Abstract: Malnutrition and anemia are common in Nepal. However, not much is known about the prevalence of malnutrition in urban slums. The objective of the study was to determine the prevalence of stunting, underweight, wasting and anemia among preschool children and the extent of chronic energy deficiency [CED], overweight and anemia among their mothers in slums of Kathmandu valley, Nepal. The survey involved 194 households with children aged 0-59 months in slums of Kathmandu valley. More than a third (38 %) of the children were stunted, a third were underweight (29 %) and almost a tenth were wasted (9 %). Male children were more stunted (53 % vs. 25 %), wasted (15 % vs. 4 %) and underweight (44 % vs. 16 %) than female children, p<0.05. Stunting was also high in children aged 24-59 months compared (48 %) to children aged 0-23 months (29 %), p<0.05. Anemia affected 35 % of the children and there was more anemia among children aged 0-23 months (53 %) than children aged 24-59 months (14 %), p<0.05. Almost one in every ten mothers (9 %) had CED, one in five (19 %) were at risk of overweight and a third (28 %) were overweight or obese. Anemia affected 16 % of mothers. Malnutrition and anemia are common among pre-school children and their mothers in the urban slums of Kathmandu valley. The presence of under-nutrition among children and mothers, along with overweight among mothers suggests a potential double burden of malnutrition in the slums of Kathmandu valley.

IntroductionLike most developing countries, Nepal has experienced a substantial increase in its urban population in the past decades. In the 2001 census, Kathmandu valley was home to 1.5 million people and had the largest share of the country’s urban population (31 %) [1]. The high population growth rate, high population density and the potentially high economic costs associated with urban living have also increased the overcrowding and sprawling of numerous slums or illegal squatter settlements in the city. Currently, there are 32 recognized slums in Kathmandu valley; home to a third of the total population of the city [2]. Like most slums, overcrowding, poor housing, inadequate sanitation, insufficient access to safe drinking water and poor sewage and drainage facilities are predominant features of the slums in Kathmandu valley. Such poor living conditions make the slum inhabitants vulnerable to poor health and malnutrition. Moreover, most children and women in these slums remain un-reached by national primary health and nutrition interventions. Accurate data on the nutrition and health status of the slum population are also lacking for various reasons. Many slum households are left out of most surveys because they are not documented in official

records. The purpose of this study was to assess and highlight the prevalence of stunting, underweight, wasting and anemia among preschool children and the extent of chronic energy deficiency (CED), overweight and anemia among their mothers in slums of Kathmandu valley.

Methods

Study design, sample size and sampling proceduresThis was a cross-sectional study involving 194 children aged 0-59 months randomly selected from 194 households in six urban slums of the Kathmandu valley. As mentioned above, Kathmandu valley has 32 recognized slums. Twelve of these are considered “large” slums because they have the highest population compared to the others. Initially, six slums were selected randomly from a list of the twelve large slums using simple random sampling procedure. A complete household census was conducted in the selected slums to identify households with children aged 0 – 59 months. The identified households were then stratified by slum and

Under- And Over-nUtrItIOn And AneMIA Are pOtentIAl prObleMs In the UrbAn slUMs Of KAthMAndU vAlley, nepAl

UrbAn nUtrItIOn bUlletIn nepAl

Helen Keller International, Nepal, 20102

194 households were randomly selected using the probability proportional to size sampling technique.

Weight and height/length of children and mothers were measured according to standard WHO procedures [3]. Hemoglobin of children was measured from a finger prick of blood using a portable HemoCue analyzer. Mothers of children were interviewed by trained enumerators to obtain data on the child’s age, gender, caste and illnesses (diarrhea, fever and acute respiratory infections) suffered by the child in the two weeks prior to the survey. Information on infant and young child feeding (IYCF) practices of mothers with children aged 0-23 months was obtained by following the 2008 WHO guidelines [4]. All mothers and heads of households in the study gave informed consent before the assessments. Weight and height/length of children were used to compute z-scores of weight for age (WAZ), weight for height (WHZ) and height for age (HAZ). Underweight, wasting and stunting were defined as WAZ less than two standard deviations (SD) below the 2006 WHO growth standards, WHZ <-2 and HAZ <-2 respectively [5]. Height and weight of mothers were used to compute body mass index (BMI) using the formula: BMI (kg/m2) = weight/ [height]2. Five mothers were pregnant at the time of the survey and one mother had BMI <12 kg/m2 and were therefore excluded from further analysis involving BMI [6]. BMI was estimated after the field survey so the survey team could not advise the mother with BMI <12 kg/m2 to seek treatment. Chronic energy deficiency among mothers was defined as BMI < 18.5 kg/m2. Mothers with BMI ≥ 18.5 - < 23.0 kg/m2 were considered to be of normal weight, those with BMI 23.0 - < 25.0 kg/m2 were considered at risk of overweight and those with BMI 25 kg/m2 were considered overweight or obese [6]. Anemia was defined as hemoglobin < 11.0 g/dl for children and pregnant mother and hemoglobin <12.0 g/dl for non pregnant mothers [7].

Chi-square tests were performed to compare proportions of stunting, underweight, wasting and anemia across groups of children categorized by characteristics such as age and gender. Statistical analysis was performed using SPSS version 16.0 (SPSS Inc., Chicago, Illinois).

results

Demographic characteristics of sampleThe mean ± SD age of children was 23 ± 16 months. The sample also comprised almost equal proportions

of male (48 %) and female (52 %) children. About 43 % of the children were ill during the two weeks before the survey. The most commonly reported illnesses were common cold (25 %), fever (21 %) and diarrhea (17 %).

Mothers of children in the sample had a mean ± SD age of 27 ± 7 years. Close to half of the mothers (46 %) had no formal education and the average number of children per mother was 2 (± 2). Families from households surveyed had lived in the slum for an average of 3 (± 5) years and the average family size was 5 (± 3). One in every two families lived in mud houses with most of the houses roofed with straw. More than 70 % of households had no access to a toilet facility and a third (31 %) did not have electricity in the house. The main source of drinking water was from tube-wells (35 %), followed by tap water (30 %), water bought from tanker trucks (24 %), uncovered wells (3 %) and other sources of water, not specified (8 %).

Malnutrition among childrenMore than a third of the children in the sample were stunted, almost one in every ten was wasted and a third were underweight (Figure 1). Stunting and underweight were more common among children aged 24 – 59 months than children aged 0 – 23 months. However, only the difference in stunting was statistically significant, p<0.05 (Figure 1). Male children were more stunted (53 % vs. 25 %), underweight (44 % vs. 30 %) and wasted (15 % vs. 4 %) than female children, p<0.05.

Figure 1. Stunting, wasting and underweight among children in urban slums of Kathmandu

Chronic energy deficiency and overweight among mothers The mean ± SD BMI of mothers was 23 ± 4 kg/m2. CED affected almost one in every ten mothers. About one in every five mothers was at risk of overweight and almost a third were overweight/obese (Figure 2).

Wasting Under weightStunting

29%

10%

24%

48%

9%

36% 38

%

9%

30%

0-23 months 24-59 months Total

Helen Keller International, Nepal, 2010 3

Figure 3: Anemia among children in urban slums of Kathmandu

Figure 2: Chronic energy deficiency (CED) and overweight among mothers in urban slums of Kathmandu

Chronic energydeficiency(BMI<18.5)

Normalweight(BMI 18.5<23)

At risk ofoverweight(BMI 23-<25)

Overweightor Obese(BMI>25)

9%

45%

19%

28%

0-23months

53%

14%

35%

24-59months

Total

in the slums. Moreover, one in every five children aged 0-23 months (21 %) was given pre-lacteals before initiation of breastfeeding. The pre-lacteals given to children included animal milk (24 %), milk from another mother (24 %), plain water (10 %), sugar and/or salt solution (5 %) and other non-specified fluids (38 %).

The proportion of children aged 6-8 months who are given solid, semi-solid or soft foods within 24 hours before a survey is the indicator used for timely introduction of complementary foods (current WHO guideline) [4]. There were only 11 children in this age range in our sample and nine of them were fed solid, semi-solid or soft foods in the 24 hours before the survey. However, diversity of complementary foods was less than adequate. Only 64 % of the children aged 6-23 months received four or more types of foods on the day before the survey.

Antenatal check up, Iron folate supplementation, deworming and tetanus injections for pregnant womenSlightly over 78 % of mothers in the sample reported seeking antenatal care during their last pregnancy. For those who received an antenatal check up, almost all of them (98 %) received care from trained health personnel (medical doctors, nurse and health assistant) and only 2 % received care from other sources (not specified). Close to two-thirds of the mothers (64 %) took iron folate tablets, 71 % reported having tetanus injections and only 18 % took deworming tablets during their last pregnancy. Of those who received tetanus injections, 22 % had only one injection, 66 % had two injections, 10 % had three injections and 2 % did not know the number of injections they received during the last pregnancy.

Discussions and conclusions Our results suggest a high prevalence of stunting, underweight and wasting among preschool children, as well as high CED and overweight among mothers of these children in the slums of Kathmandu valley. Anemia was also high among children and mothers, and the prevalence were above the WHO cut-off indicting a public health problem among this population [7]. The presence of under-nutrition among preschool children and mothers as well as overweight among mothers suggests a potential double burden of malnutrition in the slums of Kathmandu valley.

Infant and young child feeding (IYCF) practices Up to 95 % of the children aged 0-23 months were breastfeeding at the time of the survey and the majority of children in this age range (87 %) were put to breast within 1 hour after delivery. Bottle feeding was not a common practice because only two of the children had ever been bottle fed. None of the children aged 0 - 6 months (n=27) received breastmilk only on the day before the survey, an indication that exclusive breastfeeding is very low

Anemia among children and mothersAnemia affected 35 % of the children, with females (41 %) being more anemic than males (28 %), although the difference was only marginally significant (p=0.07). Anemia was higher among children aged 0-23 months than children 24-59 months, p<0.05 (Figure 3). Anemia affected 16 % of mothers.

Helen Keller International, Nepal, 20104

Our results also show that males and younger children (0-23 months) are more likely to be malnourished compared to females and older children (24-59 months). As expected, anemia was also higher among children 0-23 months than children 24-59 months in this study. We did not explore the reason for these differences because the survey was not designed to find determinants but to highlight the extent and distribution of malnutrition. However, such differences demonstrate the need to better understand the determinants of malnutrition in the slums and to increase efforts to address malnutrition among young children these areas. The high prevalence of stunting and underweight compared to wasting among children, the low proportion of mothers who practice exclusive breastfeeding and the poor diversity of complementary foods in our sample also suggests sub-optimal IYCF practices are likely a major contributing factor to childhood malnutrition in the slums of Kathmandu valley.

This study draws attention to the urgent need for a more detailed study to assess the etiology of malnutrition and highlights the need for public health nutrition interventions that address both under- and over-nutrition among preschool children and women in the slums of Kathmandu valley.

References1. Central Bureau of Statistics. Population Census

2001. National Planning Commission, Kathmandu, Nepal, 2003.

2. Sukumbasi (Slum area) Management Committee, Ramhiti, Kathmandu Metropolitan City, 2009.

3. World Health Organization. Physical status: the use and interpretation of anthropometry. Report of WHO Expert Committee. World Health Organization, Geneva, Switzerland, 1995

4. Indicators for assessing infant and young child feeding practices, part 1-definitions: conclusions of a consensus meeting held 6–8 November 2007 in Washington D.C., USA. Department of Child and Adolescent Health and Development, World Health Organization, 2008

5. WHO Multicentre Growth Reference Study Group. WHO child growth standards based on length/height, weight and age. Acta Paediatrica 2006;450 (suppl):76-85.

6. WHO Expert Consultation. Appropriate body-mass index for Asian populations and its implications for policy and intervention strategies. Lancet 2004; 363:157–63.

7. WHO/UNICEF/UNU. Iron deficiency anemia: assessment, prevention and control. A guide for program managers. World Health Organization, Geneva, Switzerland, 2001 [Distribution no. 01.3].

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