Composite Index of Anthropometric Failure and its correlates: a cross-

sectional study of under five children in an urban informal settlement of

Mumbai, India

Manjula Bahuguna, Sushmita Das, David Osrin, Dr. Shanti Pantvaidya, Anuja Jayaraman

March 2021
SNEHA (Society for Nutrition, Education and Health Action) I www.snehamumbai.org

Abstract

Introduction: The use of conventional anthropometric indices by malnutrition management programs may miss
children with dual or multiple forms of growth failure. The Composite Index of Growth Failure (CIAF) helps to identify
such vulnerable children

Objective: We aimed to assess the prevalence of undernutrition and its subgroups using the CIAF among children
under five residing in urban informal settlements of Mumbai, India. We also examined the factors associated with
undernutrition.

Methods: Data from a cross-sectional survey was used to construct CIAF; WHO Z-scores were used to categorize
children into seven subgroups: (A) no failure, (B) wasting only, (C) wasting and underweight, (D) wasting, stunting,
and underweight, (E) stunting and underweight, (F) stunting only, (G) underweight only. Undernutrition prevalence
was assessed by combining all these subgroups except subgroup A. Factors associated with undernutrition were
explored using multilevel logistic regression models adjusted for child, maternal and households socioeconomic
characteristics.

Results: 3394 out of 6489 children (52.3%) were undernourished. Of these undernourished children, 37.2% had
single anthropometric failure, 51.1% had dual anthropometric failures, and 11.6% had multiple anthropometric
failures. Among all subgroups of undernourished children, “stunting and underweight” had the highest prevalence
(44.2%). Child’s age, mother’s age and education, parity, type of toilet facility used, and household economic status
were associated with undernutrition.

Conclusions: The CIAF can be used by nutrition programs to develop need-specific interventions to reduce the risk of
aggravated morbidities and mortality. To improve child health and nutrition, Government programs should continue
to focus on issues related to women’s education and early pregnancies.

Keywords: Malnutrition, Child Health, Community-based nutrition program, Composite Index of Anthropometric
Failure, Urban Health, India

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Introduction
Malnutrition is one of the major underlying causes of preventable child deaths worldwide [1-3]. In low and middle-
income countries approximately 45% of all child deaths can be attributed to poor nutrition [4]. The Global Nutrition
Report (2018) suggests that India has the most children with stunting (46.6 million) and wasting (25.5 million) [5].
Maharashtra, one of the most urbanized states in the country, has the highest proportion of people living in slums
(18.1%), characterized by overcrowding, unhealthy living conditions, lack of basic facilities, poverty and social
exclusion [6]. Children under five years of age living in slums are at higher risk of poor health than children living in
non-slum areas [7]. They are particularly vulnerable to recurrent infections and malnutrition, which have long-term
effects on cognitive development [8].

Malnutrition management programs use anthropometric screening to assess growth patterns and nutritional status,
to identify individuals at risk, to customize nutritional counselling, and to make appropriate referrals [9]. India’s
National Family Health Survey uses World Health Organization indices - low weight for age (underweight), low height
for age (stunting) and low weight for height (wasting) - to assess undernutrition among children under five [10]. The
Integrated Child Development Services (ICDS), India’s foremost early childhood care and development program, uses
underweight for anthropometric screening and provides supplementary nutrition to undernourished children in
communities [11]. Development economist Peter Svedberg suggested that conventional indices might be insufficient
as a measure of prevalence of child undernutrition due to indices overlapping; a child who is underweight may also
be stunted and/or wasted. Svedberg proposed an alternative indicator, the Composite Index of Anthropometric
Failure (CIAF), to categorise children into six subgroups according to wasting, stunting and underweight status [12].
The CIAF was later modified to include another subgroup of children who were only underweight [13].

A UNICEF, WHO and World Bank Group report on levels and trends in child malnutrition also suggests that some
children suffer from more than one form of malnutrition and currently there are no global or regional estimates for
such children [14]. Nandy et al. (2005) suggested that children with dual anthropometric failure were more likely to
have diarrhoea than single anthropometric failure and children who were simultaneously wasted, stunted and
underweight had the highest odds of having diarrhoea and acute respiratory infections [13]. Mcdonald et al. (2013)
suggest that children with dual anthropometric failure were at a heightened risk of mortality and children with all
three anthropometric failures had a 12-fold elevated risk of mortality [15].

In a single classification, the CIAF gives a comprehensive picture of the scale of undernutrition and can help to
identify the type of intervention required for the most prevalent subgroup in the community. In India, a few studies
have assessed undernutrition prevalence using the CIAF and a few have also studied associated factors such as child
age and sex, socioeconomic status, maternal education, birth order, birth intervals, exclusive breastfeeding,
childhood morbidities, and number of siblings [16-20].

Our study aimed to establish the overall extent of undernutrition along with its associated factors, using the CIAF in
urban informal settlements of Mumbai. The objectives were (1) to assess the prevalence of undernutrition and its
subgroups using the CIAF in children aged 0-59 months residing in urban informal settlements of Mumbai, and (2) to
determine the association of undernutrition with child, maternal and household socioeconomic characteristics.

Methods
Study setting, program description and participants:
In 2011, a randomized control trial was initiated in urban informal settlements of Mumbai. 40 areas (20 control, 20
intervention) of M-East ward (HDI 0.05) and L ward (HDI 0.29); wards with lowest human development index, were
chosen for intervention [21]. Each intervention areas had a community resource centre to provide community-level
access to a range of services related to health, nutrition, and safety to women and children. Married women of
reproductive age (15-49 years) and children (0-5 years) were the primary beneficiaries. Key intervention activities
were growth monitoring through monthly anthropometric screening, regular home visits to provide information on
family health needs and appropriate referrals, day-care centres for early childhood care and development activities
for severely malnourished children, service provision by clinicians and counsellors, group meetings and community
events to create a conducive environment for women’s and children’s health.
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Data source: We used the trial’s post-intervention census data collected between February 2014 and September
2015. In each household, the youngest married woman of reproductive age (15-49 years) was interviewed to obtain
information on socioeconomic status, household characteristics, obstetric history, family planning practices and
uptake of health services. Anthropometric data of all children in census were collected by measuring height/length
and weight. Lengths of children younger than two years were measured with a Rollameter accurate to 1mm with an
assistant holding the child’s head. Heights of children aged two years and older were measured with a Leicester
stadiometer accurate to 1 mm, at the end of expiration with feet together against the backboard, back straight, and
head in the Frankfort plane. Weights were measured with Seca 385 electronic scales accurate to 10g. Training for
data collectors was repeated on two occasions, for which the indicative technical errors of measurement for height
were 0·6%, and 0·5% [22].

Study variables: Nutritional status was assessed by both conventionally used undernutrition indices (wasting,
stunting, underweight) and CIAF. Age- and sex-specific weight-for-age Z scores (WAZ), height-for-age Z scores (HAZ)
and weight-for-height Z scores (WHZ) were generated using World Health Organization growth standards and the Z
SCORE06 module in Stata/IC (version 13.1). Following Nandy et al. 2005, CIAF was constructed using Z-scores to
categorize children into seven subgroups: (A) no failure, (B) wasting only, (C) wasting and underweight, (D) wasting,
stunting, and underweight, (E) stunting and underweight, (F) stunting only, and (G) underweight only [13]. Based on
the CIAF, a child was considered undernourished if they had any form of anthropometric failure.

Data Analysis: Factors associated with undernutrition in children (0-59 months) were explored using multilevel
logistic regression model adjusting for child, maternal and socioeconomic characteristics of the household.
Independent variables with p <0.25 in bivariate analysis were included in the final regression model. These included
child’s age, mother’s age, religion, education, length of residence in Mumbai, parity, exposure to violence, uptake of
health services, number of household residents, source of drinking water, type of toilet facilities, and asset index
quartile. For each explanatory variable, the crude odds ratio was presented along with the adjusted odds ratio (AOR)
and 95% confidence intervals (CI). All analysis was conducted in STATA 12.0 (StataCorp, College Station, TX).

Ethical statement
The study received ethical approval from the Multi-Institutional Ethics Committee of the Anusandhan Trust,
Mumbai, India, in sequential reviews: formative research (February, 2011), cluster vulnerability (May, 2011), the pre
intervention census (August, 2011), and the intervention and assessments (January, 2012). It was also approved by
the University College London Research Ethics Committee, UK, in January, 2012 (reference 3546/001).

Results
Post-intervention census data were collected from 24,939 households. 16,236 married women aged 15-49 years
were interviewed including 7601 women with 10,551 children under age five. A total of 6489 children under age five
were included in the analysis for this study, as seen in Figure 1.

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Figure 1: Study profile

24,939 households

15,907 households with 17,568 married women aged 15–49

y eligible for interview

16,236 married women aged 15–49 y interviewed

7601 married women aged 15–49 y with under 5 children

10,551 children: 4544 children under 2 y and 6007 2- 5 y

children

4062 children excluded

- 2642 second born
- 298 third born/more
- 19 sets of twins
- 30 incomplete information
- 1054 anthropometry data not available

6489 children in the study

- 3578 under 2 y children in the study
- 2911 2-5 y children in the study
-
Table 1 presents the prevalence of child undernutrition. Based on the CIAF classification, more than half of the
children were undernourished.

Table 1: Prevalence of undernutrition as per CIAF classification

CIAF classification n %
Group A No failure 3095 47.7
Group B Wasting only 109 1.7
Group C Wasting and underweight 237 3.7
Group D Wasting, stunting, and underweight 393 6.0
Group E Stunting and underweight 1499 23.1
Group F Stunting only 963 14.8
Group Y Underweight only 193 3.0
Total 6489 100.0
Undernutrition (Group B + Group C + Group D + Group E + Group F + Group Y) = 52.3%

Conventional indices of undernutrition showed 11.4% wasting, 35.7% underweight and 44.0% stunting. Conventional
wasting includes children of CIAF groups B, C, and D, but omits the 40.9% of children of groups E, F, and Y.
Conventional underweight includes children of CIAF groups C, D, E, and Y, but omits the 16.5% of children of groups
B and F. Conventional stunting includes children of CIAF groups D, E, and F, but omits the 8.3% of children of groups
B, C, and Y.

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Table 2 presents frequencies and proportions of respondent characteristics, along with prevalence of CIAF growth
failure for each characteristic.

Table 2: Child, maternal, socioeconomic characteristics and proportionate undernutrition prevalence

CIAF no failure CIAF failure Total
N=3095 N=3394 N=6489
Child Characteristics
Age n % N % n %
Less than 2 years 1928 62.3 1650 48.6 3578 55.1
2-5 years 1167 37.7 1744 51.4 2911 44.8
Sex
Male 1575 50.9 1772 52.2 3347 51.6
Female 1520 49.1 1622 47.8 3142 48.4
Maternal Characteristics
Age
Less than 25 years 840 27.1 883 26.0 1723 26.5
25-29 years 1216 39.3 1302 38.4 2518 38.8
30 years or above 1039 33.6 1209 35.6 2248 34.6
Religion
Muslim 2605 84.2 2820 83.1 5425 83.6
Hindu 484 15.6 568 16.7 1052 16.2
Other 6 0.2 6 0.2 12 0.18
Education
Illiterate 764 24.7 1080 31.8 1844 28.4
Primary (grades 1-4) 142 4.6 192 5.7 334 5.1

Secondary (grades 5-10) 1867 60.3 1880 55.4 3747 57.7

Higher (grade 11 or higher) 322 10.4 242 7.1 564 8.7

Length of stay in Mumbai
<=1 year 293 9.5 359 10.5 652 10.7
2-5 years 608 19.6 652 19.2 1260 20.8
6-10 years 492 15.9 537 15.8 1029 16.9
>10 years 1501 48.5 1625 47.9 3126 51.5
Missing 201 6.5 221 6.5 422 0.06
Parity
3 or more children 1413 45.7 1732 51.0 3145 48.5
1 or 2 children 1682 54.3 1662 49.0 3344 51.5
Exposure to spousal
violence in last 2 years
No 2754 89.0 2964 87.3 5718 88.1
Yes 341 11.0 429 12.6 770 11.9
Missing 0 0.0 1 0.0002 1 0.0001
Uptake of health services
in last 1 year
None 892 28.8 995 29.3 1887 29.0
Only government 1656 25.5
(ICDS/BMC) 824 26.6 832 24.5
Community resource 1379 21.2
centre 643 20.8 736 21.7
Both 736 23.8 831 24.5 1567 24.1

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Socio-economic characteristics
Number of household
members
Less than or 5 1612 52.1 1735 51.1 3347 51.6
5 or more 1483 47.9 1659 48.9 3142 48.4
Drinking water source
Public 2295 74.1 2688 79.2 4983 76.8
Private 800 25.9 706 20.8 1506 23.2
Type of toilet facility
Public 2451 79.2 2890 85.1 5341 82.3
Private 644 20.8 504 14.9 1148 17.7
Asset index quartile
1 (Poorest) 752 24.3 1009 29.7 1761 27.1
2 680 22.0 874 25.8 1554 23.9
3 807 26.0 784 23.1 1591 24.5
4 (Least poor) 856 27.7 727 21.4 1583 24.4

Factors associated with undernutrition: The results of multivariable logistic regression suggest that child’s age,
mother’s age, her education, parity, type of toilet facility and economic status were associated with undernutrition.
Table 3 shows that children in the age group 2-5 years had higher odds [AOR 1.93, 95% CI 1.72, 2.15] of being
undernourished than children less than two years old. Older mothers (>=30years) had lower odds [AOR 0.73, 95% CI
0.62, 0.86] of having undernourished children than mothers below 25 years of age. Compared with children of
women with no education, children of women with secondary [AOR 0.78, 95% CI 0.69, 0.89] or higher education
[AOR 0.67, 95% CI 0.54, 0.84] were less likely to be undernourished. Women with one or two children had lower
odds [AOR 0.83, 95% CI 0.72, 0.94] of having an undernourished child than women with three or more children.
Households using private toilets were less likely [AOR 0.78, 95% CI 0.66, 0.91) to have undernourished children than
households using public toilets. Children living in less poor [AOR 0.75, 95% CI 0.64, 0.87] or wealthier [AOR 0.71, 95%
CI 0.59, 0.84] households had lower odds of being undernourished than children residing in poorer households.

Table 3: Factors associated with undernutrition

Adjusted odds ratio (95%
Child Characteristics Crude odds ratio (95% CI) CI)
Age
Less than 2 years 1 1
2-5 years 1.74 (1.58, 1.92) 1.93 (1.72, 2.15) ***
Sex
Male 1 1
Female 0.94 (0.86, 1.04) 0.96 (0.86, 1.06)
Maternal Characteristics
Age
Less than 25 years 1 1
25-29 years 1.01 (0.90, 1.15) 0.81 (0.71, 0.94) **
30 years or above 1.10 (0.97, 1.25) 0.73 (0.62, 0.86) ***
Religion
Muslim 1 1
Hindu 1.08 (0.94, 1.23) 1.14(0.99, 1.32) *
Education
Illiterate 1 1
Primary (grades 1-4) 0.95 (0.75, 1.21) 0.90 (0.70, 1.16)
Secondary (grades 5-10) 0.71 (0.63, 0.79) 0.78 (0.69, 0.89) ***
Higher ( grade 11 or higher) 0.53 (0.43, 0.64) 0.67 (0.54, 0.84) ***

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Length of stay in Mumbai

<=1 year 1 1
2-5 year 0.87 (0.72, 1.05) 1.0 (0.81, 1.22)
6-10year 0.89 (0.73, 1.08) 0.93 (0.75, 1.15)
>10year 0.88 (0.74, 1.04) 0.99 (0.82, 1.20)
Parity
3 or more children 1 1
1or 2 children 0.80 (0.73, 0.88) 0.83 (0.72, 0.94) **
Exposure to spousal violence in last 2 years
No 1 1
Yes 1.16 (1.0, 1.35) 1.11 (0.94, 1.30)
Uptake of health services in last 1 year
None 1 1
Government (ICDS/BMC) 0.90 (0.79, 1.03) 1.05 (0.91, 1.22)
Community resource centre 1.02 (0.89, 1.17) 1.06 (0.91, 1.23) *
Both 1.01 (0.88, 1.15) 1.21 (1.04, 1.40)
Socio-economic characteristics
Number of household members
Less than or 5 1 1
More than 5 1.03 (0.94, 1.14) 1.13 (1.00, 1.26) *
Drinking water source
Public 1 1
Private 0.75 (0.67, 0.84) 0.92 (0.80, 1.07)
Type of toilet facility
Public 1 1
Private 0.66 (0.58, 0.75) 0.78 (0.66, 0.91) **
Asset index quartile
1(Poorest) 1 1
2 0.95 (0.83, 1.09) 0.97(0.84, 1.13)
3 0.72 (0.63, 0.82) 0.75(0.64, 0.87) ***
4 (Least poor) 0.63 (0.55, 0.72) 0.71(0.59, 0.84) ***
“Statistical significance is calculated using mixed effects logistic regression models: * p value: ≤0.05; * * p value:
≤0.01; *** p value: ≤0.001"

Discussion
Undernutrition prevalence was higher as per CIAF, which can be attributed to the ability of CIAF to count children
with dual and multiple anthropometric deficits. Recent studies have assessed undernutrition prevalence using the
CIAF as 48.5% in Ethiopia, 21.7% in rural China and 47.9% in urban Bangladesh [23-25]. In India, studies from
different states used CIAF to estimate undernutrition prevalence and report a higher prevalence as compared to our
study. According to various studies from West Bengal, undernutrition prevalence ranged from 57.6% to 73.1%, much
higher than in our study [16, 17, 26-28]. Jammu and Kashmir (73.2%), Gujarat (60.5%), Chhattisgarh (62.1%), and
Orissa (54.5%) also had higher undernutrition prevalence than observed in our study [20, 29-31]. In Nagpur,
Maharashtra, 51% of children were reported to be undernourished which was similar to that in our study and in the
western suburbs of Mumbai undernutrition prevalence was 47.8%, lower than that of our study [18, 32].

Our study found 6% of children had all three forms of anthropometric failure, which is less than the corresponding
prevalence in the study by Savanur et al. 2015 conducted in the western suburbs of Mumbai, suggesting that 8.2% of
children suffered simultaneously from wasting, stunting and underweight. We found that among all groups of CIAF,
group E, “Stunting and underweight,” had the highest prevalence (23.1%), which is similar to the study done in the
western suburbs of Mumbai that reported the stunting and underweight prevalence as the highest (16.1%) [32]. Our
study showed that by using weight-for-age criteria, we missed 16.5% of children who were considered
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undernourished using other indices, which is similar to other studies missing 12.1% to 21.9% of undernourished
children [33-35]. Failure to identify these children could have consequences including increased morbidity and
mortality [13, 15].

Our study found that as the age of the child increases, the risk of undernutrition increases, a finding consistent with
the studies conducted in India [16, 19] and Ethiopia [23]. Our study found that young mothers were at greater risk of
having undernourished children, which is consistent with the studies suggesting linear growth failure in children of
teenage mothers [36, 37]. The negative association found between level of maternal education and child
undernutrition was consistent with other studies in India [16-18], Ethiopia [23], China [24], and Bangladesh [25]. This
may be because mothers with higher education are most likely to follow healthy practices while taking decisions
about their child’s health [38-40]. The association between parity and undernutrition is similar to the studies
suggesting that children with more than three siblings are at higher risk of being undernourished [17-20]. In
addition, our study found a statistically significant association between use of public toilets and undernutrition,
which may be due to environmental enteropathy caused by living in poor and unhygienic conditions [41, 42]. This,
however, needs to be interpreted carefully considering recent WASH trials [43, 44]. We found that children of poor
socioeconomic status were at greater risk of undernutrition, which is consistent with studies from Ethiopia [23],
China [24], Bangladesh [25] and India [18, 19].

CIAF has its limitations similar to conventional anthropometric indices. Anthropometric indices are used as proxy
indicators for undernutrition among children and do not distinguish between different underlying causes such as
illness versus purely poor nutrition. CIAF may overestimate the undernutrition prevalence by including children with
anthropometric failure due to the outcome of diseases and other non-nutrition related factors [12]. These indices
also do not identify specific nutritional deficiencies, which should be assessed through other methods like
biochemical, clinical and dietary assessment [9]. Our study did not consider variables such as children’s diet and
morbidity which may have confounding effect on the results. Finally, the association between undernutrition and its
correlates was based on cross-sectional data and cannot be used to establish a causal relationship.

Conclusion
More than half of children in the age group 0-5 years were suffering from one or the combined forms of
anthropometric failure. Children having young and uneducated mothers, with siblings, using public toilets and from
poor socioeconomic backgrounds were at greater risk of falling into any category of anthropometric failure.
Therefore, government programs should continue to focus on improving women education and early pregnancies
among women in urban areas. Malnutrition management programs often use conventional anthropometric indices
separately which prevents the identification of the subgroup of children who are at greatest risk with dual or
multiple anthropometric deficits. We recommend the use of the CIAF to identify these vulnerable children for better
coverage of services to improve their health and nutritional status. Each category needs specific interventions - not
one size that fits all. Given the limited resources, drawing these finer distinctions will not only help in further
reduction of undernutrition but will help in prioritizing interventions for children with multiple anthropometric
failure to reduce the risk of aggravated morbidities and mortalities. Our findings further support the advocacy of
taking length/height measurement of children by the ICDS and thereby improve the precision by which this agency
identifies nutritionally vulnerable children.

Acknowledgements
We are very grateful to the women and their families who made this study possible by allowing us into their homes
to interview them. We thank the entire intervention staff for implementation of the program operations. We are
thankful to the field investigators for data collection and field officers for supervision. We thank Neena Shah More
for reviewing the paper and Latika Bhosale and Laxmi Solanki for data management. We are thankful to Archana
Bagra, Vanessa D’Souza and members of SNEHA Research Group.

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