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Women and nutrition

Selected socio-economic, environmental, maternal, and child factors associated with the nutritional status of infants and toddlers

Tara Gopaldas, Poonal Patel, and Meenakshi Bakshi

Malnutrition is one of the most widespread public health problems facing India today. Among the highly susceptible groups are infants and toddlers (0-3 years old), who constitute nearly 10% of Indian's population. Unfortunately, they are largely ignored from a nutritional standpoint [1]. There is now a growing realization that malnutrition is not only a problem of food supply but can also be a function of more complex big-social and behavioural determinants affecting child feeding and rearing [2]. In the present study, therefore, we have attempted to identify various socio-economic, environmental, and maternal factors and the child-feeding and childrearing practices of mothers that affect the nutritional status of infants and toddlers.

Methods and materials

Sample

Ten urban slum areas in the city of Baroda and nine rural villages in the Panchmahals and Bharuch districts of Gujarat state were randomly selected for the study. These slums and villages did not have any ongoing nutrition programmes. All children 0-3 years old living in the selected study areas and available during the survey were the subjects (N = 786).

Tools

Three pre-structured, pre-tested forms - family, maternal, and child - were used to collect the required information on each subject.

Factors studied

The factors studied for their association with the nutritional status of the children included family type, family size, religion, and caste; per capita income and land holding; water facilities, house sanitation, and toilet facilities; mother's educational level, working status, child-care time, height, weight, and obstetric history; breast-feeding, bottle-feeding, and weaning practices; and the child's calorie and protein intake, sex, birth order, and clinical and immunization status.

Anthropometric measurements

All the children were weighed using a Salter scale and were classified on the basis of their weight for age, using the 50th percentile of the Harvard standard and the classification of the Indian Academy of Pediatrics [3]. The mothers, heights and weights were determined by standard procedures.

Dietary intake

The 24-hour dietary intake of each child was determined by interview and observation [4].

Statistical analysis

Percentages were calculated and the chi-square (x2) test was used to identify factors significantly associated with the subjects, nutritional status [5].

Results

The distribution of the children by nutritional status and age group is shown in table 1. As is evident, the infants (birth to 1 year old) had better nutritional status than the toddlers (1-3 years old). A higher percentage of the infants than of the toddlers were in the normal category (52% versus 20% ). Furthermore, while only 6% of the infants were severely malnourished (grade III or IV). 18% of the toddlers fell into this category.

Factors associated with the nutritional status of infants

The factors found to be significantly associated with the nutritional status of the infants are presented in tables 2-4. As is evident, the infants from families with a higher per capita income (Rs 100 or more per month); those whose mothers were 18-30 years old, were over 145 cm tall, and weighed over 45 kg; and those who had no clinical signs of nutritional deficiency had better nutritional status than their counterparts. These findings indicate that the nutritional status of infants is affected more by maternal nutritional status (judged by the height and weight of the mother) than by other socio-economic, environmental, and child factors.

Factors associated with the nutritional status of toddlers

Tables 5-8 present the factors that were significantly associated with the nutritional status of the toddlers.

Data in table 5 show that a number of socioeconomic factors were involved. Those toddlers whose families were Muslim, were from castes other than the Schedule castes and Schedule tribes, had more than nine members, had a per capita income over Rs 100 per month, and (in the rural areas) had land holdings of more than two hectares had better nutritional status than their counterparts.

As for environmental factors, toddlers from homes having access to potable water and sanitary toilet facilities had better nutritional status than those using non-potable water and having unsanitary toilet facilities (table 6).

TABLE 1. Distribution of children by nutritional status and age group

In this and the following the principal data arc percentages: figures in parentheses indicate the number of subjects. Nutritional status is calculated on the basis of the 50th percentile of the Harvard standard and the classification of the Indian Academy of Pediatrics: N = normal; I-IV are grades of malnutrition.

TABLE 2. Association between family per capita monthly income and the nutritional status of infants

x²=980: P<.05:df=3

TABLE 3. Association between maternal age, height, and weight and the nutritional status of infants

a. X²= 14.42: P <.05; df = 6.
b. X²= 9.38: P <.05; df=3.
c. X² = 12.6: P < .05: df = 6.

TABLE 4. Association between the clinical status of infants and their nutritional status

x² = 223.10; P < .001; df = 9.
a. With no clinical signs of nutritional deficiency.

TABLE 5. Association between various socio-economic factors and the nutritional status of toddlers

a. X²= 14.44: P < .05: df = 6.
b. X² = 20.03: P < .01: df = 6
c. X²= 14 73: P < .05: df = 6
d Family income per capita per month. X²= 16.79: P < .01; df = 3
e. Family land holding for subjects in rural areas only . X² = 19.70: P < .01: df = 6.

Toddlers whose mothers had some education had better nutritional status than those with illiterate mothers, as did those whose mothers did not work and whose mothers weighed over 45 kg compared with those whose mothers worked and whose mothers weighed 45 kg or less (table 7).

As for the various child factors studied, it was found that male toddlers had better nutritional status than female toddlers, and that more toddlers without clinical signs of nutritional deficiencies fell into the normal category than those exhibiting one or more such clinical signs (table 8).

Discussion

The results of the present study indicate that the infants had better nutritional status than the toddlers. This has been reported by other investigators as well. In a study from Jamaica, while about 21% of the children under one year old showed some degree of malnutrition by Gomez's classification, more than half of those over one year old were in this category [6] Earlier studies conducted in Jamaica reported a similar pattern [7, 8]. It has been hypothesized that the better nutritional status of infants is probably due to their being able to satisfy their nutritional needs through breast milk and some complementary foods. However, after the first year of life, when breast feeding no longer meets their nutrient needs and complementary food is inadequate, there is likely to be an increase in the prevalence of under-nutrition [9].

TABLE 6. Association between environmental factors and the nutritional status of toddlers

1. Water classed as potable if from community taps or bore wells: as non-potable if from open wells, rivers, lakes, ponds, etc. x² = 26.62; P < .01; df = 3.
2. Toilets classed as sanitary if outside the house with water supply; as unsanitary if in the fields or in the house with no water supply. x² = 17.15; P < .01; df = 3.

TABLE 7. Association between various maternal factors and the nutritional status of toddlers

a. X²=14.3: P <.05: df=9
b. X²= 13.9: P < 01: df = 3
c. X²=38.86: P < 01: df=6

TABLE 8. Association between child factors and the nutritional status of toddlers

1. x² = 16.94: P < .01; df = 3.
2. x² = 220.5; p<.001; df = 12.
3. With no clinical signs of nutritional deficiency.

The present study corroborates results from earlier studies that have also found significant positive associations between high per capita income, maternal age, and good nutritional status in pre-school children [10-13]. Studies in Mexico, Algeria, and the United States have shown that a child born to a woman under 20 years old is twice as likely to die in infancy as one born to a woman in her mid-twenties [13]. Other investigators, however. have not found such an association [6, 10].

Maternal height and weight were found to have a significant association with the nutritional status of the infants. This could be attributed to the fact that maternal nutritional status is a determinant of lactation performance and therefore inevitably of the state of infant nutrition [14].

A number of socio-economic factors were significantly associated with the nutritional status of the toddlers. The better nutritional status of those from the higher castes (those not belonging to the Schedule castes or tribes) concurs with the findings of earlier studies conducted in Punjab [15, 16] and Nepal [11]. Per capita income and land holding were also significantly associated with the nutritional status of the toddlers. Similar results were reported in a study conducted in Madhya Pradesh on children 6-36 months old [12].

In the same study from Madhya Pradesh, as in ours, toddlers from large families had better nutritional status than those from medium-sized or small families. It was hypothesized that in large or joint families there is a greater likelihood of adult women being available to care for the young children [12]. In contrast, however, other investigators have found large family size to be significantly negatively associated with good nutritional status [10, 17]. This was attributed to the inability of mothers to provide adequate care for their young children, especially where there was more than one pre-school child in the family. Also, intra-family distribution of food was poor, with older family members receiving the largest share [10].

As in the present study, poor housing and poor sanitary conditions were found to adversely affect the nutritional status of children (below four years of age) in Jamaica [6]. It has been hypothesized that such an association may be due to the greater frequency of infectious diseases [18].

The importance of the mother's education in relation to the health and general well-being of the child has been stressed by many. Improved levels of maternal education have been associated with reduced child mortality [19, 20], and low levels of education have repeatedly been found in mothers of malnourished children [21-23]. In Libya [24] and the Philippines [10] also, a decrease in the incidence of second- and third-degree malnutrition among pre-school children was observed with an increase in the level of education of mothers.

In Madhya Pradesh, the mothers of the most malnourished groups of children were all working outside the home [12]. Similar observations in the Philippines were explained as being due to the mothers' reduced time for child care, so that, although their increased income made more food available to the household, the children's nutritional status was actually worse [10].

Maternal weight was significantly associated with the toddlers' nutritional status; with an increase in maternal weight there was a corresponding increase in the proportion of well-nourished toddlers. Dewey [25] reported similar findings in Mexican children two to four years old.

The finding that female children had worse nutritional status than males is consonant with findings from Bangladesh [2] and the Philippines [10]. Possible reasons are that males may be seen as an important source of labour on the family farm; they are expected to provide economic and social security for their parents when they are old or incapacitated and in times of distress; and the family name is carried on by sons and therefore they receive better care than female children.

It is evident from the findings of this study that a number of socio-economic, environmental, and maternal factors play an important role in the nutritional status of children from birth to three years of age.

References

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