B YM S . P R A N O T I M A N E

M . S C . C L I N I C A L N U T R I T I O N A N D D I E T E T I C S2 0 1 2 - 2 0 1 3

G U I D E D B Y M R S . A N U R A D H A S H E K H A RH . O . D . F O O D S C I E N C E A N D N U T R I T I O N

P O S T G R A D U AT E D E PA R T M E N T O F C L I N I C A L N U T R I T I O N A N D D I E T E T I C SD R . B . M . N . C O L L E G E O F H O M E S C I E N C E

3 3 8 , R A F I A H M E D K I D WA I R O A D , M AT U N G A ,M U M B A I - 4 0 0 0 1 9 .

A F F I L I AT E D T O S N D T W O M E N ’ S U N I V E R S I T Y

ASSESSMENT OF NUTRITIONAL STATUS AND FEEDING PRACTICES OF TODDLERS IN MUMBAI CITY

Aim To study the nutritional status and feeding patterns in infants belonging to age group of 12 to 24 months and

understand the nutritive effect of different infant formulas, homemade formula and both on baby’s growth and development

Objectives To study the feeding practices among of toddlers aged 12 to 24 months To assess the nutritional status of infants using anthropometric data. To assess the nutritional status of infants using diet recall To compare between commercial and homemade formulas.

Research Methodology

Proper feeding practices during infancy and toddlerhood are essential for attaining and maintaining proper nutrition, health, and development of infants and young children. Results of studies on infant and child feeding across different developing countries have indicated that inappropriate feeding practices have profound consequences for the growth, development, and survival of infants and children, particularly in developing countries. (Edward A Frongillo, 2008)

So, a research was carried out in Mumbai city to study the feeding practices among toddlers aged 12 to 24 months & assess their nutritional status using anthropometric data. Since the toddlers cannot be interviewed for the study their mothers was targeted.90 mothers having kids belonging to 12-24 months and fulfilling the required criteria was considered. The questionnaire covered the following areas:

General information Anthropometric data Dietary recall Feeding practices among toddlers aged 12 to 24 months(Type of food fed to their babies

and the reasons for using the same.

Contd..

NULL HYPOTHESIS There was no significant change in feeding practices and nutritional status of the toddlers. RESEARCH DESIGN A structured questionnaire was designed to obtain required information. Samples of working &non working

mothers were identified and explained the purpose of the study. Face to face interviews were conducted with those women who met the desired criteria & showed willingness to participate in the survey. In some cases interviews were conducted later, at time & date convenient to the respondents.

In Household interviews- Interviews was conducted at different locations selected randomly in an area in buildings at Sion.

In Hospital interviews – some interviews were conducted with mothers sitting in the reception area. The study included questions on details of feeding pattern and also anthropometric measurements of baby like

height, weight, and head circumference. Each interview took approximately 20 to 25 minutes. The survey took approximately 3 months. After the survey was completed, the responses obtained in the survey

was coded and punched in the system wise for all respondents. The output was then analyzed.

Sampling

Quantitative research methodology was adopted for the study. The target group of the study was mothers of age group 20 to 40 years & having kids belonging to age group of 12 to

24months. The study was conducted in Pratiksha Nagar &Sion Circle areas of Sion. Permission from the housing society and maternity & nursing hospital was obtained prior to starting the actual survey. A

brief explanation of the topic, its importance and its benefits was also given to the concerned authorities. The criteria for the selection of the subjects were as follows: Age: Mothers of kid belonging to the age group of 12-24 months years old were selected for the study. Inclusion criteria: Healthy kids were selected for the purpose. Exclusion criteria: Subjects with any disease condition like diseases of the kidney, liver, cancer, etc.or other disease

condition were not selected. Young women (working and non-working) were interviewed about the nutritional status (anthropometry, dietary recall) and

feeding practices of their child. In addition babies’ height and weight at birth and current height and weight were taken and registered. A total of 90 young women were included. They were enrolled in the study purely based on their willingness to participate. The participants were first met and briefed upon the topic and they were informed about the study design.

Their role as a participant was explained to them. They were also assured of the confidentiality of personal information.

STATISTICAL ANALYSIS

The data were analyzed using the SPSS/PC+ statistical package. Analysis of variance (ANOVA) was performed to evaluate differences between age groups with respect to the different variables measured. Simple linear correlation was performed on variables in the total sample and within age groups. Unless otherwise stated, the results are expressed as the mean ± standard deviation

Findings

Findings of the study

Occupation status of the mother vs. breastfeeding

No breastfeed-ing

One time aday Two times a day

Three times aday

Any other0

1020304050607080 73.3

15.66.7 2.2 2.2

66.7

208.9 2.2

2.2 WorkingNonworking

Number of times breastfed

Percent

N= 33(73%) of working mothers & N= 30 (66.7%) non working mothers do not breast their kids.Out of the working mothers who breast feed their kid, n=7 (15.6%) give feed one time a day. Also n=9(20%) of non working mothers feed their babies one time a day

Base: All (90)

Feeding pattern

Food pattern seen in toddlers (N = 90)

Homemade24%

Readymade33%

Both42%

Type of food

Base: All (90)

From the Fig it can be observed that out of 90 subjects, 24% (N=22) of them were fed with homemade food, 33% (N=30) with readymade food and 42% (N=38) toddlers were fed with both homemade & readymade food.

Type of food in comparison with occupation of mothers

Working Non working

67

335149

Type of food by household income

Homemade Readymade Both

67 % of the working mothers feed their babies ready made food

49% of non working mothers feed their babies with home made food.

Both home made & ready made food is preferred by non working mothers (51%)

Type of food in comparison with household Income

30 - 35 k 45 - 55k 55k & more

40

25

17

30

39 39

3036

44Type of food by household income

Homemade Readymade Both

40% of the subjects having household income in range of 30 to 35ooo eat home made food.

Ready made food is preferred most by families having high income of more than 35ooo.

Also both ready made & home made food is preferred by high income families

Birth weight of toddlers – By occupation of mother

Occupation

WeightNon working Working Total

2 - 3 kg % 20.0% 2.2% 11.1%

3 – 3.5kg % 62.2% 55.6% 58.9%

3.5 – 4 kg % 17.8% 42.2% 30.0%

Total Count 45 45 90

o 62.2% of non working mothers reported their babies weight to be in the range of 3 to 3.5 Kg. n= 8 (17.8%) said that their babies weight lied in the range 3.5 to 4 kg at birth. So we can say that n = 36 (80%) non working mothers reported their babies weight at birth to be greater than 3 Kg

55.6% working mothers gave birth to babies in the weight of 3 to 3.5 Kg, while n =19(42.2%) said that their babies weight at birth was in the range of 3.5 to 4 Kg. Therefore in case of working mothers, n= 44 (98%) toddlers weighed more than 3 Kg at birth Also p value for chi square test between the 2 variables is less than 0.05 , so association between birth weight & mother’s occupation is seen.

Birth height of toddlers – By occupation of mother

Occupation

WeightNon working Working Total

30-39cm % 26.67% 17.78% 11.11%

40-49cm % 57.78% 60.00% 58.89%

More than 49cm % 15.56% 11.11% 30.00%

Total Count 45 45 90

26.67%) mothers reported their babies height to be in the range of 30 to 39 cm. Highest numbers n=26 (57.78%) mothers had babies height in range of 40 to 49 cm at birth, while n=7 (15.56%) said that their babies height was more than 49 cm at birth. So we can say that n = 33 (73.33%) non working mothers reported their babies height at birth to be greater than 49 cmN=27 (60%) of N=45 working mothers gave birth to babies having height of 40 to 49 cm, while n =15 (33.33%) said that their babies height at birth was more than 49 cm. Therefore in case of working mothers, n= 32 (71.11%) toddlers height more than 49 cm at birth. p value is less than 0.05 for height of baby at births Vs occupation of mothers. So association between height at birth & occupation is observed.

Correlation of mothers education & type of food fed

Education Type of food Total

Homemade Readymade Both

Not attended college Count 12 4 4 24

% 55% 13% 11% 22%

Graduate Count 10 17 20 63

% 45% 57% 53% 52%

Post graduate Count 0 9 14 3

% 0% 30% 37% 26%

Total Count 22 30 38 90

o 55% (N=12) mothers, who have not attended college feed their babies with homemade food, while 13% (N=4) use readymade food and 11% (N=4) use both type of food.o Of the N=63 graduate mothers, highest 57% (N=17) feed their babies with readymade food followed by 53% (N=20) both homemade & readymade and then 45% (N=10) use homemade food to feed their babieso 37% (N=14) mothers of N=3 who have completed their post graduation feed their babies with both homemade & readymade food and the rest 30% (N=9) uses readymade food.

Anthropometric parameters of the toddlers in comparison with type of food fed

Parameters Type of food fed N Mean Std. Deviation

Current Height

Home made 22 70.9 .379

Readymade 30 67.55 .183

Both home & readymade 38 69.47 .802

Current Weight

Home made 22 11.27 .000

Readymade 30 11.06 .183

Both home & readymade 38 11.27 .504

Current Head

Circumference

Home made 22 43 .000

Readymade 30 43 .000

Both home & readymade 38 43 .000

o From table 5, it can be observed that not much difference in the average figures of the different types of food eater is observed

Current weight of toddlers – By their age, occupation of mother & type of food

Age of baby Occupation Type of food

Weight 12 -16

months

17- 20

months

21- 24

months

Non

workingWorking

Home

made

Ready

madeBoth Total

8-10 kg % 83.3% .0% .0% 28.9% 26.7% 27.3% 23.3% 31.6% 27.8%

11-13kg % 16.7% 96.7% 53.3% 57.8% 54.3% 54.5% 44.7% 70% 55.6%

14-15kg % .0% 3.3% 26.7% 13.3% 6.7% 18.2% 3.3% 10.5% 10.0%

More than 15 % .0% .0% 20.0% 4.4% 8.9% .0% 3.3% 13.2% 6.7%

Total Count 30 30 30 45 45 22 30 38 90

o Highest number of toddlers having current weight of 14 to 15 kg, n=8 (26.7%) belong to 21 to 24 months of age, while only n=1 (3.3%) belongs to age group of 17 to 20 months. So we can say that weight of toddlers increase with age.

oAlso p value for chi square test between the 2 variables in less than 0.05 , so association between current weight & age of toddlers is seen.

oNot much difference in current weight of toddlers is found in case of working & non working mothers.oSame is true for different types of food fed.

oAlso the p value for chi square test between the above 2 groups of variables in more than 0.05 , so no association is observed between them

Current height of toddlers – By their age, occupation of mother & type of food

Age of baby Occupation of mothers Type of food

Height12 -16

mnths

17- 20

mnths

21- 24

mnthsNon

workingWorking

Home

made

Ready

madeBoth Total

Less than 55 cm % 3.3% .0% .0% 2.2% .0% 4.5% .0% .0% 1.1%

55 – 65 cm % 96.7% .0% 3.3% 31.1% 35.6% 27.3% 33.3% 36.8% 33.3%

66 – 90cm % .0% 100.0% 96.7% 66.7% 64.4% 68.2% 66.7% 63.2% 65.6%

Total Count 30 30 30 45 45 22 30 38 90

o Highest number of toddlers n= 59 (96.7%) out of N=30 belonging to 12 to 16 months of age have current height in the range of 55 to 65 cm, while all n=30 (100%) toddlers in 17 to 20 months age group have heights in the range of 66 to 80 cm. o n=29 (96.7%) of toddlers belonging to 21 to 24 months age group have current height in range of 66 to 90 cm.

o Also p value for chi square test between the current height & age is less than 0.05 , so association between the variables is seen.

o Not much difference in current height of toddlers is found in case of working & non working mothers.oSame is true for different types of food fed.

oAlso the p value for chi square test between the above 2 groups of variables in more than 0.05 , so no association is observed between them

Current Head Circumference of toddlers – By their age, occupation of mother & type of food

Age of baby Occupation of mothers Type of food

Head

Circumfere

nce

12 -16

mnths

17- 20

mnths

21- 24

mnths

Non

working

Non

working

Home

made

Ready

madeBoth Total

35 – 40 cm % 100.0% .0% .0% 37.8% 33.3% 31.8% 30.0% 36.8% 33.3%

40- 50 cm % .0% 100.0% 100.0% 62.2% 66.7% 68.2% 70.0% 63.2% 66.7%

Total Count 30 30 30 45 45 22 30 38 90

o Head circumference of toddlers show same trend as current weight & height.

oP value of chi square test between current head circumference & age is less than 0.05 showing association between the 2, whereas p value for chi square test between head circumference & occupation & type of food is more than 0.05.

oSo no association between them is observed

Different types of home made food fed

12 -16 mnths 17- 20 mnths 21- 24 mnths TotalKhichadi + rice porridge 30.00% 20.00% 16.60% 22.30%

Chapatti +dal + scrambled egg 10.00% 6.70% 16.70% 11.10%

Idli+ smashed fruit+ khichdi 6.60% 0.00% 13.40% 6.60%

Khichdi+chickensoup+ dalrice 3.30% 6.70% 6.70% 5.60%

Boiled & smashed veg+curdrice+breastmilk 3.30% 3.30% 3.30% 3.30%

Plain khichdi+veg+banana 0.00% 3.30% 6.70% 3.30%

Mashed fruit+idli+mashed fruit 3.30% 0.00% 3.30% 2.20%

khichadi +v.soup +rice porridge 0.00% 3.30% 0.00% 1.10%

Chapatti veg+ khichdi+breastmilk 0.00% 3.30% 0.00% 1.10%

khichdi+breastmilk+fruitjuice 0.00% 3.30% 0.00% 1.10%

Mix veg khicdi+chapathiveg+curd 0.00% 3.30% 0.00% 1.10%

Ragi porridge+khichdi+scrambled egg 3.30% 0.00% 0.00% 1.10%

Ragi+riceporridge+chickensoup+khichdi 0.00% 0.00% 3.30% 1.10%

Vegsoup+ragiporride 0.00% 3.30% 3.30% 1.10%

Dal khichdi+riceandragi porridge 3.30% 0.00% 0.00% 1.10%

Khichdi+curd+scrambled egg 0.00% 3.30% 0.00% 1.10%

Different types of ready made food fed

12 -16 mnths 17- 20 mnths 21- 24 mnths Total

No readymade 23.30% 26.70% 23.30% 24.40%

Ceralac,Milk biscuit,chocolate 46.70% 60.00% 46.70% 51.10%

Ceralac and lactogen, 13.30% 3.30% 10.00% 8.90%

Milk biscuit,chocolate,Nanpro 6.70% 6.70% 10.00% 7.80%

Powdered milk and ceralac,chocolate 3.30% 0.00% 3.30% 2.20%

Lactogen and milk biscuit 0.00% 3.30% 3.30% 2.20%

Ceralac and fruit juice 3.30% 0.00% 0.00% 1.10%

Nanpro,idli and ceralac 3.30% 0.00% 0.00% 1.10%

Chocolate and milk biscuit 0.00% 0.00% 3.30% 1.10%

Total 30 30 30 90

Nutrient intake

o Mean calorie intake of toddlers across all the three age groups were near the standard values.oThose belonging in the age group of 12 – 16 months have calorie intake (904 ±100). o Toddlers in age group of 17 to 20 months have highest calorie intake of 950 ± 112. o Those in the age group of 21 to 24 months recorded the lowest energy intake with high standard deviation. o So the energy requirements of toddlers in this age group may or may not be fulfilled with the current dietary habit.

o Carbohydrate intake in the toddlers under study was below the standards.oThe above figure also depicts that the mean carbohydrate intake of 17 to 20 months toddlers (97 ± 22 ) is slightly high than those of 21 to 24 months (95 ± 22)o Toddlers in the age group of 12 to 16 months have (92 ± 19) mean carbohydrate intake.

12-16 Months 17-20 Months 21-24 Months

904 950 890980 10001150

Energy IntakeActual mean Std

12-16 Months 17-20 Months 21-24 Months

92 97 9598 120 130

Carbohydrate IntakeActual mean Std

Nutrient intake

o Mean calorie intake of toddlers across all the three age groups were near the standard values.oThose belonging in the age group of 12 – 16 months have calorie intake (904 ±100). o Toddlers in age group of 17 to 20 months have highest calorie intake of 950 ± 112. o Those in the age group of 21 to 24 months recorded the lowest energy intake with high standard deviation. o So the energy requirements of toddlers in this age group may or may not be fulfilled with the current dietary habit. 12-16 Months 17-20 Months 21-24 Months

13 13 1318 18 19

Protein IntakeActual mean Std

12-16 Months 17-20 Months 21-24 Months

33 33 3237 40 44

Fat IntakeActual mean Std

The analysis of the data (figure) highlighted the similar trend in the consumption of fat in the diet of the selected participants of all the three age groups

Nutrient intake

12-16 Months 17-20 Months 21-24 Months

402 353 363

550450 450

Calcium Intake

Actual mean Std The above table states that calcium intake in toddlers belonging to 12 to 16 months of age is 252 ± 54 , which is significantly lower than the standard value range of 400 -500.Calcium intake across the other two age groups is also significantly low than standard

12-16 Months 17-20 Months 21-24 Months

57

4

7 7 7

Iron IntakeActual mean Std

The mean iron intake of toddlers across the three age groups was lower than the standard. However in 12 to 16 months age group toddlers the mean iron intake is 5 ± 1, which is close to the standard. In case of toddlers belonging to 17 to 20 months age, the mean iron intake is 7 ± 12, which is also close to standard.

Correlation between Nutrient Intake & anthropometric measurementsCorrelation

Energy Fat Protein CHO Calcium Iron

Current

Weight

of baby

Pearson

Correlation.047 .096 -.013 -.008 .193 .005

Sig. (2-tailed) .658 .366 .903 .939 .069 .960

N 90 90 90 90 90 90

Current

Height

of baby

Pearson

Correlation.170 .095 -.017 -.001 .031 .066

Sig. (2-tailed) .108 .374 .870 .991 .768 .534

N 90 90 90 90 90 90

Head

Circum

current

Pearson

Correlation.046 .087 -.030 -.026 .044 .061

Sig. (2-tailed) .666 .416 .776 .807 .683 .569

N 90 90 90 90 90 90

Contd…

No significant association was seen between intake of energy, carbohydrate, fat, calcium, iron and the three anthropometric indices of the subjects - current weight, height & head circumference.

This is contradicts with the earlier studies conducted on nutritional requirements in toddlers. Negative correlation exists between current weight and proteins (- 0.13), current height and protein (-

0.17) current head circumference & proteins (-0.30), current weight & height and carbohydrate (-0.08) & (-0.01) respectively.

But a positive significant correlation is seen between current weight and iron (0.05)

Reasons for using homemade food

The top 4 reasons for using homemade food are: It is healthy & nutritious for baby Recommended by elders Less expensive Easy to use

Reasons for using readymade food

Key reasons for using readymade food are found to be: Convenient to use easy to prepare baby eats it well doctor's recommendations publicity through advertisements

Reasons for using both homemade & readymade food

Key reasons for using both homemade & readymade food are: To fulfill nutritional requirements Recommended by doctors/ elders Baby eats well both type of food.

Conclusion

The present study showed that homemade food is generally a preferred choice of food for non working mothers as they believe it to be healthy & nutritious. On the other hand non working mothers’ uses readymade food more often as for them it is convenient & easy to use. Also a combination of homemade& ready made food is used by 38(42%) out of 90 subjects.

It was found that most of the toddlers were fed about 4 to 5 or even more than 5 times in a day, but their nutrient intake were not meeting the standard requirements.

This is not found related to food type, family size, household income or education or occupation of mothers. The mothers are not aware of the nutrition requirements & the type of food required fulfilling their baby’s nutritional requirements.

It is difficult to meet all of the micronutrient needs of toddlers through home-based foods only. A review of 23 complementary food combinations used in developing countries, including some animal products, revealed that although most of the homemade feed could supply enough energy and protein, none had enough iron and few had enough zinc. Animal products supply more of these nutrients but only few, such as liver, have high enough densities to meet requirements.

Thus, the study suggests that complementary feeding is important for toddlers. At the same time educating mothers about right feeding practice & food supplying right nutrition is also important.

Limitations

A larger sample size could not be obtained due to time constraints and participant inconvenience. Mothers from different locations in Mumbai city could be recruited due to feasibility issues, time

constraint. Biochemical parameters could not be conducted due to monetary constraints. 24- Hour dietary recall could not be recorded for the entire population due to feasibility issues There are variables apart from food fed that affects child’s growth, which were not considered in

the survey like mother’s health.

Recommendations

Study could be carried out in different areas and with more number of people. Few in-depth interviews with couples & doctors could be conducted to gauge their opinion on toddler’s nutrition. There could be comparative study for baby girl & baby boy. A food record diary could have been used to record food intake of the subjects. Body composition analysis could be done. Appropriate nutrition in toddlers (12-24 months of age) requires interventions across the life span; from pregnancy into the first 2 year

of life. They include support for maternal nutritional, early initiation of breastfeeding, exclusive breastfeeding for 6 months, and the introduction of adequate complementary foods at or after 6 months.

Influencing appropriate feeding practices is as critical as influencing availability and use of adequate foods. Quality counseling of mothers, and appropriate decision makers on type of food chosen for child are essential for improving infant/

toddler and young child feeding practices. They should be at the centre of any strategy to improve infant and young child nutrition. Identifying approaches to reduce the prevalence of malnutrition particularly in the vulnerable first 2 y of life is a priority in developing countries.

Similarly, strategies should maximize the utilization of locally produced foods in any given setting, and consider the promotion of additional products only if they can fill a critical gap in nutrients in an acceptable, feasible, affordable, sustainable and safe way.

References

Source: www.thousanddays.org http://articles.timesofindia.indiatimes.com/2012-07-02/india/

32508089_1_maternal-mortality-mortality-rate-mdg.