A Project report submitted to IGNOU in partial fulfillment of the requirement for

the Diploma in Nutrition and Health Education

A STUDY TO ASSESS THE NUTRITIONAL

VISHWA BODH
Enrolment No. 2002221468

Under the supervision of

School of Continuing Education

Name Vishwa Bodh

Enrolment No. 2002221468

Study Centre Govt. College Sanjauli, Shimla (H.P.)

Centre of Excellence, Govt. College, Sanjauli,

Ms. Jaivanti Chauhan, Assistant Professor,

Ms. Jaivanti Chauhan, Assistant Professor,

A STUDY TO ASSESS THE NUTRITIONAL

NAME OF PLACE
WHERE PROJECT IS Kullu (H.P.)
CONDUCTED
SECTION B: PROJECT PROPOSAL

Title :

Definition :

Summary :
SECTION C: APPROVAL OF PROJECT COUNSELOR

I certify that I have examined the project proposal submitted by the candidate,
Mrs. Vishwa Bodh and found it to be satisfactory.

Prof. (Ms.) Jaivanti Chauhan

Date :
Place : Shimla (H.P.)
 Table of Content
Chapter No. Page No.
Titles

I INTRODUCTION 2-7

II RESEARCHMETHODOLOGY 8-10

III ANALYSISANDINTERPRETATIONS 11-34

CONCLUSIONS AND
IV 35-38
RECOMMENDATIONS

BIBLIOGRAPHY 39-40

APPENDIX 41-50

1
 CHAPTER-1:INTRODUCTION

Rapid and unplanned urbanisation is a marked feature of Indian demography. The

urbanpopulation of India accounts for 27.8 percent of the total population equating to

285million (Census of India, 2001). This represents a hundred fold increase in the

pastcentury and 40 percent increase during the last decade. If urban India was considered

as aseparate country, it would be the fourth largest in world, after China, India and the

UnitedStates(Agarwal, 2005).

Urbanisation is not an evil process. It is a welcome sign of transition. But

unplannedurbanisation can cause rapid migration to cities, resulting in slums having

inhuman livingconditions (Davis, 2006). Urbanisation is also associated with several

socioeconomic

andenvironmentalproblems.Themajoronesarehousingshortage,unemployment,congestion,

pollution, possible increase in crime rates, inadequate services like watersupply,

sanitation, drainage, sewerage and also defective educational, recreational,

healthandwelfarefacilities.

However, the most basic and primary product of urbanisation is poverty and poor

housingconditions. It is reported that 23.6 percent of urban population is poor. Their

expenditureon consumption goods is less than Rs. 454 per month. These estimates, in

fact, do notreflect the true magnitude of urban poverty because of the unaccounted and

unrecognizedsquatter settlements, floating population and other„invisible‟ population

residing onpavements,constructionsites, urbanfringesetc.

Housing is a visible dimension of poverty in urban areas. Due to increasing

economicactivitiesinthemetropolitancities,peoplemoveintocities,andconsequentlytheurban

2
poorareforcedtoliveinunhygienicslumsandsquattersettlements.Thereforedevelopmentof

slums form anintegralcomponent of thephenomenon ofurbanisation.

A slum represents a habitat unit with defective physical, social andeconomic

livingconditions. UN‐Habitat Report (2003) attempts defining a slum household as „a

group ofindividuals living under the same roof that lacks one or more of the following

conditions:access to safe water, sanitation, secure tenure, durability of housing and

sufficient livingarea‟.

The concept of slums and its definition vary from country to country depending upon

thesocioeconomic conditions of each society. The basic characteristics of slums as given

byGovernment of India are ‐ dilapidated and infirm housing structures, poor

ventilation,acute overcrowding and faulty alignment of streets, inadequate lighting and

paucity

ofsafedrinkingwater,waterloggingduringrains,absenceoftoiletfacilitiesandnonavailabilityo

f basic physical and social services(Chandramouli, 2003).

The pitiable living conditions in the slums of India have already been highlighted in

theCensusofIndia(2001),referringtothefactthatslumsareusually unhygienicandcontraryto

all norms of planned urbangrowth.

The globalpicture alsopresentsthe same trenddepictingunacceptably highrate

ofurbanisation and massive increase in slum population. Many cities across the world

haveslums leading to over population of urban neighbourhood. It has beenestimated

thatabout a third of the world‟s urban residents which comes upto three billion, dwell

inslums(UN‐Habitat Report, 2003).

Indevelopingcountriesalso,thenumberofpeoplelivinginslumsandshantytowns

3
represent about one third of the people living in cities (Harpham and Stephens,

1991).United Nations Development Programme (2009) reported that India‟s urban

population isalso increasing at a faster rate than its total population. With over 575

million people,India willhave41 percent of its population livingin citiesandtowns by2030.

The data provided by NSSO (2004) revealed that there are 52 thousand slums located

inthe urban areas of the country and about 8 million urban households live in these

slums.This represented as high as 14 percent of the total urban households in the

country.Correspondingly, the total number of urban poor has also increased by 13.9

percent (9.86million) in the year 2007 (Government of India, 2007). As reported by

Government ofIndia (2004), the number of slums was highest in Maharashtra (32%)

followed by WestBengal(16%)and AndhraPradesh (15%).

The living conditions in slums are generally not very conducive for the physical,

mental,moral and social development of its inhabitants. Insanitary living conditions

coupled withlow purchasing power and poor nutrition add to the episodes of infection

particularlyrespiratoryand diarrhoeal diseases (Gracey,2002).

Such a situation ultimately hasa negative impacton the health andnutritional status ofthe

slum population especially the women of reproductive age and their children. AsWHO

(1999) rightly pointed out, when infrastructure and services are lacking, urbanslums and

settlements are amongst the world‟s most life‐threatening environment. Eventhe common

infectious diseases can often become catastrophic to thechildrenlivingthere.

It was estimated that in India, about 6 million children in the age group of zero to

sixyearsliveinslums(CensusofIndia,2001).Highincidenceofundernutrition,high

4
mortality and morbidity with a neonatal and child survival rate far lower than the

urbanaverage,aresomeof thefeatures observedbyAgarwal (2005).

As per Fry et al. (2002) neonatal, infant and under five mortality rates are

considerablyhigher among urban poor when compared to the national averages. In urban

dwellings,one out of ten children born during an year, is not destined to see their fifth

birthday andone out of 15 children is not likely to see their first birthday especially in less

developedstateslikeUttarPradesh,Madhya

Pradesh,Rajasthan,BiharandOrissa(Agarwal,2005).

Infant mortality rate among slum population is 1.6 times higher than the

correspondingnationalfigures.Thedebilitatingenvironmentinurbanpoorsettlementswhere1.

1million births take place every year, may be the root cause of this high mortality

rate.Further high incidence of low birth weight, at the rate of 50 percent of the urban

poorneonates and faulty feeding habits including inappropriate breast feeding also add to

theseverityof this problem.

Althoughtherehasbeenasignificantdeclineinchildmortalityoverthepasttwodecades, more

than 80 percent of all deaths in India still occur among children below fiveyearsofage.

Among those who survive, more than half of these urban poor children do not attain

theirfull potential in terms of growth and development. They are underweight or

stunted.Protein energy deficiency of varying degrees continues to be a major health

problem ofthe under five category of the urban poor. Respiratory infection and diarrhoea,

a productof insanitary living environment are the common illnesses that add to the

severity ofprotein energy deficiency. Hookworm infestation, anaemia, vitamin A and B

complexdeficienciesalsoposeequallytoughchallengestothehealthandwellbeingof

5
preschoolers.

Child malnutrition has its roots in mother‟s womb. There are clear‐cut evidences to

showthat the growth and development of children and the predisposition to metabolic

healthproblemsinthefuture,arecloselyassociatedwithmaternalnutritionandothersocioecono

mic parameters like female literacy, family size, purchasing power etc. Yet,poor maternal

nutrition is the single most important factor for low birth weight

babies,whoareattheriskofinfection,undernutrition,impairedphysicalandmentaldevelopment

.Raoetal.(2010)alsopointedoutthatwomenwithpoorhealthandnutritionaremorelikelyto give

birth to low weight infants.

The most prominent type of nutritional problems among mothers, which have a dent

onchild health are chronic energy deficiency and low BMI (Body Mass Index), iron

andiodine deficiency disorders (Kotwal et al., 2008). A number of factors are responsible

forthis,wherethelivingenvironmentdoesplayasignificantrole.Atransitioninthelifestyle of

women who live inurban slums;fromthe role of a wife and a mother, tomembers of

workforce demands a lot of compromise in their family and child rearingpractices. In fact

they are forced to take up outside job to support their family in an urbanset up. Owing to

illiteracy, lack of education and skill, they work in unorganised sectors.Theyareoften

underpaidor exploited.

The mothers who involve in highly labour intensive task do not get sufficient time

torecuperate after delivery. This further stresses mother‟s nutritional status and reduces

herbodily reserves (Rode, 2009), which in turn affects the lactation performance of

mothersleading to early weaning and early introduction of improper supplementary foods.

Thecompulsiontotakeupjobsinthe informallabour marketandthefearoflosingitevenon

6
occasionalabsence,imposeconstraintsontheirchildrearingpracticestoo.

As a result, young children are fed insufficient number of times with ill balanced diet,

byother care givers; who may be older siblings, relatives or neighbours. Available

healthfacilities for prenatal and postnatal care, immunization, family planning and control

ofcommunicable diseases are also not utilized appropriately because of mother‟s work

inunorganized sectors. Ultimately the young children in urban slums setup are deprived

ofmaternalcare and attention, when theyneed it to themost.

It is therefore imperative to have some targeted strategies to improve the health

andnutritional profile of mothers and children among urban poor. The population

projectionwith a cent percent increase in urban agglomeration by 2026 (Prakash, 2002),

furtherdemands the urgency for such an approach to tackle the challenges emerging out

of suchsituations.

Anessentialrequisitetoevolveviablestrategiestomitigatehealthandnutritionalproblems of

slum dwellers is baseline information. The present study was an attempt inthisdirection.

Janakpuri with largest agglomeration of slums was identified as a potential area.

Thestudy was therefore been conducted in the urban slums of Janakpuri, with the main

focusonassessingthenutritional status of preschool children.

OBJECTIVESOFTHE STUDY

Thespecificobjectiveofthestudy istoanalyzethenutritionalstatusofpreschoolchildrenin slum

areas ofJanakpuri, New Delhi.

7
 CHAPTER-2:RESEARCH METHODOLOGY

Research methodology is a way to systematically investigate the research problem.

Itgives various steps in conducting the research in a systematic and a logical way. It

isessential to define the problem, state objectives and hypothesis clearly. The

researchdesign provides the details regarding what, where, when, how much and by what

meansenquiry is initiated. Every piece of research must be planned and designed

carefully sothat the researcher precedes a head without getting confused at the subsequent

steps ofresearch.Theresearchermusthaveanobjectiveunderstandingofwhatistobedone,what

data is needed, what data collecting tools are to be employed and how the data is tobe

statistically analyzed and interpreted. There are a number of approaches to the

designofstudiesandresearchprojectsallofwhichmaybeequallyvalid.Researchisasystematica

ttempttoobtainanswers tomeaningfulquestionsaboutphenomenon

oreventsthroughtheapplicationofscientificprocedures.Itanobjective,impartial,empiricaland

logicalanalysisandrecordingofcontrolledobservationthatmayledtothe development of

generalizations, principles or theories, resulting to some extent

inpredictionandcontrolofeventsthatmaybeconsequencesorcausesofspecificphenomenon.

Research is a systematic and refined technique of thinking, employingspecialized tools,

instruments and procedures in order to obtain a more adequate solutionof a problem than

would be possible under ordinary mean. Thus, research always startsfrom question. There

are three objectives of research factual, practical and

theoretical,whichgivesrisetothreetypesofresearch:historical,experimentalanddescriptive.

Research design has been defined by different social scientists in a number of ways.

Allthesedefinitionsemphasizesystematicmethodologyincollectingaccurateinformation

8
for interpretation. Selltize et al. (1962) expressed their views as, “Research designs

areclosely linked to investigator‟s objectives. They specify that research designs are

eitherdescriptive or experimental in nature.” Research design tells us how to

planvariousphases and procedures related to theformulation of research effort(Ackoff

Russell,1961). Miller (1989) has defined research design, “as the planned sequence of the

entireprocess involved inconductingaresearchstudy.”

Kothari (1990) observes, “Research design stands for advance planning of the method

tobe adapted for collecting the relevant data and the techniques to be used in their

researchand availability of staff, time and money.” In this way selecting a particular

design isbased on the purpose of the piece of the research to be conducted. The design

deals

withselectionofsubjects,selectionofdatagatheringdevices,theprocedureofmakingobservatio

nsandthe typeofstatisticalanalysistobeemployedininterpreting datarelationship”.

Keepinginviewtherequirementsforanadequatedesignasdiscussedabove,theinvestigator

formulated an appropriate design for the purpose of the present study. Thedetailsabout

thesamearegivenasunder.

This is a descriptive study to analyze the nutritional status of preschool children in

slumareasofJanakpuri,NewDelhi.Twoslumsareaswererandomlyselectedandacomprehensi

ve list of the registered slum areas in this ward was obtained from the

localgovernmentsecretariatinNewDelhi.Parentsofattendingunder-2childrenwerecontacted

and informed fortheirconsent.

SampleSelection

Total100youngmothersandtheirpreschoolchildren(150)wereselectedforthe

9
proposedstudy.

DataCollection

Data collection was carried out with a socio-economic and nutritional survey based

onGomezClassification (1956)and Kuppuswamy(1981).

Datacollectionwasalsobeingcarriedoutwithaclinicalnutritionsurvey.

ClinicalAssessment

Clinical examination has always been and remains an important practical method

forassessing nutritional status (Jelliffe, 1989). Clinical examination also helps to assess

thelevelofhealthofindividualsorofpopulationgroupsinrelationtothefoodtheyconsume.Itinvo

lvesexternalexaminationofthebodyforchangesinsuperficialepithelial tissues especially

hair, face, skin, gums, teeth, eyes and lips with the help of aqualifiedphysician,

usingaclinicalassessment schedule (Appendix).

DataAnalysis

In this study, statistical analysis of the data wasdone using students t-test, Chi

square,andcoefficientofcorrelation.Chisquaretestwasusedtoanalyzetheassociationbetween

variables. Besides percentages, mean and standard deviation will also be used

indataanalysis.

10
CHAPTER-3:ANALYSISANDINTERPRETATIONS

When data has been obtained, it is necessary to organize them for the

interpretation.Qualitative data may have to be summarized and treated statistically to

make significantclean.” OliveR.A.G.

According to Good, Barr and Scates, “Analysis is a process which enters into research

inone form or another, from the very beginning. It may be fair to say that research,

ingeneral, consists of two large steps i.e. gathering of data and the analysis of

researchdata.”

NUTRITIONALSTATUSOFPRESCHOOLCHILDREN

Nutritionisaninputtoandfoundationforhealthanddevelopment(WHO,2010).Childhood

undernutrition remains a major health problem in India especially in slums(Bisai et al.,

2009). To assess the nutritional status of children a number of techniques aremadeuse of

in thesedays.

Childgrowthisthemostwidelyusedindicatorofnutritionalstatus(WorldHealthStatistics,

2009). Anthropometric measurements are the most widely used method toassess

nutritional status. The use of these measurements depends on age assessment

andnormalvalues forcomparison (ICMR, 2005).

11
Ageandgenderwisedistribution

Ageandgenderwise distributionofthesampleispresented intable1.

Table1:Ageandgenderwisedistributionofpreschoolchildren

Age(yrs) Male Female Pooled

1 25.83 34.13 29.52

1.5 14.35 11.97 13.29

2 28.7 22.15 25.79

2.5 12.91 6.58 10.10

3 18.18 22.15 21.27

Pooled 55.6 44.4 100

(Numberindicatespercentages)

12
 Figure1:Ageandgenderwisedistributionof preschoolchildren

35
30
25
20 Male
15 Female
Pooled
10
5
0
1 1.5 2 2.5 3
Sample for the study included 150 children out of which 55.6 percent were boys and

44.4percentgirls.

Age wise distribution indicated that children of 1 years constituted 29.52 percent of

thesample which was the highest followed by 2 year old children (25.79%) and three

years(22.15%). Female population outnumbered males in the age group of one and three

yearsFigure1 presents ageandgender wisedistributionofpreschoolchildren.

13
NutritionalstatusbasedonGomezclassification

Various methods have been suggested to classify children into various nutritional

grades,the most widely used one is the Gomez classification (Gomez et al., 1956), in

which thechildren are classified as having first, second or third degree malnutrition if

their weightfor age range is 75 to 90 percent, 60 to 75 percent or less than 60 percent

respectively ofthereferencemedian(Bamjiet al., 1998).Thefollowingtablepresents

thedetails.

Table2:NutritionalprofileofpreschoolchildrenbasedonGomezclassification®

Age Male Female

(yrs)

Normal Grade I Grade II GradeIII Normal Grade I Grade II GradeIII

(≥90) Malnutrition Malnutrition Malnutrition (≥90) Malnutrition Malnutrition Malnutrition

(75-89.99) (60-74.99) (<60) (75-89.99) (60-74.99) (<60)

1 20.4 42.6 37.0 Nil 21.1 49.1 24.6 5.3

1.5 36.7 46.7 16.7 Nil 25.0 60.0 15.0 Nil

2 25.0 48.3 21.7 Nil 29.7 54.1 16.2 Nil

2.5 18.5 33.3 44.4 5.0 27.3 45.5 27.3 Nil

3 36.8 44.7 18.4 3.7 45.2 23.8 31.0 Nil

Pooled 26.79 44.01 27.27 1.91 29.94 44.91 23.35 1.79

(Numberindicatespercentages)

14
 Figure2:NutritionalprofileofboysbasedonGomezclassification®

50
45
40 Normal
35
30 GradeIMalnu
25 trition
20 GradeIIMaln
15 utrition
10 GradeIIIMaln
5 utrition
0
1 2 3

15
 Figure3:Nutritionalprofileof girlsbasedonGomezclassification®

60

50 Normal
40 GradeIMalnutrition
GradeIIMalnutrition
30 GradeIIIMalnutrition
20

10

0
1 2 3

As per Gomez classification 26.79 percent boys and 29.94 percent of girls were found

tohave normal nutritional status. Girls were in a slightly better position than boys.

Morenumberofnormal childrenirrespectiveofgender werein the age groupof 3years.

Among the various grades of malnutrition, majority of boys (44.01%) and girls

(44.91%)hadGradeImalnutritionfollowedbyGradeIIandGradeIII.Herealsogenderdifferenc

es was not noticed much. The rate of prevalence of Grade I malnutrition wasuniformly

high in all age groups among boys (33.3% to 48.3%). Almost half of thepopulation fell

under this category. Grade II malnutrition found to occur among 27.27percent with

highest incidence among 4.5 year age group. Grade III malnutrition

wasobservedononly1.91percentofboys.Thiswasalsonoticedamong4.5to5yearage

16
group.

This trend in prevalence of malnutrition among various age groups was followed in

thecase of girls also; with the highest incidence of (44.91%) followed by Grade II

(23.35%)andGradeIII(1.79%).Theonlydifferenceobservedwastheincidenceofseveremalnut

rition (Grade III) among younger age groups (1 yrs) in girls; as against oldergroups (2.5

to 3.0years)in boys.

According to a study conducted by Mridhula et al. (2004) as per IAP criteria 60.5

percentunder five children were found to be suffering from various grades of protein

energymalnutrition and severe protein energy malnutrition was present in 5.2percent.

Girlchildrenaremorelikelyto beundernourished thanboys (Chaudhuri, 2007).

17
SOCIOECONOMICSTATUSANDNUTRITIONALSTATUSOFPRESCHOOL

CHILDREN

SocioeconomicscaleformulatedbyKuppuswamy(1981)wasusedforreferencetoclassify the

economic status of the sample. The association between socioeconomic

statusanddifferentgradesof malnutrition wasstudied and presentedin table3.

Table3:Socioeconomicstatusandnutritionalstatusofpreschoolchildren

Socioeconomic GomezClassification Pooled X2 ‘p’v

Status Normal GradeI GradeII GradeIII value alue

(≥90) Malnutrition Malnutrition Malnutrition

(75-89.99) (60-74.99) (<60)

Middle 22.2 35.6 37.8 4.4 11.96 6.383 0.094NS

Low 29.0 45.6 23.9 1.5 88.04

(Numberindicatespercentages) NS =Not Significant

18
 Figure4:Socioeconomicstatusandnutritionalstatusofpreschoolchildren

Socioeconomic status of family affects the nutritional status (Harishankar et al.,

2004).Whentheincidenceofdifferentgradesofmalnutritionwasdistributedaspersocioeconom

icstatus.

There observed no significant difference. This indicated that children in both middle

andlow socioeconomic status were equally affected by malnutrition. Figure 4 presents

thedetails. It was also surprising to note that children with normal nutritional status

weremore in the low socioeconomic status (29.0%) than the middle class group (22.2%).

SoalsotheGradeIIand GradeIIImalnutrition.

Middle class more affected than the low status group. Birth order, age, type of

family,number of living children, literacy status of mother and calorie intake were

significantlyassociatedwithgradesofmalnutritionandfrequentepisodesofinfectionarealso

19
correlated to stunting (Hassan and Jain, 2009). Children of poor socioeconomic

statusgroup hadmoderate and severely malnourished (Elankumaran, 2003).In the

presentstudy middle class group was also equally affected suggesting that the factors

other thanpoverty and poor access to services play an important role as determinants of

undernutritionin preschool children (Ramachandran, 2007).

NUTRITIONALDISORDERS

Nutrients obtained through food have vital effects on physical growth and

development,maintenance of normal body function, physical activity and health.

Nutritious food isimportant to sustain life (ICMR, 1991). Nutritional disorders occur on

deficiency ofnutrientintake.

Occurrenceofclinicalmanifestations

Clinical examination has always been and remains an important practical method

forassessing nutritional status of a community (Jelliffe, 1966). The data procured by

theclinical survey conducted among the preschoolers, was analysed and presented in

thissection.

Clinicalsignsofproteinenergyandmineral malnutrition

Protein energy malnutrition is the most common nutritional disorder among children

indeveloping countries like India (Bamji et al., 1998). Age wise distribution of

samplebasedon clinical signs is furnishedin thefollowingtable:

20
 Table4:Clinicalsignsofprotein

energyandmineraldeficienciesamongpresc

hoolers

Particulars Ageinyears(n =150) Pooled

1.0 1.5 2.0 2.5 3.0

Proteinenergydeficiency

LackofHairluster

Boys 22 10 10 15 18 15.4

Girls 26 10 5 36 21 19.2

Iron

deficiencyPale

tongueBoys 13 7 3 7 8 7.7

Girls 5 10 8 18 7 7.8

Flourosis

Boys 21 33 20 15 47 26.3

Girls 23 20 22 46 36 26.9

DentalCaries

Boys 24 43 50 48 34 39.2

Girls 44 4 38 27 50 41.9

(NumberindicatesPercentage)

21
20

15

10 Boys
Girls
5

0
LackofHairLuster

8
7
6
5
4 Boys
3 Girls
2
1
0
PaleTongue

22
 27
26.8
26.6
26.4
26.2 Boys
26 Girls
25.8
25.6
25.4
Flourosis

42
41.5
41
40.5
40
Boys
39.5
Girls
39
38.5
38
37.5
Dentalcaries

Proteinenergymalnutritionwaspresentamongthechildrenofallagegroups,butseverecasesof

kwashiorkorandmarasmus wereabsent.

23
While symptoms like lusterless dry rough hair was found among the boys(15.4%)

aswellas girls (19.2%).

Anaemia cases were there in both the groups. The symptoms of paleness of tongue

wasobserved, while koilonychia was absent. Irrespective of gender, paleness of tongue

wasseen among both boys (7.7%) and girls (7.8%). The incidence of anaemia among 1

yearboysand 2.5yeargirls.

Flourosis was noticed among the sample involving 26.3 percent of male and 26.9

percentof female children. Severe form of flourosis as chalky, pitted and mottled teeth

was seenamong3year oldboys (47.4%) and2.5year old girls (45.5%).

Results of dental observation showed that dental hygiene was low among the

children.Dental caries was comparatively more in girls (41.9%) than in boys (39.2%).

Half of theboysin theagegroupof2years andgirls of3yearshad dentalcaries.

In short, the clinical manifestation of protein energy and iron deficiencies were

moreprevalent among the preschoolers in the slum areas severe form of flourosis was also

seenin all age groups irrespective of gender. Dental caries was the most prominent

problem,affecting both boys (39.2%) and girls (41.9%). Girls in general were more

affected thanboys.

Age wise prevalence showed that irrespective of gender the upper age groups (2.5 to

3years)weremoreseriouslyaffectedthanyoungerones.Onlyexceptionwasthenutritionaldefici

encies amongboys,where1yearoldchildrenweremostaffected.

24
Clinicalsignsof vitamindeficiencies

Thedetails areshown intable 5.

Table5:Clinicalsignsofvitamin deficienciesamongpreschoolers

Particulars Ageinyears(n = 150) Pooled

1.0 1.5 2.0 2.5 3.0

VitaminAdeficiency

NightBlindness

Boys Nil Nil Nil Nil 4 0.5

Girls Nil Nil Nil Nil Nil Nil

ConjunctivalXerosis

Boys 9 30 13 11 18 15.3

Girls 21 5 13 18 14 15.6

Bitot’sSpot

Boys Nil Nil Nil Nil 4 0.5

Girls Nil Nil Nil Nil Nil Nil

CornealXerosis

Boys Nil Nil 2 Nil 5 1.4

Girls 2 Nil 3 9 7 3.6

VitaminBComplexdeficiency

25
Angular

stomatitisBoys 6 Nil 5 4 3 3.82

GirlsChe 7 Nil 3 9 2 4.19

ilosisBoy

sGirlsGl 1.9 Nil Nil Nil Nil 0.5

ossitisBo Nil Nil Nil Nil Nil Nil

ysGirls

Phrynoderma 7 Nil 8 4 5 5.74

Boys 7 10 5 9 Nil 5.4

Girls

3 Nil Nil Nil Nil 1

Nil Nil 3 Nil Nil 0.6

Vitamin C

deficiencySpongyandbleedi

ngGumsBoys 2 Nil 2 Nil 3 1.5

Girls Nil Nil Nil Nil Nil Nil

Vitamin D

deficiencyKnockkne

e 4 Nil Nil 11 Nil 2.4

Boys

26
GirlsBo 2 Nil Nil 2 Nil 1.2

legsBoys 2 Nil Nil Nil Nil 0.5

Girls Nil 5 Nil Nil Nil 0.6

(NumberindicatesPercentage)

0.5

0.4

0.3
Boys
0.2 Girls

0.1

0
NightBlindness

27
 15.6
15.55
15.5
15.45
15.4 Boys
15.35
Girls
15.3
15.25
15.2
15.15
ConjunctivalXerosis

0.5

0.4

0.3
Boys
0.2 Girls

0.1

0
Bitot'sSpot

28
 4
3.5
3
2.5
2 Boys
1.5 Girls

1
0.5
0
CornealXerosis

4.2

4.1

3.9 Boys
Girls
3.8

3.7

3.6
AngularStomatitis

29
0.5

0.4

0.3
Boys
0.2 Girls

0.1

0
Cheilosis

5.8

5.7

5.6

5.5 Boys
Girls
5.4

5.3

5.2
Glossitis

30
 1

0.8

0.6
Boys
0.4 Girls

0.2

0
Phrynoderma

1.6
1.4
1.2
1
0.8 Boys
0.6 Girls

0.4
0.2
0
Spongyandbleeding

31
2.5

1.5
Boys
1 Girls

0.5

0
KnockKnee

0.6
0.58
0.56
0.54
0.52 Boys
0.5 Girls

0.48
0.46
0.44
BowLegs

32
VitaminAdeficiency

Conjunctival xerosis and corneal xerosis, the two manifestations of vitamin A

deficiencywerediagnosedamongthepreschoolers.Amongthesample15.3percentofboysand

15.6 percent of girls had conjunctival xerosis followed by corneal xerosis involving

1.4percent of boys and 3.6 percent of girls. Only one case each of nightblindness and

bitot‟sspot was also reported among 3 year old boys. Age wise distribution indicated that

seniorage group (2.5 to 3.0 years) was slightly more affected; although not much a

differencewasobserved amongthedifferentagegroups studied.

In India, Vitamin A Deficiency (VAD) is still a major micronutrient deficiency

lurkingbeneath childhood morbidity and mortality due to common illnesses (Bains et al.,

2009).Vitamin A deficiency often in association with protein energy malnutrition

principallyaffects preschool children. It is estimated that almost 250 million children in

developingcountriesareat risk (NIPCCD, 2007).

AsgivenbyAnejaetal.(2000)signsofVitaminAdeficiencylikebitot‟sspot,xeropthalmia and

increased morbidity in terms of repeated bouts of acute respiratoryillness, diarrhoeal

disease in infants and children and resultant mortality as well as nightblindnessin

pregnantwomenwere rampantacrossmostcommunities.

Ocular signs of vitamin A deficiency were more present among the children aged 1-

5years. Children of illiterate mothers suffered from vitamin- A deficiency. Nutrient

intakedecreaseswiththeincreaseoffamilysize,andinchildrenofmultiparamothers(Chatterjee

et al., 2009).

The prevalence of night blindness, conjunctival xerosis and bitot‟s spot was more and

itincreasedsignificantlywithincreaseinage,eventhiswashigheramongthechildrenof

33
lower socioeconomic communities, in 3-5-year age group and those children of

illiteratemothers (Arlappa et al., 2009). All the deficiencies were more common amongst

malechildren(Sharma et al.,2009).

Vitamin A supplementation proved to be definitely effective to improve the health

statusof the slum dwellers, about 75 percent of them suffered from at least one episode of

acuterespiratoryinfectionsirrespectiveof thevitamin A supplementation (Kar et al.,2001).

Das et al. (2009) observed the overall prevalence of night blindness, bitot‟s spot

andconjunctival xerosis. Higher morbidity rate of diarrhoea, respiratory disease, measles

andskindiseasewas suggestiveof high prevalenceof vitamin A deficiency.

VitaminBcomplexdeficiency

Angular stomatitis, cheilosis, glossitis and phrynoderma were the symptoms observed.

Ofwhich angular stomatitis and glossitis presented a slightly more prevalence rate

thanothers. However the overall prevalence rate was less than 5 percent. Here also girls

of allage groups weremore affected than boys.

VitaminCdeficiency

OccurrenceofvitaminCdeficiencyasspongyandbleedinggumswasfoundonlyamong

1.5percentof thesample; thattooamongboys,notamonggirls.

VitaminDdeficiency

Knock knee (1.2 % to 2.4%) and bow legs (less than 1.0%) were the two

manifestationsobserved among preschool children. The age group of 1.0 years and 2.5

years were moreaffectedthan other agegroups.

34
 CHAPTER4:CONCLUSIONSAND

RECOMMENDATIONS

CONCLUSIONS

Sample for the study included 150 children out of which 55.6 percent were boys and

44.4percentgirls.

Age wise distribution indicated that children of 1 years constituted 29.52 percent of

thesample which was the highest followed by 2 year old children (25.79%) and three

years(22.15%).

As per Gomez classification 26.79 percent boys and 29.94 percent of girls were found

tohave normal nutritional status. Girls were in a slightly better position than boys.

Morenumberofnormal childrenirrespectiveofgender werein the age groupof 3years.

Among the various grades of malnutrition, majority of boys (44.01%) and girls

(44.91%)hadGradeImalnutritionfollowedbyGradeIIandGradeIII.Herealsogenderdifferenc

es was not noticed much. The rate of prevalence of Grade I malnutrition wasuniformly

high in all age groups among boys (33.3% to 48.3%). Almost half of thepopulation fell

under this category. Grade II malnutrition found to occur among 27.27percent with

highest incidence among 4.5 year age group. Grade III malnutrition wasobserved on only

1.91 percent of boys. This was also noticed among 4.5 to 5 year agegroup.

This trend in prevalence of malnutrition among various age groups was followed in

thecase of girls also; with the highest incidence of (44.91%) followed by Grade II

(23.35%)andGradeIII(1.79%).Theonlydifferenceobservedwastheincidenceofsevere

35
malnutrition (Grade III) among younger age groups (1 yrs) in girls; as against

oldergroups (2.5 to 3.0years)in boys.

It was also surprising to note that children with normal nutritional status were more in

thelow socioeconomic status(29.0%) than the middleclass group (22.2%). So

alsotheGradeIIandGradeIIImalnutrition.

Protein energy malnutrition was present among the children of all age groups, but

severecasesof kwashiorkorandmarasmus wereabsent.

While symptoms like lusterless dry rough hair was found among the boys(15.4%)

aswellas girls (19.2%).

Anaemia cases were there in both the groups. The symptoms of paleness of tongue

wasobserved, while koilonychia was absent. Irrespective of gender, paleness of tongue

wasseen among both boys (7.7%) and girls (7.8%). The incidence of anaemia among 1

yearboysand2.5yeargirls.

Flourosis was noticed among the sample involving 26.3 percent of male and 26.9

percentof female children. Severe form of flourosis as chalky, pitted and mottled teeth

was seenamong3year oldboys (47.4%) and2.5year oldgirls(45.5%).

Results of dental observation showed that dental hygiene was low among the

children.Dental caries was comparatively more in girls (41.9%) than in boys (39.2%).

Half of theboysin theagegroupof2years andgirls of3yearshad dentalcaries.

In short, the clinical manifestation of protein energy and iron deficiencies were

moreprevalent among the preschoolers in the slum areas severe form of flourosis was

also seeninallagegroupsirrespectiveofgender.Dentalcarieswasthemostprominentproblem,

36
affecting both boys (39.2%) and girls (41.9%). Girls in general were more affected

thanboys.

Age wise prevalence showed that irrespective of gender the upper age groups (2.5 to

3years)weremoreseriouslyaffectedthanyoungerones.Onlyexceptionwasthenutritionaldefici

encies amongboys,where1yearoldchildrenweremostaffected.

Conjunctival xerosis and corneal xerosis, the two manifestations of vitamin A

deficiencywerediagnosedamongthepreschoolers.Amongthesample15.3percentofboysand

15.6 percent of girls had conjunctival xerosis followed by corneal xerosis involving

1.4percent of boys and 3.6 percent of girls. Only one case each of nightblindness and

bitot‟sspot was also reported among 3 year old boys. Age wise distribution indicated that

seniorage group (2.5 to 3.0 years) was slightly more affected; although not much a

differencewasobserved amongthedifferentagegroups studied.

Angular stomatitis, cheilosis, glossitis and phrynoderma were the symptoms observed.

Ofwhich angular stomatitis and glossitis presented a slightly more prevalence rate

thanothers. However the overall prevalence rate was less than 5 percent. Here also girls

of allage groups weremore affected than boys.

OccurrenceofvitaminCdeficiencyasspongyandbleedinggumswasfoundonlyamong

1.5 percentofthesample;thattoo amongboys, notamonggirls.

Knock knee (1.2 % to 2.4%) and bow legs (less than 1.0%) were the two

manifestationsobserved among preschool children. The age group of 1.0 years and 2.5

years were moreaffectedthan other agegroups.

37
RECOMMENDATIONS

 Similar studies may be conducted among the slum population of other cities

ofNewDelhi.

 A detailed study with a wider sample coveragecould beundertaken to

obtainmoreinformation on theselines.

 An in-depth exclusively on goitre prevalence among preschool children of

slumcouldbe done.

 Afieldbasedresearchonbehaviourmodificationsofpreschoolchildrentoimprovethenu

tritional status ofchildren maybeconducted.

 An action research could be undertaken on slum development: “to uplift one

ortwo selected slums by providing cost effectiveinfrastructural and service

needsby a joint action of Governmental and Non- Governmental agencies and

slumorganizations and an evaluation study on its impact on nutrition /health

profile ofvulnerable groups.

38
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44
 APPENDIX

SOCIOECONOMICSCALE

Kuppuswamy’sSocioeconomicStatusScale

Ref:KuppuswamyB. Manualof socioeconomicstatus (Urban),Manasayan, Delhi,1981.

(A) Education Score

1.ProfessionorHonours 7

2.Graduateorpost graduate 6

3. Intermediateorposthighschooldiploma 5

4.Highschool certificate 4

5.Middleschoolcertificate 3

6.Primaryschool certificate 2

7.Illiterate 1

(B) Occupation Score

1.Profession 10
2.Semi-Profession 6

3.Clerical,Shop-owner,Farmer 5

4.Skilledworker 4

5.Semi-skilledworker 3

6.Unskilledworker 2

7.Unemployed 1

Income Score

1.Rs.19575 12
2.Rs.9788-19574 10

3.Rs.7323-9787 6

4.Rs.4894-7322 4

45
5.Rs.2936-4893 3

6.Rs.980-2935 2

7.Rs.=979 1

TotalScoreSocioeconomicclass

1.26-29Upper (I)

2.16-25UpperMiddle (II)

3.11-15Middle Lowermiddle (III)

4.5-10 LowerUpperlower (IV)

5.<5 Lower (V)

CLINICALNUTRITIONSURVEY

Nameofslum:

Nameof thesample:

Age

Sex

SerialNo.

I.Generalappearance Scores

Good 3

Fair 2

Poor 1

46
 VeryPoor 0

II Eyes(A)Conjunctiva

1. Xerosis

Absent 3

SlightlyDry 2

Drywrinkled 1

Verydryand Bitots spots 0

2. Pigmentation

Normal 3

Slightdiscolour 2

BrownPatches 1

Earthydiscolour 0

3. Discharge

Absent 3

Watery 2

MicroPurulant 1

Purulant 0

B) Cornea

1. Xerosis

47
 Absent 3
Slightlydry 2
Diminishedtransparency 1
Ulceration 0

2. Vascularisation

Absent 2

Infectionofbloodvessels 1

VascularCornea 0

C) Lids

1.Excoriation

AbsentQ 2

Slightlyexcoriation 1

Blepharitis 0

2.Folliculosis

Absent 3

Fewgranules 2

Extensivegranules 1

Hypertrophy 0

3. AngularConjunctiva

48
 Absent 1

Present 0

4. Functionalnightblindness

Absent 1Present 0

III Mouth

1. LipsCondition

Normal 3

Angularstomatitismild 2

Angularstomatitismarked 1

Cheilosis 0

2. Tongue

ColourNormal

Palenotcoated 2

Red 1

Redandraw 0

3. Surface

Normal 3

Fissured 2

49
 Ulcered 1

GlazedAtrophic 0

4. NormalBuccalmucosa

Normal 1

Stomatitis 0

5. Gums

Normal 4

Spongy 3

Bleeding 2

Pyorrhoea 1

Retracted 0

IV.Teeth

1. Flourosis

Absent 3

Chalky 2

Pitting 1

Mottled&Discouloured 0

2. Caries

Absent 2

50
 Slight 1

Marked 0

HairCondition

Normal 3

Lossofluster 2

Discoloured and dry 1

Sparse&brittle 0

Skin

(A) General

Appearance

Normal 3

Lossofluster 2

Dryand roughor 1

Crazypavements 1

Hyperkeratosis,Phrynoderma0

Elasticity

Normal 2

Diminished 1

Wrinkledskin 0

51
(B) Regional

Trunk

Normal 1

Dermatitispigmentation 0

Face

Normal 2

NasolabialSeborrhoea 1

Suborbitalpigmentation 0

Perinium

Normal 1

Dermatitis 0

Extremities

Normal 1

Dermatitis 0

Adiposetissue

Normal 1

Deficient 0

Oedema

Present 0

52
 Absent 1

Bones

Normal 1

Stigmata 0

AlimentarySystem

Appetite

Normal 1

Anorexia 0

Stools

Normal 1

Diarrhoea 0

Liver

Notpalpable 1

Palpable 0

Spleen

Notpalpable 1

Palpable 0

Nervoussystem

Calftenderness 0

53
 Paresthesia 1

Normal 2

Glandsenlargement

Thyroid 0

Parotid 0

Nails

Normal 1

Koilonychia 0

Rachiticchanges

Knockknees 0

Bowlegs 0

Pigeonchest 0

Epiphyscalenlargement 0

54