UNIVERSITY OF BEDFORDSHIRE FACULTY OF PUBLIC HEALTH

MSc. PUBLIC HEALTH

A Dissertation submitted to Bedfordshire University in partial fulfilment for the Award of MSc Public Health

Title of Work CHILDHOOD MALNUTRITION IN INDIA- A SYSTEMATIC REVIEW Unit Lead: SUSAN SAPSED Unit Code: PUB010 -6

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Submitted by: RENJITH S BHADRAN Student ID: 1031388

Abstract Childhood is a prominent chapter of everyones life and deprivation during this period can lead to long-term adverse effects on the wellbeing of a child. Reduction in infant and child mortality rates should be considered as one of the most important goals for a nations prosperity and success as children represent the building blocks of a nation. The aim of this paper is to examine the existing picture of childhood malnutrition and prevalence of underweight children in India. For this purpose data has been collected from seven primary researches which include three rounds of the National Family Health Survey of India (NFHS). The analysis reveals that there has not been any improvement in the state of underweight since 1990 in India and trend still continuous. The effects of under-nutrition are complicated adverse, however, is not unrecoverable. Treatment of childhood illnesses needs to be improved, as underweight remains to be a major health problem for many children. Although knowledge about under-nutrition issues and for the treatment of its consequences, especially weight loss, is well documented, millions of children are still suffering with chronic illness from deficiency of nutrition. The results have interesting social and policy implications and indicate several promising lines of research. Background: Studies investigating the magnitude of childhood malnutrition and underweight children of India. Seven major surveys has been carried out from 1990 to 2011 reveals the health status of every Indian child which is published after the completion of each surveys. Many researchers began to study on various interested area of malnutrition throughout the country. Although, there are number of studies about the prevalence of underweight and the magnitude of childhood malnutrition so far, no systematic review has been done on this particular area at researchers knowledge. Objective: To systematically review acquainted major studies that have examined malnutrition effects on Indian children in order to identify underweight prevalence of children aged between 0 and 15. Search Strategy: The search for appropriate studies included scientific databases like PubMed, CHINHAL Plus, PsycINFO, as well as those included in the reference and bibliography lists of all possible identified studies. Selection criteria: 274 studies published in English between 1990 to till date that examined childhood malnutrition effects and prevalence of underweight in Indian children. Data collection and analysis: Data on outcome measures such as underweight prevalence in Indian children with in age group of between 0 and 15 will be taken for detail analysis.

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Results: Results show a significant number of underweight children in India. It identifies higher prevalence of underweight condition among female children than the opposite sex. Included studies showed almost similar higher prevalence of underweight although, it represents various rage of participants. The most significant effect of under-nutrition contributed India to a higher ranking country in underweight prevalence. Authors conclusion: The results of the review identified the significant higher prevalence of underweight among children in India. The findings from this study give a clear picture of underweight and nutrition status of Indian children together with a meta-analysis conclusion. The most important factor was that the prevalence rate is still higher after various stages of primary researches.

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Authors Declaration

The study was completely undertaken and written by Renjith Seela Bhadran. The author used his own words or images, and ideas. After conducting the study, author has formed the results from his work. This study was not copied from the scripts of other authors or candidates, and no unauthorised materials were used. No false information has been included.

Name: RENJITH SEELA BHADRAN Date: 04- 01-2012

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Acknowledgements Foremost, my sincere gratitude to Almighty God for to give me such a wonderful experience. I thank god also to making me it possible to achieve all success throughout the course. I thank you Dr.Chris Papadopoulos, his support and strong vision to lead his students in to higher success. I respect and proud of Susan Sapsed, a wonderful person and a great course leader. I respect the great efforts of Dr.R.V Nair and Dr.Bhagyalekshmi (Father in Law & Mother in Law) for their good support and guidance. I respect my mother and father for their blessings and prayers. Finally, my loving wife Ambika, thank you for your good support. Thank you everyone those help me and encourage me, without you, the study would not have been possible.

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TABLE OF CONTENTES

Chapter 1: Introduction..................................................................................................9 1.1 Aims and Objectives............................................................................................11 Chapter 2: Literature Review.........................................................................................12 2.1. The concepts of under-nutrition and under-weight.......................................................12 2.2 Consequences of childhood under-nutrition................................................................14 2.3. Prevalence of Under-weight children- A global perspective...........................................17 2.4. Demographic profile and nutritional status of India.....................................................19 2.5. Prevalence of Underweight children in India.............................................................22 Chapter 3: Methodology...............................................................................................23 3.1. Study Design....................................................................................................23 3.2. Rationale for the method of study chosen.................................................................26 3.3. Inclusion or Exclusion Criteria for selecting Literature.................................................26 3.4. Search strategy..................................................................................................27 3.5. Screening Strategy:.............................................................................................27 3.6. Quality Assessment............................................................................................27 3.7. Data extraction..................................................................................................29 3.8. Ethical Considerations.........................................................................................30 3.9. Data Analysis....................................................................................................30 4.1. STUDY SELECTION.........................................................................................31 4.2. Description of Evidence:......................................................................................33 4.3. Key Findings of the Seven Primary Researches Analysed for Study.................................41 4.4. META ANALYSIS...............................................................................................43 Chapter 5: Discussion..................................................................................................48 Page6 Chapter 6 Conclusion...................................................................................................52 Chapter 7 Dissemination...............................................................................................54 Assignment Top sheet..............................................................................................57 Extension deadline................................................................................................58

Extension deadline

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List of Figures
Fig 2.1: A pictorial framework showcasing the causes of Malnutrition.....................................................12 Fig 2.2: Global Distribution of cause specific mortality among children under five...............................17 Fig 2.4 : Early Childhood Mortality Rates.................................................................................................22 Fig: 3.1 . An example of a flow chart which illustrates the literature identification process......................26 Figure 4.1 Mapping OF Search Strategy With Literature Evidence...........................................................34 Fig 4.2: key finding on prevalence of underweight....................................................................................44 Fig: 4.3. Key finding on prevalence of underweight among male children................................................45 Fig: 4.3 Key finding on prevalence of underweight among female children.............................................45 Fig:4.4 Forest plot 1 Over all Prevalence of underweight among children from included studies for meta-analysis.............................................................................................................................................49

Fig:4.5 Forest plot 2 Over all Prevalence of underweight among female children from included studies for meta-analysis.......................................................................................................................................50 Fig:4.6 Forest plot 3 Over all Prevalence of underweight among male children from included studies for meta-analysis.............................................................................................................................................51

Fig: 4.6 Forest plot 3 Over all Prevalence of underweight among male children from included studies for meta-analysis

List of Tables

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Table 1.1 Weight Statuses for Body Mass Index (BMI)..........................................................................15 Table 2.1 Description of Evidence on Demographic Information of India and a Comparison with USA & UK.............................................................................................................................................................21 Table 3.1 The data extraction matrix used in this study.............................................................................31 TABLE 4.1 Evidence of Screening :( Studies screened at first stage of the study)....................................32 Table 4.2 : Description of evidence of results identified from National Family Health Survey -1............36 Table 4.3: Description of evidence of result identified from National Family Health Survey -2..............36 Table 4.4: Description of evidence of result identified from National Family Health Survey -3..............38

Table 4.5 : Description of evidence of result identified from Kumar et.al. (1996)....................................38 Table 4.6: Description of evidence of result identified from Bisai et.al (2010)........................................39 Table 4.7 : Description of evidence of result identified from Bisai et.al (2011).......................................41 Table 4.8 : Description of evidence of result identified from Biswas et.al (2011).....................................42 Table 4.9 : Qualitative Analysis of the included studies............................................................................43 Table 4.10 Evidence from primary research to the Meta analysis..............................................................46 Table 4.11: Figures of the Different NFHS Studies between states...........................................................52

Table 4.11: Figures of the Different NFHS Studies between states

Chapter 1: Introduction
Malnutrition remains unacceptably high in most of the developing nations. Food and Agriculture Organization of the United Nations found one child dies every five seconds as a result of direct or indirect cause of malnutrition worldwide (FAO, 2004). The word malnutrition is derived from Malus, a latin word (Morris, 1992). Malus means not correctly nourished. Malnutrition essentially means bad

nourishment (WHO, 2011).Although, malnutrition refers both to under nutrition and overnutrition (McGuire & Beerman, 2011, p.35) this study focuses on under nutrition and its effects on children. According to the statistics, Under-nutrition affected nearly one billion people around the world (Bogden & Louria, 2010, p.568). Furthermore UNICEF (2011) states that, more than 400 million children under the age of five are malnourished in the world. Under-nutrition is not a state of disease which affects only for children. According to Collins et al. (2005) Malnutrition may affect every group in the community in different levels; however, childhood malnutrition is considered predominant among them due to several reasons.
According to UNICEF (1998) Malnutrition is largely a silent and invisible emergency, exacting a terrible toll on children and their families. It is a state of nutrition deficiency due to many reasons. In developing countries, malnutrition is mostly associated with reduced calorie intake or imbalanced diets

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(UNICEF, 1998). UNICEF reveals that, out of 12 million child death across developing countries, the majority of cases were due to the deficiency of nutrition in children (UNICEF, 1998). Malnutrition collapses intellectual property in to a non-productive condition and disturbs society into a low standard of living (The World Bank, 2011). The impact of nutritional deficiency among children makes them nonproductive due to many illnesses. It may affect their schooling, personal improvement in various skills and technology, and also physical, social, mental limitations (World Bank, 2011). It has been directly linked with family expenses for medical cost and in low standard of living as many reports proved. For example, The Malawi Demographic and Health Survey conducted in Africa (DHS, 2004) revealed that malnutrition is associated with diarrhea, malaria, measles, acute respiratory infections and other infectious diseases which is a direct reason for nonproductive community and their low standard of living. Aside from physical illness, some other factors are contributing towards mental retardation and resistance loss for children. Inaccurate Vitamin A supplementation and the inadequate iodization in salt are some of the concerns (ICCIDD, 2011). As vitamin A deficiency is a direct cause of anemia as well as Iodine deficiency which is the primary cause of preventable mental retardation and brain damage in children. Malnutrition is not only a cause for any disease but also it works as a cycle in the community (Li, 2006). In order to break the cycle, each issue associating to it should be closely monitored. Similarly, to identify the magnitude of malnutrition effects, studies should be conducted in different forms. Community based programs including motherhood (women) participation is proven to be a best example for this. Good nutrition should not be an inaccessible right for a child. International law for children significantly points out the accessibility of every child to a good nutrition (Nathan, 2008). To protect their rights, society has the obligation to take this issue as a public health priority.

Studies relating to malnutrition has been carried out across the world especially Asian and sub Saharan region. For example World Food Programme (WFP, 2011) found that 70% of underweight children in the world reside in just ten countries. Out of these ten countries, 8 countries are located in South Asian region (UNICEF, 2006). Among these, India is considered as one of the largest malnutrition affected countries .According to UNICEF (2006), the prevalence of underweight children in India was the top most among all other countries in the south Asian community. It was estimated that half of the total population of Indian children were either severe or moderately underweight (UNICEF, 2006). Under- nutritional effects are heavily affected in people who are not accessible to the health services in India (IIPS & MI, 2007). Imbalance diet together with low standard of living creates disorder in nutritional life and leads to many infectious diseases. Poverty and unfavorable environmental conditions built vulnerable situations in social life. Basic needs of people such as food, drinking water; housing, health care services are closely related to peoples standard of living and hygiene. Infectious diseases are caused by how the people they live. According to Global Health Council (GHC, 2011), it has been identified that infectious diseases are the major cause for the hike in the mortality rate of children around the world. Malnutrition can be argued to be both a cause and consequences of many other important social phenomena (Keusch, 2003). Malnutrition increases economic and social burden but at the same time it is also an outcome of economic and social issues such as poverty, overpopulation, environmental factors and quality of health care services (Keusch, 2003). In one hand, malnutrition works as the reason for economic and social burden in a society but at the same time it is also an outcome from those determinants as a cycle. Overall, malnutrition is an enormous public health concern which increases the morbidity and mortality

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rates of effected community.Hence, breaking the malnutrition cycle in order to reduce the impacts of malnutrition in children should be considered a prime goal for research in India.

1.1 Aims and Objectives

The objective of this research is to increase our knowledge and understanding about the current picture of underweight children in India. More specifically, it aims to:

Systematically review existing primary researches to establish the overall prevalence of underweight among children in India aged between 0 and 15. Systematically review existing primary researches to establish whether the prevalence of underweight differs across gender among children in India aged between 0 and 15.

The rationale for this study is associated with the issues related to the magnitude of childhood under-nutrition among children in India. It is also associated with the higher prevalence of underweight children in India as compared to any other developing country in the world. As world health organization referred India as a home for 60 million underweight children in the world (prinja, 2009), the scope for this study increases and so does the importance of educating the public about the effects and causes of underweight. During a survey conducted by the Indian government, called National Family Health Survey (IIPS & MI, 2007), it has been found that India is highest in severe childhood under-nutrition issues among 16 different countries, in a cross country comparison (IIPS & MI, 2007). According toDepartment of Economic and social affairs, India is a country with one of the youngest populations in the world (Ivanov, 2011). In order to protect the health of next generation, proper health settings should be done at right time. As of now there have been plenty of researches that have been conducted on this same issue, however; the prevalence rate of underweight published by various agencies reminds the lack of clarity about the issue in the public. Most of the researches indicate underweight as a major concern for under nutrition among Indian children (The World Bank, 2005). Hence, in order to make the concerned issue as well as finding the prevalence rate of underweight children would be a prime motive for this research. The research will be evaluating the prevalence rate of underweight children from primary researches in order to make an analysis of overall prevalence. Study will be evaluating prevalence of underweight across gender to find the causes of discrimination of health care among children in India. Many researches have been undertaken using various methods to find the result however, it is been considered in this study that a systematic review would be more applicable to suit the purpose of this research.

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Chapter 2: Literature Review.

2.1. The concepts of under-nutrition and under-weight. 2.1.1. Under-nutrition.

Under-nutrition is a state of body affected by deficiency of nutrients such as protein, energy, minerals, vitamins etc. (RCPL, 2002, p.5). Under nutrition occurs in people, if their diet does not provide adequate calories and protein for growth and maintenance or they are unable to fully unitize the food they eat due to illness (WHO, 2001). Under nutrition is caused by several reasons. The mismanagement in political resources, unfavourable economic structure of a society, political and ideological superstructure in a community, ineffectiveness of formal and non-formal institutions working for the public, inadequate education among general public, inadequate care for children and mothers from the health services (WHO, 2001). These factors in turn lead to inadequate access to food or insufficient health services and unhealthy environment in the society which are immediate reason for diseases and inadequate dietary intakes. As mentioned in the earlier part of this report, under-nutrition is a state of nutrition deficiency in the body and many studies have proved that inadequate dietary intakes and diseases are the cause of malnutrition and thereby death [Please see Figure 2.1]. Malnourishment is a global concern as well as a social burden which affects not only the children but also their family and the entire development of the nation. One of the reasons behind under nutrition is poverty (Misselhorn, 2007, p.4). Not only has under nutrition affects the economic status of a nation but also it increases the health care costs as well (Misselhorn, 2007, p.4). Under-nutrition contributes to infectious diseases which in turn leads a larger number of child deaths and other vulnerable conditions (Calder & Jackson, 2000).
Fig 2.1: A pictorial framework showcasing the causes of Malnutrition.

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Conceptual framework of the causes of under- nutrition. Adopted from UNICEF conceptual framework (1990).

2.1.2. Under-Weight:

According to Tulchinsky and Varavikova (2009, p.303) Underweight is a state of nutritional deficiency resulting from either inadequate energy or protein intake and manifesting in either marasmus or kwashiorkor. Low weight in proportion to height and later proposition to age are main features of Underweight in children and results in body wasting, stunt and failure to thrive (Fishman et al., 2011). It is believed that, under-nutrition especially protein energy malnutrition is the cause of underweight among children. It has been measured in different scales worldwide. According to CDC (2011) for American children, underweight is defined among children who are below 5 percentile of BMI. In India, most of the studies followed National Centre for Health Statistics/ World Health Organization reference median (NCHS/WHO). According to NCHS/WHO underweight in children is measured according to their weight for age below -2 standard deviations( SDs) (weight-for-age <-2SDs, or weight-for-age z-score [WAZ] <-2) (WHO, 2011). Underweight for adults is calculated worldwide by using Body Mass Index calculation (CDC, 2011). In BMI calculation there are certain standards which segregate underweight and normal weight according to their height and weight. For adults BMI of 18.5 -24.9 is defined as normal weight. Below BMI 18.5 is considered as underweight. Similarly, above BMI 24.9 will be conceder as overweight and then by Obese [Please see Table 1.1]. According to WHO (2011), the prevalence of underweight in children were extremely high during 90s as compared to the present situation around the world. The trend of underweight proportion of children under five years old reported an 11% of decrease from 29% to 18% (19902010). WHO (2011) also stated that, eastern Asia, Latin America, Caribbean islands, and central Asia were the regions that showed a decline in underweight percentage in children. However, it has been also noted the same about Southern Asian region, where the story remains the same for the past two decades. BMI Below 18.5 18.5 24.9 25.0 29.9 30.0 and Above Underweight Normal Overweight Obese Weight Status
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Table 1.1 Weight Statuses for Body Mass Index (BMI).

2.2 Consequences of childhood under-nutrition.

Malnutrition is the reason behind 5 million deaths globally every year (UNICEF, 2007). It is considered as a major burden for the affected societies.Nutritional deficiencies among children such as protein energy malnutrition, deficiencies of micronutrients, Iron deficiency, vitamin A deficiency and iodine deficiency diversely affects the development of children physically, socially and mentally. World health organization (Ustan & Jacob, 2005) defines health as "a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity." According to this definition, childhood under nutrition is a major public health issue to be tackled as such for the physical, mental and social wellbeing of a child.
2.2.1 Protein Energy Malnutrition (PEM): PEM is one of the major reasons which contribute towards malnutrition in children (Mesham & Chatterji, 1999, p.10). Severe PEM can also result higher mortality rates in the not so privileged communities of the society. Malnutrition in the early stages of a child can severely affect a childs growth. The consequences of protein energy malnutrition in children usually results in underweight (less weight in proportion to age), stunting (less height for age), and body wasting (less weight for height). According to WHO Global Database on Child Growth (Onis et al, 1992), which covers 87% of the total population of under-5-year olds in developing countries, Asia was the highest ranking in under nutrition affected region. According to this study Asia has 42.0% of underweight, 47.1% of Stunting, 10.8% of wasting children, which shows the consequences of protein energy malnutrition in that region. 2.2.2. Iron Deficiency: It is one of the primary reasons for nutritional deficiency. Iron deficiency can lead to iron deficiency anaemia (Bowden & Greenburg, 2010). It normally affects children and women before their menopausal stage of life. According to WHO (2001) the report revealed from the studies of children below age 4 years suggest ,On anaemia prevalence (1990-95), industrialized countries had 20.1% and non-industrialized countries 39.0% as well. 2.2.3. Vitamin A Deficiency: As the name suggests is a condition where humans lack Vitamin A in their body (Anderson, 2007). It is rarely reported in developed countries but widely recorded in developing nations of the world. Vitamin A can lead to night blindness (Anderson, 2007). It also affects immunity of a human being to fight infections. According to WHO (1995), approximately one third of the worlds pre-school population have vitamin A deficiencies and of that less than 1 % are prone to night blindness. 2.2.4. Iodine Deficiency Disorders (IDD): Iodine deficiency can lead to brain damage and mental ill-health and can be a cause for a range of problems like goitre and other physical ailments (Preedy, 2009, p.461). These dis orders caused by the lack of iodine in body due to the deficiency of the same in cultivated food items, is referred to as Iodine Deficiency Disorders(IDD) (Preedy, 2009, p.461).). In fact under-nutrition contributes many deadly diseases such as marasmus, kwashiorkor, anaemia, goitre, hypernatremia, hypokalaemia, vitamin A deficiency etc. Page14

It is a disease that is caused by the deficiency, in fact chronic deficiency of proteins and calories in the body and is one of the most common diseases caused by malnutrition in children and hence can lead to general lack of energy in them (Koukul, 1991, p.123). It affects normally infants under the age of one. Edema, skin problems like dry and scaly skin or loose skin can also be caused by Marasmus (Whitney et al., 2010, p.127).
2.2.5. Marasmus:

2.2.6. Kwashiorkor: Kwashiorkor is one of the most acute protein malnutrition diseases in the

world (Whitney et al., 2010, p.127).It is similar to Marasmus but what makes it different is the presence of Edema in feet. It can also lead to distended abdomen, swollen liver, thinning of hair which is normally coarse in texture, teeth lose, skin depigmentation, and dermatitis. Children affected by Kwashiorkor also show signs of irritability and anaemia.
2.2.7 Anaemia: It is regarded as one of commonly reported malnutrition ailment around the

world. It can be caused due to many reasons but the primary being the lack of iron and Vitamin B12 in the diet and has been generally reported in pregnant women (DeBruyne et al., 2008). People who are anaemic also show signs of tiredness, loss of breath and have pallor skin which is caused due to the lack of haemoglobin in their blood (DeBruyne et al., 2008).
2.2.8 Goitre: This is caused due to the lack of iodine content in food and can lead to swelling of

thyroid gland around the neck. Lethargy, weakness, low metabolic rate and increased susceptibility to cold are other signs of lack of iodine in the diet (Ottoboni & Ottoboni, 2002,
p.153). 2.2.9 Hypernatremia: Hypernatremia is a condition that is caused due to deficiency of sodium in

the blood and diet. This is a serious type of electrolyte disturbance that is normally seen in people who have high levels of antidiuretic hormone. In this disease, the concentration of sodium in the plasma is less than 135mEq/L (Lagua & Claudio, 1996, p.76). This condition is often seen as a result of a complication of some other serious medical illness, like diarrhoea, excessive vomiting, polydipsia, etc. Typical symptoms include nausea, vomiting, headache, etc. If the symptoms are not treated in time and worsen further, there may even be mental clouding, confusion, convulsions, stupor and the person may even eventually go into coma (Lagua & Claudio, 1996, p.76). The treatment for this disease depends on the underlying cause. In cases of severe volume depletion, there may be need of intravenous administration of saline. Serious symptoms like seizures normally require treatment using hypertonic saline.
2.2.10. Hypokalaemia: It is a condition which results from the lack of potassium in the diet. A

person suffering from this disorder may lack potassium in his or her body (Teitelbaum et al., 2007, p.189). Dehydration or diarrhoea and malnutrition can all lead to this disorder. Hypokalaemia is followed by symptoms like myalgia, muscle cramps, tetany, slight change in blood pressure, constipation, etc. Respiratory depression and cardiac arrhythmias can be the extreme cases of hypokalaemia (Teitelbaum et al., 2007, p.189).
2.2.11. Vitamin Deficiency: Vitamin deficiency can also be a consequence of under-nutrition. The

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following is a list of those vitamins and the condition they lead to due to their lack of it: Vitamin A: Vitamin B1: Vitamin B2: Vitamin B3: Vitamin B12: Vitamin C: Vitamin D: As can be seen in figure 2.2, approximately 50% of total deaths in children less than 5 years of age are because of various infectious diseases in the world (UNICEF, 2008). The reason behind

these diseases is found to be under-nutrition. They key factors from this study as per figure 2, neonatal period is claimed to be more dangerous period exposed to under-nutrition. Approximately 40 % of child death are reported in this study is at neonatal period. It includes 19% of children affected by pneumonia, 17% from diarrheal diseases, 10% from severe infectious diseases etc.
Fig 2.2: Global Distribution of cause specific mortality among children under five

Source: UNICEF, The State of the Worlds Children Report 2008, New York, December 2007.

The problems relating to under-nutrition among Indian children is relatively very high. According to NFHS-3(IIPS & MI, 2007), Under-nutrition contributes 22% of Indias burden of disease. It includes iron deficiency, anaemia among preschool children as 75%, vitamin A deficiency as 57%, and iodine deficiency as 85 % of districts, etc. Similarly protein energy malnutrition contributed to higher prevalence of underweight, stunted, wasted children in India as compared to any other Asian region. NFHS-3 (IIPS & MI, 2007) also states that, undernutrition contributes either directly or indirectly, in half of the total child death below age of 5 years across the country.

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2.3. Prevalence of Under-weight children- A global perspective. The effects of under-nutrition in children in different places are varied. World agencies such as WHO, UNICEF etc. conducted many studies to find the real causes and its effect on children in various terms. According to the World Health Organisation Global Database (2011) on children growth and

malnutrition, they have succeeded in finding out the decreasing stage of it or some of its effect in some regions, especially, the prevalence of underweight which was recognized as one of the major consequences of under-nutrition (WHO, 1997). A major study which carried out 419 nationally representative surveys on 31 million children from both developing and developed countries, revealed the changes in prevalence of underweight since 1990. It found that the trend in the prevalence of underweight children in the study area was slowly decreasing compared to the earlier phase (Onis et al., 2004). It was reported that during 1990s the prevalence of underweight was 26.5% and it slowly showing a trend of decrease by 2000 and is projected to be at 17.6% by 2015 (Onis et al., 2004). Furthermore, the prevalence rate of underweight children in developed countries was estimated to decrease from 1.6% to 0.9% (Onis et al., 2004). It was more specific in the case of developing countries with an estimated decline from 30.2 % to 19.3 % during the same time period (Onis et al., 2004). The study identified some regions such as Africa and southern Asia still maintain higher prevalence rate among underweight children. It was found that the prevalence of underweight in Africa has increased from 24.0 % to 26.8 % since 1990. Asia in total, there are positive trends towards underweight prevalence as reported same as in any other region stated here .Asia has a prevalence in underweight children of 18.5 percentages which was 35.1 percentages in 1990 (Onis et al., 2004).. According to this study the total number of underweight children in the world was 163.8 million in 1990. Study concludes, the number of underweight children in the world will decrease from 163.8 million to 113.4 by 2015 (Onis et al., 2004). Some south Asian regions such as India, Bangladesh and Nepal still have higher prevalence rate which is said to be higher than any other countries even double than sub Saharan countries. NFHS-3 study conducted in India supported this findings of WHO. During a study of underweight children in India, NFHS -3 compared the prevalence status of India with other 16 regions and found that India was the most affected country than any other region [Please see Figure 2.3].
Fig 2.3 The percentages of children with under nutrition are aged five years or under among selected countries based NFHS -3:

For this study it is considered to be as much important to analyse the status of china and sub Saharan countries about the same issue. According to the State Statistical Bureau study (Chang, 1996)
with the representation of 26 states in 1992, China has a prevalence of underweight children below age 5 recorded as 17.9%. During the same study, it was also reported that chronic malnutrition among children was 34.7% and wasting by 4.7%. Study observes the wide difference of prevalence in underweight children from rural and urban areas of china. According to Svedberg (2007), through the comparison of various past surveys, with consistent economic development together with conducting malnutrition programs throughout the region will help in decreasing the intensity of malnutrition issues among children at least half with in ten years. It was reported that since 1990, sub Saharan region shows a dramatic increase in the rate in childhood malnutrition as 20% (Schulz ,1999, p.66). It was claimed that two hundred million people on the continent, both children and adults, were undernourished (FAO, 2003). More than one third of children below age five are undergoing chronic malnutrition in most of the sub Saharan regions. According to the study, more than 28% of deaths among children below age five are associated with under nutritional issues. Apart from mortality rate and association of nutritional deficiency, study finds almost 30% of burden of diseases are caused by malnutrition among children.

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2.4. Demographic profile and nutritional status of India

India is one of the 10 fastest growing economies in the world having a total population of 1.21 billion people according to 2011 census report (Census India, 2011). It includes 623.7 million males and 586.5 million females. The total population of India is estimated to account for 17.31% of the world population. India is believed to have the youngest population in the world by having 50% of total population representing people below age of 25. According to 2011 census, the life expectancy in India at birth was estimated as 66.8. It has counted for males as 65.77and females 67.95. The life expectancy in India is reported as below average of world estimation. There is a huge difference in percentage of life expectancy when we compare Indian life expectancy with the United Kingdom and the United States of America. According to National Health Service (2011), life expectancy of British people had risen from 72 to 80 within the last three decades. In UK the average life expectancy of male population is 78 as compared to the opposite sex of 82. According to the United States census Bureau (2011), the life expectancy of American people was estimated as 77.8, males 75.3 and females 80.3. Infant mortality rate in India is also extremely high compared to the United Kingdom and the USA. According to CIA World Fact Book (2011) Infant mortality rate (IMR) of India per 1000 live births is estimated to be 47.57. It is far lesser in the case of the UK and the US as 4.62, 6.06 respectively (CIA, 2011). In 2009 India had a mortality rate of 65.6/1000 for children under the age of 5. That means 65.6 out of every 1000 children died before reaching the age of 5 years (CIA, 2011). WHO Mortality country fact sheet displays the mortality rate of Indian children aged below 5 years as 85(Male 81, Female 89) at every 1000 live births (WHO, 2006). Mortality rate of British children below the age of five was estimated 6 for male child and 5 for the opposite sex, a total of 6 for every 1000 live births (WHO, 2006). Mortality rate of American children below the age of five was estimated at 8 and 7 for male and female counterparts, a total of 8 for every 1000 live births (WHO, 2006). The other important area to be overviewed is maternal mortality rate in India. According to CIA World Fact Book (2011), it was recorded that UK has a maternal mortality rate of 11 per100000 live births. USA showed 14 per 100000.As in the case of India it was 540 per 100000live births.
Table 2.1 Description of Evidence on Demographic Information of India and a Comparison with USA & UK. Page18

Highlighted Information on : Total Population Life expectancy

UK

USA

INDIA

62.3 million 80 (M 82, F 78)

3,12.68 million 77.8 (M 75.3, F 80.3)

1.21 Billion 66.8 (M 65.77 , F 67.95)

(Years) Infant Mortality Rate 4.62 (1000 Live Birth) Child Mortality below 6 ( M 6, F 5) age 5 (1000 Live Birth) 6.06 8 ( M 8 , F 7) 47.57 85 (M 81, F 89)

Maternal Mortality 11 Rate ( 100000 Live Birth)

14

540

As per the stated information and comparison of some key areas in demographic profile of India with the UK and the US, it has been found that the infant mortality rate and child mortality under age 5 in India is significantly high. The life expectancy rate in India is very low and even lower than the global average. The maternal mortality is found to be another issue as statistics prove, which is directly affecting child nutrition and breast feeding. Apart from this report, a large scale national survey conducted in 2005, called National Family Health Survey, which gives overall information surrounded nutritional life of an Indian children. Under-nutrition is related to various environmental factors which directly or indirectly affects a childs life since its birth. It is claimed important to observe all these factors to evaluate the chances of under-nutrition from various perspectives. NFHS (IIPS &MI, 2007) provided wide information about the matter which showed the real picture of Health status of India. It is also very important to mention that, the methodology (see page no: 35) used by NFHS to update the statistics was predominantly successful. It covers the total population of India and the representation from each group from the community. According to NFHS-3 report, the primary health distribution was not as effective according to its mission. This study is evaluating some key information from NFHS-3 to analyse the factors governing health of children in India. It found that only 24.9% children received a vitamin A dose in their last 6 months (12-35 months children).It describes about the inaccessibility of health services for a child. According to NFHS3 (IIPS & MI, 2007) 26% of Children below age 3 been found with diarrhoea and have not received ORS for two weeks. NFHS also found the breastfeeding practices of mothers. Study claims that only 46.3% mothers breastfed their child during their first 5 months of age. It has been also noted that the prevalence of anaemia in children aged 6- 35 months were 78.9%. Further figures as per the NFHS study reveal that children aged between 12-35 months who received a Vitamin A dose in last 6 months amounted to 24.9 per cent (IIPS & MI, 2007). The results show the children less than 3 years who received ORS in the previous 2 weeks amounted to 26.2 per cent and those who were taken to health institution were recorded to be 61.5 per cent

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whereas the children with acute respiratory infection or fever in the last 2 weeks taken to a healthy facility is around 70.5 per cent. Child feeding practices and nutritional status of children showed the following figures. Children less than 3 years who were breastfed with the first hour of birth amounted to 23.4 per cent where 46.3 per cent of children were breastfed between 0 to 5 months of their birth (IIPS & MI, 2007). Children aged between 6 and 9 months who received solid or semi-solid food and breastfed were recorded to be 55.8 per cent but the figures for children aged between 6 to 35 months who were anaemic were 78.9 per cent. These figures depict the state of health service distribution and hence directly points to the status of under-nutrition among Indian children hence been portrayed here as part of the research study conducted here. One of the sources to reflect the under nutrition status among children could be linked to the mortality rate of the land. This is emphasised using major surveys as below. Three major surveys conducted in India since 1990, found that the mortality rate in Indian children is very high (IIPS & MI, 2007). Study revealed more than half (54%) of every death in Indian children before age five years are due to various effects of under-nutrition. As the results show from three surveys, the mortality rate was gradually decreasing, however, it still stands as high among all other developing countries.
Fig 2.4: Early Childhood Mortality Rates

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In India, approximately 1.72 million children die each year before reaching their first birthday (WHO, 2007). Infant mortality has declined significantly in India from 129 in 1970 to 68 in the year 2000 Fig.3. Though, the Infant Mortality Rate (IMR) is decreasing at an annual rate of 2.11 per cent from the early seventies, the decadal rate (compounded annually) is decreasing at a slower rate when compared between 1981-91 and 1991- 2001. The slow pace of education in the

IMR is a major worry for the countrys development. To that extent its performance when compared to other Southeast and East Asian countries is poor. While the expected fall in IMR is at 47 based on the current rate, it is still above the millennium development goal of 28 per 1000 live births by 2015.
2.5. Prevalence of Underweight children in India

The prevalence of underweight children in India was very high over the decades (IIPS & MI, 2007). NFHS surveys conducted three times since 1990 show the magnitude of underweight issues among Indian children. As underweight is the consequence of under-nutrition, it shows the magnitude of nutritional deficiency in a community (Mesham & Chatterji, 1999, p.10). As far as India, a land of diversity, with having more than 30 states, different religions, castes, sub-castes, tribes, the social strata is varied from one to another (Duiker &Spielvogel, 2006, p.38). India has a wide rural population as same as the urban one with vast difference of socio economic infrastructure. The discrimination among children according to the gender also plays a part nutritional disorder in Indian community (IIPS & MI, 2007). Hence, the higher prevalence of unweight children in India is due to many reason. The first ever in Indian history, a study conducted with the total representation of people from each groups in the community was National Family Health Survey in 1992. It has gone through each level of analysis to determine the nutritional deficiency problems and underweight prevalence among children in India. It found that, the prevalence of underweight among children in India is amongst the highest in the world, and nearly doubles that of Sub-Saharan Africa (IIPS, 1995). Studies show nearly half of children with in the age group of 0-5 are chronically malnourished. Further, many studies have undertaken from various dimensions by both Indian and foreign agencies since first NFHS. Each study found the alarming situation of under-nutrition, especially the higher prevalence rate of underweight children in India. Organizations like WHO, UNICEF, WORLD BANK have focused their attention to promote large scale of further studies and health programs in order to make improvement of health services to tackle this issue. Following this, two other NFHS studies have been accomplished with higher intentions, and it has been also evaluated the same issue in each level. The third NFHS carried out in 2005 attempted to compare the prevalence rate of underweight children in India with 40 other countries. Precisely, it was the highest most prevalence rate of underweight children among 40 countries considered for the study (IIPS & MI, 2007). The prevalence rate of underweight children in the world is in decaling state. However, most of the studies conducted in India shows, prevalence rate of underweight children is almost same as since 1990. Although, India has achieved many improvements in distribution of health services, there arises a question about the improvement of prevalence rate of underweight children in the country. Underweight is a consequence from under nutrition as early stated, it can be taken as one of the measurement to evaluate the nutritional status of children in India. Every study should have to be initiated with a common interest to make people aware about the concerned issue. In order to make them understand, the transparency and clarity in results is much needed. A review of primary researches updated the prevalence of underweight children in India can offer more clear picture about the seriousness of the issue.

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Chapter 3: Methodology
This chapter describes how the research will be undertaken as per the chosen area of study. The chapter also explains the method of study undertaken with full description of data collection, extraction and analysis.
3.1. Study Design

Systematic review aims to review all selected literature in a systematic fashion in identifying the relevant studies necessary within the given review. It is claimed that, a systematic review establishes consistent findings which can be generalised across populations and settings of interest (Mulrow 1994). Primary research involves qualitative, quantitative or a combination of both methods. Systematic review is a method of reviewing and synthesising primary research in order to produce findings which accurately represent all of the studies that have been reviewed (Mulrow 1994). More specifically, it consists of identifying, screening, appraising, and synthesising evidences. Part of the systematic review process involves setting objectives, searching relevant literature through the use of a search strategy with key words and electronic search engines (Mulrow 1994). Once literature has been identified, a set of predefined inclusion and exclusion criteria is applied (e.g. of a considered criteria includes Work published in the English language only). A data extraction process involves a quality appraisal of the identified literature. A flow chart is often produced in order to concisely illustrate the stages of the literature identification process (see figure 3.1). The quality appraisal process is important as it involves assessing the quality of identified literature as well as the level of bias and error that could be inherent in each study. The final stage involves synthesising relevant extracted data from the identified literature in order to produce evidences that address the research question(s). Synthesising can be done through meta-analysis and using narrative method. Narrative method can be described as findings summarised and explained in words. It refers to the approach adapted in bringing together the findings from studies included in a systematic review. It is not similar to metaanalysis but can be an alternative to the same. The statistical approach in bringing together the findings from each study considered would be most appropriate for a valid result in this study. Meta- analysis is a statistical method of summarising results from each study in to a single conclusion.

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Fig: 3.1. An example of a flow chart which illustrates the literature identification process

Systematic review has its own advantages over primary research studies. For example, systematic review can systematically and comprehensively review primary research literature it can produce findings which is arguable, more reliable and less at risk of bias and error than single primary research studies (Holly et al., 2011, p.201). Another advantage is that a systematic review provides readers with more data of interest in one document compared to potentially many documents that a reader would have to hunt for themselves. One of the main advantages is that a meta- analysis can be produced in a systematic review. Meta- analysis is considered to be the gold standard of research (Holly et al., 2011, p.199). The need for a systematic review occurs in many situations. If there is much information about a particular topic and the need of synthesised decision making emerges, a systematic review would be adopted (Holly et al., 2011, p.199). Systematic review has other advantageous such as they

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can be an ideal stepping stone for a research as they offer researchers a range of comprehensive literature available in one document. It could also be argued that a systematic review can be more appropriate when researches have less time and resources available to them (Brown, 2006, p.503).
3.2. Rationale for the method of study chosen

It is an ideal method for synthesising consolidated prevalence of data from lots of available research material. A systematic review has never done in India in this context before, to find the overall prevalence of underweight among Indian children. It would be more appropriate to combine the results and to evaluate by means of undertaking a meta-analysis and is highly appropriate in the present scenario (NLM, 2009). Another reason for choosing a systematic review for this research is that many practical reasons limit researchers ability to conduct his own prevalence study in India, particularly because a researcher normally prefers to have a representative prevalence statistic. This would make a primary research even more difficult and complicated. Also in this research, researcher would want to limit the bias and error that comes from a solitary study. Avoiding bias and errors gives more generalizability, validity and clarity to the research.
3.3. Inclusion or Exclusion Criteria for selecting Literature.

Setting Inclusion and Exclusion criteria consists of careful thinking and frame work in every systematic review. As Inclusion and exclusion criteria have an enormous role in the generalizability of research findings, it is claimed to be a very important part in setting the selection criteria cleverly at the beginning of every systematic review. The inclusion criteria specifies which study is to be included in the review. Similarly exclusion criteria defines literature those to be excluded from the review. Hence selecting both criteria cleverly helps in finding the most suitable literature for the study. The following inclusion criteria were applied: Literature published in 1990 or after; literature published in English. Literature representing children of the age of 15 and below were also considered. Literatures representing both male and female children residing in India and born in India were also included in the inclusion criteria. Literature which studies prevalence of underweight among Indian children was another inclusion criterion.
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The following exclusion criteria were applied: Literature published prior to 1990; literature published in any language other than English. Literatures with the age limit of study participants above 15 were excluded. Literatures that do not represent both genders were avoided. Literature, which is not studied about prevalence of underweight were also part of the exclusion criteria. Inclusion and exclusions consist of rules that mainly relied upon the selected population, age ranges, gender, risk status, presents of co-morbidities, and range of severity. This study focused in national level of population in India. This research particularly focuses on underweight problem in children in order to find the frequency of childhood malnutrition in India. Due to the difficulties that may arrive in the translation of non-English articles, this study considered the articles only published in English language between the year of 1990 and till date. The search of journals will be limited to the area of medical, nursing, human resource, mental health

etc. to assure the clarity and authenticity of findings of the articles. In order to avoid any publication bias, researchers and research institutes will be contacted with respect to access unpublished works for the reference.
3.4. Search strategy.

The search strategy is the method to identify the literature to be selected. The search strategy acts as a filter based on the specific keywords that relate to the predetermined inclusions and exclusion criteria. Finding literature is often conducted using a range of relevant electronic databases. In this study, the following electronic databases will be included: MEDLINE (a general medical database), PsycINFO (international database for psychology, behavioural and social sciences), CINAHL (Database for nursing and allied health disciplines) and PubMed. The study will also search for literature through handpicking of journals, internet sources and from the reference list of identified published primary research literatures from the list. The searching strategy that will be applied as follows: The search will be conducted using the following key words and combination of keywords: underweight OR under-weight OR weight OR BMI OR body mass index OR nutrition OR, malnutrition OR prevalen* AND child* OR India* OR infant OR baby OR babies OR adolescen* OR neonatal OR malnourished OR malnourishment. A search diary will be maintained detailing the names of the databases searched, the keywords used and the search results. Titles and abstracts of studies to be considered for retrieval will be recorded on an Endnote database, along with the details of where the references have been found. Inclusion/exclusion decisions will be recorded in the same database. Retrieved studies will be filed according to inclusion/exclusion decisions.
3.5. Screening Strategy:

An effective screening strategy based on pre-defined inclusion and exclusion criteria is the key method towards filtering out ineligible literature and identifying the most relevant studies for analysis. The screening process involves three stages. During the first stage retrieved literature is screened against the study titles and abstracts. In second stage, the full texts of the studies which cannot be included or excluded during the first screening stage (due to uncertainty) are accessed and again screened using the inclusion of exclusion criteria.
3.6. Quality Assessment.

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Every systematic review requires quality assessment as it is considered to be one of the main ingredients of such a system of reviewing of literature (Gilbody & Bower, 2011, p.44). A quality assessment helps in finding variations or deviations in quality from the chosen literature or studies considered in a systematic review and Meta-analysis (Littell, 2008, p.66). Every review process should consider highest standards in determining the quality of study or literatures selected .It holds true for a systematic review as well. Moreover, it is essential that the process involved in ensuring quality of the studies should be explicit, well documented, unbiased and reliable (Aparasu, 2011, p.136). It is also considered important that the systematic review and

meta-analysis report clarifies on the quality of the data and studies considered for these reviews and analysis (Aparasu, 2011, p.136). A close monitoring of the participants, study design, aims and objectives of the study, sample size of the study, applied methodology, intervention of interest, data analysis, instruments, description of findings, validity of outcomes, would be applied during the assessment. It consists of 10 questions which will apply on each primary research to evaluate the quality of the studies. Each question contains three answers (Y (yes), N (no), and C (not clear). Following are the questions used in this process.
1. Is the hypothesis aim objective of the study clearly described? : It will examine the

description of research aim, hypothesis and objective clearly stated. It assures the quality of literatures fulfils the basic standards. 2. Appropriate Method: It will assure whether the study followed appropriate methods in order to find the study interest. It also examines the study bias as well. 3. Are the main outcomes to be measured clearly described in the Introduction or Methods section? : The clarity of information from the studies will be analysed. 4. Are the interventions of interest clearly described? It would be evaluated whether the studies clearly mentioned the interventions of interest in the methodology. 5. Are the main findings of the study clearly described? It will examine the transparency of description of findings in the study. It will help to find the study bias by evaluating this. 6. Were the participants representing the entire population from which they were recruited? : It evaluates the generalizability of the study findings. 7. Were the statistical tests used to assess the main outcomes appropriate? : It reveals the authenticity of research findings. 8. Were the main outcome measures used, accurate (i.e., valid and reliable)? : It will compare the description of methodology its application in outcome measures. 9. Can the result be applied to every child population? : It reveals the generalizability of the research findings. 10. Do results fit with other available evidence? It produces the comparability and standard of evidence.
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3.7. Data extraction

The data extraction process consists of identifying pre-specified data elements from eligible literatures retrieved from screening. It describes the what, who, and how the included studies are coded. Data extraction is usually performed by designing a table or a database in which important data from the literatures is extracted into. The term data reflects any relevant information derived from the literatures such as participates, methodology, intervention, outcome, results, limitations, researchers identity and publications. For this study, an extraction matrix in Microsoft Excel was created. The specific kind of extracted data is

included in the source of the study, eligibility, participants, methods, and results (see table 3.1). Sources include study ID as well as author information. The participants column contains total number of participants, setting, diagnostic criteria, age and sex of participants. The column methods have been used to record data about study designs of each literatures, sequence generation, allocation sequence concealment etc. Results column have been used for recording sample size of each study, missing participants information if any, summary data about the interventions. Some missing data from the literatures have been requested to the authors by sending email to them with specific pointed questions. It has been also decided; make email to the authors without overwhelming them by asking too many questions.
Table 3.1 The data extraction matrix used in this study
Sl.No: Author Paper title Instrume nts Male weight Female weight Sample ages Any other malnutrition Limitation s

Aims

Method

Weight

The columns of the data extraction matrix could be explained as follows. The SL No represents the number of primary researches that will be included in this research as part of the evaluation of the condition of childhood malnutrition in Indian children. Each serial number will correspond to the primary research being included and analysed. The author column will represent the name of the person or persons who conducted such a research or contributed towards it. The next column named Paper title will refer to the name of the research paper under study. It will also give a glimpse into what the study was about. Aim will mention or refer to the main of the research being discussed as part of this study. Each primary research or study being discussed here will have chosen a method of study to undertake the research. This section will discuss the methodology adopted by the researcher in conducting the primary research, for example, clinical trials, surveys, experiments conducted during the research for results, interviews conducted while gathering data, etc. The instruments used or utilized during the research process will be mentioned in the next column. The next column is about the data relating to the weight of the children under study during the research. Weight related data emerged through reviews will be segregated according to weight of each male population under study will go into the next column. Weight related data emerged through reviews will be segregated according to weight of each female population will follow in the next column. The next column is about the sample ages considered during the study. This area will cover all other issues related to research question from primary researches. Limitations and scope of each study will be extracted and noted in the final column of the matrix table.
3.8. Ethical Considerations

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As this study is a systematic review of primary research, there are few ethical considerations to be concerned. Primary researches with ethical insufficiency will be avoided in this research. All non-ethical research data will be avoided for the review in this paper. The conflict of interest

reports and financial data will be respected in this research. As far as confidentiality is concerned it will be highly respected and the primary research information will be protected in this study. As a whole no such issues come in this systematic review in concern with ethical consideration.
3.9. Data Analysis

Results included in each study relating to the underweight of Indian children will be described and critically evaluated. All comparable prevalence data will be entered in to stata (version 11) and Meta analysed in order to calculate an overall pooled estimate (with 95% confidence intervals) of the prevalence of underweight among children living in India. Data synthesis provides researchers with the result of the systematic review (Filipe et al., 2006, pp.129). Data analysis of these 7 primary researches will go a long way in conducting a study of childhood malnutrition of children in India. The results of the data analysis will be discussed in detail in the results section of this final report and will be mentioned later in this paper.

Chapter 4 Results
Seven eligible studies were found as applicable for the review (Please see Figure 4.1). The research papers accessed through the search strategy were studied for the under nutrition and underweight of Indian children below age of 15. Studies were accessed mainly from four research databases: Medline, Ebsco Host and CHINAL, PubMed. Literatures have been retrieved from these databases include studies conducted since 1990 to till date. A total of 274 studies been found in first screening as either matching its title or abstract with the subject of interest for this research. From this, 194 were from PubMed, 36 from Ebsco Host, 22 from Medline and 21 from CHINAL (Table 4.1). Furthermore 1 literature was screened out from reference lists.

TABLE 4.1 Evidence of Screening :( Studies screened at first stage of the study) Page28

Name of the Databases

No: Studies accessed

Total

PubMed

194

Ebsco Host

36

Medline

22

CHINAL

21

Study retrieved reference list

from

the 1

Studies from hand searching

Total studies

274

4.1. STUDY SELECTION

The method of selection of studies after the first screening were precisely been accomplished. Please see Figure 2, for mapping search strategy. During the second stage of screening, each literature had been taken for the detail analysis to find whether the full text fulfils all inclusions and exclusions. During the second stage 192 studies has been excluded due to the fact that the content does not support the study interest. The excluded studies mainly focus the other age groups or other study interest apart from underweight. One important study has been accessed from the reference list during the second stage of screening. At the third stage of the screening which included 82 remaining studies, 7 studies has been taken for the final literature.

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Figure 4.1 Mapping OF Search Strategy with Literature Evidence Electronic Search

Key Words
Under- nutrition, Underweight, Prevalence, Malnourishment, Indian, Children, Infants, Adolescents, BMI

Data Bases Medline, CHINAL Ebsco Host, Pubmed.

Inclusion Criteria
Studies Published from 1990 English Publication Age group 0-15 Prevalence of Under-Weight Indian based Indian Children

Stage 1: Titles and Abstracts accessed from databases search (Total Number= 274)

Exclusion Criteria
Studies published before 1990 Non English Publication Age group above 15 Not relevant to the study Non-Indian Children

Stage 2: Excluded studies= 192 Full copies accessed for Inclusion = 82

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Stage 3: Studies considered for Studies not considered= 4 4.2. Description of Evidence: Review Studies= 7

The study assessed seven literatures after the selection process of finding literature papers. According to this process study retrieved most appropriate literatures which are able to answer the research question. The seven studies are titled as : NFHS-1 , NFHS-2, NFHS-3, Nutritional Status of children: Validity of mid-upper arm circumference for screening under-

nutrition, Prevalence of underweight, stunting and wasting among urban poor children aged 1- 5 years of West Bengal, India, Prevalence of under-nutrition among Kora-Mudi children aged 213 years in Paschim Medinipur District, West Bengal, India, and Assessment of Health, Nutrition and Immunisation status amongst under -5 children in migratory brick klin population of periurban Kolkata, India. In these research studies, NFHS studies focused on national data of prevalence of underweight children whereas the rest of the studies focused on different states according to the research interest. The summery of each studies and table of evidence will now be described.
4.2.1: IIPS, 1995 (National Family Health Survey-1): The first National Family Health Survey was conducted in 1992-93 with a nationally representative sample from each group. Total 89,777 married women within age group of 13-49 were interviewed from 24 states in different stages (IIPS, 1995). NFHS-1 coordinated with International Institute of Population Science (IIPS) with the support of 18 populations research centres in India. The main objective of the study was to identify up-to-date information about fertility, family planning, mortality and maternal and child death (IIPS, 1995). Data collection for this study was conducted under three phases since April 1992 to September 1993. The survey used uniform questionnaires, sample designs, and field

procedures to facilitate comparability of the data and to achieve a high level of data quality.
Survey has been found as a source of vast knowledge about each population in India, mainly women and children and their nutrition status. It followed NCHS/ WHO growth standard [please see page no: 14] to define underweight among Indian children. According to this standard, the prevalence of underweight children less than three years was estimated as 51.5 % (IIPS, 1995). NFHS -1 was the first study been held with the total participation of total population groups (IIPS, 1995). It was a milestone for the development of demographic database as well as a platform for the next survey conducted in 1998. Table 4.2: Description of evidence of results identified from National Family Health Survey -1

Reference

Study Design

Study Sample Size

Input variables

Output Variable

Results Underweight Prevalence:

Total 89,777 married International Survey women within Child Health Institute of performed age group of were Child Population interviews and 13-49 Mortality Science (IIPS, questionnaires interviewed 1995) among study from 24 states in different population stages

Prevalence of Underweight

Total= 51.5 % Mortality and Health

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(Urban= 44% , Rural= 55%, Female= 52%, Male = 53% )

4.2.2 IIPS& ORCM, 2000 (National Family Health Survey-2): The second National Family Health Survey was conducted in 1998-99. It was focused to strengthen the demographic database which formed through NFHS-1 as well as monitor the health status of each population. It was aimed at to provide state base and national base estimates of health status in each group of total population. It was conducted by IIPS with technical support from ORC Macro (USA) and funded by the United States agency for international development (USAID). It covered 90,000 women as a sample compromising for the entire total population of India (IIPS, 2000). Data collection was in the form of interview and identical questioners. NFHS-2 also followed NCHS/WHO child growth standard to define underweight NFHS-2 finds the prevalence of underweight children less than age three was 47 percentages (IIPS & ORCM, 2000). Among them 49% of children was belong to female group and 45% from male. Similarly it also finds 19.7 percentages of children were wasted (low weight proportionate to height) as well. Study found the prevalence of underweight children in urban areas as 38% whereas in rural area showed to be 50%. Comparing with NFHS-1, the prevalence of underweight among children less than the age of three declined from 51.5 to 47 % during the year of 1998 (IIPS & ORCM, 2000). Table 4.3: Description of evidence of result identified from National Family Health Survey -2

Reference

Study Design

Study Sample Size

Input variables

Output Variable

Results Underweight Prevalence:

International Institute of Population Science and ORC Macro (IIPS & ORCM, 2000)

Survey followed by interviews and questionnaires among study population

Total 90000 Child married women Health with in age group of 1549 were
interviewed from 26 Child states in different Mortality stages.

Prevalence of Underweigh t

Total= 47%

Nutrition and Health

(Wasted children = 19.7%, Urban= 38%, Rural= 50%, Female= 49%, Male = 45%)
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4.2.3 IIPS & MI, 2007 (National Family Health Survey-3): The third National Family Health Survey was conducted by IIPS with the technical support of MACO International (USA) in 2005-2006. It has revealed enormous facts and figures about the health status of Indian population including some not

so pleasant information about childhood malnutrition. It was carried out with the participation of each population representation from 29 states in India. A nationally collected sample of 124,385 women within the age group of 15- 49 and 74,369 men within age group of 15-54 from 109,041 households been taken under this massive study (IIPS & MI, 2007). NFHS-3 was supported by 18 research centres including 5 population research centres (PRCs). It was funded by various organisations such as the United States Agency for International Development (USAID), The United Kingdom aid for the Department For International Development (DFID), the Bill and Melinda Gates Foundation, United Nation International Children Emergency Fund (UNICEF), United Nation Fund for Population Activities (UNFPA), and Ministry of Health and Family Welfare Government of India (MOHFW). According to NFHS -3, nearly half of children within age group of 0 to 5 were under chronic malnutrition. Study defines underweight according to NCHS/ WHO international growth standard as well as newly accomplished WHO child growth standard. However, here the study only focused on NCHS/WHO standard as same as all other litterateurs defined underweight. This is focused to perform a meta-analysis to find overall prevalence of underweight. According to NCHS/ WHO standard, the prevalence of underweight children was 48 per cent (IIPS & MI, 2007). (Newly established WHO standard finds 43 per cent in prevalence of underweight among Indian children which is same to the NCHS/ WHO 48%, which is not taken for this review as early mentioned). Prevalence rate across gender was estimated as female 43.1% and for the male counterpart as 41.9%. Also study describes the rural and urban prevalence such as 43.7% and 30.1% respectively (IIPS & MI, 2007). Table 4.4: Description of evidence of result identified from National Family Health Survey -3

Reference

Study Design

Study Sample Size

Input variables

Output Variable

Results Underweight Prevalence:

(International Institute Population Science and MACRO International, IIPS & MI 2007)

Survey followed by interviews and questionnaires among study population

Nationally collected sample of 124,385 women within the age group of 15- 49 and 74,369 men within age group of 15-54 from 109,041 households

Child Health

Prevalence of Underweigh t

Child Mortality Nutrition and Child Health

Total = 48% (NCHS/ WHO International Growth Standard)

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(Urban= 30.1% , Rural= 43.7% 43.1% , 41.9% )

,Female= Male =

4.2.4. Kumar R, et al. (1996).

Kumar et al. (1996) aimed at determining the nutritional status and validity of mid upper arm circumference (MAC) in diagnosing malnutrition among preschool children. It conducted cross sectional household surveys with 3747 children below six years at 47 villages in Ambala, a district of Haryana. Trained field workers have been used to identify the data for this research. Study reported 49.6% of total underweight prevalence in children whereas 48.8 were stunted (low height for weight) and 9.1% of children wasted in its results (Kumar et al., 1996). According to this study the prevalence of underweight across gender classified as 47.4% of male children and 52% of female children. Study concluded with an assumption of almost every second child in this study was undernourished.

Table 4.5: Description of evidence of result identified from Kumar et.al. (1996)

Reference

Study Design

Study Sample Size

Input variables

Output Variable

Results

Kumar Crosset.al , (1996) sectional household survey(Train

ed workers recorded age, weight, length/ height and MAC of children)

3747 children nutritional malnutrition aged less than six status and among years validity of preschool mid upper children field arm circumference Prevalence (MAC) of Underweight

Underweight Prevalence:

Total = 49.6%

( Female= 52%

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Male = 47.4% )

4.2.5. Bisai et al. (2010).

The purpose of the study was to assess the nutritional status among urban poor children aged between 1 and 5 years in 3 municipal wards of 24-parganas district of west Bengal, India. A total of 899 children (boys=517; girls=382) were selected for the study. The study followed a cross sectional survey with having a questionnaire and simple random sampling method. According to the results of the study, the underweight prevalence of children among urban poor children within a selected community was 63.6 % (Bisai et al., 2010). It also reports 5.7% of stunted and

22.0% of wasted children. The underweight prevalence of male children was 65.5% whereas as female population being 60.9%. Also study found the percentage of underweight among Tribal, Muslim, Hindu children as 71.5%, 67.2% and 57.6% respectively. Study concluded with an assumption that selected group of children found higher prevalence of underweight and noted that it is a critical situation among that classification of children (Bisai et al., 2010).

Table 4.6: Description of evidence of result identified from Bisai et al. (2010)

Reference

Study Design

Study Sample Size

Input variables

Output Variable

Results Underweight Prevalence:

Bisai et. al, cross (2010) sectional study

Total 899 children (boys=517; girls=382) aged 1-5 years.

Urban, Poor children, Underweight , Stunting, Wasting. Hindu, Muslim, Tribal.

Prevalence of Underweigh t

Total = 63.6 %,

[age, sex, religion, caste, weight and height were collected from each subject through questionnaire Following simple

prevalence of stunting and wasting

(Female= 60.9 % ,
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Male = 65.5% , Wasted = 22.0 %, Stunted = 5.7 % Tribal (71.5%), Muslim (67.2%), Hindu (57.6%))

random sampling method.]

4.2.6. Besai et.al (2011).

Besai et al. (2011) aimed at determining the prevalence of underweight, stunting and wasting in Kora-Mudi children of Paschim Medinipur, West Bengal, India. It has undertaken a cross sectional survey with participants of 119 children aged between 1and 13 years (59boys & 60 girls) from two villages of the Paschim Medinipur District, West Bangal, India. Study found the prevalence of underweight of 52.9% among children (Besai et al. (2011). It also found that the wasting and stunting percentage was 22.7% and 49.6% respectively. The underweight prevalence of male children was 57.6% and female as 48.3%. Study concluded with indicating the dangerous situation of higher prevalence among children in Kora-Mudi children aged 2-13 years in Paschim Medinipur District, West Bengal, India.

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Table 4.7: Description of evidence of result identified from Bisai et al. (2011)

Reference

Study Design

Study Sample Size

Input variables

Output Variable

Results

Bisai et al Cross(2011) sectional Study

underweight, Prevalence stunting and of 119 children aged wasting Underweigh 2-13 years, 59 boys t [a cross and 60 girls sectional weight-forstudy was age, height- prevalence undertaken for-age and of stunting in two weight-forand wasting villages of height the Paschim Medinipur District]

Underweight Prevalence:

Total = 52.9%

(Female= 48.3%, Male =57.6%, )

Prevalence of stunting and wasting was 49.6% and 22.7%

4.2.7. Biswas et al. (2011).

Biswas et al. (2011) aimed at determining health, nutrition and immunization status of children under the age of five among brick kiln internal migrant population of periurban Kolkata, India. It was also aimed at finding the different risk factors associating with nutritional status of study population. A cross sectional survey (observational community based) has been undertaken among brick kilns of periurban Kolkata, along the eastern banks of the river Hooghly, India. Direct interview, clinical examination and anthropometric measurements followed to measure the prevalence of underweight among children under five among stated population. Research found the prevalence of underweight as 64.9% whereas stunting and wasting 64.9% and 20.3% respectively Biswas et al. (2011). The prevalence of underweight among male children was identified as 47.9% and female population as 52.1%. Study identifies the risk factors associated with under nutrition as Acute Respiratory Infections, Improper immunization, socioeconomic status and the lack of proper breast feeding. Study concluded with an emphasis of proper breast feeding for the improvement of nutritional status of children.
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Table 4.8: Description of evidence of result identified from Biswas et al. (2011)

Reference

Study Design

Study Sample Size

Input variables

Output Variable

Results

Biswas et al Cross(2011) sectional, Observational Community based study [House to house visit, Clinical examination and Anthropometri c measurements of the under five children and interview of the adult care-givers with a predesigned pretested proforma]

74 children aged less than five years

Migratory, Brick Klin, Under five children, Under nutrition.

malnutrition among preschool children

Underweight Prevalence:

Total = 64.9% Prevalence of Underweigh t

(Female= 52.1%, Male = 47.9% , Wasting 20.3%, Stunting 64.9%)

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Study considered the highest standards in determining the quality of study or literatures selected as described as follows (see Table 4.9):
Table 4.9: Quality Assessment of the included studies.

Questions

NFHS-1 (1992)

NFHS2 (1998)

NFHS-3 (2005)

Kuma r et al (1996

Bisai et al (2010 )

Bisai & Malic k (2011)

Biswas et al (2011)

Y
Is the hypothesis=aim=o bjective of the study clearly described?

Appropriate Method

Y
Are the main outcomes to be measured clearly described in the Introduction or Methods section? Are the interventions of interest clearly described? Are the main findings of the study clearly described? . Were the participants represents entire population from which they were recruited? Were the statistical

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tests used to assess the main outcomes appropriate? Were the main outcome measures used accurate (i.e., valid and reliable)? Can result be applied to every child population Do results fit with other available evidence

Y Y Y Y Y Y

Y Y Y Y Y Y

Y Y Y Y Y Y

Y Y Y Y Y Y

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N Y Y Y N N

C Y Y Y Y Y Y

(KEYS: Y = Yes, N = No, C = Not Clear)

4.3. Key Findings of the Seven Primary Researches Analysed for Study

The lowest prevalence of underweight children in India below the age of 15 from the study is 47%. The highest prevalence of underweight children in India below the age of 15 from the study is 65%.
Fig 4.2: key finding on prevalence of underweight from selected studies.

The lowest percentage of underweight prevalence among boys is 41% The highest percentage of underweight prevalence among boys is 65%

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Fig: 4.3. Key finding on prevalence of underweight among male children

The lowest percentage of underweight prevalence among girls is 43%

 The highest percentage of underweight prevalence among girls is 61%

Fig: 4.3 Key finding on prevalence of underweight among female children

4.4. META ANALYSIS

Of seven studies reviewed, five are considered as eligible for meta-analysis. The data provided by each study describes its findings clearly and identically. Meta-analysis is defined as The statistical analysis of a large collection of analysis results for the purpose of integrating the findings (Glass, 1976).In order to integrate the findings and to come out from narration of old results, meta-analysis was found to be essential in this study. The table shows the details of five primary researches, been taken for the Meta analysis. It describes the Author and title of the study, total number of children taken as a sample for each study, Age group description, Number of children in each age group, the prevalence of underweight for children in each group, and the total underweight percentage of children both males and females. Table 4.10 Evidence from primary research to the Meta analysis.
Prevalence of Underweight per age group %

Author & Year

Study title

Number of Participants below age 15

Ages of Participants

Number of Children

Total Prevalence of Underweight %

Kumar Nutritional status et al of children: validity of mid(1996 ) upper arm circumference for screening under-nutrition

3747 children (53% Boys + 47% girls) aged less than six years

<6 months 6- <12 12 - < 24 24 - < 36 36 - <48 48 - < 60 60 - < 72

229 323 647 623 615 545 648

8.7 29.4

Total =49.6%

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54.3 60.5 55.4 48.8 54.3

(Female= 52%

Male = 47.4%)

Bisai et al (2010)

Prevalence of underweight, stunting and wasting among urban poor children aged 15 years of west Bengal, India

899 children (boys=517; girls=382) aged 1-5

Male below age 1 2 3 4 5 Girls below age 1 2 3 4 5

54 100 92 114 157

72.2 65.0 67.4 59.6 66.9

Total=63.6 %

47 65 82 84 104

48.9 64.6 57.3 67.9 61.5

(Female= 60.9 %,

Male = 65.5%)

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Biswas Et al. (2011)

Assessment of Health, Nutrition and Immunisation status amongst under -5 children in migratory

Total=64.90% 74 under five children (Males 36 , Females 0-5 months 6-11 12-23 24-35 7 6 18 12 15 42.9 66.7 83.3 66.7 53.33

(Female=52.1%

brick klin population of periurban Kolkata, India

38)

36-47 48-60

16

62.5

Male = 47.9%)

IIPS & MI (2007)

National Family Health Survey -3

46655 Children (male 24,346 + female 22,309) Under Five years

0-6 months 6-8 09-11 12-17 18-23 24-35 36-47 48-59

3845 2570 2086 4642 4636 9335 9780 9762

29.5 34.7 36.7 40.2 45.9 44.9 45.6 44.8

Total =48%

(Male 41.9%

Female =43.1%

24600 IIPS & National Family ORCM Health Survey -2 (2000) (Male 12,822 Female 11,778) Under five years

<6 months 6-11 12-23 24-35

4,203 4,116 8,295 7,986

11.9 37.5 58.5 58.4

Total 47%

(Male 45.3%

Female 48.9%)
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Of the five studies included in the meta-analysis, each study clearly states the required information for this meta-analysis. In order to find the overall prevalence from the included studies, a forest plot has been designed to illustrate the relative strength of each study representing the same study interest. Forest plot is a graphical design used to perform metaanalysis. According to the Meta analysis as provided in forest plot [please see figure 4.4], it has

been identified that the overall prevalence rate of underweight children under the study is approximately fixed to be as 54%. The confidence intervals for the overall prevalence estimated as 47 to 62 %. The minimum prevalence of underweight was 47% as per NFHS-2 findings and the highest prevalence of underweight was 64.90%. Study significantly proved that overall prevalence is about 54%.
Fig: 4.4 Forest plot 1 Over all Prevalence of underweight among children from included studies for meta-analysis

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Study analysed prevalence across gender as determined in its objective, designed in second forest plot. The second forest plot shows prevalence rate of male children from each studies to undertake the meta-analysis. From the analysis it has been found that the prevalence rate among male children remained between 42% and 66%. The overall prevalence of underweight among male children has been identified in the meta-analysis to be approximately 49% with a confidence interval of 45 to 54 %. [Please see figure 4.5].

Fig: 4.5 Forest plot 2 Over all Prevalence of underweight among male children from included studies for meta-analysis:

The third stage of the Meta analysis analysed the prevalence rate of female children from each primary researches in order to find the overall prevalence of underweight. It describes the findings from each study and the variation of prevalence rate from one to another. From the analysis it has been found that the prevalence rate among female children was found in between 42% and 66%. Hence, the Meta analysis identified the overall prevalence of underweight among female children as approximately at 50% with a confidence interval of 46 to 55 %. [Please see figure 4.6].

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Fig: 4.6 Forest plot 3 Over all Prevalence of underweight among male children from included studies for meta-analysis:

4.4.1 National Family Health Survey - A comparison of Phase I, II & III

NFHS-3 found the proportion of children under the age of five years who are underweight. It ranges from 20 per cent to 60 per cent from state to state. Sikkim reports minimum prevalence of underweight children in India whereas Madhya Pradesh stands at the peak. Most of the states have higher prevalence of underweight up to one in four children of total population. States that boast of a lower prevalence of underweight are Mizoram, Sikkim, and Manipur. However they report higher prevalence in stunted &wasted children. It estimates that one-third of children among these states are stunted. Prevalence of underweight differs from rural to urban areas. As far as
under -nutrition is concerned it is directly associated with life style and accessibility to the health care services. Studies found that people living in rural areas are more exposed to under -nutrition impacts. NFHS-3 found that 47% of children under three years old are chronically malnourished whereas 37% of children living in urban areas are undergoing with same issue. Children those who are wasted in rural areas found as 24% whereas in urban areas it was only 19%. As in the case of underweight among children under the age of three, the prevalence in urban area was 30% but it was 43% in children living in rural areas.

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According to National Family Health Survey-3, the prevalence of underweight children differs from rural to urban areas as well as poor to rich population. During a cross examination in eight major cities, it has found that Indore (One of the eight cities) having highest prevalence in

underweight children as 39%. Hyderabad and Kolkata was the lowest among other cities in the prevalence of underweight as (20-21%). It was also found that underweight prevalence was higher in every slum area compared to the non-slum areas during the study.
Table 4.11: Figures of the Different NFHS Studies between states

NFHS-1 (1992-93) State Haryana Andhra Pradesh J&K Assam Karnataka Gujarat Kerala Madhya Pradesh Arunachal Pradesh Tamil Nadu Orissa Meghalaya Himachal Pradesh Utharanjal Maharashtra Rajasthan Delhi Uttar Pradesh Manipur Punjab Chhattisgarh West Bengal 43.6 45.0 0 49.2 50.6 48.1 27.0 0 38.4 45.7 52.4 44.4 43.7 0 51.4 44.3 40.9 0 26.8 46.0 0 54.8

NFHS-2 (1998-99)

NFHS-3(2005-06)

34.6 37.7 34.5 36.0 43.9 45.1 26.9 53.5 24.3 36.7 54.4 37.9 43.6 41.8 49.6 50.6 34.7 51.8 27.5 28.7 60.8 48.7

41.9 36.5 29.4 40.4 41.1 47.4 28.8 60.3 36.9 33.2 44.0 46.3 36.2 38.0 39.7
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44.0 33.1 47.3 23.8 27.0 52.1 43.5

Chapter 5: Discussion
The analysis of under-nutrition among Indian children aged between 0 and 15 using nationally representative survey literatures from 1990 to 2011 presented a complex picture. The study aim is to determine the prevalence of underweight among children below age of 15 and across gender and was apparently addressed by each reviewed study. Studies chosen were significantly found to be focused on child nutrition and child health. In detail, the literatures from three stages of National family health survey conducted in India (year 1993, 2000, and 2007) and the rest of the four studies (Kumar et.al (1996), Biswas (2011), Bisai ( 2010 & 2011) clearly described the prevalence of underweight children in India below the age of 15 and prevalence across gender (Please see chapter 4). Study discussed about three major findings in this chapter; among them two are predominantly compromises with research aim. First, review finds an overall prevalence of underweight which shows a troubling picture and significant sign of chronic childhood malnutrition. Secondly, the study identifies the prevalence across gender in which, female children have slightly much more overall prevalence rate than male children. Finally, the study discusses about the declining trend of underweight prevalence among children across the world (Please see chapter 2, prevalence of underweight global perspective) and the Indian figures portraying prevalence rate. The transparency of overall findings discussed in this chapter will be significantly benefited as evidence by the clinical world and health professionals. Of seven primary researches evaluated (since 1990), the study found an overall prevalence of underweight, which is more than half of the total population. It has been proved from the findings produced by the Meta analysis that the underweight prevalence in India is higher than any other developing country. According to the World Bank report (Gragnolati et.al, 2005), India has the highest prevalence of underweight children among all other developing countries across the world. World Bank states, half of the total children population in the country below the age of five years are underweight. The Meta analysis report supports this statement with evidences of showing a slightly more prevalence rate than the World Bank report findings. The study reviewed both national represented literatures such as NFHS and the state ones. Out of seven, the three phases of national family health survey carried out from past two decades reports of consistent higher prevalence rate of underweight across India. Apart from this the three studies that have been carried out in rural, urban and among preschool children found almost same findings in the total prevalence or somewhat higher to NFHS since 1990. Another study conducted among group of inter-migrants had also backed the same findings. Overall, in a cross comparison, it has been significantly proved that the prevalence rate of underweight children is very high and is at an alarming situation across the nation. What makes these figures even more alarming is that the fact that India is considered to be one of the rapidly developing

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countries when it comes to education, economical status and per capita income but still the situation among the children of India of being underweight is critical and is a situation that could have been addressed effectively. The lack of political will also reflects in these figures as all three major surveys still show no improvement in this phenomenon. The study also found the overall prevalence rate across gender. According to the study, female children have slightly more prevalence of underweight than among the male children. The study initiated to find the prevalence rate across gender was to evaluate any discrimination or chances of other inaccessibility to the children in health services. From the study, it has been proved that female child population are more prone to under nutrition. The inaccessibility of female children to health services is comparatively than the male children in India (Gragnolati et al., 2005). According to Grangnolati et al. (2005) the gender inequality creates barriers to female children in nutrition accessibility, privileges to health services, education, vaccinations, immunization etc. Perhaps, it could be one the major reasons behind the higher percentage of female children in underweight prevalence. The majority of literatures reviewed in this study also indicate the role of gender inequality among with nutritional deficiencies in the country. On pooling the retrieved measures of association, review found that the overall prevalence rate of both gender are comparatively higher and is more than half of the total population. Among this, it has also been noted that prevalence of underweight among female children are pretty higher than their male counterparts, indicated the urgent attention towards this issue. According to the selected studies for this research (For example: Biswas et al. (2011)), the association of poverty, rural and urban regional effect, inadequate diet, internal migration of children, and breastfeeding practice of mothers, vitamin supplementation and their living behaviour would be contributing factors of chronic malnutrition among children in India. Finally study discusses about the comparison of previous researches held in the county in a global context. Results found that the underweight prevalence in India is same without having made any progress over the years. Worldwide, there has been a decline in the trend of prevalence of underweight among children (Onis, 2004). According to the report, global underweight prevalence was projected to decline almost eleven percentages since 1990 and when it reaches 2015 (Onis, 2004). An overall improvement in the global situation is anticipated by the study; however, also suggested some indications about countries which will have significant upward tendency in prevalence of underweight (Onis, 2004). In this research it has been clearly evaluated and found that, the projection of World Health Organisation report (Onis, 2004) about the upward tendencies above stated would be appropriate to Indian context of underweight prevalence. The identifications from NFHS-3 (IIPS & MI, 2007) significantly supported the upward trend in India against the steadily global improvement and have to be closely monitored. The Meta analysis report also showed almost much higher prevalence than NFHS-3 in an overall status of selected primary researches. Apart from meta-analysis, study also attempted to make a cross comparison of each NFHS studies since 1990 to 2011. From the cross comparison, it has been found that, the increasing tendency of prevalence in underweight is found in many states within the country. The gradual increase found in the cross comparison

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report and the overall prevalence trend from the Meta analysis explains the urgent attention in the field of childhood malnutrition in the country. The study result has a major significance in the public health and towards the clinical context. In order to base their clinical practice on evidence, healthcare providers need access to reliable and relevant evidence (Green, 2005). Data synthesis in this study performed Meta- analysis which produced a consolidated result and is likely to be an efficient method of accessing evidence. The rationale behind this study and steps followed to estimate a single result from combining different researches can empowered clinicians to recognize and implement the findings from this study as evidence in to their clinical practice. The result obtained from this study provides wide knowledge about the prevalence status of underweight children and its danger to the clinical world. As under-nutrition as called as a massive public health issue, Indian children are the most victim of it. The chronic malnutrition and underweight issues among children may lead the country in to vulnerable situation and related consequences. The meta analysis and cross comparison between three major survey reports can provide excellent knowledge to the health care professionals who are the key personals working behind this chronic issue. A well conducted meta-analysis can provide complementary information that is valuable to a researcher, clinician, or policy-maker (Walker, 2008). Also, Study recommended more individual counselling by the health care professionals in order to sort out this issue and better awareness in the public. In this study, it has been reflected that systematic review is most apt method for this research by integrating existing information cleverly presented with new vision which is absolutely helpful to the health affairs and clinical world. In this study, researcher got the chance to evaluate each finding with a broad vision which reflects the necessity of future researches in same method in a phased manner. It was fully evidence based finding with statistical data and will facilitate individual researchers to start their research with a strong platform. Through this study, it has been revealed that the issue is chronic and not rare but rarely has been a research conducted so detailed in the country. This is a dangerous situation among children with nutritional issues and is a common issue to each state and should be closely monitored and resolved. The major limitation of the study was absence of time for such an exhaustive study. Time limitation limited this study to cover each consequences of under nutrition effects, from evaluating resources comprehensively and find its consequences among underweight children. As stated earlier, under-nutrition works as a cycle in human life. On one hand, under nutrition is the cause for many deadly diseases and in other diseases itself act as a cause for nutritional deficiencies in the body. Poverty, absence of proper education, low standard of living and the reasons are many and all of them contribute towards under-nutrition among children. As stated, the relative reasons for this issue are comprehensive and a collective effort would be recommended to find a better solution for this issue. Due to the lack of sufficient time, the study could focus only in a particular area of this issue. Lack of time also limited the scope for primary research during this study. Though the research was based on Indian children and the prevalence of under-nutrition, a research of this magnitude should have included primary research as the means to gather data and assess the situation of Indian children. However not just time constraints, financial restrictions and geographical limitations also played a part in studying this critical situation without the primary research that was required .However the availability of some world class studies on the prevalence of under nutrition in Indian children and their expansive database of results helped the researcher to conduct an exhaustive secondary research

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and compare their references and results to come up with eye opening facts and figures. A systematic review and meta-analysis thus played a huge role during the different phases of this study. This study recommends the scope for future periodic systematic reviews in various sectors related to nutrition and health researches in the country. This can improve the quality of life by having clarity of information in the nutritional life and health of Indian children. By summarising the overwhelming volume of published studies, it can make more impact in the health research field by having consolidated data of information from various researches. It will highly influence the health professionals and also can provide more information to the readers in the society. It is claimed as, a systematic review can fix the boundaries of known and unknown information in particular field of study. India is facing a major public health issue with having higher prevalence of under- nutrition consequences such as underweight. The quality of information provided from the researches can influence the authorities to bring more attention and effectiveness in the health distributions. In this study it has been found that there is lack of systematic review been done in India related to this particular issue? This study gives a glimpse of the role of researches and the quality of data from the findings to the wellbeing of the children in the Indian society.

Chapter 6 Conclusion
Study concludes with all its key findings supporting to a high prevalence rate of underweight children in India as found by many past researches both national and international. Malnutrition in children around the world is due to either under- nutrition or over- nutritional levels. In this modern era, where some parts of the world are facing over nutritional issues such as overweight and obesity, some of the developing and underdeveloped countries are mostly affected by under nutrition issues. For example: According to the White Paper (ALAS, 2011), one third percentages of American children are subject to the treatment under overweight and obesity. The medical cost of United States of America associated with over nutrition issues estimated in excess of $147 billion (Gustafson, 2011). Same as this, under nutrition is a great concern for many south Asian countries and countries from the African continent. There have been many researches which were carried out to identify the magnitude of this issue in these regions. Some counties for example china have showed improvement in overcoming this issue (Chang et al., 2006). As far as India is concerned, the reports show that the country has a higher prevalence rate over the last two decades and the situation has not improved. In order to find better solution for this issue, authorities and general population need higher support from the researchers. This study followed a systematic review of primary researches and has tried to make available research reports clear to the clinical world. Hence, evaluated primary researches provide a better knowledge about the prevalence status of underweight children and there by under- nutrition intensity in India.

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Systematic review has been done by following the study design appropriately, and found the overall prevalence which was certainly much higher to any nation affected by under nutrition issues. Underweight was the examined study area among children as it is considered to be them consequence of nutrition deficiency. From the study, a concept was better confirmed that the female children are more exposed to the under nutrition issues. It was identified by the analysed researches that poverty, lack of education, inaccessibility to medical services and other activities contributed towards gender inequality in the Indian community. The study discussed in detail with a cross comparison of state wise prevalence data in order to augment general information about under nutrition to the general public of the nation. Cross comparison and meta-analysis both initiated in this study have enormously identified the worrying situation of the real problem of the nation to the children. This study hopes that the findings would be highly benefited to the health professionals by means of its simple consolidation and transparency while clubbing information of the last two decades. Although systematic review here provides some strong insights into the effects of under-nutrition and the prevalence of underweight, questions remain. In practice, authorities and health professionals would rationate decisions a priori, acting to eliminate this major concern from the root level. Rationing decisions can result change in the life standard, socio economic, education; health distribution etc. of people then by narrowing the severity of health related under-nutrition issues. The combination of study outputs and the systematic efforts of policy makers would bring higher state of wellness in the society. India is rich with human resources. To protect life and to promote people in to a higher standard of living with nutrition, lead country in to less financial barriers of health cost. Under- nutrition perhaps affected physical, mental and social health of every individual as studies proved. To assure good health and wellbeing of Indian children, state ministry of health affairs would take better decisions to improve the real health of the nation. Study recommended for state wise decision for better action is because; India is famous for its diversities in life behaviour. The combination of actions among various states and further studies both primary researches and its reviews could emerge unity in action in future from these diversities. India is a land of largest youth population resides. Child health is recognized as the future health of every nation. Ever since the economic reforms in 1991, India has come a long way in terms of economic development but the findings in this report should be considered as a blot to its future. Children are the future and they are the building blocks of any nation. When you consider that a major part of Indian population is less than 25 years of age, it does not bode well for a population which is underweight and malnourished. The results of the study speak for themselves for a change and a new beginning in the way we think about child health in India. Though poverty plays a leading role in contributing towards a malnourished childhood, the government can go a long way in finding solutions for such an age old problem among Indian children. The surveys and the analysis all point towards the lack of not just proper healthy attitude towards a healthy nation, it also draws attention in terms of gender and caste in equalities. Gender in equality has been a plague in Indian society for centuries, it is time that this phenomenon becomes a thing of past which should bring about positive changes in the underweight prevalence of female population in the country. It is high time that the Indian political community opened its eyes to

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this alarming situation among Indian children and takes concrete steps towards a solution. Every child has the fundamental right to have the best possible health standards in life and it should not just be a myth. As they say, a country is only as strong as its people, and to have a strong country let us make sure we have a healthy population. So this study winds up with the thought that To wish to be well initiates wellbeing.

Chapter 7 Dissemination
In disseminating the findings of this study, I wish to use two key journals referenced through Indian paediatrics and the Journal of Indian medical association (JIMA) Indian Paediatrics is the most recognized journal publisher related to the findings of this study in India. It is the official journal of Indian Academy of paediatrics. It is claimed that it has about 18,000 subscriptions of journals in a month. This journal is indexed in most of the standard databases like PubMed, Medline etc. By using this journal publisher the result and key findings of this research will be more utilized for further improvement. Indian Paediatrics is available online at www.indianpediatrics.net Indian Medical Association is a national voluntary organization of doctors in India. IMA aims at working for the interest of doctors as well as the wellbeing of the public in the society. To disseminate the findings of the study, it will be appropriate to include JIMA to publish the article. JIMA is available online at: http://www.ima-india.org/

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References

Appendices NHS 1 / NHS 2/ NHS 3 The National Family Health Survey (NFHS) is a large-scale, multi-round survey conducted in a representative sample of households throughout India. The NFHS is a collaborative project of the International Institute for Population Sciences (IIPS), Mumbai, India; ORC Macro, Calverton, Maryland, USA and the East-West Center, Honolulu, Hawaii, USA. The Ministry of Health and Family Welfare (MOHFW), Government of India, designated IIPS as the nodal agency, responsible for providing coordination and technical guidance for the NFHS. NFHS was funded by the United States Agency for International Development (USAID) with supplementary support from United Nations Children's Fund (UNICEF). IIPS collaborated with a number of Field Organizations (FO) for survey implementation. Each FO was responsible for conducting survey activities in one or more states covered by the NFHS. Technical assistance for the NFHS was provided by ORC Macro and the East-West Center. NCHS/WHO International Growth Reference The National Center for Health Statistics (NCHS) reference is widely used to compare the nutritional status of populations and to assess the growth of individual children throughout the world. The NCHS reference has been used in the national programmes of about 100 countries. The adoption by WHO of the NCHS-based growth curves resulted in their wide international dissemination. Throughout the 1980s, several microcomputer-based software versions of the NCHS/WHO international growth reference were developed and supported by Centre for Diseases Control and Prevention and World Health Organization. These software-based references have contributed to the wide acceptance of the concept of the international growth reference because they simplified the handling of anthropometric data from surveys, surveillance, and clinical studies.

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WHO Child Growth Standards

In 2006, WHO published child growth standards for attained weight and height to replace the previously recommended 1977 NCHS/WHO child growth reference. These new standards are based on breastfed infants and appropriately fed children of different ethnic origins raised in optimal conditions and measured in a standardized way. The same cohort was used to produce standards of mid-upper arm circumference (MUAC) in relation to age. The new WHO growth standards confirm earlier observations that the effect of ethnic differences on the growth of infants and young children in populations is small compared with the effects of the environment. Studies have shown that there may be some ethnic differences among groups, just as there are genetic differences among individuals, but for practical purposes they are not considered large enough to invalidate the general use of the WHO growth standards population as a standard in all populations. These new standards have been endorsed by international bodies such as the United Nations Standing Committee on Nutrition, the International Union of Nutritional Sciences and International Paediatric Association and adopted in more than 90 countries.

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