ISSN- 0301-1216

Indian J. Prev. Soc. Med. Vol. 42 No.2, 2011

DETERMINANTS OF PROTEIN ENERGY MALNUTRITION (PEM) IN 0-6 YEARS
CHILDREN IN RURAL COMMUNITY OF BAREILLY
HS Joshi 1, MC Joshi 2, Arun Singh3, Preeti Joshi 4, Nadeem Israr Khan5

ABSTRACT
Background: Nutritional status of children is an indicator of nutritional profile of entire community. It is a major
public health problem and accounts for about half of all child deaths worldwide. Objectives: To study the
prevalence of Protein Energy Malnutrition (PEM) and its various determinants in children 0 -6 years in rural
community. Method: A cross-sectional study done by conducting house to house survey, 449 children (0-6
years) covered from the sub centre villages of additional Primary Health Center (PHC) of Rithora, District
Bareilly. Result: The overall occurrence of PEM in under 6 years children was observed to be 49.44%,
however it was found to be significantly higher (64.87%) in the age group of 3-6 years as compare to other age
group. The proportion of grade I, II, III and IV of under nutrition observed was 45.49%, 38.30%, 14.86 and 1.35%
respectively. Prevalence of underweight was significantly higher in children belonging to nuclear families and in
children of illiterate mothers. . There was direct association of underweight in relation to caste, poor housing and
environmental sanitations and low standard of living index. Conclusion: The occurrence of PEM is more in children
of 3-6 age group specially in females, which may be due to lack of attention to this age group in rural areas.
Key Words: Under nutrition, malnutrition, nutritional correlates, nutritional status, PEM.

INTRODUCTION
Malnutrition continues to be a primary cause of ill health and mortality among children in developing countries. It is a
1

major public health problem and accounts for about half of all child deaths worldwide . About 150 million children in developing
1

countries are still malnourished and more than half of underweight children live in South East Asia Region (SEAR) . The high
levels of under nutrition in children in South Asia pose a major challenge for child survival and development. Besides poverty,
there are other factors that directly or indirectly affect the nutritional status of children. Several studies showed that maternal
3

education emerges as a key element of an overall strategy to address malnutrition .The best global indicator of childrens well
being is growth. Poor growth is attributable to a range of factors closely linked to overall standards of living and the ability of
populations to meet their basic needs, such as access to food, housing and health care. Assessment of growth is the single
measurement that best defines the nutritional and health status of children, and provides an indirect measurement of the
quality of life of the entire population.

__________________________
1. Associate Professor; 2. Assistant Professor, Dept. of Community Medicine; 3. Assistant Professor, Dept. of Pharmacology;
4. Public Relation Officer, 5. Medical Officer, Rohilkhand Medical College & Hospital, Bareilly, UP, India.
Indexed in : Index Medicus (IMSEAR), INSDOC, NCI Current Content, Database of Alcohol & Drug Abuse, National Database in TB &
Allied Diseases, IndMED, Entered in WHO CD ROM for South East Asia.

HS Joshi et al

Determinants of protein energy malnutrition (PEM) in 0-6 years children in rural community

Despite improvements in some measures, poor nutrition is still a serious problem, especially in Uttar Pradesh,
among children from low socioeconomic groups. The present study was conducted with the objectives of : 1.

To find out the PEM prevalence among 0-6 years age group

2.

To identify the different factors which affect the prevalence of PEM among rural population of Bareilly district.

MATERIALS AND METHODS

The present study was conducted among children (0-6 year) in all the six sub center villages of randomly
selected additional primary health center of Rithora, district Bareilly, India, during the period of August 2007 to July 2008,
which is the Rural Field Practice area of the Department of Community Medicine, Rohilkhand Medical College and
Hospital, Bareilly, Uttar Pradesh, India. A multi-stage random sampling technique was used for selection of villages. An
optimum sample size for study was obtained by an estimated PEM prevalence of 50% in children 0 -6 years age group
with 10% relative precision and 95% confidence interval, the minimum sample size calculated out was 384 children. A
total of 449 children (0-6 years) were covered by house to house visit. Detailed information was collected on a
predesigned and pretested questionnaire and supplemented by physical and anthropometric examination of child. The
grading of PEM was done as per the recommendations of Nutrition Sub-Committee of Paediatrics (ICMR 1972).
Statistical Analysis: Data were entered and analyzed using statistical software SPSS 10.0 for windows (SPSS Inc.,
Chicago, IL, USA). The Chi-square test was used for testing the significance of association between the socioeconomic
characteristics and malnutrition.

RESULTS
The overall prevalence of PEM was 222 (49.44%) out of total 449 children of age group 0-6 years surveyed. The
prevalence of underweight in children 3-6 years (64.87%) was significantly higher than other age group, followed by 21.62% in
age group of 1-3 years. Out of total 449 children 248 (55.23%) were males and 201(44.77%) were females and prevalence of
under nutrition was observed 39.92 %( 99 out of 248) in males and 61.19% (123 out of 201) in females. Significant difference
observed between prevalence of PEM and sex - Table-1.
Table-1: Age and sex wise prevalence of PEM in under six years children
Male
Age
(years)

No. of
children

Female
Under
weight

Total

No. of
children

Under
weight

No. of
children

Under
weight

No.

No.

No.

No.

No.

No.

65

68.0

19

29.23

31

32.3

11

35.5

96

21.4

30

13.51

1-3

51

54.26

25

49.02

43

45.74

23

53.49

94

20.94

48

21.62

3-6

132

50.97

55

41.7

127

49.03

89

70.01

259

57.68

144

64.87

Total

248

55.23

99

39.92

201

44.77

123

61.19

0-1

Age

= 16.78, df = 2, p =0.000234 ; Sex

Indian J. Prev. Soc. Med Vol. 42 No.2

155

449

100

222

100

=19.26, df = 1, p =0.0000114

April-June, 2011

HS Joshi et al

Determinants of protein energy malnutrition (PEM) in 0-6 years children in rural community

Table-2: PEM in children (under six years) according to Its severity

Severity

Proportion of grade I, II, III and IV under

nutrition was 45.49%, 38.30%, 14.86% and 1.35%
respectively. The grade I, II, III and IV of underweight

Underweight

Male

No.

No.

Female
%

No.

Grade I

101

45.49

37

36.63

64

63.37

Grade II

85

38.30

42

49.41

43

50.59

males. Out of total 222 underweight children 99

Grade III

33

14.86

15

45.45

18

54.55

(44.59%) were males and 123 (55.41%) were

Grade IV

03

1.35

01

33.33

02

66.67

Total

222

100.0

99

44.59

123

55.41

observed higher in females (63.37%, 50.59%,

54.55% and 66.67% respectively) as compare to

females, as shown in Table-2

Out of total 449, 278 (61.92%) children belonged to joint family and 171 (38.08%) to nuclear family. Prevalence of
underweight was observed 50.9% in nuclear and 49.1% in joint family children of 0-6 year's age group. The association
observed between underweight and type of family was significant (p=0.000001), as shown in Table-3.
Table-3: Determinants of PEM in under six years children
Variables

No. of Children
No.

Underweight
No.

Significance
value

Types of Family
Joint

278

61.92

109

49.1

Nuclear

171

38.08

113

50.9

Upper

207

46.1

65

29.28

Lower

242

53.9

157

70.72

High

128

28.51

31

13.96

Medium

174

38.75

89

40.10

Low

147

32.74

106

45.94

= 29.52,
df = 1, p = 0.000001

Caste
2

= 48.68,
df = 1, p = 0.000001

SLI
2

= 62.85,
df = 2, p = 0.0000001

Housing and environmental condition

Poor

133

29.62

87

39.19

Satisfactory

249

55.46

126

56.76

Good

67

14.92

09

4.05

Illiterate

257

57.24

145

65.32

Literate

192

42.76

77

34.68

449

100.0

222

49.44

= 48.46,
df = 2, p =0.000001

Mother Education
2

Total

= 11.06,
df = 1, p =0.00088

Out of total 449 children, 207 (46.1%) belongs to upper caste and 242 (53.9%) belongs to lower caste, in that 70.72%
of lower caste children were found under weight. Out of total 222 under weight children maximum 106 (45.94%) belongs to
family with low Standard of Living Index (SLI), 126 (56.76%) children were from families having housing and environmental
condition satisfactory and 87(39.19%) children were from poor housing and environmental conditions. Out of total 449,
mothers of 257 children were illiterate and 65.32 % (145) of those children were found to be under weight.

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HS Joshi et al

Determinants of protein energy malnutrition (PEM) in 0-6 years children in rural community

Significant association was observed between prevalence of underweight and different factors like type of family,
2

caste, Standard of Living Index (SLI), Housing, environmental sanitation and literacy with
2

p=0.000001,

=48.68, p=0.000001,

=62.85 p=0.0000001,

=48.46, p=0.000001 and

value and p value

=29.52,

=11.06, p=0.00088 respectively

(Table-3).

DISCUSSION
In present study prevalence of PEM and its relation to various epidemiological factors was assessed in 449 children
on the basis of weight for age. Out of total 449, 21.4% of children were in 0-1 years age group, 20.94% were in 1-3 years age
group and 57.68% were in 3-6 years age group. 55.23% were males and 44.77% were females.
The overall prevalence of underweight was 49.44%. The difference in prevalence of underweight in relation to age
and sex was found to be statistically significant (p < 0.0001). Chakraborty et al (2006) in rural Jhansi reported overall
prevalence of underweight in 0-6 years age group as 67% and reported same significant difference in prevalence of
underweight in relation to age and sex, as present study other studies including NFHS II (1998-99) reported PEM more
prevalent in female as compare to males specially in rural areas, this may be due to more concern for male child

1, 3, 7

. But

Dwivedi et al in their study in urban slum found more males affected with lower grades of under nutrition than females.
Early malnutrition among rural children as compared to urban children may be attributed to the better parental care
given to the urban children. A comparatively higher prevalence of underweight (60.0%) was reported by Vijayaraghavan et al
5

(1998) . In present study prevalence of PEM observed more in 3-6 years age group (64.87%) as compare to other studies
3

Chakraborty et al (2006) and Swami et al (2001)

who observed malnutrition was more prevalent in the younger age group,
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i.e. 3 years(80.9% and 71% respectively). In NFHS III (2005-06) done in children <3 years of age prevalence of underweight
was 43.7% in rural population of Uttar Pradesh. The prevalence of PEM being significantly higher (p < 0.00001) in the nuclear
family (50.9%) in comparison to joint family (49.1%), may be due to the reason that children in the joint family are nutritionally
better cared as there is tendency to share the food with the children by all the family members.
In the present study, the proportion of children with grade I, II, III and IV PEM were 45.49%, 38.30%, 14.86% and
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1.35% respectively, where as 29.0%, 25.5%, 9% and 3.5% reported by Chakraborty et al . Mild, moderate and severe grades
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of malnutrition reported by other workers are as follows: Srivastav et al (1979) 29.5%, 10.6% and 2.9%; Kakkar et al (1987)

38%, 31% and 9%. In National Family Health Survey II (NFHS II) (1998-99) value for, moderate and severe grades of
malnutrition according to underweight were 47.0% and 18.0% respectively with corresponding figures for U.P. being 51.7%
and 21.9% respectively. In present study severe grades (III and IV) observed more in females (54.55% and 66.67%) as
3

compare to males which were higher than as observed by Chakraborty et al who observed only 7.3% and 2.7% respectively.
In present study PEM was reported significantly higher (p<0.0001) in lower caste (70.72%) as compare to upper
1

caste (29.28%), similar findings were given by NFHS II (1998-99). In the present study PEM was inversely associated with
standard of living index with prevalence of 45.94% in children of low standard of living index (p<0.00001) as also observed in
1

NFHS II (1998-99)

both at national level and Uttar Pradesh level. A similar finding of malnutrition being more prevalent in

children belonging to lower socioeconomic groups was also found by , Rao et al (1990)

10

11

and Jayaseelan et al (1997) . The

reason for malnutrition being more prevalent among lower socioeconomic groups may be due to their lower purchasable
capacity for food and unavailability of hygienic and healthy living environment among them.
The prevalence of underweight in the present study was higher in children of illiterate mothers (65.32%) as
compared to children of literate mothers (34.68%). Similar results that prevalence of malnutrition decreased with increasing
1

3,

12

parental literacy was found by NFHS II (1998-99) , Chakraborty et al Arya et al (1991) , Harishanker et al (2004)

Indian J. Prev. Soc. Med Vol. 42 No.2

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and

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Determinants of protein energy malnutrition (PEM) in 0-6 years children in rural community

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Bishnoi et al (2004) . In the present study it was found that prevalence of PEM higher (39.19% and 56.76%) when housing
and environmental sanitation conditions were poor and satisfactory while only 04.05% when environmental and sanitary
14

conditions were good (p<0.0001) which is comparable with finding Bishnoi et al (2004) .

CONCLUSION
The present study shows that the prevalence of underweight was significantly higher in children of 3-6 years of age,
sex, caste, nuclear family, low standard of living index, mothers illiteracy and poor housing and environmental sanitation.
Female child had a higher occurrence of overall and grade III and IV PEM. This may be because of the lack of attention that a
girl child receives. The PEM is higher in illiterate mothers because of lack of awareness among them. The extent of
malnutrition can be countered by educating the parents with respect to basic nutritional requirements of their children and
encouraging them to consume locally available low cost foods.
The study suggests intensification of ICDS with multi sectorial strengthing will also help a they help in taking care of
the child and educating the child along with providing meals which compliment the childs diet, thus improving their nutritional
status.

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National Family Health SurveyII (1998-99). International Institute of Population Sciences. Mumbai, India.

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