Undernutrition in the Kora Mudi tribal population, West Bengal, India: A comparison of body mass index and mid-upper-arm circumference

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1 Undernutrition in the Kora Mudi tribal population, West Bengal, India: A comparison of body mass index and mid-upper-arm circumference Samiran Bisai and Kaushik Bose Abstract Background. Undernutrition among adult tribal women is a major health problem in India. Objectives. To compare the utility of two different anthropometric indicators of chronic energy deficiency (CED) among tribal Kora Mudi women and to determine which of these two is a better indicator of undernutrition. Methods. A cross-sectional study of 123 individuals was conducted. The body mass index (BMI) and mid-upper-arm circumference (MUAC) were used to evaluate CED. Results. The prevalence of CED based on BMI less than 18.5 was 55.3%, and the prevalence of CED based on MUAC less than 22.0 cm was 51.2%. Both of these prevalence rates are classified in the very high-prevalence category ( 40%) and indicate a critical situation according to World Health Organization recommendations. Mean BMI increased significantly with higher quartile of MUAC. There was a significant difference in the prevalence of CED between the MUAC quartiles. The risk ratio for CED for women in the lowest quartile of MUAC was 9.33 compared with those in the highest quartile. There was a significant positive association between MUAC and BMI. Regression analysis demonstrated that MUAC had a significant positive impact on BMI; the percentage of the variation in BMI explained by MUAC was 52%. Logistic regression analysis demonstrated that overall, 82.11% of cases of CED were correctly classified with the use of MUAC. The use of MUAC correctly diagnosed 82.35% of cases of CED and 81.82% of women with normal nutritional status. Conclusions. This population was facing severe nutritional stress. With limited resources and in the absence The authors are affiliated with Vidyasagar University, West Bengal, India. Please direct queries to the corresponding author: Kaushik Bose, Department of Anthropology, Vidyasagar University, Midnapore , West Bengal, India; banda@ vsnl.net. of skilled manpower, it may be more appropriate to use MUAC for human population surveys, particularly among tribal populations of developing countries. Key words: Body mass index, humans, India, Kora Mudi, mid-upper-arm circumference, nutritional status, tribe Introduction Only recently has there been an attempt to assess the prevalence of malnutrition among adults living in developing countries [1]. This seems surprising, given the widespread concern about world hunger and whether food supplies are adequate for the populations of different regions of a country or for those living in refugee camps [2]. India remains one of the poorest countries in the world, with a population of over 1 billion and a fertility rate well above replacement level [3]. Moreover, improvements in the nutritional status of the population during the last two to three decades have not been impressive [1]. More than half of the world s undernourished people live in India [4]. Various tribal populations are among the most underprivileged people in India. According to the latest census of India, there are more than 84 million tribal people, who constitute 8.2% of the total population [5]. India probably has the largest number of tribal communities in the world [6]. The vast majority of tribal people reside in rural areas of the country. The Kora people, who speak an Austro-Asiatic language, live in the three eastern provinces of West Bengal, Orissa, and Bihar. The Koras are the fifth largest tribal community in West Bengal. The majority of the Koras in West Bengal are found in the districts of Bardhaman, Puruliya, Paschim Medinipur, Birbhum, Bankura, and Hugli. Kora seems to be a generic name signifying the occupation of earth digging. They have four endogamous groups: Mudi Kora, Kurmi Kora, Nagbanshi Kora, and Dhangar or Orang Food and Nutrition Bulletin, vol. 30, no , The United Nations University. 63

2 64 S. Bisai and K. Bose Kora [7]. Information on the Kora Mudis is extremely scanty, and there are no published data on the anthropometric characteristics and nutritional status of Kora Mudi women of Paschim Medinipur District of West Bengal [8]. It has been well established that anthropometry can be used to assess the nutritional and health status of adult humans [9]. The body mass index (BMI) is the most established anthropometric indicator used for assessment of adult nutrition status [10]. The BMI is an indicator of overall adiposity [11]. CED (measured by BMI) is a major public health problem, especially among rural underprivileged adults in developing countries [9]. Although adult nutritional status can be evaluated in many ways, the BMI is most widely used because measurement of BMI is inexpensive, noninvasive, and suitable for large-scale surveys [2, 10, 12, 13]. BMI is generally considered a good indicator of not only the nutritional status but also the socioeconomic condition of a population, especially adult populations of developing countries [2, 13 16]. A BMI less than 18.5 is widely used as a practical measure of chronic energy deficiency of individuals or populations. CED is caused by inadequate intake of energy accompanied by high levels of physical activity and infections [17, 18]. CED has been associated with reduced work capacity [19, 20], reduced performance and productivity [21], and increased morbidity due to suppressed immune function [17, 22 24]. Another anthropometric measure that can be used to evaluate adult nutritional status is mid-upper-arm circumference (MUAC). MUAC is particularly effective in the determination of malnutrition among adults in developing countries [2]. MUAC is a simpler measure than BMI, requiring a minimum of equipment, and in practice has now been found to predict morbidity and mortality as accurately as deficits in weight [25]. The rationale and justification of the present study were to compare the utility of two different anthropometric indicators of nutritional status. The present investigation was undertaken to determine the nutritional status, based on BMI as well as MUAC, of adult Kora Mudi women of Paschim Medinipur in order to determine which of these two measures was a better indicator of CED. The results were compared with those from other tribal populations of West Bengal. It is hoped that the results will be valuable for further research in human nutrition, particularly on evaluation of nutritional status among tribal populations, not only in India, but also elsewhere. Methods and materials Methods Institutional approval for the study was obtained from the Vidyasagar University Ethical Committee. Prior permission and approval were obtained from local community leaders as well as relevant authorities. Oral consent was obtained from each subject. Trained investigators took anthropometric measurements using standard techniques [12]. Height was measured to the nearest 0.1 cm, weight to the nearest 0.5 kg, and MUAC to the nearest 0.1 cm with the use of an anthropometric rod, weighing scales, and nonstretchable fiber tape, respectively. The scales were calibrated daily against standard weights. Technical errors of measurements (TEM) were computed for each fieldworker by measuring the MUAC, height, and weight of a set of 10 individuals. The fieldworker and the supervisor measured the MUAC of each individual in succession (reading 1). Serial second measurements of MUAC were then obtained (reading 2). The TEM for each person was calculated by a standard formula: TEM= ( reading 1 reading 2) / 2n where n is the number of subjects measured. Similar procedures were used to standardize height and weight measurements. The training process continued until the fieldworker achieved TEM values within the acceptable limits [26]. BMI was calculated as the weight in kilograms divided by the square of the height in meters. The nutritional status of individuals was evaluated according to internationally accepted World Health Organization (WHO)[9] guidelines for adults. CED III was defined as BMI less than 16.0, CED II as BMI of 16.0 to 16.9, CED I as BMI of 17.0 to 18.4, and normal as BMI of 18.5 to We followed the WHO [9] classification of the public health problem of low BMI (< 18.5), based on adult populations worldwide. According to this classification, a low prevalence (5% 9%) of low BMI is considered a warning sign requiring monitoring, a medium prevalence (10% 19%) as indicating a poor situation, a high prevalence (20% 39%) as indicating a serious situation, and a very high prevalence ( 40%) as indicating a critical situation. Nutritional status was also evaluated based on internationally recommended [2] cutoff points for MUAC, according to which MUAC under 22.0 cm indicates undernutrition and MUAC of 22.0 cm or more normal nutritional status. MUAC was further divided into four groups on the basis of quartile cutoff values to study the differences in mean BMI and the prevalence of CED between these groups. The corresponding cutoff values for MUAC groups I, II, III, and IV were 19.9 cm, 20.0 to 21.5 cm, 21.6 to 22.9 cm, and 23.0 cm, respectively. Materials This cross-sectional study was conducted over a period of 3 months from March to May The estimated number of study subjects was calculated to be 95 by 2

3 Undernutrition among Kora Mudi women the formula n = (z 2 x p x q)/d 2, where z = 1.96, p is the prevalence of chronic energy deficiency among adult Kora Mudi women in Bankura District (56.4%) [8], q = 1 p, and d is the desired precession of 10%. Therefore, 123 nonpregnant and nonlactating women were measured following a simple random-sampling method. The data were collected from two villages, Jamunapar and Krishnanagar in Paschim Medinipur District of West Bengal. These villages were selected because they were predominantly inhabited by Kora Mudis. These villages are located within 3 km of Gokulpur railway station, which is approximately 120 km from Kolkata (the provincial capital of West Bengal). The residents of all houses in the two villages were contacted, and a total of 123 adult women (> 18 years of age) were included in the study. The response rate in the study villages was 96%. The vast majority of the subjects were illiterate, very low-income manual laborers of the low socioeconomic class. Statistical analyses All statistical tests were performed following standard techniques [27]. The distributions of the anthropometric variables were not significantly skewed. Pearson correlation coefficient (r) and linear regression analysis were used to study the relationship of MUAC and BMI. For regression analysis, BMI was used as a dependent variable. Logistic regression analysis was done using MUAC for the classification of chronic energy deficiency and normal cases. One-way analysis of variance (ANOVA) with Scheffé s procedure was used to test for differences in mean BMI among the four MUAC groups. The risk ratio was calculated by standard statistical formula to measure the risk. The chi-square test was used to compare the prevalence of CED in different MUAC groups. Statistical analyses were performed with SPSS, version 7.5. P <.05 was considered to indicate statistical significance. Results The mean age, height, weight, MUAC, and BMI of the subjects were years, cm, kg, TABLE 1. Characteristics of the subjects Variable Mean ± SD (n = 123) Age (yr) ± Height (cm) ± 5.99 Weight (kg) ± 6.25 MUAC (cm) ± 2.18 BMI ± 2.07 BMI, body mass index; MUAC, mid-upper-arm circumference 65 cm, and 18.33, respectively (table 1). The prevalence of CED, based on a BMI of less than 18.5, was 55.3%; 12.2% of the women had grade III CED, 17.9% had grade II CED, and 25.2% had grade I CED. The prevalence of CED, based on an MUAC of less than 22.0 cm, was 51.2%. There is no significant difference in the proportion of CED according to these two methods. There was a strong significant positive correlation between MUAC and BMI (r = 0.722, p <.001). BMI and MUAC were not significantly correlated with age; hence, linear regression analyses between BMI (dependent variable) and MUAC (independent variable) were performed. Regression analysis showed that MUAC had a significant positive impact on BMI (B = , p <.001; constant = 3.585); the percentage of the variation in BMI explained by MUAC was 52%. This significant impact of MUAC remained even after controlling for age. Furthermore, a logistic regression analysis was performed, and the results showed that overall, 82.11% of cases were correctly classified (Wald Statistic = 29.82, p <.001) with the use of MUAC. The use of MUAC correctly identified 82.35% of cases of CED and 81.82% of normal women. There were significant differences in mean BMI (t = 7.24, p <.0001) and prevalence of CED (χ 2 = 43.46, p <.0001) between the two (CED vs. normal) MUAC groups. Table 2 shows the results of the analysis of variance of mean BMI by MUAC quartile. The lowest mean BMI was observed in MUAC group I (16.60) and the highest in MUAC group IV (20.41). The means in MUAC group II (17.83) and MUAC group III (18.50) were intermediate. There existed a significant increasing trend in mean BMI between the MUAC quartiles (F ratio = 32.67, p <.001). Moreover, there was a TABLE 2. Distribution of mean BMI and total prevalence of chronic energy deficiency according to MUAC group Variable Group I (n = 30) Group II (n = 33) Group III (n = 29) Group IV (n = 31) BMI (mean ± SD) a ± ± ± ± 1.71 CED (%) b RR (95% CI) of CED 9.33 ( ) 8.03 ( ) 4.28 ( ) 1.00 c BMI, body mass index; CED, chronic energy deficiency; MUAC, mid-upper-arm circumference; RR, risk ratio a. F ratio (df1 = 3, df2 = 119) = 32.67, p <.001. b. Chi-square for linear trend = 48.33, p <.001. c. Reference category.

4 66 S. Bisai and K. Bose significant difference in the prevalence of total CED (χ 2 for linear trend = 48.33, p <.001) between the four groups. The highest prevalence of total CED (90.32%) was observed in MUAC group I. The prevalence of total CED was significantly lower in MUAC group II (78.13%), MUAC group III (41.38%), and MUAC group IV (9.68%). The risk ratio for total CED in low- MUAC women (MUAC group I) was 9.33 (95% confidence interval [CI], 3.16 to 27.53) as compared with high-muac women (MUAC group IV). Similarly, the risk ratios for MUAC groups II and III were 8.03 (95% CI, 2.71 to 24.03) and 4.28 (95% CI, 1.34 to 13.63), respectively, compared with MUAC group IV. This implies that women who belonged to the upper MUAC group had ninefold, eightfold, and fourfold lower risks of chronic energy deficiency than women belonging to MUAC groups I, II, and III, respectively. Discussion Several recent studies in India [15, 28 32] have utilized BMI to study the nutritional status of tribal populations. Similarly, the use of MUAC cutoff points has been applied worldwide [2], particularly among adults in developing countries. The economic and health burden of high frequencies of adult CED has been well documented [2, 13, 28, 33, 34]. The functional and economic significance of a high prevalence of CED has already been established [13]. Therefore, efforts must be made to investigate the consequences of the functional impairments commonly associated with low BMI in various ethnic groups. It is also essential to ascertain the relationship of the high prevalence of undernutrition with morbidity and mortality among adults. The outcome of the present study clearly indicated that the prevalence of CED among adult female Kora Mudis was very high on the basis of either BMI (55.3%) or MUAC (51.2%). Both of these percentages are greater than 40%, placing the population in the critical situation, according to WHO recommendations. High rates of CED have also been reported from other tribal populations of West Bengal (table 3) and India [15, 28 32]. Table 3 presents the mean BMI and the prevalence of CED among tribal women of West Bengal. The mean BMI ranged from 17.7 to The rate of CED ranged from 31.7% to 67.9%; these values are classified as high (20% 39%) to very high ( 40%) rates according to WHO. These results clearly indicated that women of these tribes were under serious or critical nutritional stress. In the present study, the relative risk of low MUAC with low BMI was highly significant (p <.001), which indicated that these measures were well correlated. This implies that either of these measures could be used to evaluate nutritional status among adult female Kora Mudis. However, the difference in the prevalence of CED according to the two measures may have public health implications, especially in larger populations. Moreover, because MUAC is much easier to measure than BMI [9, 26], the use of MUAC should be preferred in large-scale studies. Therefore, with limited resources and in the absence of skilled manpower, it may be more appropriate to use MUAC for human population surveys, especially among rural populations of developing countries. Thus, although both BMI and MUAC could be used to evaluate nutritional status, MUAC may be preferred for its simplicity. However, it must be mentioned here that some limitations of the present study were the small sample size and the nonavailability of data on dietary intake. From the public health perspective, of paramount importance is the immediate initiation of appropriate nutritional intervention programs among this ethnic group. The Indian government should play an active role in reducing the prevalence of undernutrition among tribal people such as the Kora Mudis. Acknowledgments All subjects who participated in this study are gratefully acknowledged. Sanjib Ganguli, Argina Khatun, Priyanka Das, and Swapan Dikhshit helped with data collection. TABLE 3. Mean BMI and prevalence of total CED (based on BMI) among various tribes of West Bengal Variable Dhimal (n = 146) Kora Mudi (n = 250) Munda (n = 234) Oraon (n = 150) Santal (n = 213) Study area Darjeeling Bankura Kolkata Jaipaiguri Paschim Midnapore Santal (n = 400) Bankura Kora Mudi (n = 123) Paschim Midnapore Tribal women (n = 287) West Bengal Mean BMI a CED (%) Reference Banik et al. [35] Bose et al. [8] Ghosh and Bharati [37] BMI, body mass index; CED, chronic energy deficiency a. BMI was calculated based on the reported weight and height. Mittal and Srivastava [5] Bose et al. [36] Ghosh and Malik [38] Present study NFHS-2 [39]

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Int. J. Exp. Res. Rev., Vol. 8: (2016)

Int. J. Exp. Res. Rev., Vol. 8: (2016) International Journal of Experimental Research and Review (IJERR) Copyright by International Academic Publishing House (IAPH), Website: www.iaph.in ISSN: 2455-4855 Original Article Nutritional status of