Beyond Food Insecurity: Multidimensional Determinants of Moderate and Severe Acute Malnutrition Among Children Aged 6–60 Months in Rural India

Author

Atul Gopal Agrawal, Ankita Agrawal

Abstract

 Background: Acute malnutrition remains a leading preventable cause of child morbidity and mortality in India. Most local evidence on its determinants is cross-sectional, so strengths of association are poorly quantified. We identified risk and protective factors for moderate (MAM) and severe (SAM) acute malnutrition among rural children aged 6–60 months.

Methods: We conducted a community-based, age-matched case–control study (January–October 2024) in Anganwadi catchment areas of a rural block in Karimnagar, using four-stage sampling (1 block, 2 primary health centres, 4 sub-centres, 28 Anganwadi centres). Cases (n = 133) were children with weight-for-length/height Z-score < −2 (WHO standards); controls (n = 133) had Z-scores between −2 and +2 and were selected from the same villages within the same age band (6–24 or 25–60 months). Exposures were collected by pretested questionnaire. Associations were assessed using χ² tests and crude odds ratios (OR); variables significant on univariate analysis entered a multivariable logistic regression to obtain adjusted ORs (aOR) with 95% confidence intervals (CI).

Results: In the final model, the strongest independent risk factors were indoor air pollution (aOR 8.7; 95% CI 5.9–17.3), birth interval ≤24 months (6.8; 3.3–12.3), low birth weight (4.65; 2.52–8.5), absent proper waste disposal (4.2; 2.3–7.3), unsafe hand-washing (4.14; 1.56–10.9), incomplete vitamin A supplementation (3.58; 1.4–8.8), non-use of a sanitary latrine (3.3; 1.89–5.4), and continued breastfeeding for <1 year (3.1; 1.7–5.7). Overcrowding, nuclear family, late breastfeeding initiation, non-exclusive breastfeeding, bottle feeding, failure to meet minimum dietary diversity, meal frequency and acceptable diet, untrained caregivers in infant and young child feeding (IYCF), and frequent illness were also independently associated (aOR 1.9–2.9). Higher socioeconomic status (0.33; 0.16–0.67), safe drinking water (0.35; 0.20–0.62) and normal vaginal delivery (0.44; 0.24–0.80) were protective. Sex, religion, parental occupation and type of housing were not associated.

Conclusions: Acute malnutrition in rural India is driven by a cluster of modifiable household-environment, maternal-birth and feeding-practice factors. Integrating clean-household-energy, sanitation and hygiene promotion, birth-spacing and low-birth-weight prevention, and IYCF counselling into Anganwadi and POSHAN Abhiyaan platforms may deliver the largest gains.

Keywords

acute malnutrition; wasting; severe acute malnutrition; case–control study; risk factors; infant and young child feeding; indoor air pollution; India

Full Text:

Download Paper PDF

References

1. World Health Organization. Guideline: prevention and management of wasting and nutritional oedema (acute malnutrition) in infants and children under 5 years. Geneva: WHO; 2023.
2. Assessing and managing children at primary health-care facilities to prevent overweight and obesity in the context of the double burden of malnutrition: updates for the Integrated Management of Childhood Illness (IMCI). Geneva: WHO; 2017.
3. UNICEF, World Health Organization, World Bank Group. Levels and trends in child malnutrition: UNICEF/WHO/World Bank Group Joint Child Malnutrition Estimates, key findings of the 2025 edition. New York/Geneva/Washington DC; 2025.
4. International Institute for Population Sciences (IIPS), ICF. National Family Health Survey (NFHS-5), 2019–21: India. Mumbai: IIPS; 2021.
5. Black RE, Victora CG, Walker SP, et al. Maternal and child undernutrition and overweight in low-income and middle-income countries. Lancet. 2013;382:427–51.
6. WHO Multicentre Growth Reference Study Group. WHO Child Growth Standards: length/height-for-age, weight-for-age, weight-for-length, weight-for-height and body mass index-for-age: methods and development. Geneva: WHO; 2006.
7. WHO, UNICEF. Indicators for assessing infant and young child feeding practices: definitions and measurement methods. Geneva: WHO; 2021.
8. Ambadekar NN, Zodpey SP. Risk factors for severe acute malnutrition in under-five children: a case-control study in a rural part of India. Public Health. 2017;142:136–43.
9. Ansuya, Nayak BS, Unnikrishnan B, et al. Risk factors for malnutrition among preschool children in rural Karnataka: a case-control study. BMC Public Health. 2018;18:283.
10. Ayana AB, Hailemariam TW, Melke AS. Determinants of acute malnutrition among children aged 6–59 months in public hospitals, Oromia region, West Ethiopia: a case–control study. BMC Nutr. 2015;1:34.
11. Prashanth MR, Savitha MR, Prashantha B. Risk factors for severe acute malnutrition in under-five children attending nutritional rehabilitation centre of tertiary teaching hospital in Karnataka: a case control study. Int J Contemp Pediatr. 2017;4:1721–6.
12. Madhusudhan K, Rajeev PK, Shireesha A, Ushashree GV. Study of risk factors of severe acute malnutrition (SAM) in children 6 months to 5 years of age and evaluation of effect of micronutrient supplementation on serum zinc and magnesium levels: a case control study. Int J Contemp Pediatr. 2017;4:1198–205.
13. Bhadoria AS, Kapil U, Bansal R, Pandey RM, Pant B, Mohan A. Prevalence of severe acute malnutrition and associated sociodemographic factors among children aged 6 months–5 years in rural population of northern India: a population-based survey. J Family Med Prim Care. 2017;6:380–5.
14. Ghimire U, Aryal BK, Gupta AK, Sapkota S. Severe acute malnutrition and its associated factors among children under-five years: a facility-based cross-sectional study. BMC Pediatr. 2020;20:249.
15. Ulahannan SK, Wilson A, Chhetri D, Soman B, Prashanth NS. Alarming level of severe acute malnutrition in Indian districts. BMJ Glob Health. 2022;7:e007798.
16. Chaudhari S, Kumar Y, Nirupama AY, Agiwal V. Examining the prevalence and patterns of malnutrition among children aged 0–3 in India: comparative insights from NFHS-1 to NFHS-5. Clin Epidemiol Glob Health. 2023;24.
17. Dipasquale V, Cucinotta U, Romano C. Acute malnutrition in children: pathophysiology, clinical effects and treatment. Nutrients. 2020;12(8):2413.
18. Murarkar S, Gothankar J, Doke P, et al. Prevalence and determinants of undernutrition among under-five children residing in urban slums and rural area, Maharashtra, India: a community-based cross-sectional study. BMC Public Health. 2020;20:1559.
19. Singh S, Srivastava S, Upadhyay AK. Socio-economic inequality in malnutrition among children in India: an analysis of 640 districts from National Family Health Survey (2015–16). Int J Equity Health. 2019;18:203.
20. Harding KL, Aguayo VM, Webb P. Factors associated with wasting among children under five years old in South Asia: implications for action. PLoS One. 2018;13(7):e0198749.
21. Khan S, Zaheer S, Safdar NF. Determinants of stunting, underweight and wasting among children <5 years of age: evidence from 2012–2013 Pakistan Demographic and Health Survey. BMC Public Health. 2019;19:358.
22. Ghosh-Jerath S, Singh A, Jerath N, Gupta S, Racine EF. Undernutrition and severe acute malnutrition in children. BMJ. 2017;359:j4877.
23. Rasmussen J, Andersen A, Fisker AB, et al. Mid-upper-arm-circumference and mid-upper-arm circumference z-score: the best predictor of mortality? Eur J Clin Nutr. 2012;66:998–1003.
24. Victora CG, Christian P, Vidaletti LP, Gatica-Domínguez G, Menon P, Black RE. Revisiting maternal and child undernutrition in low-income and middle-income countries: variable progress towards an unfinished agenda. Lancet. 2021;397:1388–99.
25. Government of India, Ministry of Women and Child Development. POSHAN Abhiyaan and malnutrition among children [Internet]. New Delhi: Government of India; 2022 Mar 16.
26. United Nations General Assembly. Transforming our world: the 2030 Agenda for Sustainable Development. A/RES/70/1. New York: United Nations; 2015.
27. Sahu SK, Kumar SG, Bhat BV, et al. Malnutrition among under-five children in India and strategies for control. J Nat Sc Biol Med. 2015;6:18–23.
28. von Elm E, Altman DG, Egger M, et al. The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: guidelines for reporting observational studies. Lancet. 2007;370:1453–7.
29. Hosmer DW, Lemeshow S, Sturdivant RX. Applied logistic regression. 3rd ed. Hoboken (NJ): Wiley; 2013.