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| ORIGINAL ARTICLE |
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| Ahead of print publication |
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Prevalence of underweight, stunting, wasting and obesity among urban school going children – Need for action
Shikha Tyagi1, Ravishekar N Hiremath1, Taramangalam Sethuraman Ramakrishna1, Niraj Chourey2, Sandhya Ghodke3
1 Department of Community Medicine, AFMS, New Delhi, India
2 Department of OBG, AFMS, New Delhi, India
3 Department of Anaesthesiology, Rainbow Children's Hospital, Bangalore, Karnataka, India
| Date of Submission | 31-Oct-2021 |
| Date of Decision | 18-Feb-2022 |
| Date of Acceptance | 19-Feb-2022 |
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Correspondence Address:
Shikha Tyagi,
Department of Community Medicine, AFMS, New Delhi
India
 Source of Support: None, Conflict of Interest: None DOI: 10.4103/mjdrdypu.mjdrdypu_861_21
Background: The mental and physical growth, nutritional status, academic achievements of school-going children in the age group of 6-15 years are some of the important factors that would play a key role in shaping the future of our country in the coming years. Objectives: To assess the prevalence of underweight, stunting, wasting and obesity among urban school going children of Western Maharashtra, India so that corrective actions can be taken to improve the nutritional status. Methodology: We conducted a cross-sectional study on children aged 6-15 years studying in urban schools of Western Maharashtra. 2276 children were included in the study and a simple random sampling technique was used to select the sections of classes I to X standard. All children belonging to that section were included in the study. Institutional ethical clearance was taken, and informed consent was taken from all parents. Data was collected by the investigator himself by using a standard protocol and anthropometric measurements were taken using standard techniques Results: In our study, according to WHO MGRS standards, the total prevalence of underweight was 3.57% among 5-9 years old children. Out of this, 0.4% of children were severely underweight. 3.3% boys and 3.87% girls were underweight. Stunting was observed in 1.4% of children. About 0.1% of children were severely stunted. Sex specific prevalence observed was 1.2% in boys and 1.8% in girls. Wasting was observed in 11.1% children. About 1.9% children were severely wasted. Among boys, 12.6% were wasted. As for girls, 9.3% were wasted. About 19.1% and 5.1% children were overweight and obese, respectively. Sex distribution for overweight was, 22.1% boys and 15.2% girls and that for obesity was, 6.4% boys and 3.4% girls. Conclusion: Although the prevalence of underweight, stunting, and wasting was less among the study participants, nutritional education should be imparted to children, regarding the type of food to be eaten, major food groups, nutritive value of various foods, and common nutritional problems and their effects. Overweight and obesity prevalence was high, hence requiring special emphasis to be given to these children. Health education should be imparted to parents during parent teacher meetings and IEC campaigns, regarding correct dietary practices such as food diversification and common nutritional problems in children and their consequences.
Keywords: Obesity, prevalence, school going, stunting, underweight, wasting
How to cite this URL:
Tyagi S, Hiremath RN, Ramakrishna TS, Chourey N, Ghodke S. Prevalence of underweight, stunting, wasting and obesity among urban school going children – Need for action. Med J DY Patil Vidyapeeth [Epub ahead of print] [cited 2023 Mar 20]. Available from: https://www.mjdrdypv.org/preprintarticle.asp?id=345912 |
| Introduction | |  |
Children in the age group of 5-15 years are referred to as school going children[1] which constitutes about 24.6% of the total population of India.[2] Not only do they constitute about one fourth of the population today, but it is also they, who will be the productive group of our country in the future. The mental and physical growth, nutritional status, academic achievements of these children are some of the important factors that would play a key role in shaping the future of our country in the coming years. The saying “the more you sweat in peace, the less you bleed in war”, is applicable here as well “more attention we give to the health and growth of children today, the less they will suffer in future”. Although these children have survived through the crucial first 5 years of life, their journey doesn't get easy, especially in a country like ours where stunting and wasting affect approx. 38.4% and 20.1%[3] of children respectively. School going children have their own distinct set of problems that may cause hindrance in their growth and development.
WHO defines malnutrition as “deficiencies, excesses or imbalances in a person's intake of energy and/or nutrients”.[4] The term malnutrition includes two major groups of disorders namely – under-nutrition and over-nutrition. The prevalence of under-nutrition in India is double that of Sub-Saharan Africa. Data from NFHS 3 for children under 4 years of age, shows 42% prevalence of underweight, 48% prevalence of stunting, and 19.8% prevalence of wasting.[5] When compared to NFHS 4 data, the prevalence was found to be- underweight – 35.7%, stunting- 38.4%, and wasting – 21.0%.[3] According to AHS 2014, the prevalence of under-nutrition was more than over-nutrition. As per the survey reports, Bihar recorded the highest percentage of undernourished population among 5-18 years at 33% in below 2 SD category while Uttarakhand recorded the lowest percentage (19.9%) is below 2 SD category. Uttar Pradesh recorded a minimum percentage of over-nutrition (1.1%) cases whereas Uttarakhand recorded the highest percentage (3.1%). AHS also brought out the fact that the prevalence of under-nutrition is more in rural areas than urban areas, and under-nutrition and over-nutrition both are more prevalent in males as compared to females.[6]
In April 2000, a partnership of UN agencies, with the world bank and education international, used the world education forum in Dhaka, Senegal to launch a joint effort to Focus Resources on Effective School Health, Nutrition and Hygiene (FRESH).[1] This partnership emphasized the importance of hunger, malnutrition, and ill-health as constraints on both 'Education for All' and the second and third Millennium development goals of achieving universal primary education and gender equality in education access. Since then more than 20 low-income countries have launched FRESH programs targeting more than 45 million school children. These programs seek to ensure that all schools: Have effective nutrition and health policies, Offer adequate sanitation and access to clean water, Deliver effective life skills messages about nutrition, health, and hygiene, and provide access to nutrition and health services. This study was thus carried out with an objective to assess the prevalence of underweight, stunting, wasting, and obesity among urban school going children of Western Maharashtra, India so that corrective actions can be taken to improve the nutritional status.
| Methodology | | |
We conducted a cross-sectional study on children aged 6-15 years studying in urban schools of Western Maharashtra. With the assumption of malnutrition prevalence among 6-15 years school children as 50% and alpha error of 5% and an expected deviation of 4%, we calculated the sample size of 600. However, 2276 children were included in the study. A simple random sampling technique was used to select the sections of classes I to X standard. All children belonging to that section were included in the study. Institutional ethical clearance wide letter number PSM/2018/1 dated 29 Nov 2018 was taken, and informed consent was taken from all parents. Data was collected by the investigator himself by using a standard protocol and anthropometric measurements were taken using standard techniques.[7] Data analysis was done by using SPSS software. WHO standards were used to compare underweight, stunting, wasting, and obesity among children.
| Results | | |
Prevalence of Underweight (Weight for Age) according to WHO standards
WHO gives results for weight for age up to 10 years of age. Among 1189 in the age group of 5-9 years, 4 children were severely under-weight and 31 children were underweight. A total of 35 children was found to be underweight [Table 1] and [Figure 1]. Among 654 boys in the age group of 5-9 years, none of the boys was found to be severely under-weight and 18 boys were underweight. Total 18 boys were found to be underweight. Among 531 girls in the age group of 5-9 years, 4 girls were found to be severely under-weight and 13 girls were underweight. A total of 17 girls was found to be underweight. | Table 1: Prevalence of Underweight (Weight for Age) according to WHO standards for both sex
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 | Figure 1: Prevalence of Underweight (Weight for Age) according to WHO standards for both sex
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Prevalence of stunting (Height for Age) according to WHO standards
WHO gives results for height for age up to 19 years of age. Out of the total of 2276 children, 30 (1.4%) children were found to be stunted. The maximum proportion of severely stunted children belong to the 15-19 years age group. Whereas the maximum proportion of stunted children was seen in the 10-14 years age group, followed by 15-19 years. No severely stunted child was found in the 5-9 years age group. The minimum proportion of overall stunting was also seen in this age group [Table 2] and [Figure 2]]. Among 1280 boys, 2 (0.2%) were found to be severely stunted and 12 (1%) were found to be stunted making a total of 14 stunted boys. Severely stunted boys were seen only in the 15-19 years age group. The maximum proportion of stunted boys was found in the 15-19 years age group followed by 10-14 years. Overall maximum stunting was seen in 15-19 years age group in boys. Among 996 girls, 1 (0.1%) was found to be severely stunted and 15 (1.7%) were found to be stunted making a total of 16 stunted girls. The severely stunted girl was seen only in the 10-14 years age group. A maximum proportion of stunted girls were found in the 15-19 years age group followed by 10-14 years. Overall maximum stunting was seen in 15-19 years age group in girls, which was same as boys. | Table 2: Prevalence of Stunting (Height for Age) according to WHO standards by age group
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 | Figure 2: Prevalence of Wasting, Overweight and Obesity (BMI for Age) according to WHO standards by age group
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Out of total of 2276 children, 232 (11.1%) children contributed to total wasting. 5-9 years age group contributed to maximum proportion of total wasting. The maximum proportion of severely wasted children belongs to the 15-19 years age group. Whereas, the maximum proportion of wasted children were seen in 5-9 years age group, followed by 15-19 years. Minimum wasting was seen in children between 10-14 years.
Out of total 2276 children, 396 (19.1%) were found to be overweight, 106 (5.1%) were obese and 18 (0.9%) were severely obese. Maximum overweight (27%), obesity (8.1%) and severe obesity (1.3%) was seen in children between 10-14 years of age, followed by 15-19 [Table 3] and [Figure 3]. | Table 3: Prevalence of Wasting, Overweight and Obesity (BMI for Age) according to WHO standards by age group
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 | Figure 3: Prevalence of Wasting, Overweight and Obesity (BMI for Age) according to WHO standards by age group
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Boys: Out of total 1280 boys, 147 (12.6%) boys contributed to total wasting. 15-19 years age group contributed to maximum proportion of total wasting. Maximum proportion of severely wasted boys belongs to the 15-19 years age group. Whereas, the maximum proportion of wasted boys were seen in the 5-9 years age group, followed by 15-19 years. Minimum wasting was seen in boys between 10-14 years.
Out of the total of 1280 boys, 258 were found to be overweight, 75 were obese and 16 were severely obese. Maximum overweight (29.7%), obesity (9.6%), and severe obesity (1.8%) weres seen in children between 10-14 years of age.
Girls: Out of total of 996 girls, 85 (9.3%) girls contributed to total wasting. 5-9 years age group contributed to maximum proportion of total wasting. The maximum proportion of severely wasted girls belong to the 5-9 years age group and the maximum proportion of wasted girls was also seen in the 5-9 years age group, followed by 10-14 years. Minimum wasting was seen in girls between 15-19 years.
Out of total 996 girls, 138 were found to be overweight, 31 were obese and 2 were severely obese. Maximum overweight (23.2%), obesity (5.9%), and severe obesity (0.6%) were seen in children between 10-14 years of age.
| Discussion | | |
Stunting
Prevalence of stunting
In the present study, it was observed that, out of total 2276 children, 30 (1.4%) children were found to be stunted according to the WHO reference. Overall maximum stunting was observed in 15-19 years age group. Out of these 30 stunted children, 14 (1.2%) children were boys and 16 (1.8%) were girls.
Grades of stunting
According to WHO reference 2007 classifies a child having height for age between -2 SD to -3 SD as “Stunted” and less than -3 SD as “Severely Stunted”. In the present study, out of 2276 children, 03 (0.1%) children were severely stunted, and 27 (1.3%) children were stunted. Among 1280 boys, 02 (0.2%) were severely stunted and 12 (1%) were stunted and among 996 girls, 01 (0.1%) was severely stunted and 15 (1.7%) were stunted.
It can be commented that the height of the children of the present study is comparable with that of the WHO reference standards. This may be due to the fact that these standards have been prepared including the anthropometric parameters of the Indian population also.
Comparison with other studies
On comparing with other Indian studies, it was observed that the overall stunting in the study population was less than that reports by the study conducted in 2016 in West Bengal[8] in school-going children, where 54% of children were found to be stunted as compared to 1.24% in the present study. According to the study conducted in 2001 in Kolkata[9] 52% of boys from Kolkata are stunted. According to a study conducted in 2016 in schools of eastern India, it was observed that the prevalence of stunting among children of 6-13 years of age was found to be 6.3%.[10] In another study conducted in 2017, it was found that the prevalence of stunting was 24.5% which is much more than what was found in our study.[11] A higher prevalence of stunting was also reported by a study among school children of Punjab in 2017.[12] Author in 2006 studied the anthropometric parameters in the school children of Ethiopia and found that the prevalence of stunting was 9.8%, more as compared to our study.[13] The study conducted in 2015 in Nepal brought out that 44.2% of school children between the age of 5-10 years were stunted.[14] All the studies above have used WHO references for comparison.
Underweight
Prevalence of weight for age of the present study population with WHO reference it was observed that, out of 1189 children in the age group of 5-9 years, 35 (3.57%) children were underweight. Out of these 35 children, 18 (3.3%) were boys and 17 (3.87%) were girls.
Grading of underweight
WHO reference classifies children having weight for age between -2 SD and -3 SD as “Underweight” and less than -3 SD as “Severely underweight”. According to this classification, out of 1189 children, 04 (.04%) were severely underweight and 31 (3.2%) were underweight making a total of 35 underweight children. None of the boys was found to be underweight, all the 04 (0.9%) severely underweight children were girls. The remaining 13 (3%) girls and 18 (3.3%) boys were underweight.
Comparison with other studies
The overall prevalence of underweight was less than that reported in the study in 2016 among the school children of eastern India which was 5.5%.[10] Prevalence of underweight was recorded as 27% by the study conducted in 2008 in a district in West Bengal which is higher than that found in the present study.[15] The study conducted in 2017, also found a higher prevalence of underweight in school children of Assam.[11] Results were also compared to a study conducted in 2001 in armed forces, where the prevalence of underweight was found to be 31.73% as per NCHS standard.[16] In his study conducted in 2015 on adolescent girls in Nepal, the author found that 32% of girls were underweight which is much more than the present study.[17] Another study conducted in 2016 in Indonesia, had similar results with the prevalence of underweight to be 14.5% which is again higher than the present study.[18] All the studies mentioned above have used WHO/NCHS standards for comparison.
The probable reason for the lower prevalence of underweight in the present study group may be is the fact that most of the children in the study group were children of Government employees. The parents' awareness about nutrition and child care is generally better. Also, they have better access to free and quality health care which in all probability contributed to these children having a lower rate of malnutrition.
Wasting
On comparing the BMI for the age of the study population with that of WHO reference, it was observed that out of a total of 2276 children, 232 (11.1%) children contributed to total wasting. 5-9 years age group contributed to maximum proportion of total wasting. In the study, 147 (12.6%) boys and 85 (9.3%) were found to be wasted.
Grades of wasting
WHO reference classifies children having BMI for age between -2 SD and -3 SD as “Wasted” and less than -3 SD as “Severely wasted”. According to this, out of 2276 children, 39 (1.9%) children were severely wasted and 193 (9.3%) were wasted, making a total of 232. Among severely wasted children 25 were boys and 14 were girls. The remaining 122 boys and 71 girls were wasted.
Comparison with other studies
When the results of the present study were compared with other studies, it was found that the prevalence of wasting was 48.75% in a study conducted in the year 2016 in West Bengal, which is much higher than that found in the present study.[8] In another study conducted in 2017, the prevalence of wasting was found to be 51% which is also higher than the present study.[11] Similar results were found in the multi-centric study carried out in 2001, where he found the prevalence of wasting to be 30%.[9] In a study carried out in 2017 in Punjab, 25% of children were found to be wasted, which is more than the present study.[12] In his study conducted in 2015 in Nepal, the author reported the prevalence of wasting to be 12.75%, which is close to what was found in the present study.[15] In 2006 in Ethiopia, the study observed the prevalence of wasting to be 24%.[13]
Overweight and obesity
On comparing the BMI for the age of the study population with that of WHO reference, it was observed that out of a total of 2276 children, 396 (19.1%) were found to be overweight, 124 (6%) were obese. Maximum overweight (27%), obesity (8.1%), and severe obesity (1.3%) were seen in children between 10-14 years of age, followed by 15-19. In the present study, 258 (22.1%) boys and 138 (15.2%) girls were found to be overweight and 91 (7.8%) boys and 33 (3.6%) girls were found to be obese.
Grades of Overweight and obesity
WHO reference classifies children having BMI for age between +1 SD and +2 SD as “Overweight”, more than +2 SD as “Obese” and more than +3 SD as “Severely Obese”. According to this, out of 2276 children, 396 (19.1%) were found to be overweight, 106 (5.1%) were obese and 18 (0.9%) were severely obese. Out of this, 258 were found to be overweight, 75 were obese and 16 were severely obese and remaining were girls. Boys contributed more to all the three categories as compared to girls.
Comparison with other studies
On comparing the results of the present study with other studies, it was observed that the prevalence of overweight and obesity was higher in the children of the present study. Prevalence of overweight was found to be 7.7% in a study conducted in Karnataka in 2015, which is less as compared to the present study, however, the prevalence of obesity (9.7%) in the same study was found to be more than the present study.[19] A lower prevalence of overweight-obesity (4.64%) was found by the author in their study conducted in 2015 in West Bengal.[8] Similar results were found in the multi centric study carried out in 2001[9] and another study conducted in 2006 at Ethiopia,[13] where they found the prevalence of overweight/obesity to be 4.3% among Indian adolescent boys and 3.3% in Ethiopian children respectively. A much lower prevalence (1.3%) was reported by the author in his study conducted in Assam.[11] The prevalence of overweight/obesity in 2017 in Punjab was found to be around 7.3%, which is again lower than that found in the present study.[12] However, a study conducted in 2017 in Tamil Nadu reported the prevalence of overweight/obesity to be 14% among school going children in Tamil Nadu, which is close to the results of the present study.[19]
In the present study, a higher proportion of boys (9.9%) was found to overweight/obese as compared to girls (6.2%), similar results were found in the studies conducted in 2016 in West Bengal and another study conducted in Punjab.[12] However, the study conducted in 2015 in Karnataka, reported a higher prevalence of overweight/obesity among girls (10.4%) as compared to boys (6.9%).[20]
| Conclusion | | |
In our study, according to WHO MGRS standards, the total prevalence of underweight was 3.57% among 5-9 years old children. Out of this, 0.4% children were severely underweight. 3.3% boys and 3.87% girls were underweight. Stunting was observed in 1.4% of children. 0.1% children were severely stunted. Sex specific prevalence observed was 1.2% in boys and 1.8% in girls. Wasting was observed in 11.1% children. About 1.9% of children were severely wasted. Among boys, 12.6% were wasted. As for girls, 9.3% of girls were wasted. 19.1% and 5.1% of children were overweight and obese respectively. Sex distribution for overweight was 22.1% boys and 15.2% girls. And that for obesity was 6.4% boys and 3.4% girls.
Recommendations
Nutritional education should be imparted to children, regarding the type of food to be eaten, major food groups, nutritive value of various foods, and common nutritional problems and their effects. Health education should be imparted to parents during parent-teacher meetings and IEC campaigns, regarding correct dietary practices such as food diversification and common nutritional problems in children and their consequences. Training of schoolteachers in health and nutrition as well as identification of easily identifiable nutritional deficiencies. Regular refresher courses are of equal importance. Health and nutrition education should be included in the school curriculum. Periodic medical examination of the children by health authorities should be carried out and appropriate records should be maintained. The children detected to be suffering from stunting, wasting, underweight, or overweight/obesity should be given immediate attention by concerned health authorities and should be kept under surveillance to monitor their growth.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3]
[Table 1], [Table 2], [Table 3]
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