Indian Pediatrics 2001; 38: 60-65
Pilot Study of the Nutritional Status of Disabled and
It is recognized that disabled children living in poverty are among the most deprived in the world(1). However, there is limited data regarding their nutritional status(2,3). Feeding difficulties contributing to poor nutrition have been reported among disabled children living in more affluent environments(4). Studies in developing countries are complicated by widespread malnutrition among the general population and by a lack of appropriate means of assessing nutritional status. United National guidelines for anthropometric assessment of nutritional status(5) do not provide sufficient information to enable health workers to identify malnutrition among disabled children in the community.
Dharavi, in Mumbai, is an extremely deprived area; 54% of the population have income below the Indian poverty line, and many of the children are at risk from poor nutritional status. It is possible that the presence of a disabled child in a family may further limit the economic activities of the family by preventing members from working outside the home. Therefore, we investigated whether disabled children are more vulnerable to malnutrition than non-disabled children. The impact of disability upon the nutritional status of the siblings was also determined.
A group control study, using an opportunistic sample, was designed. Children between 2 and 10 years of age on the register of the Karuna Sadan Center (an integrated school run by a local non-government organization), in Dharavi were identified for the study. A total of fifty families with disabled children agreed to participate. A further fifty families with non-disabled children agreed to participate as the control group. The children were then divided into three groups: Group I comprised disabled children, Group II comprised non-disabled children from the same neighborhood matched for age and sex with the disabled children (neighbor control group), Group III comprised siblings of either sex, nearest in age to the disabled child. Group III was included to investigate whether disability in the family affects the nutritional status of other siblings.
The disabled children were divided into 6 groups using the WHO classification of impairments: 13 had motor impairments (mainly due to post polio syndrome); 12 had neurological impairments (mainly cerebral palsy); 9 had sensory impairments, (mainly hearing impairments); 7 had speech impairments, 5 had learning impairments and 2 had epilepsy. A diagnosis for two of the disabled children could not be determined.
Anthropometric measurements [heights, weights, and mid-upper arm circumferences (MUAC)], were carried out using standard methods(5). Height was measured to the nearest 0.5 cm as this was found to be the most reliable for the measurer (Leicester Portable Measure, UK). Weight was measured to the nearest 0.1 kg on solar scales (Seca, UNICEF) and MUAC was measured to the nearest 0.1 cm (CMS Weighing Equipment Ltd., UK). Hemoglobin levels were assessed at the local municipal hospital. Information on the dietary intake of the children was collected using a semi-quantitative food frequency table. Three main Z scores assess nutritional status: weight-for-age (WAZ) is a measure of underweight, height-for-age (HAZ) is a measure of stunting and weight-for-height (WHZ) is a measure of wasting.
Data was entered into Epi-Info software (Version 6.04c) and Z scores for nutritional status were calculated by Epi-Nut (version 2.0) which uses the National Center for Health Statistics (NCHS) reference data. Analysis was completed on the statistical package for social sciences (Version 8.0).
Parental permission was obtained to assess the nutritional status for a total of 129 children.
A summary of the anthropometry results is shown in Table 1, with male and female children combined since the data did not indicate any sex differences. Children in all three groups were malnourished as compared to the NCHS reference population. Stunting was a larger problem than wasting. Of the total study population 71% were identified as being moderate-severely malnourished (WAZ<–2 SD), 66% were identified as being moderate-severely stunted (HAZ <–2 SD) and 21% were identified as being moderate-severely wasted (WHZ <–2 SD). No differences were found between the siblings and the neighbor controls.
Height-for-age was found to be the only statistically different result. The authors are aware there may have been room for a slight over-estimation of stunting in the disabled group (Group I). The largest impairment groups in the study were the motor and neurological groups, and in these children it was sometimes difficult to obtain an accurate measure of height due to kyphosis or scoliosis. However, the numbers of children in each impairment group were too small to permit a more in depth analysis.
Each group had a mean MUAC below 13.5 cm indicative of moderate and severe malnutrition(6), and 63% of the total study population had low MUAC. The mean hemoglobin results for each group were below 110 g/L, the cut off point indicative of anemia in children(7), and 57% of the total study population were found to be anemic.
Semi-quantitative food frequency data was collected on all participating families. The daily eaten foods for the majority of children were cereals and pulses. Tea was also con-sumed daily. Non-nutritional liquids (e.g., rice and vegetable water) were rarely consumed.
Fruit and vegetables were consumed 3-5 times a week by most children in each type of family and were rarely eaten by approximately a fifth of children in each type of family (Table II). Anecdotal evidence suggested that there was little variety in the fruit and vegetables consumed. Most children in both types of families (Table II) consumed meat, fish and dairy products infrequently, about once a week. Children in families with disability more rarely consumed these items than children in families without disability. The lack of dairy products consumed, in particular yoghurt was unexpected. Anecdotal evidence suggested yoghurt was too expensive and not easily available.
When food items were analyzed separately, no statistical difference (p <0.05) was seen in food consumption between the children in the two types of families except for in fish which was more frequently eaten in families with no disability. However, most families were still eating it only once a week, (36% of children in families without disability and 44% of children in families with disability).
The anthropometry results show children to be malnourished at levels comparable to the overall prevalence rates of underweight for India(8). The present study identified more than half the population as anemic which is similar to the prevalence across India(9).
No differences were identified between the nutritional status of the sibling group and the neighbor controls. The present study found no evidence to suggest that the disabled child may be an additional drain on scarce family resources. These results are in agreement with previous studies carried out in Nigeria and the Philippines(2,3).
Height-for-age was significantly lower in disabled than non-disabled children. The results are in agreement with previous studies(2,3). It is difficult to determine accu-rate height among physically impaired children and thus, the present study may have over-estimated the prevalence of stunting among disabled children. Few field studies have addressed the issue. In Nigeria, we found that halfspan (measured from the tip of the middle finger to the mid-sternal notch), could be used as an alternative to height for assessing nutri-tional status in young children(2).
The food frequency results show that for the majority of food groups intake was similar between the two types of families. However, meat and vegetables were eaten a little more frequently among families without disabled children. The study clearly shows a lack of variety in the diet.
A case-control study in rural Philippines compared children with cerebral palsy with siblings and neighborhood controls. The children with disabilities were found to be more malnourished than the controls. The degree of malnourishment is likely to affect the child’s development(3). In a cross-sectional survey in Nigeria disabled subjects had mean HAZ and WAZ significantly lower (p <0.05) than the siblings and neighborhood controls. The authors suggest disabled children with neurological impairments and consequent feeding problems were nutritionally at risk(2). A previous cross-sectional study in Nigeria compared disabled school children with children in a mainstream school. The study identified all the disabled children as mildly malnourished by the Quetelet’s index(10). The present study also reveals significantly lower HAZ among disabled children. None of the previous studies compared dietary intakes of the children.
The authors are unaware of any data having assessed feeding difficulties of disabled children in poorer communities. A larger survey, using a randomly selected population, is required to investigate disabled children who may be at a greater risk of malnutrition including micronutrient deficiencies. Alter-native measurements to height must also be investigated. This is essential if health workers are not to miss cases of malnutrition among disabled children.
There is very little information with regards to nutrition status and food frequency in Indian urban slums. A study by Rao indicated that the urban population might be nutritionally worse off than the average rural Indian(11). As migration to urban areas continues to rise, the numbers living in slums will also continue to increase(12). This will have many implications for health policy planners to ensure the needs of vulnerable groups are addressed. Urgent attention needs to be paid to the nutritional health of children living in Dharavi.
The authors would like to thank Professor S. Grantham McGregor for her advice in the design of the study. We are thankful to the staff and children of the Karuna Sadan Center and to Mr. I. Tayade and Mr. S. Shirture for their help in the fieldwork and the Preventive and Social Medicine, Department of Sion Hospital in Mumbai for the hemoglobin analysis
Contributors: MP contributed to study design and supervised the fieldwork; MA contributed to writing; SW contributed to the study design, analysis and writing; SF contributed to the study design, analysis and writing and is the guarantor for the work; SP performed preliminary statistical analyses; and AY conducted the statistical analyses and drafted the paper.
funding from a Department for International Development (DFID, UK), work
program supported the research.