CHILD HEALTH SITUATION IN COOCH BEHAR DISTRICT: AN ANALYSIS IN RESPECT OF PROTEIN-ENERGY MALNUTRITION [PEM]

Transcription

1 CHILD HEALTH SITUATION IN COOCH BEHAR DISTRICT: AN ANALYSIS IN RESPECT OF PROTEIN-ENERGY MALNUTRITION [PEM] Author: Subhasis Bhattacharya, Assistant Professor, Department of Economics, Cooch Behar College, Cooch Behar, West Bengal, - ABSTRACT: Malnutrition is a continuous process, exist in the past and also remain continued in the recent time. Like other developing countries India also faces a grades nutrition deficiency and bad health. Malnutrition is a contributing factor in nearly 60% of deaths in children for which infectious disease is an underlying cause. Protein-Energy Malnutrition (PEM) and vitamin A deficiency are prominent among the pre-school children. The degree and distribution of protein energy malnutrition and micronutrient deficiencies in a given population depends on many factors like the political and economic situation, the level of education and sanitation, the season and climate conditions, food production, cultural and religious food customs, breast-feeding habits, prevalence of infectious diseases, the existence and effectiveness of nutrition programs and the availability and quality of health services. The Cooch Behar district, a unique biosphere located in the extreme north of West Bengal. The human face of the district epitomizes abject of poverty, deprivation and acute suffering. Regarding the relationship of prevalence of PEM and place of delivery, the study found the prevalence rate is higher for those children whose deliveries are occur at home than those in the deliveries at hospital or health centre. The study also found that children with lower birth weight are more prone to PEM prevalence.

2 INTRODUCTION: Nutrition is the Combination of process by which the living organism receives and utilises the material necessary for the maintenance of its functions and for the growth and renewal of its components (Turner 1959). Malnutrition is a continuous process, exist in the past and also remain continued in the recent time. Now, developing world is facing the resource scarcity. Thus better utilisation of resources with the increasing pressure of population is an important task of the state. As the food scarcity increases ailments, infectious diseases, and malnutrition are growing rapidly. Like other developing countries India also faces a grades nutrition deficiency and bad health (Gopalan, 1968). Worldwide, an estimated 852 million people were undernourished in , with most (815 million) living in developing countries. Expectedly new born infants and pre-school children are rapidly affected by the nutrition deficiency than the adults during their growing period. Because infants and pre-school children require 2-3 times more nutrients than adults as per body weight. In 1999 World Health Organisation found more than half of all under-nutrition children are found in Asia. Possibly 70% of the world stunted children age under 5 years live in Asia. Malnutrition continues to be a major public health problem throughout the developing world, particularly in southern Asia and sub-saharan Africa. Malnutrition is a contributing factor in nearly 60% of deaths in children for which infectious disease is an underlying cause. Malnutrition defined as a pathological state which derived from relative or absolute deficiency of important nutrients. The state can be identified by the Bio-chemical, Anthropometric or Psychological assessment. There is an association between increasing severity of anthropometric deficits and mortality, and a substantial contribution is made by all degrees of malnutrition to child mortality. World Health organisation defined the state of under-nutrition as a pathological state generated from the consumption of inadequate quality of food over an extended period of time. In India, for example, 2.8% of children under 5 are severely wasted. A study on decreasing effect on stunting from World Health Organisation database shows that in India the reduction of stunting is not yet very impressive i.e. lies in the gray zone. PROTEIN-ENERGY MALNUTRITION: Protein-Energy Malnutrition (PEM) and vitamin A deficiency are prominent among the pre-school children. Different studies suggested that in India, diet contents are suffering from lack of energy (Ghai et al. 2005). Due to this lack of energy body starts utilising its protein for transformation into energy. When this process continued for a long period of time PEM started. Protein deficiency causes immunologic deficiency in the cellular subsystem which also familiar as tumour necrosis factor. PEM is basically generated by the causes of deficiencies between nutrient requirements and supplies. Diets are the composition of macronutrients and micronutrients. The basic macronutrients are protein, carbohydrates and fat, where as the micronutrients are electrolytes, minerals and vitamins. Deficiencies of either macronutrients or micronutrients or both cause malnutrition. Basically causes and determinants of malnutrition is poverty. The degree and distribution of protein energy malnutrition and micronutrient deficiencies in a given population depends on many factors like the political and economic situation, the level of

3 education and sanitation, the season and climate conditions, food production, cultural and religious food customs, breast-feeding habits, prevalence of infectious diseases, the existence and effectiveness of nutrition programs and the availability and quality of health services. PEM generate two types of identified variations, one is 'marasmus' and other is kwashiorkor. Marasmus is diagnosed when subcutaneous fat and muscle are lost because of endogenous mobilization of all available energy and nutrients. Kwashiorkor usually manifests with edema i.e. excess fluid in body cavities or tissue, changes to hair and skin colour, anaemia, hepatomegaly, lethargy, severe immune deficiency and early death. Marasmus is defined as severe wasting. The word kwashiorkor originates from Ghana and it implies the disease that the young child developed when displaced from his mother by another child or pregnancy. The international Dietary Energy Consultative Group (IDECG), which is a subcommittee of United Nations, formulated a method to measure Chronic Energy Deficiency (CED) which is independent of age and sex. According to IDECG the Body Mass Index (BMI) expressed as a ratio of weight in kg. to height square in meter, can be a well defined parameter for grading chronic energy deficiency. Malnutrition is also linked to an increased risk of death in children with diarrhoea and acute infections of the lower respiratory system and it may be linked to malaria and possibly measles too. Death rates caused by severe malnutrition have changed little over the past few decades in hospitals of developing countries (median 23.5% during the 1990s) because malnutrition was inappropriately managed. EARLIER STUDIES: Williams in 1930 carried out the seminal investigation on PEM. In the 1950s the United Nations and its agencies became involved in evaluating the extent of the problem, and PEM became the subject of worldwide study. In May 1993 at a meeting attended by representatives from WHO, UNICEF, and Save the Children Fund (SCF), together with senior academics and experienced doctors, it was considered what action, if any, should be taken to combat the continuing high case fatality associated with PEM. In 1995, James L. Newman defines PEM as "...includes a range of syndromes among infants and pre-school children who displaying growth and biochemical abnormalities produced by the synergistic effect of dietary deficiencies and various infections". Corinne H. Robinsen et al (1997) illustrate the working of PEM more elaborately. If the dietary intake is low for a larger period of time, then energy and protein in the diet are expanded more and excretion of nitrogen from urine and stool is reduced and which will generate mild to moderate PEM. Several studies explained the PEM under conditions of insufficient protein and sufficient calories (Kwashiorkor) and some with insufficient protein and insufficient calories (Marasmus). In India several studies are found for tribal and non-tribal areas but studies on PEM among 0-6 years age group are very much limited. Nutritional status is influenced by the genetic factors and also strongly by different socio-economic factors of which diet is an important one (Hunumantha Rao & Sathyanarayana, 1976). Malnutrition among pre-school children has been recognised as a major public health problem in developing countries, particularly in India (Visweswara Rao, 1978).

4 Research finding reveal that pre-schoolers from economically advanced groups are well nourished when compared to low income groups (Banik, 1982). Smythe PM et al 1997 found that severe PEM adversely affect the cell mediated immune response. METHODOLOGY: West Bengal a middle income state in the country and according to census report 2001 the health index is 0.7 which is 20th position in our country. The birth rate is fourth lowest (17.2 according to Sample Registration System, 2009) and infant mortality rate is also fourth lowest (33 according to Sample Registration System, 2009) within the country. According to expectation of life at birth during period its position in the country is third for male (68.2 years) and female (70.9 years). Proportion of institutional delivery has registered an increase from 56.3% in 2004 (NSSO-2004) to 60.2% (Coverage Evaluation Survey, UNICEF). The full immunisation coverage for children between months reported 75.8% in DLHS-3 ( ) compared to 50.3% reported in DLHS-2 ( ). The nutrition section is mandated with the task of monitoring the nutrition level of the general population of the state West Bengal, with a special emphasis on children up to 6 years of age. Due to lack of knowledge, faulty social beliefs, poor economic conditions and unhealthy surroundings of rural as well as slum dwellers in the cities, a huge number of children (0-14 years) and adults (basically ante/post natal mothers) are vulnerable to undernutrition. In the state, arrangement of the districts in terms of sex-ratio in the 0-6 years age group, the position of Cooch Behar district is 12th and also in terms of health index its position is 16th. Government of India identifies this district as a backward districts in term of some educational and caste indicators. There are three criteria to identify child malnutrition, these are (i) bipedal oedema (indicating kwashiorkor), (ii) marasmus indicators visible severe wasting, and (iii) a weight for height z score of < 3 (more than three standard deviation units below the median of the international reference population) were associated with three to four times the risk of mortality. WHO has recommended using these three criteria as the best way to identify children with severe malnutrition. A low cut off z score for weight for age was not associated with an increased risk of mortality. This may be because low weight for age is largely the result of low height in populations where stunting is prevalent and severe. Weight for height rather than weight for age is the better indicator of recent or on-going weight loss or wasting. Visible severe wasting may be used to identify severe malnutrition when height cannot be measured; it can be recognised by muscle wasting, loss of subcutaneous fat; and prominence of bony structures, particularly over the thorax. The comparability of survey results is a major ground of difficulty in case of monitoring child malnutrition. The studies of 1980s and 1990s used anthropometric indicators, reporting system, reference values and now it is difficult for before stated reason to compare those studies. Thus WHO in 1986 prompted procedure for systematic collection and standardisation of data on nutritional status of children aged under 5 years.

5 Figure 1: Map of Cooch Behar (Map not to Scale) [Source NIC-Cooch Behar] ] The Cooch Behar district, a unique biosphere located in the extreme north of West Bengal. The human face of the district epitomizes abject of poverty, deprivation and acute suffering.. The district is partly surrounded by international border with Bangladesh. Cooch Behar district has a population (2011 Census Report) which is 3.09% of state population. The percentagee of male and female population are 51.50% and 48.50% respectively of which percentage of rural population is 89.75% (Census 2011). In compare to 2001 census report the sex ratio reduces from 949 to 942 in 2011 census of this district. The population under six years is 11.77% of total population according to 2011 census report and the sex ratioo of 0-6 years population is 963. The dominancy of schedule caste population (50.1%) which is also double than the state West Bengal (23.0%) is another significant feature. Almost people depend upon rain-fed/mono-crop agriculture and the extent of poverty can also be gauged by the fact that a little less than half of the population (46.1%) belongs to the historically marginalised groups (such as schedule castes and schedule tribes) with BPL character, and 38.7% of the farming community is landless labourers. The suffering face of Cooch Behar district is perpetuated by a poor physical infrastructure. There are only 102 km of railway line and about 799 km of metal roads in the entire areaa of about 3387 square km, almost half of which are inaccessible in the monsoons. In terms of 2001 census, the health index rank is 16 in the state which is quite low than the state level. The same scenario iss observed for the education index and income index for the district Cooch Behar. In brief, the Cooch Behar district symbolise a world of human poverty and fragility packaged with natural richness; a world which is so close to the lights of development, yet so far. In the selected village schedule castes are dominated than any other category of population.

6 The objective of the study is (1) to observe the child health (0-6 years) condition; (2) to find the prevalence of PEM by using anthropometry and (3) to observe the diet pattern, socio-cultural health practices and demographic features related with PEM. Table 1: Child Demographic Character of Sampled Villages Block Mathabanga-II Dinhata-I Sitalkuchi Tufanganj-I Village No of Children (0-6 Yrs) Caste in Percentage Total Study Sample Boys Girls SC & ST Others Boys Girls Total Bherbheri % 43% Bailpari % 23% Purbba Putimari % 14% Khar Kharia % 41% Bara Bhita Pratham Khanda % 19% Bajejama Pakhihaga % 33% Atiabarinepra % 47% Bara Kaimari % 32% Jatamari % 29% Amlaguri % 42% Chhat Rampur Pratham Khanda % 43% Gopalerkuthi % 35% Total Total The present study was carried out in three villages of each block like Mathabanga-II, Dinhata-I, Sitalkuchi and Tufanganj-I. The child demographic characters of the sampled villages are shown in table 1. Each villages are chosen purposively on the basis of maximum concentration of reserve category (SC & ST) of population. In our sampled village the average percentage of reserve category is 66.5%. The health seeking behaviour of the district shows that majority of the population are dependent on government provided facilities, although there is a great tendencies to go to rural medical practitioners (Unqualified) for general ailments. Most of the public health facilities are not within the proximities, and during crisis like delivery pain, ambulance services also not available, as a result dependence upon private rented vehicles increases the health costs. The study found 58.37% incidence of child birth at home for reserve category population. The study found a large number of male members are migrated to western cities mainly for construction work. Children are born at home and the percentage of institutional delivery for the district is 71. The children are breastfed on second day of delivery because as they believe that only after the first day of birth colostrums secreted waste material. Population of this research is 0-6 years old children from the village. The list of the children collected from Anganwadi (ICDS) workers of each village. The population which are present during the study are known as de-facto population and those are used for the study. The total sample size is 876 children (0-6 years) of which 442 boys and 434 girls. The sample selection is made by choosing almost 25% of the boys and girls from each villages. Study participants were infants and young children, age 0 to 6 years, from block Mathabanga-II, Dinhata-I, Sitalkuchi and Tufanganj-I of Cooch

7 Behar district under State West Bengal, India. Cooch Behar district was selected due to its behaviour of low energy density food consumption like potatoes, sweet potatoes, and rice which are high dietary and low energy density. The study defined household as a group of people living, cooking, and eating together. Twelve villages (clusters) were randomly selected from 4 blocks in Cooch Behar and all the households with a child 0-6 years of age had an equal chance of participating. The study is performed during August Methods of Investigation A comprehensive, pre-coded questionnaire was validated for the study. The questionnaires were searched to the respondents, preferably the mothers of the children, in their home by the principal researcher and assistants. The questionnaire was translated into the local languages at the time of administration. The precautions to minimize survey errors the age of the children, to the nearest month, was obtained through birth certificates. The anthropometric study assessed height, weight, head circumference (HC) mid upper arm circumference and chest circumference (CC) by standard methods. For the interview stratified non-proportionate sampling method is used for interview schedule. After considering the anthropometric measures the sampled children's are divided into two categories: children affected with PEM (Category I) and children not affected with PEM (Category-II). During survey, a structured interview schedule was made from mother of children from each stratum. The interview deals with type of the family, place of delivery, health status, major ailments from last 365 days, hospitalisation during last 60 days, no of days of Rural Medical Practitioner (Unqualified) visits due to ailments, breast feeding practices, education level of mothers etc. The laboratory and biochemical examination was not made due to time and economic constraints. The survey also linked with dietary assessment and nutritional status assessment of the children of these areas. Different methods like diet history questionnaire, food frequency questionnaire are used for the assessment of children's diet. All of these questionnaire were incorporated into the main questionnaire. During interviews sample foods for the children were collected to make an idea regarding the nutrient content of it. These samples were collected and analyzed individually and used as a proxy for usual diet. Physical standard of the children is the main assessing factor of the child health. By the interview with mother regarding the symptoms of the child in the week before interview, the presence of diarrhoea, measles, malaria, or cough/influenza was assessed. The height, weight, and mid upper arm circumference (MUAC) were measured by available weight measuring balance and non-stretchable insertion tape commonly used in anthropometric measures and recommended by Indian Medical Associations. The dataset comprised the observations on chosen variables and was analyzed with SPSS. Two-way and three-way cross-tabulations were performed on some selected variables (bivariate analyses). Statistical significance was determined using Pearson s χ 2 test. Correlation analysis was done using Pearson correlation coefficients. The risk factors for malnutrition of the children were further investigated using logistic regression analysis.

8 Findings: The Health Status of the Children: The health status of the children in Cooch Behar district is in sorry state. This is partly reflected in the nutritional status of the children under the age of 6 years. In the study area 33% children were reported as immunized and 27.5% hold immunisation card. The study found that immunized children had significantly better general health than children who were not immunized in terms of cross tabulation. The location of residence had a significant effect on immunisation. The study identified that families uses water from unprotected sources had a lower prevalence of immunisation. In the study area diarrhoea prevalence found high among the children and 46% children found having an episode of diarrhoea during the week of interview. However 12% children are found who got MMR( Malaria-Measles-Rabies Vaccine) for future security. According to the collected data from Anganwadi workers and after complete interview status the study compare the mean weight and height of girls and boys with World Health Organisation (WHO) standard value. Table 2: Weight and Height distribution of Sampled Girls (Comparison With WHO Standard) Age Groups Sample Size Weight WHO STD Height WHO STD (Mean-Kg) Weight (2006) (Mean-Cm) Height (2006) 0-1 Yrs yrs Yrs Yrs Yrs Yrs Total 434 Table 3: Weight and Height distribution of Sampled Boys (Comparison With WHO Standard) Age Groups Sample Size Weight WHO STD Height WHO STD (Mean-Kg) Weight (2006) (Mean-Cm) Height (2006) 0-1 Yrs yrs Yrs Yrs Yrs Yrs Total 442 The study of child malnutrition based on weight-for-age height-for-age, and weight-for height data, which also identifies the gradation of PEM. All these three indices provide us different information about nutritional status of children. The first one is weight-for-age that measures chronic and acute malnutrition in terms of underweight. The height-for-age index measures linear growth retardation among the children, which is otherwise known as stunting. The third index is weight-for-height, captures body mass relation to height i.e., wasting. World Health Organisation (WHO) recommended a standard with reference to international population. The before mentioned three indices of child

9 malnutrition are measured in terms of standard deviation (S.D.) units from the median. Children, who fall more than 1SD below the reference median are considered as normal, those who fall in the interval of 1SD to 2SD below the reference median are considered as mildly malnourished, those who fall within the interval 2SD to 3SD below the reference median are known as moderately malnourished, and those who fall more than 3SD below the reference median are considered as severely malnourished. On the basis of above mentioned marked line, in case of height-for-age we defined stunted and severely stunted category, and in case of weight-for-age, the study defined underweight and severely underweight, and in case of weight-for-height category defined wasted and severely wasted. The sampled height and weight data collected, found in lower than the WHO standard for both the boys and girls of age group 0-6 years. Based on weight, age and height data of 876 children (< 6 years) are shown in Table-4. The anthropometric indicators reflected that about half of the children (58%) were stunted (i.e., low height for age), or in other words, were suffering from chronic malnutrition. The proportion of chronic malnourished children is higher than both state (45%) and national average (48%) implying that in the Cooch Behar district a comparatively higher k proportion of the children are growing up with serious nutritional retardation. Let X i n represent weight or height of a specific child i in a age group n and k denote the sex of the child. Then we use Z k scores for weight or height, which is calculated as Z= [X i n -- X k n ] / σ k n ; Where X k n denote mean or median of the same age group for that particular sex and σ k n is the standard deviation of that same group of the reference population. The study assumes that Z scores are easily calculated on the basis of assumption that nutritional indicators are approximately normally distributed in the reference population. For explanation consider a girl has a weight for age Z score below , then her weight is below the 95 % of girls in the reference population of same age group. Table 4: Nutritional status of preschool children (0-6 years) according to SD classification Nutritional Index as per NCHS standard Boys (434) Girls (442) Total (876) Weight for Age >-1SD (NORMAL) 13.6 (59) Underweight (% ) 14.0 (62) 13.8 (121) Between -1SD- 2SD (MILD) 24.4 (106) 22.9 (101) 23.6 (207) Between -2SD - 3SD (MODERATE) 29.3 (127) 26.7 (118) 28.0 (245) <-3SD (SEVERE) 32.7 (142) 36.4 (161) 34.6 (303) Height for Age >-1SD (NORMAL) 16.8 (73) Stunting (% ) 13.6 (60) 15.2 (133) Between -1SD- 2SD (MILD) 19.8 (86) 21.7 (96) 21.0 (182) Between -2SD - 3SD (MODERATE) 32.7 (142) 31.0 (137) 31.8 (279) <-3SD (SEVERE) 30.7 (133) 33.7 (149) 32.1 (282) Weight for Height >-1SD (NORMAL) 13.2 (57) Wasting (% ) 20.8 (92) 17.0 (149) Between -1SD- 2SD (MILD) 17.5 (76) 19.3 (85) 18.4 (161) Between -2SD - 3SD (MODERATE) 31.3 (136) 31.2 (138) 31.3 (274) <-3SD (SEVERE) 38.0 (165) 28.7 (127) 33.3 (292)

10 Table-4 presents the percentage of children below age 6 years who are malnourished in terms of height-for-age, weight-for-age and weight-for-height in sampled area as a total. The study found 26% are stunted and 32.1% are severely stunted and the severe stunting is more effectivee for girls. The underweight behaviour shows 28% are underweight and 35% are severely underweight. Like Stunting, the prevalence of underweight is higher among girls than boys. In case of wasting, the study found 33% are severely wasted and wasting is also higher among boys than girls. Cogil 2003, pointed out weight is the first indicator of PEM, so prevalence of PEM in total population is calculated here on basis of weight for age indices. Within the age group 0-6 years, in terms of weight-for-age, the study found mild form of malnutrition is 23.6 %, moderate malnutrition is 28 % and severe malnutrition is 35 % from 0-6 years age group, whereas 14 % children are found normal. Thus from this index, both boys and girls are suffering from moderate level PEM is clear. The study found that 62 % boys and 63 % girls are suffered jointly by moderate and severe PEM in the district. The study purposively defined Grade-I PEM who are in normal and mild level, Grade-II PEM is identified by moderate level and Grade-III PEM is defined by the severe level. In terms of weight-forare in Grade-III age, the study found 37 % are in Grade-I PEM, 28 % are in Grade-II PEM and 35 % PEM. Thus a closer look identifiedd the fact that the occurrence of Grade-I and Grade-III PEM are almost same. The existence of nutritionally nourished and severely malnourished proportion of children are stayed in the district. The factors responsible for such existence are discussed latter. Someone pessimistically defined Grade-III PEM by the juxtaposition of underweight and severely underweight level, which shows 63 % of the children are under such category and this will identify the severity of level malnutrition. The frequency of grade III PEM is more (7 %) than grade II in case of former gradation (Fig-2), but in case of juxtaposition Grade-III PEM is more or less doubled than the Grade-I. Fig 2: Prevalence of PEM in total population PEM 35% 28% 37% Grade I Grade II Grade III

11 Fig 3: Weight-for-age distribution among boys, girls & total at four levels Boys Girls 10 Total 0 Normal Mild Moderate Severe The underweight specification shows (Fig-3) that in case of mild and moderate levels, girls position is quite better than boys but in case of severe underweight boys are in relative safe position. Thus a gender based inequality exist in case of underweight specifications. But if the gradation of PEM can be done by three category (Fig-4), i.e., by normal, mild and the juxtaposition of moderate and severe underweight, the severity of malnutrition is observed. The study found no incidencee of marasmus among the children of the district. In case of reference population for weight-for-age index 3 standard deviations (SD) from the median according to gender and with no visible edema. Fig 4: Weight-for-age distribution among boys, girls & total at three levels Normal Mild Juxtapose of Moderate & Severe Boys Girls Total Stunting is a chronic malnutritionn which develops slowly throughout before it is evident. J.C. Waterlow first introduced the term "stunting" during 1970 (19). He describe it as a linear growth retardation for which children became very short in compare their age and this generated from the continued nutritional deprivations with repeated infections. World Health Organisation (20) recommended classification of stunting during 1983 on the basis of an international reference population. A child was classified as stunted if his/her height was 2 SD or more below the median of the reference population for height-for-age and gender and it becomes severe when his/ /her height was 3 SD or more below the median of reference population. In the study, we measure the supine length

12 for children of 0-6 years of age and which is a de-facto height for them. The study found 25.5 % children were short and 32.1 % were extremely stunted i.e. 3 SD below the reference. In the table- 5 the age-wise height distribution of boys and girls are shown, which identifies thatt at which age stunting becomes severely observed. Among the boys, the study found at the age group 2-3 years and 5-6 years stunting exposed and for girls, it is only at age 2-3 years, which is also the total behaviour. Table 5: Age wise stunting among boys and girls in the sampled areaa Age Normal Boys Girls Total Boys Mild Moderate Severe Girls Total Boys Girls Total Boys Girls Total 0-1 yrs (10.9) 8 (11.6) 7 (11.3) 15 (14) 12 (8.3) 8 (11) 20 (9.9) 14 (9) 12 (9.3) 26 (9.7) 13 (10.1) 15 (9.9) yrs (15.1) 11 (16.7) 10 (15.7) 21 (11.6) 10 (13.5) 13 (12.5) 23 (13.4) 19 (13.1) 18 (13.3) 37 (15.8) 21 (16.8) 25 (16.3) yrs (16.4) 12 (20) 12 (18.1) 24 (22.1) 19 (21.9) 21 (22) 40 (21.8) 31 (17.5) 24 (19.7) 55 (20.3) 27 (21.5) 32 (20.9) yrs (20.6) 15 (15) 9 (18.1) 24 (18.6) 16 (15.6) 15 (17) 31 (19) 27 (20.3) 28 (19.7) 55 (19.6) 26 (15.4) 23 (17.4) (20.6) (20) (20.3) (17.4) yrs (16.4) (16.7) (16.5) (16.3) yrs Total (24) 23 (16.7) 16 (21) 38 (16.5) 30 (17.6) 25 (18.3) 26 (19) 26 (21.1) 29 (18.3) 51 (19.7) 55 (14.3) 19 (20.3) 27 (17.4) 26 (18.8) 28 (16) 45 (19.5) The height-for-age distribution for boys, girls and total are shown in the three figure 5,6 and 7. If we compare the figure and find that 20 percent and above number of cases for a particular age group identifies as significant level, then for f boys, the age group 2-3 years for moderate stunting and the age group 2-3 years and 5-6 years for severe stunting. The same thing for girls is in the age group 5-6 years in moderate stunting and for age group 2-3 years for severe stunting. But the severity is found Fig 5: Age wise height distribution for boys to observe stunting yrs Normal Mild Moderate Severe 1-2 yrs 2-3 yrs 3-4 yrs 4-5 yrs 5-6 yrs

13 Fig 6: Age wise height distribution for boys to observe stunting Normal Mild Moderate Severe 0-1 yrs 1-2 yrs 2-3 yrs 3-4 yrs 4-5 yrs 5-6 yrs Fig 7: Age wise height distribution for boys & girls to observe stunting Normal Mild Moderate Severee 0-1 yrs 1-2 yrs 2-3 yrs 3-4 yrs 4-5 yrs 5-6 yrs when we juxtapose the boys and girls vale of height-for-age, the age groups are 2-3 years, 3-4 years and 5-6 years are found in moderatee stunting and 2-3 years and 5-6 years are for severee stunting. The study found prevalence of PEM is maximum for 2-3 years while it is minimum in 0-1 years children than any other groups. Prevalence is found higher among boys than girls. Among the boys, PEM is higher among 2-3 years old boys, while among girls it is higher in 5 years of age. Thus the general question arises that why are so many children stunted or chronically malnourished. Stunting, which is usually regarded as the best indicator of children's long run health status and well being is a biological adaptation to inadequate food, frequent episodes of disease, or both during the first few years of life. In other words, a high stunting level among the children in the Cooch Behar district mirrors chronic poverty and food insecurity among a large part of the population. Wasting is used as a measurement of nutritional problems specially after an episode of illness (Diarrhoea). Wasting defined as 2SD of the median of a reference population for weight-for-height and it becomes severe when it is less than 3SD of the median of reference population. The

14 corresponding classification can be done gender wise. In this study 566 children are found affected of wasting which is 67% of the total sample and boys are more wasted than the girls. In the study Mid-Upper Arm Circumference (MUAC) of 337 younger children (2-4 years) measured by non-stretchable, tear resistance tape. Children with low MUAC are classified as they have measurements is less than 120 mm. That class having MUAC less than 120 mm is known as severe, MUAC is between is known as moderate and MUAC higher than 135 mm is known as Table 6 shows the MUAC data in percentage form for the children of age group 2-4 years. Table 6: Distribution of MUAC according to age and sex among sampled population. MUAC 2-3 yrs 3-4 yrs Boys Girls Total Boys Girls Total Normal (32.6)29 (24.7)22 (28.7)51 (31)26 (30.7)23 (30.8)49 Moderate (30.3)27 (40.5)36 (35.4)63 (33.3)28 (30.7)23 (32.1)51 Severe (37.1)33 (34.8)31 (35.9)64 (35.7)30 (38.6)29 (37.1)59 Total The study found more than one third of the age group of 2-4 years of boys are suffered by lower MUAC, which is 36 % of the total boys surveyed. The same picture also occurred in case of girls, which shows the absence of gender discrimination in case of lower MUAC. The similar results also obtained for normal level of MUAC in case of boys and girls of the same age group. The MUAC in case of different age groups also identifies no significant behaviour. The study found 36.5 % of the total sampled population have lower MUAC. To find the relation between MUAC and height, the study found for the age group 2-4 years a positive correlations (r = 0.431) and same for MUAC and weight (r = 0.652) also. So low value of MUAC can be identified as an indicator of child malnutrition in the district. Several demographic and socio-economic factors are identified for such poor child health situation in the Cooch Behar district. The study basically uses cross tabulations for bivariate analysis of influencing factors on underweight, stunting and low MUAC etc. This is the most significant part of the research, where the study try to identify the contribution of suspected factors for PEM. The cross tabulation results shows that young children are more stunted than the new born and also gender wise stunting is also insignificant in the study area. But the cross tabulation shows a greater incidence between stunting with underweight, and stunting with low MUAC. The study also found lower incidence of underweight and stunting for those children who consume cow milk or at least three eggs in a week. The study found better educated mother had less stunted children. In the study area no infants are found stunted whose mother completed primary level education. Several studies shows such positive association between mother education and reduction of stunting of general health. The economic profiles of the families are important factor to influence stunting. The families found with low economic status being more stunted. Conclusion: Cooch Behar district have large number of moderate and severely moderate malnourished children of below 6 years according to underweight, stunting and low MUAC

15 anthropometric data collected by the survey. The study found that out of the total surveyed children 63 percent are underweight, 64 percent are stunted and 65 percent are wasted. Mothers education is found an important indicator for the PEM in the district. Study area is dominated by reserve caste population, and that also identifies such lower outcome of child health for such category of population who are socially under privileged than the rest. The findings also imply that the prevalence of malnutrition can be reduced by improving educational levels of mothers, by raising household living standards, and by reducing higher order births by means of family planning. Thus to recover such situation more initiatives from the governments and other stake holders are needed for better future of the child health in this district. References: 1. International Institute for Population Sciences and ORC Macro 2000: National family health survey (NFHS 2 ), Mumbai, India: International Institute of Population Sciences, World Health Organization 2002: Global forum for health research. Child health research: a foundation for improving child health. Geneva: WHO, Rice AL, Sacco L, Hyder A, Black RE 2000: Malnutrition as an underlying cause of childhood deaths associated with infectious diseases in developing countries. Bull World Health Organisation,2000,78: pp Schofield C, Ashworth A. 1996: Why have mortality rates for severe malnutrition remained so high'. Bull World Health Organ 1996;74: pp World Health Organization 2000: Management of the child with a serious infection or severe malnutrition. Guidelines for care at the first referral level in developing countries. Geneva: WHO, adolescent health/publications/referral_care/homepage.htm (accessed 20 Nov 2002). 6. Smythe PM, Schonland M, Brereton-Stiles GG, et al. 1971:'Thymolymphatic deficiency and depression of cell mediated-immunity in protein calorie malnutrition'. Lancet 1971;ii: pp Banik N.D.D 1982: 'Semi longitudinal growth evaluation of children from birth to 14 years in different socio-economic groups'. Indian J. Pediat, 19, pp Hunumantha Rao & Sathyanarayana 1976: 'Nutritional Status of People of different Socioeconomic groups in a rural area with special reference to pre-school children'. Ecology Food Nutrition 4, pp Gopaldas Tara &Subrata Seshadri 1987: 'Nutrition monitoring and Assessment'. OUP, Bombay. 10. Turner D.F. 1959: 'Handbook of Diet Therapy'. 3 rd ed. University of Chicago Press, Chicago. 11. Cogil Bruce 2003: 'Anthropometric Indicators Measurement Guide'. Office of Health, Infectious disease & Nutrition bureau of Global Health. 12. Gopalan C. 1967: Kwashiorkor &Marasmus: Evolution and Distinguishing features, Caloric deficiencies and Protein deficiencies.

16 13. Bern C, Zucker JR, Perkins BA, Otieno J, Oloo AJ, Yip R. Assessment of potential indicators for protein energy malnutrition in the algorithm for integrated management of childhood illness. Bulletin World Health Orgaisation 1997; No-75, pp Mercedes de Onis, Edward A. Frongillo, & Monika Blossner 2000: ' Is malnutrition declining? An analysis of changes in levels of child malnutrition since 1980'. Bulletin of the World Health Organization, 2000, No 78, pp Pelletier D, Frongillo EA, Habicht JP. Epidemiologic evidence for a potentiating effect of malnutrition on child mortality. American Journal of Public Health, 1993, 83: Martorell R, Habicht JP. 1986: 'Growth in early childhood in developing countries'. In: Falkner F, Tanner JM, eds. 'Human Growth: A Comprehensive Treatise, III'. New York, NY: Plenum Press; pp: Alleyne GAO, Hay RW, Picou DI, Stanfield JP, Whitehead RG. 1979: ' Protein-energy Malnutrition'. London, England: Edward Arnold; 18. Waterlow JC.1992: 'Protein Energy Malnutrition'. London, England: Edward Arnold; 19. Waterlow JC.1990: 'Reflections on stunting'. Presented at the First Symposium of the Nutrition Foundation of India; December 1990; New Delhi, India 20. WHO 'Measuring Change in Nutritional Status'. Annex 3: Reference Data for Weight and Height of Children. Geneva, Switzerland: WHO; 21. Ahmed S. 1990: Feeding, weaning and infant growth in rural Chandpur, Bangladesh. London, England, University of London, Thesis.