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ASSESSMENT OF MALNUTRITION BY DIFFERENT ANTHROPOMETRIC METHODS AND EFFECT OF POVERTY AND MATERNAL EDUCATION AS A BARRIER TO HEALTHY NUTRITIONAL STATUS AMONG CHILDREN UNDER FIVE YEARS OF AGE

.. Objectives: Pakistan is facing double burden of malnutrition. The purpose of current study was to access the nutritional status by different anthropometric methods and common barriers that affect the nutritional status of children. Study Design: Cross Sectional study. Setting: Children Hospital & Institute of Child Health Multan, Pakistan. Period: From 1st March 2019 to 1ST January 2020. Material & Methods: The study 405 children with 216 boys and 187 girls. The data was collected by trained nutritionist in OPD of Children Hospital & Institute of Child Health and data was analyzed by using SPSS version 21.0. Results: The study showed that malnutrition is caused by poor socioeconomic status and low education level of care giver. The data showed that 318 (78.51%) participants involved in this study were malnourished. Nutritional status mostly affected during first birthday (36.79%). In this study 50.12% participants belonged to poor nutritional status and 47.65% mother were uneducated. Conclusion: The mother education and good socioeconomic status can prevent children from malnutrition. Feeding practices and weaning starting time also play role in defining nutritional status of children. More prone to diseases so well balanced diet and mother feeding upto-2 years of age can prevent children from chronic diseases and improve nutritional status.


INTRODUCTION
Nutrition plays a key role in maintenance of standard of life among children and adults. 1 Malnutrition leads toward various illnesses and the risk of mortality and morbidity rate increased among children and adults and this directly affect the economy of a country. Malnutrition occurs when intake between energy and nutrients are deficient or excess. It divided into three broader groups under nutrition: it includes underweight (low weight for age), stunting (low height for age) and wasting (low weight for height), Micronutrient related-malnutrition: includes micronutrient access or micronutrient deficiencies and Overweight, Obesity and Diet related non communicable diseases includes diabetes, stroke, heart disease etc. Worldwide, children under five years of age roughly calculation 230 million are long standing malnourished and half of them die by malnutrition. 2 Numerous studies have showed that malnutrition is linked with significantly increased risk of mortality and morbidity in the short-term as well as work capacity reduced significantly and due to this productivity in life later also changed. 3 Many studies also showed that malnutrition is common in people whose background is poor and not affording nutrient rich food. Malnutrition is common in low and middle income countries. 4 Food access and security affected by household income, health services and hygiene also affect the nutritional status. Good nutritional and hygienic practices results in good nutritional status of children under five years of age. Children under five years of age are very sensitive to DOI: 10.29309/TPMJ/2020.27. 10.4468 pathogens and nutrition. 5 Many anthropometric techniques are available to check the nutritional status of children and adults which include body mass index (BMI), mid-upper arm circumference (MUAC), measurement of the thickness of triceps or subscapular skinfolds, and calf circumference. 6 Anthropometric techniques like MUAC and height to weight ratio contemplate less dependable for evaluate malnutrition than advanced but costly body composition evaluation skills such as electronic bio-impedance, dual energy X-ray absorptiometry hydro-densitometry, and so on. 7,8,9 The technique and instrument used for MUAC and height to weight ratio are inexpensive, less time consuming and easy to use and can be used with little training. 9,10 To evaluate the nutritional status and adiposity body weight checked in kg and height in meter square and then divide the given weight by height and Nutritional status evaluate. This method is noninvasive and inexpensive with less training and efforts, therefore it is widely used in any health survey and at clinic to minimize the time duration for evaluating nutritional status in developing country. 11,12 BMI cut off values 18.5-24.9 kg/m 2 is considered as good sign of nutritional status and BMI <18.5 kg/m 2 considered underweight less reliable for energy storage in body. Their energy intake considered equal to energy expenditure and more prone to chronic diseases. BMI >24.9 kg/m 2 are also in undesirable range of nutritional status and are also more prone to different diseases. 13 Research studies proposed that BMI is a responsive indicator for nutritional deficiencies and considered a critical determinant of morbidities connected with malnutrition 14 , and also an indicator of low socio-economic status of a family of a country. 12,15 MUAC, a wellliked anthropometric measurement method for evaluating the nutritional status of less than five years of age children, can also been used in resource-limited community for assessing nutritional status. 16,17 For anthropometric measurement MUAC usage was considered most reliable with lesser equipment required and less time consuming than BMI for assessment of underweight and is being used since a long time. 17,18 Therefore, this current study was aimed to access nutritional status by different anthropometric methods and common barriers to achieve healthy nutritional status.

MATERIAL & METHODS
This is a cross sectional study conducted in Children hospital & Institute of Child Health Multan, Pakistan. The total participants involved in this study are 405 which are below five years of age and 318 participants were malnourished and only 87 children were normal. Out of 318 malnourished children 167 were boys and 151 were girls. Data collected by trained nutritionist. These participants belonged to different socioeconomic status and mostly were from rural areas of region Multan.
The approval from higher authority was taken and during data collection all ethical the consent from mother was also taken so that no objection from the participants is involved later. Care taker of children were agreed from collection of data for study.
Selection of children for study based on consent which parents gave permission of data utilization in study only those children were involved in this study and came hospital for proper follow up. The children which were in sever critical condition and had chronic diseases were excluded from study.
The data collected in questionnaire base performs. Performa were filled by trained nutritionist in OPD of Children Hospital & Institute of Child Health hospital while taking their history. Different types of question were on Performa including socioeconomic. Appetite test also checked by feeding RUTF. If ate one third of RUTF then their appetite as positive. They called malnourished if their weight is less than weight recommended by World Health Organization (WHO) and MUAC base cut off value also used to check their nutritional status.
After data collection by using SPSS version 21.0 data was analyzed and according to WHO cut off values malnourish and normal children were declared.  (Table-II).
Feeding method was checked of participants, only 119(29.38%) participants feed on mother milk. At the 4 month of age complementary feeding started to 94(23.21%) children and at the age of 6-month complementary feed started to 226(55.80%) children. Diarrhea was found in 267 children on admission followed by vomiting 119(29.39%) and fever 107(26.42%) children were severely sick. There were only 88(21.72%) participants were those whose energy intake was normal (Table-III).
The chi square test was found significant (p-value <0.05) among nutritional status and age groups. Nutritional status according to gender also checked. Percentage of girls was more affected than girls by malnutrition. 80 % girls affected by malnutrition while 77 % boys were affected. More children affected before their first birthday as compared to 5 th birthday (   Lodhi et al., found that underweight children were 21% in which severely underweight children were 50% and among them 22% were male and 19% were girls. This high level of malnutrition may be due to acute diseases and feeding practices. 19 46.17% children involved in study were on bottle feeding and 24.44% were on cup feeding and only 29.38% children were on mother feeding. In our conducted study 78.76%% were severely wasted. Under five years of age underweight ratio was reported in in other countries like Bangladesh (48.0%), India (47.0%), Afghanistan (39.0%) and Nepal (48.0%). 20 In 2018 National Nutritional Survey conducted, according to this survey 40.2% children under five years of age were stunted, 17.7% were wasted, 28.9% were underweight and 9.5% were overweight. According to this survey boys were more prone to risk than girls. 21 Present study reported that only 119 participants feed on mother milk and 187 were feed on formula milk and 99 were feeding through cup. At the 4 month of age weaning started to 94 children and at the age of 6-month weaning started to 226 children and 85 children were those whose weaning started at the age of 1 year.
Energy intake level of 88 participants were normal. Energy intake level of 211 participants were low. Mother education and residential status also a contributor factor in malnutrition to some extent. In this study more children that were malnourished belonged to rural areas and their mother education were also low. Previous study 22 reported that malnutrition linked with low socioeconomic status, food insecurity and poor feeding. Insufficient access to education, Children nutritional status under five years of age is a measure of children survival and household well-being. Infant and children mortality rate is high due to malnutrition. Breastfeeding prevents from different chronic diseases and maintain a strong immunity level in children which protect children from different diseases. Breastfeeding can minimize mortality rate in infants and children. 24 These are the real determinants of undernourishment in society as they impact on the quality of life directly. Nutritional status affect the health of infants and children. Good nutritional status helps good health maintenance and physical growth results in good mental health. Poor nutritional status leads towards the poor physical growth and mental health. Poverty and low education level is linked with malnutrition in Pakistan. 25 Due to mother's less education, they started breastfeeding late and follow poor feeding and hygienic practices in children which are under two years of age due to which diarrhea and vomiting practices are common which leads towards the poor nutritional status. 26 For proper nutrition of children primary barrier is inadequate food resources. The availability of variety of food was limited, and mothers also failed to provide food that is mandatory in specific periods of life to maintain a proper growth of children.

CONCLUSION
In this study examined that prevalence of malnutrition under five years of age is significantly high in Multan region. Low socioeconomic status of family due to which people did not afford variety of food and nutrition leads towards malnutrition. Low education level of mother also contributor in malnutrition because mother had less knowledge of introducing right food at right time. Feeding practice and weaning time showed that bottle feeding and late start of weaning leads towards malnutrition. Breastfeeding prevent children from different chronic diseases.  Collection and assembly of data, Analysis and interpretation. Collection and assembly of data.