting early in life, with high levels of overweight/obesity in adulthood, particularly among women. In the context of a rapid increase in urban population, particularly in urban poor settings, this calls for urgent action. Multisectoral action may work best given the complex nature of prevailing circumstances in urban poor settings. Further research is needed to understand the pathways to this coexistence, and to test feasibility and effectiveness of context-specific interventions to curb associated health risks.
doi:10.1371/journal.pone.0129943
PMCID: PMC4476587  PMID: 26098561
24.  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
25.  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

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