CHAPTER-II

CONCEPTUAL AND
THEORETICAL FRAMEWORK

44

CHAPTER-II
CONCEPTUAL AND THEORETICAL FRAMEWORK
2.1 Introduction
Good nutrition is indispensable component of healthy life and access to healthy
diet and optimum nutrition are important to good health. Better nutrition means
stronger immune systems, less illness and better health. Whereas developing countries
such as India is experiencing micronutrient malnutrition and undernutrition. The
negative externalities of undernutrition are many, especially among the younger age
group. Nutritional deprivation and infectious diseases among preschoolers feature
prominently among the major public health concerns in developing countries
(UNICEF, 1998; WHO, 1999; Kuate- Defo, 2001). Poor child health and nutrition
impose significant and long-term economic and human development costs, especially
on the poorest countries and communities, further entrenching their status. Improving
child health and nutrition is not only a moral imperative, but also a rational long-term
investment. Under six years old children are most vulnerable section of the society and
the present study focuses on these age groups.
2.2 Theoretical framework
The theoretical approach has its origins in Beckers Microeconomic models of
household production (Becker, 1965, 1981) in which households allocate goods and
time to the production of commodities that are either sold on the market, consumed at
home, or for which there is no market. This work was expanded to the demand for
health by Grossman (1972) and it also modified by several economists like Behrman
and Deolalikar (1989), Strauss and Thomas (1995) and Currie (2000).
Becker (1965) has proven in illuminating the household determinants of
nutrition. A nutrition production function relates the childs nutritional status
(measured in terms of height for age or weight for age) to a set of health inputs.
These include the childs nutrient intake, whether the child is breastfed and the
duration of breastfeeding, preventive and curative medical care, and the quantity and
quality of time of the mother or others in care-related activities. The quality of child
care time in turn is likely to be functions of the caregivers age, experience, education,
own health status and environmental factors are also enter the production function. The
potentially conflicting effects of maternal labour supply on child nutrition are readily

45

seen within the production function framework. Greater income from mothers
employment translates into higher consumption of market-purchased inputs such as
food and medical care that raise nutritional status, but reductions in the level or the
quality of time in health-related activities reduce nutritional status.
A childs nutritional status reflects the combined effects of many factors,
including nutrient intake, health, birth order, and behavioural factors governed by
parental preferences. In recognition of the interrelated variables are expressed childs
nutritional production function, they represented as
Childs Nutritional status = f (nutritional input, childs health, childs death, births,
biological factors, childcare time, technology factors)
The model is estimated at two levels: at the household level and at the child
level. Child nutritional status provides an indirect indicator of overall child health as
well as a direct measure of access to adequate nutritious foods. Malnutrition is a
vigorous indicator of the presence of severe child deprivation. Theories of social
arrangements emphasized on the freedom, equality and justice in social order in the
society. John Rawls Theory of Justice proposes the universal access is called social
primary goods (like liberties, opportunities, self-respect etc) for all individuals in the
society equally. One of the primary good, though not explicit in his theory but implicit,
that has to be ensured to every citizen of the society is health. Moreover, it assumes
primary significance in the perspectives of human capital, human development and
human rights, the health and nutritional deprivation of children can have severe
negative implications. But the unfinished reality is that even today many children in
the developing societies are deprived in health and nutrition. Anthropometry is widely
recognized as one of the useful techniques to assess the growth and nutritional status
of an individual or population (Rao et al, 2001). Malnutrition is frequently part of a
vicious cycle that includes poverty and disease. The three factors, viz., malnutrition,
poverty and disease are interlinked in such a way that each contributes to the presence
and performance of the others.
Anthropometric (body measure) parameters such as weight-for-age, height-forage and weight-for-height are commonly used for assessing child nutritional status. In
practical terms, anthropometric values need to be compared across individuals or
populations in relation to an acceptable set of reference values. Controversy arises over

46

the use of an international population both as reference and standard, which has
given rise to the emergence of two groups of experts one is influenced by the
Genetic potential theory or Deprivation theory and the other by Heretic Views
(Osmani, 1992). According to Genetic potential theory, each individual is endowed
with a maximum potential of growth, especially in the case of children below 5 years
of age. The failure to achieve the maximum genetic potential is believed to be affected
by the socio-economic factors like nutrition, socio-economic condition, etc., thereby
resulting in growth retardation. The exponents of the Heretic View, on the other hand
argue that deviation from genetic potential does not entail any functional impairment.
Instead, children or adults may be small but healthy (Seckler, 1982). In this context,
present study is attempts to correlate socio-economic variables are the basic
determinant of poor genetical endowment on the part of preschool children in rural
areas of Kasaragod district in Kerala.
2.3 Approaches to the Measurement of Undernutrition
The different approaches to the measurement of undernutrition are illustrated in
figure 2.1; the main sets of reasons why an individual may be undernourished are
listing in the left most column (1) of the figure. The columns 2-4, where different
indicators of undernutrition are listed. In principle, there are three levels at which a
persons energy balance can be estimated. One is to estimate energy intake and or
expenditure directly (column 2). The second is to explain anthropometric
measurements and other symptoms which indirectly reflect an inadequate energy
balance (column 3). The third is to find measurable indicators of negative
consequences of an unduly low energy balance (column 4). The way figure is drawn
reflects the causal links in the economics-nutrition-health complex (Svedberg, 2000).

47

Figure 2.1 Causes, Symptoms and Consequences of Undernutrition

Household
Income

Impairment of
cognitive and
psychometric
capabilities

Physical
inactivity

Habitual energy
intake<required
expenditure

Impaired work
capacity in adult
hood

Wasting (W/H)
Health
Underweight (W/A)

Intra
household
distribution

Stunting (H/A)

Disease

Source: Peter Svedberg (2000), Poverty and Undernutrition: Theory, Measurement and Policy.

48

Excess
mortality risk

2.4 Methodological Issues

There are mainly two approaches to measure the incidence of malnutrition among
vulnerable groups of the society. (i) Calorie/nutrition intake approach (Sukhatme,
1977, 1982; Gopalan, 1992; Seckler, 1982, 1984), and (ii) Anthropometric approach
(Strauss and Thomas, 1995; Kakawani, 1997; Svedberg, 2001; Pal, 1999; Osmani,
1992). Dietary approach is taken in to consider one nutritional element only. viz the
energy (calorie) content in the food. But over the years it has been agreed upon that
anthropometric approach is a better measurement than calorie approach. The present
study focuses on anthropometric approach which is considered as more reliable
measurement over calorie intake approach due to the following grounds.
1. Calorie intake approach is based on data collected from households, on their
consumption of major food items in last 7 days or 30 days. This is called
reference period. In India, NSSO collects data on calorie consumption of the
people. This approach ignores the requirement of calorie of a person in terms
of age and sex. It also does not take in to account the variation due to the
factors like body weight, nature of work, state of current health of the person
concerned.
2. In Calorie intake approach, anybody consuming below the required norm is
considered undernourished. It ignores the effects of inter-personal and intrapersonal variations in calorie requirement. One individuals calorie requirement
might vary from time to time in given period due to change in climatic
condition, changing work pattern, and state of the health of the individual.
Calorie requirement among individuals from similar age, sex, work pattern, and
health status also likely to vary due to difference in their genetics.
3. Calorie-adequate diet is not necessarily a balanced diet containing adequate
amount of protein, fat and other micro-nutrients like vitamins, minerals etc.
Nutritionists argue that the energy intake is a poor measure of nutritional status,
which depends not only on the nutrient intake but also on non-nutrient food attributes,
privately, and publicly provided inputs and health status (Martorell and Ho, 1984). The
non-food factors which influence biological absorption are also considered as
important for food security as food factors. It is suggested that the assessment of
malnutrition should be based on outcome measures rather than input measures. The

49

suggested outcome measures include anthropometric measures, clinical signs of

malnutrition, biochemical indicators and physical activity. Outcome indicators are
more closely related to health and functional capacity. Among the outcome measures,
anthropometric measures are considered to have an advantage over other indicators
since body measurements are sensitive to even minor levels of malnutrition whereas
biochemical and clinical indicators, on the other hand, are useful only when the level
of malnutrition is extreme.
Anthropometric observations as measurements and indicators of undernutrition
have come to dominate increasingly since the early 1980s. Information about nutrition
is often collected with the explicit aim of selecting people for targeted intervention.
Then it need to know who is undernourished and who is not, and standardized dietary
intake norms cannot be used to detect undernutrition in individuals. For this purpose,
anthropometric and related methods have to be applied. Nevertheless, most
development economists and contemporary nutritionists seem to believe that
anthropometric measures provide more reliable and useful indications of nutritional
status than do dietary intake measurements. The basic advantages of the
anthropometric approach are simplicity and accuracy.

Until recently,

the

anthropometric approach was used almost exclusively to estimate undernutrition

among children under the age of five.
Based on the above arguments the anthropometric approach is preferred to
calorie-intake approach because it reflects the past nutritional status in terms of
stunting, wasting, underweight, body mass index and mid upper arms circumference
(MUAC). The nutritional status of infants and small children, in particular, has proved
almost impossible to estimate accurately through calorie intake approach. For these
age groups, it is generally agreed that anthropometric method provides more reliable
estimates

(Sen, 1984; Svedberg, 2000).

2.5 Conceptual framework

Mothers of selected preschool children who were willing to participate in the
study were interviewed for collecting the desired information. Causes of malnutrition
in children are complex, ranging from biological and social to environmental factors
(Wamani et al, 2005; Engle and Haddad, 1999; Mosley and Chen, 1984; Smith and
Haddad, 2000). To handle the complex hierarchical inter-relationships between these

50

variables which are risk factors of ill health in children, particularly in less developed
countries, Victoria et al have proposed the use of frameworks and models for studying
and predicting the risk factors of health outcomes (Victoria et al,1997). Based on the
previous research about the causes of malnutrition, here constructed a conceptual
hierarchical framework of the determinants of nutritional status. Variables in this
model (figure 2.2) can be divided into three groups: socio-economic variables (place of
residence, religion, community, mothers education status, maternal employment
status, household deprivation status etc), intermediate factors include environment
variables (type of house, house structure, type of latrine, sources of water etc), and
maternal variables (mothers age at birth, mothers nutritional status, mothers
knowledge on nutrition), and proximal factors which include weight at birth, birth
order, weight-for-age, height-for-age and weight-for-height.

51

Figure 2.2

Conceptual framework of the determinants of Child nutritional status

Socio-Economic variables
Place of residence
Religion
Community
Mothers education status
Maternal employment status
Household deprivation status

Intermediate factors
Environment variables
Type of house
House structure
Type of latrine
Sources of water
Maternal variables
Mothers age at birth
Mothers nutritional status
Mothers knowledge on nutrition

Age and
Sex

Proximal factors (Individual variables)

Weight at birth
Birth order
Weight-for-age
Height-for-age
Weight-for-height

Child Nutritional Status

According to the conceptual model, socioeconomic factors may affect directly

or indirectly on all other groups of risk factors with the exception of sex and age.
These include environmental factors (such as type of house, house structure, type of
latrine, sources of water), maternal factors (mothers age at birth, mothers nutritional
status, mothers knowledge on nutrition, role of food habits and beliefs) and proximate
factors (weight at birth, birth order, time of initiation of breast-feeding and duration of
exclusive breast feeding, weight-for-age, height-for-age and weight-for-height). These
variables, in turn, may affect the nutritional status of preschool children.
52

The causes of nutritional deprivation are diverse, multi-sectoral, interrelated

and entail biological, social, cultural and economic factors, and their influences
operate at various levels such as child, family, household, community and nation. In
this context, the present study constructed a household deprivation score (HDS) based
on the socio-economic status of household. The index of deprivation is based on
simple measurement of deprivation of the households in three dimensions of
deprivation: 1) basic economic assets; 2) basic amenities and 3) basic communications
with the outside world. This deprivation index is not a direct measure of the economic
condition of the household as the per capita income or expenditure or the standard of
living index but a measure of the extent to which the household is deprived in the
above three dimensions. The household deprivation score (HDS) is based on six
variables at the household level. The variables used in each of these three dimensions
are in a binary scale. They are 1) whether the household has a pucca and semipucca/kutcha house, 2) whether the household has some land, 3) whether the
household has electricity, 4) whether the household has drinking water facilities in the
residence, 5) whether there is at least one literate adult member in the household and,
6) whether the household has a radio, a T.V, or a newspaper. In modern market
oriented economy the possession of basic economic, social and physical necessities of
life could be considered as the basis of a dividing line of different levels of
deprivation. The advantage of such a classificatory system is that it is based on actual
physical or social possessions (adult literacy) rather than income data and can be used
to measure the changes in deprivation levels over time (Srinivasan and Mohanty, 2004,
2008). The total score is an addition of the six variable scores and ranges from 0 to 6.
household which does not have any of the above six possessions as in abject
deprivation (AD); those which have one or two of the possessions in moderate
deprivation (MD); three or four as in just above the deprivation (JAD) and 5 or 6
items in well above deprivation (WAD).The two categories AD and MD together
constituting the deprived sections of the population. Table 2.1 provides detailed
discussion of the variables in the construction of the deprivation index.

53

Table 2.1
Variables used in computing Household Deprivation Score (HDS)
Variables used
Description
Categorization of households on
deprivation based on total score
1. Adult literacy 0 = No adult literate in the
household
1 = Presence of any adult 0: Abject deprivation (AD)
literate
in
household
1-2: Moderate deprivation (MD)
2. Type of house 0 = Katcha house
1 = Semi Pucca/ Pucca 3-4: Just above deprivation (JAD)
house
3. Electricity
0
=
House is not 5-6: Well above deprivation
(WAD)
electrified
1 = House is electrified
4.Drinking water 0 = No arrangement in
facility
the residence
1 = Own arrangement in
the residence
5.Radio or T.V or 0 = No radio or T.V or
newspaper
newspapers
1 = At least one of these
6. Land Holding 0 = No land
1 = Have some land
Source: Srinivasan and Mohanty, 2004, 2008

In this context, the present study constructed a household deprivation score

(HDS) based on the socio-economic status of household. The index of deprivation is
based on simple measurement of deprivation of the households in three dimensions of
deprivation. In HDS-I, those which have no above six possessions or have one or two
possessions, it indicates moderate deprivation (MD) and it indicates the deprived
sections of the population. Three or four as in HDS-II indicate just above deprivation
(JAD) and five or six items in HDS-III indicate well above deprivation (WAD). This
simple measure of deprivation at the household level shows health and nutrition
conditions and income levels are highly related. Against this background, this study is
designed in an attempt to examine variations among communities in childhood
deprivation, and to investigate how the household deprivation index (HDS) of
communities and that of households affect child nutritional status regardless of their
individual characteristics, and how they interact in this process.

54

2.6 Research Design

2.6.1 Locale of the study: Rural areas of Kasaragod district
The overwhelming majority of the people of Kerala lives and works in villages.
The working and living conditions of the rural people are different from that of their
urban counterpart (Taylor and Adelman 1996) in other Indian states. The rural areas in
Kerala are in general characteristically different from their apparent urban traits. For
instance, the transport infrastructure in rural Kerala is more developed and integrated
compared to most of the Indian states and the less unequal distribution and spread of
the rural roads have minimized access problems and progressively increased the
utilization of health services. Nevertheless, in backward districts like Kasaragod the
rural-urban differences are more revealing.
Kasaragod is one of the backward districts of Kerala. Within the district, there
are variations in natural conditions and socio-economic and demographic conditions.
Some areas in the district are well developed and the others are in poor condition. Out
of the 14 districts, the rank of Kasaragod has been one of the lowest and much below
the state average defined in terms of socio-economic and health development
indicators. Though Kerala is in the forefront of all health and nutritional indictors
compared to other states in India, the rural areas of Kasaragod district of Kerala suffers
severe handicaps in the health and nutritional arena. In this context, the present study
is confined on rural areas of Kasaragod district in Kerala.
2.6.2 Sample Selection
According to Gupta (2003) sampling is simply the process of learning about
population on the basis of a sample drawn from it. Under this, small group of the
universe is taken as the representative of the whole mass and the results are drawn. It is
a method to make social investigation which is practically applicable.
At the first stage of sampling, Kerala was classified on the basis of human
development index, high HDI districts (Ernakulam, Kottayam, Pathanamthitta,
Alappuzha and Thrissur), medium HDI districts (Kollam, Kannur, Kozhikode,
Thiruvanthapuram and Palakkad) and low HDI districts (Kasaragod, Idukki, Wayanad
and Malappuram). Kasaragod district was one of the low HDI districts. Within the
district, there are variations in natural conditions and socio-economic and demographic
conditions. Some areas in the district are well developed and the others are in poor

55

condition and thus the present study was confined in rural areas of Kasaragod district.
In the present study, the total sample size comprised of 400 preschool children in rural
areas of Kasaragod district in Kerala. The required numbers of samples (below 6 years
children) were selected from various households through stratified sampling
techniques. According to Best and Khan (2001), the characteristics of the entire
population, together with the purposes of the studies, must be carefully considered
while applying the stratified sampling techniques. In Kasaragod district comprises of
two taluks- Kasaragod and Hosdurg. Almost all child development indicators were
poor in hosdurg taluk and majority of the rural people lived in this taluk. After the
selection of rural areas of Kasaragod district, the next step was to select the primary
health centres/community health centres (PHC/CHC). Total 22 PHC in Hosdurg taluk,
5 PHC were selected on random basis and in each PHC 50 samples were taken. These
PHCs include Narkkilakkad, Vellarikundu, Cheruvathoor, Panathoor and Ajanoor.
Among the three CHCs two were selected randomly which include, Thrikkaripur and
Nileshwar and 75 samples were drawn from each of them.
After the selection of PHC/CHC, the next step was to list out various
households in the PHC/CHC area. The lists of households were obtained from the
concerned panchayth offices and anganwadis in the study area. Then, through stratified
sampling techniques, the households in the lists were divided into strata to ensure
effective sampling from each corner. Subdivision of the population in to smaller
homogeneous group, known as strata, would ensure more accurate representation.
Form each stratum, households comprising children in the age group from birth to six
years old were identified and a total of 400 preschool children were thus listed out. In
the case of households having more than one eligible preschool child, only one
preschool child was selected.

56

Figure 2.3 Structure of Sample Design

High HDI districts

(Ernakulam, Kottayam,
Pathanamthitta,
Alappuzha, Thrissur)

Medium HDI districts

(Kollam, Kannur,
Kozhikode,
Thiruvanthapuram, and
Palakkad)

Low HDI districts

(Kasaragod, Idukki,
Wayanad Malappuram)

Kasaragod District

Kasaragod Taluk

PHC-1
50

Hosdurg Taluk

PHC-2
50

PHC-3
50

PHC-4
50

PHC-5
50

CHC-1
75

CHC-2
75

Source: Survey data

Note: * The classification of high, medium and low HDI districts is based on the Human development indicators, Human development report-Kerala 2005

57

For the collection of data, an interview schedule is developed on the basis of

extensive review of available literature and discussions with experts in the field. The
schedule is divided into different sections. viz, descriptive identification of the
household, demographic particulars, housing and environment conditions, nutritional
status of children and child care, parental characteristics etc. Under each section,
several relevant questions are raised to elicit all possible information about each of the
selected samples under study. The information is gathered from 400 samples using
well-structured schedule through survey method.
The preliminary version of the schedule is pre-tested for its validity and
precision and suitable modifications were made in the schedule of questions wherever
found necessary. This re-structured schedule is used for the collection of data of the
survey. The collection of data was done by the investigator himself and thereby the
non-sampling was also minimized to the extent possible. The data for this study was
collected during four months from November 2008 to February 2009.
2.7 Assessment of Nutritional status using Anthropometry method
Data were gathered by a combination of a structured questionnaire and the
collection of anthropometric data through measurements of height and weight was
measured. The anthropometric measurement by National Center for Health Statistics
(NCHS) and WHO standards (WHO, 1995) were used for the determination of
nutritional status of preschool children. Standard deviation of scores (Z-scores) for
weight-for-age (WAZ), height-for-age (HAZ) and weight-for-height (WHZ) were
calculated. The Z-score (SD score) is calculated as follows.
Z score = (individual value-median value of reference population)/ SD value of
reference population.
For each of the anthropometric indicators of malnutrition a cutoff point of-2
standard deviations (-2 SD) below the median of that of the NCHS/WHO reference
population was used. Anthropometry has an important place in nutritional assessment
(Jelliffe and Jelliffe, 1989; Gibson, 1990), and clinical setting (Gibson, 1990) is used
in nutritional screening, surveillance and monitoring. The literature on anthropometric
measurement and interpretation are used in child nutritional status (Cameron, 1984;
Lohman et al, 1988; Jelliffe and Jelliffe, 1989; Gibson, 1990; Norton and Olds, 1996;

58

Ulijaszek, 1997). Anthropometric indices are used as the main criteria for assessing the
adequacy of growth and hence optimal nutritional status in infancy and childhood.
Assessment of the nutritional status of the child by nutritional anthropometric
indicators of growth has been used not only to provide information on the nutritional
and health status of children, but also as an indirect measure of the quality of life of the
entire community. Anthropometric method is a quantitative method; it also considers
the different types of measurements like, height-for-age, weight-for-age and weightfor-height.
1. Height-for-age (HAZ)
Low height-for-age index identifies past undernutrition or chronic malnutrition.
Height-for-age (HAZ) is an indicator of stunting, which can result from chronic
malnutrition, but genetic factors are also related to it. It cannot measure short-term
changes in malnutrition. Stunting is associated with a number of long-term factors
including chronic insufficient protein and energy intake, frequent infection, sustained
inappropriate feeding practices and poverty.
2. Weight-for-age (WAZ)
Low weight-for-age index identifies the condition of being underweight, for a
specific age. This index reflects both chronic and acute undernutrition. Underweight is
based on weight-for-age, is a composite measure of stunting and wasting and is
recommended as the indicator to assess changes in the magnitude of malnutrition over
time. There is relation between prevalence of underweight and several factors such as
gross national product, infant mortality rate, energy intake per capita, female
education, governmental social support, child population, food sources of energy,
distribution of income, access to safe water, female literacy rate and region.
3. Weight-for-height (WHZ)
The weight-for-height (WHZ) index is an indicator of thinness or wasting.
Wasting is short-term malnutrition due to acute starvation or severe disease, famine
etc., but it may result also from chronic dietary deficiency or disease. Wasting
indicates current or acute malnutrition resulting from failure to gain weight or actual
weight loss. It is associated with the causes include inadequate food intake, incorrect
feeding practices, diseases and infection.
59

The nutritional status of a child is normally expressed in the Z-score of the

concerned indicator. Weight and height of children of a certain age group follow more
or less the normal distribution. In the present study Z-scores for the three
anthropometric indices height-for-age, weight-for-age and weight-for-height are used
to assess the nutritional status of children. The height-for age Z-score compares the
height of a child of a certain age with the median height of a healthy reference
population of that age group, the weight-for-age Z-score does the same for height; and
the weight-for-height Z-score compares the weight of a certain height with the
reference median weight for a child with the same height. A Z-score of -2 was used as
a cut-off point for estimation of status of malnutrition of children. The Z-score is
defined as the deviation of the value observed for an individual from the median of the
reference population, divided by the standard deviation (SD) of the reference
population. The reference standards

most commonly used

to standardize

measurements were developed by the US National Center for Health Statistics (NCHS)
and are recommended for international use by the World Health Organization. The
Nutrition Foundation of India support that the WHO standard is applicable to Indian
children (Dibley et al, 1987; Agarwal et al, 1991).
The basic idea is to assume that the given child comes from a healthy
population. Under this null hypothesis, the z-score showed follow the child is too low
as to give it a very small probability of occurring child as malnourished. The usual cut
off point is to classify the child as malnourished. Deviations of Z-scores less than 2
SD (standard deviation) from the international reference population were used to
classify children as moderately low weight-for-age, low height-for-age and low
weight-for-height, Deviation of Z-scores less than 3SD put children in the severe
undernutrition category.
WHO system
< -1 to > -2 Z-score: Mild Malnutrition
< -2 to > -3 Z-score: Moderate Malnutrition
< -3 Z-score: Severe Malnutrition

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2.8 Method of Analysis

Both bivariate and multivariate analysis are employed to identify the
determinants of underweight, stunting and wasting in preschool children in rural areas
of Kasaragod district in Kerala. These analysis focus on two outcomes of nutritional
status for children: whether they are undernourished or not. In the bivariate analysis,
the Chi-square test was employed to see the association between each of the
independent variables under study and the nutritional status of preschool children as
measured by underweight, stunting and wasting, and p-values less than 0.05 were
considered as significant. The Chi-square analysis does not consider confounding
effects and therefore, the net effects of each independent variable are estimated
controlling other factors using the logistic regression multivariate analysis. Logistic
regression predicts the probability that the dependent variable event will occur given a
subjects scores on the dependent variables. Logistic regression analysis is especially
useful when the distribution of responses on the dependent variable is expected to be
nonlinear with one or more of the independent variables.
2.9 Statistical Analysis
The statistical programs SPSS and GRETL were used to descriptive statistics,
statistical significance was set at p < 0.05. It was used for the analysis of
anthropometric measures. Weight, height and age data were used to calculate weightfor-age, height-for-age and weight-for-height Z-scores based on the National Center
for Health Statistics/WHO reference data (Center for Disease Control and Prevention
and National Center for Health Statistics, 2002).

61