Evaluation of the Nutritional Status of Khasi Children under ICDS Programme in Mawsynram Block of East Khasi Hills, Meghalaya

Introduction

Malnutrition remains a major health problem in the world, especially in Southern Asia [1]. The joint report by the FAO, IFAD, UNICEF, WFP and WHO [2] shows that there is not much progress to reach the WHO nutrition targets set for 2025, adopted by the World Health Assembly in 2012, and the United Nations Sustainable Development Goals set for 2030. In Asia, despite the rapid economic growth and nutrition transition during the last decade or so, Southern Asia has the highest prevalence of under nutrition (about 15 percent or 278.5 million people) followed by Western Asia (over 12 percent or 38 million people). It is also reported that the prevalence of child stunting in the world has Investigation Paper declined significantly over the past 20 years, but overweight and obesity along with co-morbidities are emerging rapidly.

In India, under nutrition continues to be a major health problem among children under five years of age. According to the National Family Health Survey 2015-16 (NFHS-4), about 38 percent of children below five years of age were stunted or too short for their age, 36 percent of them were underweight, and 21 percent of them were wasted or too thin for their respective height [3]. Although stunting and underweight have declined since 2005, which may be associated with the positive economic growth in the country, the prevalence of stunting in many states is more than 30 percent, and it is highest in Bihar (48%) followed by Uttar Pradesh (46%) and Jharkhand (45%).

In Northeast India, NFHS-4 data show that Meghalaya has the highest prevalence of stunting (44%) followed by Assam (36%), Arunachal Pradesh (29%), Manipur (29%), Nagaland (29%), and Tripura (24%) [3]. The prevalence of stunting in Meghalaya has, however, decreased from 55 percent in 2005-06 to 44 percent in 2015-16, and the prevalence of underweight has declined from 49 percent in 2005-06 to 29 percent in 2015-16 [3, 4]. The prevalence of wasting has also declined from 31 percent in 2005- 06 to 15 percent in 2015-16, thereby suggesting that the overall nutritional status of children under age-five years has improved substantially during the last decade or so. However, it is not clear whether this trend of improvement in the nutritional status of children in Meghalaya is consistent across communities in the state. It is also unclear about the impact of the Supplementary Nutrition Programme (SNP) under the Integrated Child Development Services (ICDS) Scheme during the last ten years or so. Therefore, the purpose of this paper is to evaluate the nutritional status of Khasi children under the ICDS Programme in Mawsynram Block of East Khasi Hills, Meghalaya.

Materials and Methods

The present study was conducted in the Mawsynram Community Rural Development Block (CRDB) of the East Khasi Hills district of Meghalaya during 2018-19. Mawsynram CRDB is predominantly inhabited by the two Khasi subgroups, namely Khynriam and War Khasis. A cross- sectional method of anthropometric study was carried out during 2018-19 for evaluating the growth and nutritional status of 549 children aged 2-6 years. Two anthropometric measurements, namely height and weight were taken on the target groups of children from all the selected Anganwadi Centres, following standard techniques [5, 6].

The study was part of the monitoring study carried out by the Department of Social Welfare, Government of Meghalaya, in collaboration with the Department of Anthropology, North-Eastern Hill University [7]. Applying a multi-stage random sampling method, two CRDBs (where ICDS Centres also located) were selected from each of the seven districts in the state during 2008-09. Consequently, Mawsynram and Mylliem CRDBs were selected from East the Khasi Hills district. Therefore, Mawsynram CRDB was selected purposely in the present study for two reasons: (i) In order to make our data more comparable with those collected in 2008-09, and (ii) for understanding the impact of SNP on the nutritional status of children under the ICDS Scheme in the proposed study area. The same villages covered under the above study were also included in the present study. The study included five villages, viz., Langsymphut, Phlangwanbroi, Kynrang, Mawtapiew and Tyngnger. All these villages are located in the War area of the Block.

In the present study, three anthropometric indices, such as weight-for-age, height-for-age, and weight-for-height were used as indicators of the nutritional status of children [8]. These indices are expressed as a Z-score of a child’s measurement to the median weight of the WHO reference population [9], using the Lambda-mu-sigma (LMS) method [10]. The formula for obtaining the Z-score for a given measurement relative to the WHO growth reference is given as:

where, X is the anthropometric measurement (weight or height) and L (power in the Box-Cox transformation), M (median) and S (standard deviation) are the reference values corresponding to a given sex and age in months.

The Z-score of–2 was used as the cut-off point for screening the children who were likely to be undernourished. Children with the Z-score below – 3 were arbitrarily categorized as having moderate to severe undernutrition. The cut-off point of > 2 was also used to categorise children as overweight.

The Z-score, as calculated above, is a measure of the distance between the child’s measurement and the median of the growth reference. It depends to a great extent on the growth reference. The choice of appropriate growth reference is therefore very crucial for getting comparable and reliable information on growth and nutritional status. The justification for the use of international growth reference is that the effect of ethnic/genetic differences in growth of young children, especially below 5 years of age, is not large enough when compared with the effects of environmental factors including poverty and inadequate nutrition [11]. In India, several studies have supported such a contention [12, 13]. In other words, growth retardation among under- five children is generally considered an indicator of poor nutritional status, or a failure in the expression of the “genetic potential” for growth.

All data were managed and analyzed using SPSS/PC Software (Version 22). The differences between two means were tested by using the student’s t-test. The Pearson chi- square (χ2) test was used to test the differences between proportions or percentages.

Discussion

The present study indicates that mean Z-scores for the three anthropometric indices, namely weight-for-age, height- for-age and weight-for-height have increased significantly from 2008-09 to 2018-19. The prevalence of undernutrition according to these three indices has also declined during the last decade. Prior to 2009, about 55 percent of under-five children in Meghalaya were stunted, or too short for their age, and about 49 percent were underweight [3]. According to the NFHS-3 [4], the nutritional status of children in Meghalaya had not improved from 1998-99 to 2005-06. Instead, the prevalence of underweight had increased from 38 percent during 1998-99 to 49 percent in 2005-06, and the prevalence of stunting had increased from 45 to 55 percent. The NFHS- 3 data showed that Meghalaya had the highest prevalence of undernutrition in Northeast India, and it was among the worst in India where underweight in particular was among the highest in the world. As a result, the major concern was about the impact of SNP under the ICDS Scheme, which has been implemented by the State Government for more than four decades. In Meghalaya, the first ICDS project was launched in 1975 as an experimental basis at the Songsak Community and Rural Development Block, East Garo Hills District. Since then the scheme had been expanded in 32 Community and Rural Development Blocks with 39 ICDS Projects and 3179 Aganwadi Centres in 2008 when this evaluation study started.

The present study indicates that the prevalence of underweight has decreased from 42 percent in 2008-09 to 22 percent in 2018-19, and the prevalence of stunting has reduced from 52 percent in 2008-09 to 33 percent in 2018-19. The present findings seem to be in line with the NFHS-4 Report [3] that the prevalence of underweight and stunting has declined considerably from 2005-06 to 2015- 16. Although it may be associated with the overall economic development in the country during the last decade or so, the impact of supplementary nutrition under the ICDS Programme in the state cannot be ruled out. It may be noted that the ICDS provides a number of integrated services like supplementary nutrition, immunization, health check-ups and referral services at Anganwadi centres to children, pregnant women and lactating mothers. The increasing coverage and improvement in services under the ICDS Programme during the last ten years may have contributed to the overall improvement in the nutritional status of children under the present study. It is, however, evident that undernutrition in terms of underweight (22%) and stunting (33%) continues to be a major nutritional problem in the state. According to the NFHS-4 [3], Meghalaya has still the highest prevalence of stunting in Northeast India, and is one of the four states in India with a large number of under-five children who are too short for their age. Therefore, efforts to maintain and strengthen the implementation of the ICDS Programme in the state are still needed to achieve the Global Nutrition Targets 2025 [15].

The present study also indicates that there is an emerging trend of overweight among children in addition to the problem of underweight and stunting. About 4 percent of children in the present study are found to have a Z-score of more than 2 with respect to weight-for-height. Although undernutrition remains a major nutritional problem, it is likely that the prevalence of overweight and obesity is also emerging in the state. It is generally reported that the decline in child underweight and stunting due to socioeconomic development in a population is also associated with increasing overweight and obesity [16, 17]. This nutritional situation is known as the double burden of malnutrition, which is characterized by the coexistence of undernutrition along with overnutrition in terms of overweight, obesity or diet-related morbidities [15]. The double burden of malnutrition may exist at household, population, regional and national levels, depending on a variety of nutritional and socioeconomic factors [15, 16, 17, 18, 19]. Thus, while interventions are still necessary to reduce child underweight and stunting; simultaneous preventive measures to control child overweight and obesity in terms of public health and education programmes may also be initiated in the state.

Conclusion

The present study indicates that the prevalence of underweight and stunting has declined during the last decade, although undernutrition especially stunting continues to be a major nutritional problem. Despite the limitations of the present study in terms of sample size and lack of socioeconomic data, it is evident that the nutritional status of Khasi children has substantially improved during the last decade or so. This improvement in the nutritional status of children may be associated with the overall socioeconomic development in the state during the last ten years or so, but the impact of the supplementary nutrition under the ICDS Programme, which has been implemented in the state since 1975, cannot also be ruled out. Therefore, the implementation of the ICDS Programme in the state should be maintained and strengthened with a view to achieving the Global Nutrition Targets 2025.

There is also evidence of the prevalence of overweight children, suggesting that there is an emerging trend of the double burden of malnutrition. While interventions are still necessary to reduce child undernutrition especially stunting; public health and education programmes to control overweight and obesity may also be implemented in the state.