The study was conducted as a part of the school health survey conducted in rural Puducherry. The study population comprised of all the school children with the age group of 7 to 15 years from seliamedu village, Bahour commune, Puducherry, India.

Written permission was obtained from the Directorate of School Education, Government of Puducherry. Prior to the start of the study, informed consent was obtained from the school heads in the seliamedu village. The ethical clearance was also obtained from Institutional Human Ethical Committee. The importance of the study was explained to the staffs, students and teachers in their local language.

Out of 815, 792 (97.2%) students who were present during survey were enrolled from six schools during November 2013 and January 2014. All the students who were present during the survey were included.

Anthropometric measurement like height, weight and mid-arm circumference were recorded as per the standard recommendations [6]. The heights of the students were measured using a portable height measuring device in a standing position. A standard weighing machine was calibrated and the zero error was checked before starting the examination every day. The weight and height were recorded to the nearest 0.1 kg by weighing scale and 0.5 cm by measuring scale respectively.

The z-score for nutritional indices were calculated using WHO Anthro-Software. The prevalence of underweight, stunting and wasting was calculated at cut-off level <-2SD (z-score <-2). Prevalence of severe underweight, stunting and wasting was calculated at cut-off level <-3SD (z-score <-3) [6]. The children on the basis of the z-score were categorized as per the subgroups of Svedberg’s model and Nandy et al., to get the overall CIAF prevalence of undernutrition [7,8]. Statistical analysis was done using EpiInfo 7 [9]. Chi-square test was used to find the associations. A p-value <0.05 was considered statistically significant.

Total 792 school students participated in the study. The response rate was 97.2%. Majority of the students belonged to Hindu religion (91%); 56% of the students were living in nuclear family. Most of the families (64%) belonged to class IV socio-economic status.

Among 792, boys and girls were in nearly equal number (Boys 47.3% and Girls 52.7%) and more than one third of study population (36.4%) belonged to the age group > 158 months followed by 108-132 months [Table/Fig-2].

[Table/Fig-3] shows prevalence of undernutrition among school going children. Around 38%, 34% and 19% of the school children were under-weight, wasting and stunting respectively as per the WHO z-score criteria.

[Table/Fig-3]:

Prevalence of undernutrition based on WHO z-score (n=792).

*undernutrition denotes “below-2 SD” and “below-3 SD”

[Table/Fig-4] shows the sex wise prevalence of under nutrition among the school going children. It was observed that, the prevalence of underweight and wasting were more among male children than female children with significant difference (p<0.05), whereas in stunting, no significant difference found between male and female.

[Table/Fig-5] shows the age wise nutritional status of the school children. It was observed that the prevalence of under-nutrition increased as the age advanced among school children with significant difference (p<0.05).

[Table/Fig-6] shows the nutritional status of the students as per CIAF, based on their anthropometric status. Out of 792, 51.3% of the children were anthropometrically normal; 48.7% of the students were suffering from one or more form of anthropometric failure. It was observed that 6.4 %, 4.4 % and 4.5% of students had only wasting, stunting and underweight respectively. Compared to all the groups, undernourishment was high in C group (wasting +Underweight) that is 18.7%.

The present study was done in a Bahour commune in Puducherry district. The principle focus of the study was to assess the magnitude of undernutrition using z-score and CIAF in the rural school going children. The study participant’s age groups were between 7 to 15 years, 36.4% of the participants were from the age group of 13 to 15 years. Female students (52.7%) enrolment were little higher than the male students (47.3%) in the present study area. This shows that pattern of sex ratio in Puducherry (i.e.,) higher female sex ratio than males [10].

As per WHO z-score system of classification, it was observed that underweight (37.9%) was the most prevalent form of under-nutrition followed by wasting (33.7%) in the current study area, which was similar to the study conducted in Coimbatore, Tamilnadu [11]. In contrast, studies conducted in rural area of Tamilnadu and Kashmir among school children reported higher prevalence (89% and 74%) [12,13]. This stresses the factor that wide range of undernutrition was prevalent in and around Puducherry. This may be due to prevailing socio-economic cultures in the area.

In the present study prevalence of under-nutrition as per WHO z-score system increases as the age advanced among school children with significant difference. Similar to our study, Rema N and Vasanthamani G, and Caroline PK et al., also reported similar pattern of under nutrition prevalence in their studies [11,12]. This stresses the fact that children as age advances have high physical activity leads to excess energy loss together with infections and lack of adequate nutrition could make them more undernourished.

It was observed that the prevalence of underweight and wasting were more among male children than female children using z-score system. Similar to our study, Rema N and Vasanthamani G, reported higher prevalence of underweight among males compared with females whereas Caroline PK et al., reported that prevalence of underweight were common for females than males [11,12]. Higher prevalence of undernutrition among male children was probably due to lack of awareness, delay in seeking health care facility and low education among rural mothers.

As per CIAF criteria in the present study, “children with no failure” (Group A) accounts for 51.3% while children with “Group C” consists of 18.7% and children in Group D “Wasting and Stunting and Underweight” accounts for 9.3%. Relatively high prevalence of wasting and underweight (Group C) was observed among school children is indicative of chronic illness and also food deprivation among them. In contrast, the study done by Nandy et al., reported that, “Children with no failure” (Group A) account for 40.2% while children with “Wasting and Stunting and Underweight” (Group D) account for 7.2% and in another study done by Seetharaman N et al., (31.4%) children were normal and 5.7% of children had “Wasting and Stunting and Underweight” (Group D) [8,14].

By using the conventional growth monitoring used in school health programme based on weight for age i.e., as per WHO method, we can assess only magnitude of undernutrition belonging to groups C, D, E and Y in CIAF method which is about 37.9%. Further we will miss the children in group B and F which form about 10.9% of study population. Therefore, these 86 children (10.9% of study population) who are actually undernourished will be labelled as normal if only weight for age criterion is used. So CIAF can be used to identify the actual number of undernourished children and also by using CIAF classification, undernourished children were disseminated into different groups, which helps to identify children with multiple anthropometric failures and priority can be set for planning the management. Combining WHO along with CIAF method would be better to identify all types of undernutrition instead of using weight for age alone as the criteria.

Prevalence of under-weight, wasting and stunting as per WHO criteria were 38%, 34% and 19% respectively. As per CIAF classification around 49% of the children had anthropometric failure. Using weight for age as the sole criteria for assessing the magnitude of undernutrition in school health programme would give us an underestimate of undernourished children of about 10%.

In India only very few studies had conducted to determine the prevalence of undernutrition using CIAF especially in school children. The study recommends incorporating CIAF system of classification in routine growth monitoring activities in schools to identify the different anthropometric failures, so that priority for policy development can be set for multiple growth failure children followed by others.