J Ayub Med Coll Abbottabad 2016;28(1)

ORIGINAL ARTICLE
NUTRITIONAL STATUS AND ASSOCIATED FACTORS IN UNDER-FIVE
CHILDREN OF RAWALPINDI
Shafaq Mahmood, Sehrish Nadeem, Tayyaba Saif, Mavra Mannan, Urooj Arshad
Medical Student, Rawalpindi Medical College, Rawalpindi-Pakistan

Background: Malnutrition is a serious child health issue throughout the developing world.
Pakistan has the second highest infant and child mortality rate in South Asia. This study was
carried out to assess the nutritional status of children under 5 years of age and to determine
the frequency and association of malnutrition with various demographic variables in the study
group. Methods: A multi-centre, cross sectional study was conducted at the immunization
centres of the 3 allied hospitals of Rawalpindi Medical College during March-May 2014.
Healthy children of under 5 years of age without confirmed diagnosis of any disease/ailment
were included. Guardians of 100 children were interviewed using a structured questionnaire.
Demographic variables include age, gender, family size, family income, breastfeeding,
maternal education, presence of a family member with special needs and presence of siblings
under 5 years in family. Weight (kg) was measured and malnutrition was assessed by weight
for age. Results: Malnutrition was found to be present in 32% of children. Adequately
nourished children were 68%, while moderately and severely malnourished children were
14% and 18% respectively. Our study indicated malnutrition to be significantly associated
with maternal illiteracy (p=0.01) and presence of a family member with special needs
(p=0.05). No significant association was found between malnutrition and gender, family size,
family income, breast feeding and presence of siblings under 5 years of age. Conclusion:
There is a need to plan composite interventions to elucidate the factors that place children at
greater risk for malnutrition.
Keywords: Malnutrition, Child nutrition, Child nutrition disorders, Child nutritional status, Infant
nutrition disorders
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INTRODUCTION objective to assess the nutritional status of children

<5 years of age and to determine the frequency and
World Food Programme (WFP) defines malnutrition
association of malnutrition with various demographic
as “A state in which the physical function of an
variables in those children. Furthermore, it has the
individual is impaired to the point where he or she
potential to develop better understanding of the risk
can no longer maintain adequate bodily performance
factors involved in under-five malnutrition, which
process such as growth, pregnancy, lactation,
may strengthen related advocacy and awareness
physical work and resisting and recovering from
measures. The conclusions drawn from the study can
disease.”1 Malnutrition is a serious child health issue
be used for creating a conducive environment at local
throughout the developing countries and the cause of
level by eliminating those risk factors. At the national
approximately 50% of the 10.7 million deaths each
level, this could be used to mobilize opinion leaders
year among under-five children in the developing
and decision makers. The study is expected to enrich
world.2
the existing body of research and may herald further
The Lancet series on maternal and child
research aiming at defining linkage between under-
under nutrition (2008) reported that 20% of
five malnutrition and various demographic variables.
underweight children younger than 5 belonged to low
and middle income countries.3 After India (39%) and MATERIAL AND METHODS
Bangladesh (5.7%), Pakistan (5.5%) contributes the
This was a multi-cantered cross-sectional study
third largest share of under-weight children in the
conducted at the immunization centres of three
world.4
allied Hospitals of Rawalpindi Medical College
Malnutrition has a complex aetiology related
from March to May 2014. The allied hospitals
to several factors that alter the nutritional status of a
include Benazir Bhutto Hospital (BBH), Holy
child at varying levels. It should be kept in mind that
Family Hospital (HFH) and District Headquarter
malnutrition is totally a preventable pandemic
Hospital (DHQ). The study population comprised
provided that the risk factors involved are identified
of children presenting to the immunization centres
and combated at an early stage of child growth.5
of these three public sector hospitals. The general
Keeping in view, this study was conducted with an
health status of children was assessed by taking a

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 J Ayub Med Coll Abbottabad 2016;28(1)

detailed history from their parents/guardians. value of the reference population for the same age
Healthy children, under-five years of age, without or height, divided by the standard deviation of the
confirmed diagnosis of any disease/ailment, based reference population. This can be written in
on history taken from their guardians or absence of equation form as:
any illness record, were included in the study. All
children either greater than five years of age or
diagnosed with any morbidity or illness were
excluded. The nutritional status of children in our study
According to the reference study, the population is compared with the WHO Child Growth
expected proportion of children with malnutrition Standards.9
would be 30.9%.6 By applying the statistical The data was entered and analysed using
formula n=Z21-α/2p (1-p)/m2 (where n=sample size, Statistical Package for Social Sciences (SPSS)
p=expected proportion of malnutrition, version 22. Weight-for-age (W/A) Z-scores were
m=maximum tolerable error or margin of error) calculated using WHO Anthropometric Calculator
minimally required sample size for this study was version 3.2.2. For categorical variables,
calculated, keeping 95% confidence interval (CI) frequencies and proportions were calculated and
and a 10% margin of error. It came out to be 86 but for continuous variables means and standard
a sample size of 100 was chosen. 33, 33 and 34 deviations were calculated. On the basis of Z-
children were selected from HFH, DHQ and BBH score, the frequencies of malnutrition were
respectively. assessed according to each variable studied. To
Multistage sampling technique, determine any existing statistical association
incorporating stratified random sampling of between variables (age group, gender, maternal
hospitals, simple random sampling of 3 education, and presence of a family member with
immunization days per week, followed by special needs) and nutritional status of children,
selection of children through systematic random Chi-square test at 5% level of significance was
sampling for each day was used for this study. applied. For dichotomized variables where the Chi-
The study was approved by the Ethical square test was not applicable due to deficient
Review Board of Rawalpindi Medical College and expected count in more than 10% of cells of cross
allied Hospitals. A pre-tested questionnaire was tabulation, Fisher’s exact test was applied at 5%
used to collect information from the guardians of level of significance, to determine the association
the children after taking their informed oral between variables (family size, family income,
consent. Demographic variables include age, breastfeeding, presence of siblings <5 years of age)
gender, family size, family income, breastfeeding, and nutritional status of a child. A p-value of less
maternal education, presence of a person with than 0.05 was taken as statistically significant. For
special needs in the family and the presence of determination of associations, status of
siblings <5 years of age in the family. Weights malnutrition was also dichotomized as adequately
(kg) of the children were measured using standard nourished/malnourished, while the severity of
measuring devices in all the three hospitals. malnutrition was not taken into account.
The World Health Organization (WHO)
classification of weight-for-age (W/A) index was RESULTS
used to assess the nutritional status of the children. A total of 100 subjects were included in this study
Underweight, based on weight-for-age, is a comprising 59 males and 41 females with a mean age of
composite measure of stunting and wasting and is 20.31 (SD+14.59) months ranging from 0–60 months.
recommended as the indicator to assess changes in According to the Z-score system of classification, 68%
the magnitude of malnutrition over time.7 children in our study had adequate nutritional status
Results were expressed in terms of Z- while 32% children were found to be malnourished,
score system of malnutrition classification. 14% being moderately and 18% being severely
According to this classification, children having Z- malnourished. The mean Z-score of the sample was -
score > -2 and <+2 are considered to be adequately 1.68 (SD+1.77). Mean Z-scores of the three groups are
nourished. Whereas those having Z-score < -2 and mentioned in table-1. The association of each factor
< -3 are classified as moderately and severely with nutritional status was determined and their findings
malnourished children, respectively. This is the are displayed in table-2.
preferred method of expressing prevalence of The frequency of malnutrition was highest in
malnutrition obtained through survey results.8 the 16–30 months age group and was comparatively
Z-score is defined as the difference lower in other groups. No significant association was
between the value for an individual and the median

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found between malnutrition and gender. It occurred with special needs in the family, though marginal. No
the same frequency in both males and females. significant association was found between malnutrition
A statistically significant (p=0.01) and family size, family income, breastfeeding and
relationship was established between maternal presence of siblings <5 years of age in the family.
education and malnutrition in our study. The frequency
Table-1: Mean Z-scores of the three groups.
of malnutrition was higher in the children whose Nutritional Status Mean SD. Deviation
mothers had no or very little education. Our results Adequately Nourished -0.77 +0.87
indicated a statistically significant (p=0.05) association Moderately Malnourished -2.40 +0.33
between malnutrition and the presence of a person with Severely Malnourished -4.56 +1.64

Table-2 Association of different variables with malnutrition

Baseline characteristics Total Adequately Moderately Severely Malnourished
p-value
F (100%) Nourished Malnourished
Age Group (mo)
0–15 41 (100%) 28 (68.29%) 7 (17.07%) 6 (14.63%)
16–30 39 (100%) 24 (61.53%) 5 (12.82%) 10 (25.64%) 0.55
31–45 10 (100%) 8 (80%) 0 (0%) 2 (20%)
46–60 10 (100%) 8 (80%) 2 (20%) 0 (0%)
Gender
0.97
Male 59 (100%) 40 (67.79%) 8 (13.55%) 11 (18.64%)
Female 41 (100%) 28 (68.29%) 6 (14.63%) 7 (17.07%)
Maternal Education
Primary or Nil 49 (100%) 31 (63.26%) 4 (8.16%) 14 (28.57%) **0.01
More than primary 51 (100%) 37 (72.55%) 10 (19.61%) 4 (7.84%)
Presence of a family member
with special needs
*0.05
Yes 41 (100%) 22 (53.65%) 8 (19.51%) 11 (26.82%)
No 59 (100%) 46 (77.96%) 6 (10.16%) 7 (11.86%)
Family Size
Members < 5 39 (100%) 27 (69.23%) 6 (15.38%) 6 (15.38%) 0.83
Members > 5 61 (100%) 41 (67.21%) 8 (13.11%) 12 (19.67%)
Family Income(Rs)
<8000 31 (100%) 22 (70.97%) 2 (6.45%) 7 (22.58%) 0.81
>8000 69 (100%) 46 (66.67%) 12 (17.39%) 11 (15.94%)
BreastFeeding
Nil 12 (100%) 7 (58.33%) 3 (25%) 2 (16.66%) 0.51
Yes 88 (100%) 61 (69.32%) 11 (12.50%) 16 (18.18%)
Presence of siblings <5 years 0.80
in family
Yes 77 (100%) 53 (68.83%) 10 (12.99%) 14 (18.18%)
No 23 (100%) 15 (65.22%) 4 (17.39%) 4 (17.39%)
*significant **highly significant

DISCUSSION malnourished, whereas, in our study the results were

68%, 14% and 18% respectively.12
Worldwide, malnutrition is an underlying cause of
In the first place, according to a study
death for 2.6 million children each year.10 To combat
conducted in Iran (2011), male gender was
such a high mortality rate, a vigilant identification
considered as a protective factor against malnutrition,
and comprehension of each factor influencing
whereas, females were found to be more strongly
malnutrition is required. To our knowledge, this is
related to under-nutrition13, however, as per a study
probably the first study to recognize the associated
from Luangprabang province, Laos, males were more
factors of under-five malnutrition in Rawalpindi. Our
likely to be underweight14. On the other hand, in our
study, which was conducted in 2014, found
findings, gender is not a key indicator of
malnutrition to be present in 32% of children.
malnutrition.
Whereas in our neighbouring countries like Iran,
Secondly, our study has shown that the
India, China, Bangladesh and Nepal, the prevalence
frequency of malnutrition was highest in the age
rate of underweight children was reported as 4.1%,
group of 16–30 months as compared to remaining
43.5%, 3.4%, 36.8% and 29.1% respectively.11
age groups. Conversely, a study of Oromia indicated
According to Pakistan Panel Household Survey
the highest prevalence of underweight in children
(PPHS-2010) micro-data, 56.9% children were
aged 48–59 months.15 A similar study conducted in
adequately nourished, 15.7% were moderately
Sialkot found the highest proportion of malnourished
malnourished and 23.7% were severely
children in 13–36 months age group.16 This demands
further research to probe if this is a high-risk group in

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our population and to explore factors responsible for MDG 4 sets its targets (from 1990 to 2015) as a
it. Likewise, In Peshawar 31.7% cases of reduction in under-five mortality by two-thirds and
malnutrition were reported in large sized families, MDG 1 as a reduction in prevalence of under-weight
whereas, in our study this frequency was found to be children by half. According to the United Nations
32.7%, the results being somewhat consistent.17 Development Programme (UNDP) report in Pakistan,
Furthermore, poverty and nutritional status of the progress on all indicators is lagging in MDG 1.
child are not the directly correlating factors in this Progress on MDG 4, in all but 1 target, is also off-
study, a finding consistent with a similar study track. Currently, Pakistan stands among the worst in
carried out in India.18 In addition to that, previous child and infant mortality. The child mortality rate
studies have suggested malnutrition to be has only marginally decreased, from 117 per
significantly associated with breastfeeding. Whereas thousand live births in 1990–91 to 94 per thousand in
this factor remained insignificant in our study 2006–07.25 The performance of Pakistan in achieving
contrary to previous results.19,20 these goals is severely lagging and it is likely to miss
Moreover, Bahawaluddin J et al21 concluded them. The need, of measuring progress towards
in 2012 that the maternal illiteracy plays a major meeting these goals, has always been strongly felt by
contributing role to child malnutrition. Another study public health professionals and policy makers. Our
in Ludhiana found 40.7% cases of malnutrition study has tried to help satisfy this need by developing
associated with maternal illiteracy.22 Identically, our a better understanding of the individual contribution
results also established a statistically significant of each factor towards malnutrition. This may go a
association between malnutrition and maternal long way in strengthening the impact of the Child
education and found 36.73% cases of malnutrition Nutritional Programmes in Pakistan.
associated with maternal illiteracy. Similarly, Henry Some of the limitations of this study need to
FJ et al23 stated an increased risk of malnutrition be noted. The sample size of this study was small due
among children with siblings under-five years old. to limited resources and time, but to make it
Our results also identified a comparatively higher representative, the study population was taken from
percentage of malnourished children in families three different healthcare facilities, located in three
having more than 1 child under 5 years of age. different areas of Rawalpindi, to include population
However, this result was not statistically significant. with varied socio-demographic backgrounds.
Besides other factors, an interesting finding Moreover, data was collected only from the
of our study was a significant association between immunization centres of three public hospitals, and
malnutrition and the presence of a family member the children not accessing immunization services
with special needs (i.e., disabled or diseased). This from public health facilities were missed in our study
risk factor has only been taken into consideration by therefore the results cannot be generalized to all the
Mahgoub et al in 2006, but no significant association children of Rawalpindi as a whole but still represent a
was observed.24 The reason of this contrast might be large population. In this regard, a community-based
the difference in the social and cultural set-up of the survey with large sample, including the children
families in the two regions. In our social setting, the visiting the private setup in addition to public
majority of households have large family size due to facilities is strongly recommended in the future.
which there is unequal division of resources among
the members. In addition to the economic burden CONCLUSION
posed by a person with special needs, an extra Children are the most vulnerable members of the
amount of time and attention which is to be provided society and to allow their development to be affected
by the caretaker of the household, which in our setup by poor nutrition is a waste of human potential. This
is mostly the mother, may also compromise a child's research study would be of little value if the
health and nutrition. Therefore, in order to affirm assessment is not followed-up by policy actions,
relation between malnutrition and the presence of a which are most likely to have the greatest impact on
family member with special needs, further research is child malnutrition if directed at an early stage of child
recommended in this area as very little has been growth. In order to attain better nutritional outcomes
reported about it in earlier studies. for their children, women must be educated beyond
The specific objectives of this study target primary school level.
child-survival and well-being. These have been a Moreover, offering frequent nutritional
focus of public health communities for over last two education programs can also be beneficial to the
decades. Unfortunately, they still remain an mothers, particularly those with no or very little
important issue in a developing country like Pakistan. education. The Government should take an initiative
This is reflected in United Nations Millennium to provide financial and professional support to the
Development Goals 4 (MDG 4) and 1 (MDG 1). families having members with special needs like

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 J Ayub Med Coll Abbottabad 2016;28(1)

disabled or diseased. An appropriate surveillance 10. Save the children. A LIFE FREE FROM HUNGER Tackling
child malnutrition. [Online]. 2012 [cited 2012 May 18].
system should be devised for prompt and timely
Available from:
diagnosis of malnutrition in children and its http://www.savethechildren.org/atf/cf/%7B9def2ebe-10ae-
management in our country. 432c-9bd0-df91d2eba74a%7D/EMBARGOED%20-
%20A%20LIFE%20FREE%20FROM%20HUNGER%20-
ACKNOWLEDGEMENTS %20TACKLING%20CHILD%20MALNUTRITION.PDF
11. Global health observatory data: World health statistics 2014.
We are extremely thankful to Dr. Faiza Aslam [Online]. 2014 [cited 2014 May 18]. Available from:
(Research Coordinator, Research Unit, Rawalpindi http://www.who.int/gho/publications/world_health_statistics/
Medical College) for data analysis and for her EN_WHS2014_Part3.pdf?ua=1
continuous support, guidance and thoughtfulness 12. Arif GM, Nazir S, Satti MN, Farooq S. Child malnutrition in
Pakistan: Trends and determinants. Pak Inst Dev Econ 2012.
throughout the research period. We would also like to 13. Sharghi A, Kamran A, Faridan M. Evaluating risk factors for
thank Syed Muhammad Ali Shah (President, Student protein-energy malnutrition in children under the age of six
Research Society, Rawalpindi Medical College) for years: a case-control study from Iran. Int J Gen Med
his guidance. 2011;4:607–11.
14. Phengxay M, Ali M, Yagyu F, Kuroiwa C, Ushijima H. Risk
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AUTHOR’S CONTRIBUTION years: study from Luangprabang province, Laos. Pediatr Int
SM, MM, SN, TS, UA: Study conception and design 2007;49(2):260–5.
& Acquisition of data. SM: Drafting of 15. Mengistu K, Alemu K, Destaw B. Prevalence of malnutrition
and associated factors among children aged 6-59 months at
Questionnaire. SM, TS, Interpretation of data. SM, Hidabu Abote district, North Shewa, Oromia regional state. J
TS, MM, SN: Drafting of manuscript, Final Approval Nutr Disorders Ther 2013;1:1–15.
of the version to be published. SM, TS, US: Critical 16. Masood-us-Syed SS, Muhammd S, Butt ZK. Nutritional
revision assessment of children under the age of sixty months in
district Sialkot, Pakistan. J Pioneer Med Sci 2011;1(1):7–12.
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Address for Correspondence:

Shafaq Mahmood, House No. 104, EGQ, Street E-1, New Gulzar-e-Quaid, Aiport Road, Rawalpindi-Pakistan
Cell: +92 336 115 8480
Email: shafaq.mahmood93@gmail.com

http://www.jamc.ayubmed.edu.pk 71