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EJBS 3 (1) April-June 2010: 43-49

Bisai & al. Very High Prevalence of Thinness

Very High Prevalence of Thinness among Kora-Mudi Tribal Children of Paschim Medinipur District of West Bengal, India

Samiran Bisai 1, 2, Tarapada Ghosh 3, Gautam Kumar De3 and Kaushik Bose2 1. Department of Anthropology, North Eastern Hill University, Shillong, Meghalaya, India. 2. Department of Anthropology, Vidyasagar University, Midnapore, West Bengal, India. 3. Department of Pediatrics, Midnapore Medical College & Hospital, Midnapore, West Bengal India. Address for correspondence: Dr. Samiran Bisai, Department of Anthropology, Vidyasagar University, Midnapore -721102, West Bengal, India E-mail: [email protected] ABSTRACT To assess the nutritional status among Kora-Mudi children based on recently developed body mass index (BMI) cutoff points for children and adolescents. The study subjects were selected following simple random sampling method form two villages in Paschim Medinipur District of West Bengal, India. A total of 119 children (49.6% boys and 50.4% girls) aged 2-13 years were measured and included in the present study. Height and weight were measured and BMI was computed following standard formula. New age and sex specific international cutoff points were utilized to assess nutritional status. The overall prevalence of thinness, normal weight and overweight were 67.2%, 31.9%, and 0.8 %, respectively. There was no significant sex difference of thinness, normal weight and overweight. However, prevalence of grade-I and grade-III thinness were 1.31 and 1.51 times higher among girls than the boys. Moreover, the prevalence of grade-II thinness was 2.58 times greater among boys compared to girls. The nutritional status of these children is not satisfactory. There is much scope for improvement of their nutritional status. Therefore effective public health policies should be undertaken to combat the child malnutrition in India and adjoining countries. Keywords: Children; Kora-Mudi, Thinness, Overweight, India. INTRODUCTION: The prevalence of under-nutrition is highly prevalent in low and middle income countries. In Asia, the rate of undernutrition is the highest in the world [1]. It is well documented that 46 percent children under five in South Asia is moderately or severely underweight. Half of the world's malnourished children are to be found in only three countries, India, Bangladesh and Pakistan [2]. India accounts for about 40 percent undernourished children in the world, which significantly associated with high rates of morbidity and mortality in the country [3]. Half of all children under five suffer from malnutrition and 53% of children are underweight [4]. Also in West Bengal, half of the children are suffer from different types of under-nutrition [5]-[6]. A recent analysis by the maternal and child under-nutrition study group estimated that stunting, severe wasting and intrauterine growth restriction together were responsible for 2.2 million deaths annually [7] and most of these mortalities were found in underprivileged communities. Tribal communities in India are considered as underprivileged. In general, childhood under nutrition is assessed by stunting (low height for age), underweight (low weight for age) or wasting (low weight for height) following different internationally and regionally recommended standards [8]. Body mass index (BMI), as measured by weight in kilogram (kg) divided by height in meter (m) squared, has been widely used for assessing nutritional status of adults [8]-[9] and thinness in adolescents and more recently in children aged 0-5 years [10]. Very recently international cut offs child overweight and obesity for the age range of 2-18 [11] and for thinness [12] have been produced. In the latter study under nutrition has been termed as thinness (as in adults) defined as low BMI for age [12] and it has been graded as III, II, I (severe, moderate and mild, respectively) similar to adult chronic energy deficiency (CED) grades of CED I, II and III.

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Kora is the fifth largest tribal community in West Bengal. According to the latest census, the total population of Kora is 142789, who constituted 3.2 % of the total tribal population of the state. Kora-Mudis speak the Kora tongue, which belongs to Austro-Asiatic language family. It has been well documented that more than 90 % of the Kora people reside in rural areas of the country. They are distributed in three eastern provinces of India namely: West Bengal, Orissa and Bihar. The majority of the Koras in West Bengal are found in the districts of Bankura, Bardhaman, Birbhum, Hugli, Puruliya, and Paschim Medinipur. Koras are mainly engaged in earth digging. They have four endogamous groups, viz. Mudi Kora, Kurmi Kora, Nagbanshi Kora, Dhangar or Orang Kora. Mudi-Kora; a genetically homogeneous group was considered for the present study. Their literacy status is poor, as only 43.3 % of the Kora children aged 5 -14 years have been attending any educational institution. However, information on Kora-Mudis is extremely scanty and there is no data available on BMI distribution and BMI based nutritional status of Kora-Mudi children of Paschim Medinipur District of West Bengal. In view of this context, our study was conducted to report the prevalence of thinness, normal weight and overweight as measured by BMI among KoraMudi children in Paschim Medinipur District of West Bengal, India. MATERIALS AND METHODS: A total of 119 children (49.6% boys and 50.4% girls) aged between 2-13 years have been investigated between May 2008 to March 2009 in two rural villages of Paschim Medinipur district of West Bengal. This cross sectional study was conducted among Kora-Mudi children, a tribal population living in the villages of Krishnanagar and Jamunaparh near Gokulpur Railway station, between two big cities: Midnapore and Kharagpur, which is 125km away from Kolkata, the provincial capital of West Bengal. Information on age, sex, height and weight were collected on a pre-tested questionnaire following interview and examination. The age of children was recorded by interviewer with the parents. All study protocol was approved by the institutional ethical committee and informed consent was obtained from the parents. Anthropometric measurements (i.e. height and weight) were performed in all subjects according to the standard procedures [13]. The weight was measured by using digital scale to the nearest 0.1 kg and height was measured using anthropometer to the nearest of 0.1cm, respectively. BMI was computed using the following standard equation: BMI = Weight (kg) / height (m2). Nutritional status such as thinness [12] and overweight [11] was evaluated following the recently published international BMI cut-off points [14]-[15]. Those children with BMI less than the cut off value corresponding to the respective age and sex were assigned to the particular grade of thinness. Those having BMI value higher than or equal to the age and sex specific grade-I thinness value and lower than to the age and sex specific cutoff value passing through adult BMI 25kg/m2 at age 18 years were considered normal. While BMI value higher than the age and sex specific cutoff value passing through adult BMI 25kg/m2 at age 18 years was considered overweight. Age and sex specific new international body mass index cutoff points for the assessment of nutritional status among children are shown in Table 1. These age and sex specific cut off values were established based on international survey [11] and recommended by International Obesity Task Force (IOTF). The study subject was selected following simple random sampling method. The estimated sample size (n=113) was calculated by using standard formula found elsewhere [16] based on 61.9 % prevalence of thinness among girls aged 5-10 years [17], with desired precision of ± 10%. An additional 5% (113+6=119) child were added to make the sample more representative and compensate for the design effect. Student's t-test were undertaken to test for sex differences in BMI. Proportion test were performed to test for differences in prevalence of thinness between sexes. Odds ratio (OR) was also calculated to measure the risk of being thinness between sexes. All statistical analyses were performed using the EPI6 statistical package. Statistical significance was considered as p value less than 0.05. RESULTS: The details age and sex specific nutritional status of the subjects are presented in table 2. The overall prevalence of thinness, normal weight and overweight were 67.2%, 31.9%, and 0.8 %, respectively. There was no significant sex difference of thinness, normal weight and overweight. However, prevalence of grade-I and grade-III thinness were 1.31 (OR=1.31; 95% CI: 0.45-3.79) and 1.51 (OR=1.51; 95% CI: 0.71-3.24) times higher among girls than the boys.

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In contrast, the prevalence of grade-II thinness was 2.58 (OR=2.58; 95% CI: 0.97-6.89) times higher among boys compared to girls.

Table 1. Age and sex specific new international body mass index cutoff points for the assessment of nutritional status among children Boys Girls Age Thinness Thinness (Years) Normal Overweight Normal

III II I III II I

Overweight

2.0 3.0 4.0 5.0 6.0 7.0 8.0 9.0 10.0 11.0 12.0 13.0

13.37 13.09 12.86 12.66 12.50 12.42 12.42 12.50 12.66 12.89 13.18 13.59

14.12 13.79 13.52 13.31 13.15 13.08 13.11 13.24 13.45 13.72 14.05 14.48

15.14 14.74 14.43 14.21 14.07 14.04 14.15 14.35 14.64 14.97 15.35 15.84

15.14-18.41 14.74-17.89 14.43 -17.55 14.21-17.42 14.07-17.55 14.04-17.92 14.15-18.44 14.35-19.10 14.64-19.84 14.97-20.55 15.35-21.22 15.84-21.91

18.41 17.89 17.55 17.42 17.55 17.92 18.44 19.10 19.84 20.55 21.22 21.91

13.24 12.98 12.73 12.50 12.32 12.26 12.31 12.44 12.64 12.95 13.39 13.92

13.90 13.60 13.34 13.09 12.93 12.91 13.00 13.18 13.43 13.79 14.28 14.85

14.83 14.47 14.19 13.94 13.82 13.86 14.02 14.28 14.61 15.05 15.62 16.26

14.83-18.02 14.47-17.56 14.19-17.28 13.94-17.15 13.82-17.34 13.86-17.75 14.02-18.35 14.28-19.07 14.61-19.86 15.05-20.74 15.62-21.68 16.26-22.58

18.02 17.56 17.28 17.15 17.34 17.75 18.35 19.07 19.86 20.74 21.68 22.58

Table 2. Age and sex distribution of nutritional status of the studied subjects

Age Years 2 3 4 5 6 7 8 9 10 11 12 13 Total Overall

n Boys 5 7 6 5 6 4 5 7 5 4 2 3 59 Girls 4 7 5 8 3 7 6 5 6 3 3 3 60 119

Thinness gradeIII Boys Girls 0 0 0 14.3 16.6 0 43.3 25.0 0 66.7 0 14.3 0 0 28.6 0 20.0 33.3 0 0 0 33.3 33.3 0 11.9 15.0 13.4

Thinness grade-II Boys Girls 60.0 25.0 28.6 0 50.0 0 20.0 12.5 33.3 0 0 14.3 0 16.7 14.3 0 40.0 16.7 25.0 0 0 33.3 0 33.3 25.4 11.7 18.5

Thinness grade-I Boys Girls 20.0 0 57.1 14.3 16.7 80.0 0 37.5 33.3 0 0 71.4 40.0 66.7 42.9 40.0 20.0 33.3 50.0 66.7 0 0 66.7 33.3 30.5 40.0 35.3

Normal Boys Girls 20.0 75.0 14.3 71.4 16.7 20.0 20.0 25.0 33.3 33.3 100 0.0 60.0 16.7 14.3 60.0 20.0 16.7 25.0 33.3 100 33.3 0 33.3 30.5 33.3 31.9

Overweight Boys Girls 0 0 0 0 0 0 20.0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1.7 0 0.8

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Figure 1 presents the comparison of BMI by age and sex of the studied children. No definite trends were observed in mean BMI with age in both sexes. Moreover, the mean BMI was significantly higher among boys at the age of 7 years. While significantly higher mean BMI was observed among girls at the age of 9 years than boys. Figure 1. Comparison of BMI by age and sex of Kora-Mudi children

17

Boys Girls

16 15

BMI

14 13 12 11 2 3 4 5 6 7 8 9 10 11 12 13

Age (years)

DISCUSSION: The underfed still outnumber the overfed in the developing world among Asian, African and Latin American populations. In spite of the economic development in the region, undernutrition remains an important public problem in many Asian countries [18]. Undernutrition is a significant problem and continues to be a cause of morbidity and mortality among children in developing countries like India [19]-[20]. Malnutrition among children and adolescents is a serious public health problem internationally, especially in developing countries. The recent study of Cole et al [12] has stated that undernutrition is better assessed as thinness (low body mass index for age) than as wasting (low weight for height). Prior to this report, there were no suitable thinness and overweight/obesity cut-offs for 2-18 years age group [11]-[12]. The uses of these new cut-off points are suggested to encourage direct comparison of trends in childhood thinness and overweight/obesity worldwide. Moreover, these cut-offs provide a classification of thinness and overweight/obesity for public health purposes at the national level. There are some limitations of our study such as small sample size in some age groups and inability to employ any strict sampling strategy, which may make the district and state level extrapolation of the sample questionable. However, the results of the present study clearly indicated that the nutritional situation of these children was not satisfactory with very high rates of thinness of 67.8 % and 66.7% in boys and girls, respectively. The comparison of prevalence of under-nutrition among Indian children is presented in table 3. Most of the studies reported lower prevalence of under-nutrition than the present study [21]-[22]-[23]-[24]-[5]-[25]. On the other hand some of the studies show that almost similar prevalence of under-nutrition [17]-[26]-[27]. Only one study shows that higher prevalence of under-nutrition than the present study [28]. It is important to mention that the prevalence of undernutrition is significantly higher than the national prevalence of under-nutrition as assessed among tribal children [29]. Similarly, high rates of thinness (boys = 62.9 % and girls = 61.6 %) was reported among rural children aged 510 years from Purba Medinipur district of West Bengal [17]. Another recent study documented a very high 46

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prevalence of thinness, compared to the present study, among rural children aged 2-5 years. Their reported prevalence was 84.8% for boys and 85.65% for girls, respectively [28]. An earlier study from Nadia District reported lower (boys = 49.7% and girls = 51.6 %) prevalence of thinness among rural children aged 3-5 years [25]. A noteworthy point was that all studies reported that both sexes had similar rates of thinness. It is well documented that thinness is an indicator of acute undernutrition, the results of more recent food deprivation [8]. Malnutrition (under-nutrition and over-nutrition) continues to be a problem of considerable magnitude in most developing countries of the world [30]. Several studies have shown that dietary and environmental constraints are the major determinants of differences in growth pattern between children of both developed and developing countries [31][32]-[33]-[34]. In the present study, result reveals that the prevalence of overweight was 0.8%. An earlier study found similar rates (0.3%) of overweight among adolescent tea garden workers [22]. Earlier reports have revealed that in recent years malnutrition among the children has increased [35]. Improvement of the level child nutrition which leads to better growth and development of the children has been regarded as one of the universal humanitarian goals [36]. Under the above scenario, we recommend that further investigations in India may utilize these cut-off points proposed by Cole et al [11]-[12] to determine the rates of thinness and overweight/obesity among children and adolescents. This kind of studies may provide a database towards the formulation of effective public health policies to combat the child malnutrition in India and adjoining countries where high prevalence of child under-nutrition. Table 3. Comparison of the prevalence of under-nutrition among Indian children Studied children Preschool children, Nadia district, West Bengal School children, Bankura District, West Bengal School children, Paschim Medinipur and Puruliya district, West Bengal School children, Purba Medinipur, West Bengal Bauri scheduled caste children, Puruliya district, West Bengal School children, Dibrugarh district, Assam Children, Dibrugarh district, Assam Children of Central Orissa. India ICDS children, Hooghly district, West Bengal Tribal children, India Tribal children, West Bengal Kora-Mudi tribal children, Paschim Mediniapur, West Bengal Age group 3-5 6-14 10-15 n 2016 454 2016 Methods Thinness by BMI BMI/age score ZPrevalence (%) 50.7 23.1 44.5 References Biswas et al.2009 Bose et al., 2008 Bose and Bisai, 2008

Thinness by BMI Thinness by BMI Thinness by BMI Thinness by BMI Thinness by BMI Thinness by BMI Thinness by BMI Weight/age Z-score Weight/age Z-score Thinness by BMI

5-10 2-6 6-14 10-18 1-5 2-6 <5 <5 2-13

569 219 304 605 292 1012 4448 150 119

62.2 65.3 53.9 50.2 48.0 85.2 54.5 59.7 67.2

Chakraborty and Bose ,2009 Das and Bose, 2009 Medhi et al., 2006 Medhi et al., 2007 Mishra and Mishra, 2007 Mondal et al., 2009 IIPS, 2007 IIPS, 2008 Present Study

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Acknowledgement: The author would like to thanks all the subjects and their parents for help and cooperation during period. REFERENCES: 1. 2. 3. 4. 5. 6. 7. World Health Organization, "Health situation in the South East Asia Region 1994-1997", WHO regional office for South East Asia, New Delhi, 1999. V. Rattan, "Women and child development: sustainable human development", New Delhi: S Chand and Co, Vol 1, 1997. J. F. Levinson, "India sector review of nutrition programmes. A background paper prepared for the World Bank", World Bank, New Delhi, 1998. India Fact File, Available at: http://www.indianngos.com/factfile.htm, accessed in may 2002. K. Bose, S. Bisai and S. Mukherjee. "Anthropometric characteristics and nutritional status of rural school children", Intern J Biol Anthropol, Vol 2, 2008, No: 1. S. Bisai, K. Bose and A. Ghosh, "Nutritional Status of Lodha Children in a village of Paschim Medinipur district, West Bengal India" Indian J Public Health, 52(4): 2008, 203-206. R. E. Black, L.H. Allen, Z.A. Bhutta, L.E. Caulfield, M. de Onis, M. Ezzati, C. Mathers, J. Rivera, "Maternal and child undernutrition: global and regional exposures and health consequences". Lancet, Vol. 371, 2008, pp.243-260. World Health Organization, "Physical Status: The Use and Interpretation of Anthropometry", TRS -854. Geneva, World Health Organization 1995. International Diabetes Institute, "The Asia-Pacific perspective: redefining obesity and its treatment", Geneva: World Health Organization", 2000. World Health Organization, "Child Growth Standards based on length/height, weight and age. Acta Paediatrica., Vol. 450, 2006, pp.76-85. T.J. Cole, M. C. Bellizzi, K.M. Flegal, W.H. Dietz, "Establishing a standard definition for child overweight and obesity worldwide: international survey". BMJ., Vol. 320, 2000, pp. 1240-1243. T. J. Cole, K. M. Flegal, D. Nicholls, A. A. Jackson, "Body mass index cut offs to define thinness in children and adolescents: international survey". BMJ., Vol. 335, 2007, pp 194 198. T. Lohman, A. F. Roche, R. Martorell, "Anthropometric Standardization Reference Manual". Chicago: Human Kinetics Publication, 1988. P. Marques-Vidal, R. Ferreira, J. M. Oliveira, F. Paccaud F, "Is thinness more prevalent than obesity in Portuguese adolescents?", Clin. Nutr., Vol. 27, 2008, pp. 531-536. P. Jeemon, D. Prabhakaran, v. Mohan, K. R. Thankappan, P.P.Joshi, F. Ahmed, V. Chaturvedi, K. S. Reddy, for the SSIP Investigators, "Double burden of underweight and overweight among children (10­19 years of age) of employees working in Indian industrial units", National Med. J. India, Vol, 22: 2009, pp.172-176. S. Bisai, "Nutritional status and growth pattern of urban infants in relation to birth weight", Curr. Sci. Vol. 95: 2008, pp. 175. R. Chakraborty, K. Bose, "Very high prevalence of thinness using new international body mass index cut off points among 5-10 year old school children of Nandigram, West Bengal, India", J. Res. Med. Sci.., Vol. 14, 2009, pp.129-133. V. P. Wickramasinghe, S. P. Lamabadusuriya, N. Atapattu, G. Sathyadas, S. Kuruparanantha, P. Karunarathne, "Nutritional status of schoolchildren in an urban area of Sri Lanka", Ceylon Med. J., Vol 49, 2004, pp.114-118. S. Nandy, M. Irving, D. Gordon, S. V. Subramanian, G. S. Davey, "Poverty, child undernutrition and morbidity: new evidence from India", Bull. World Health Org., Vol. 83, pp. 210-216. UNICEF, "Report Progress for Children ­ A report card on nutrition". New York: UNICEF, 2006. G. K. Medhi, A. Barua, and J. Mahanta, "Growth and Nutritional Status of School Age Children (6-14 Years) of Tea Garden Worker of Assam", J. Hum. Ecol., Vol. 19, 2006, pp. 83-85. G. K. Medhi, N. C. Hazarika and J. Mahanta, "Nutritional Status of adolescents among tea garden workers", Indian J. Pediatr., Vol. 74, 2007, pp.343-347. B. Mishra and s. Mishra, "Nutritional anthropometry and preschool child feeding practice in working mothers of central Orissa". Stud. Home Comm. Sci., Vol. 1, 2007, pp.139-144. K. Bose and S. Bisai, "Prevalence of undernutrition among rural adolescents of West Bengal, India", J. Trop. Pediatr., Vol. 54, 2008, pp. 422-423. 48

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25. S. Biswas, K. Bose, S. Bisai, R. Chakraborty, "Prevalence of thinness among rural Bengalee pre-school children in Chapra, Nadia district, West Bengal, India", Malay. J. Nutr., Vol. 15, 2009, pp. 155-164. 26. S. Das and K. Bose, "Anthropometric Characteristics and Nutritional Status of Bauri Pre-School Children of Nituria Block, Purulia, West Bengal", Intern. J. Biol. Anthropol., Vol. 3, 2009, No- 2. 27. International Institute for Population Sciences (IIPS) and Macro International, "National Family Health Survey (NFHS-3), India, 2005-06: West Bengal", Mumbai: IIPS, 2008. 28. G. C. Mandal, K. Bose, S. Bisai, "Thinness among rural children in Bengal". Indian J Pediatr., Vol. 76, 2009, pp. 817-819. 29. International Institute for Population Sciences (IIPS) and Macro International, "National Family Health Survey (NFHS-3), 2005­06: India", Mumbai: IIPS, Vol. I, 2007. 30. S. Som, M. Pal, B. Bhattacharya, S. Bharati, P. Bharati, "Socieconomic differentials in nutritional status of children in the states of West Bengal and Assam". J. Biosoc. Sci., Vol. 38, 2006, pp. 625-642. 31. F. Serenius, "Attained growth of privileged Saudi children during the first three years of life", Acta. Pediatrica Scandinavia, Vol. 1346 (Suppl), 1988, pp. 80-92. 32. A. E. Dugdale, M. Muller, L. Alsop-Shields, "Patterns of weight growth in Aboriginal children on Queensland communities", J. Pediatr.Child Health, Vol. 30, 1994, pp. 55-8. 33. V. J. Quinn, M. O. Chiligo-Mpoma, K. Simler, J. Milner, "The growth of Malawian preschool children from different socioeconomic groups", Eur. J. Clin. Nutr. Vol. 49, 1995, pp. 66-72. 34. Z. Mei, R. Yip, F. Trowbridge, "Improving trend of growth of Asian refugee children in the USA: evidence to support the importance of environmental factors on growth", Asia Pac. J. Clin. Nutr., Vol. 7, 1995, pp. 111-116. 35. P. Chatterjee, "Child malnutrition rises in India despite economic boom", Lancet, Vol. 369, 2007, pp. 1417-1418. 36. S. Rajaram, T. S. Sunil, L.K. Zottarelli. "An analysis of childhood malnutrition in Kerala and Goa", J. Biosoc. Sci., Vol. 35, 2003, pp. 335-351.

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