Assessing the prevalence of malnutrition in tribal children using MUAC as a screening tool [version 1; peer review: 1 approved, 1 approved with reservations, 1 not approved]

Children malnutrition is a major public health problem in India. Malnutrition has the maximum impact on children living in rural and tribal areas. Various anthropometric indices such as weight–for-age, height-for-age, weight-for- height and Body Mass Index (BMI) are used to assess the nutritional status of the children. Mid-upper-arm circumference (MUAC) is being used as an alternative to traditional measurements like height and weight, particularly in emergency settings. The World Health Organization (WHO) has recommended MUAC to be used as an independent diagnostic criterion for assessing severe acute malnutrition among children. A total of 4502 children between 6-59 months of age were screened over a period of 12 months, in seven Medicins Sans Frontiers (MSF) Project mobile clinic sites located in states of Andhra Pradesh and Chhattisgarh border areas in India. MUAC was measured with MSF-designed fiber optic measuring tapes. In general, the overall prevalence of malnutrition among 6-59 months children was 15.2%. However the prevalence of malnutrition was higher among children of 6-23 months age group (25.8%) as compared to children of 24-59 months (5.4%). Despite various national nutritional intervention programs have been in operation for about four decades, the malnutrition remains very high particularly among the children living in hilly and remote tribal villages.


Introduction
Periodic growth monitoring of children is an important indicator of the health and nutritional well being of the population. Child undernutrition remains a major public health problem in many countries, and continues to hamper children's physical growth and mental development 1 . India registered an impressive growth in term of GDP during last few years, but the malnutrition rates among the Indian children remains high. As reported by UNICEF, in India, about 46% of children below three years have stunting (height-for-age <Median-2SD), while 47% have underweight and 16% are wasted 2 .
Traditionally, nutritional status was evaluated using anthropometric measures like height, weight and indices like body mass index (BMI) 3 . However mid-upper-arm circumference (MUAC) is being used as an alternative index of nutritional status for children during famines or refugee crises and as an additional screening tool in nonemergencies, and is based on a single cut-off value for all the children less than five years of age 4 . Studies showed that under conditions of reduced food intake, lower levels of subcutaneous fat and muscle mass in human arms tend to correspond to a decrease in the MUAC 5 . In 2005, the World Health Organization (WHO) recommended a MUAC cut-off of 110 mm as an independent diagnostic criterion for severe acute malnutrition. However a higher cut off point of 115 mm was recommended later by WHO as it allows to identify a more accurate number of infants and children with severe acute malnutrition and has a high specificity of more than 99% over the age range 6-60 months 6 . There is large body of evidence strongly suggesting that MUAC is a better indicator of acute malnutrition than weight/height particularly for use in emergency feeding programs 7 .

About MSF, India
Since October 2006, MSF (Médecins Sans Frontièrs, Doctors without Borders) is committed to providing health services to the people in the Naxal-affected regions of Dantewada (Chhattisgarh state) and Khammam (Andhra Pradesh state) in India. MSF India provides impartial medical assistance to the populations with little or no access to health care in these regions. The agency provides primary and secondary healthcare including reproductive health, immunization, health education and treatment of tuberculosis (TB), malaria and diarrhoea among other diseases in conflict-affected areas. MSF runs a Mother and Child Health Centre (MCHC) in Bijapur, Chhattisgarh, also in addition to other mobile clinics that provide health care directly to people in both states 8 .

Materials and methods
MSF teams carried out MUAC screenings at the Maita, Mallampeta, DharmanaPeta, Pusuguppa, Tippapuram, Yampuram and Puttapalli mobile clinics. MUAC was measured using MSF-designed fiber optic color-coded measuring tapes divided into 2 mm additions 12 . A girth of the child's arm within the green part of the tape indicates a normal nutritional status. The yellow part of the tape indicates that the child is at risk of malnutrition, the orange color indicates that the child is moderately malnourished and the red color indicates a severe malnutrition and threat of death [MSF Refugee Handbook] (Table 1).
From January 2012 to December 2012, in the above mentioned clinics (Table 2), 2162 children between 6 and 23 months of age and 2340 children between 24 and 59 months of age were screened, making a total of 4502 children. The data were collected over a period of 12 months from seven MSF project clinics in the states of Andhra Pradesh and Chattisgarh namely Maita, Mallampeta, DharmanaPeta, Pusuguppa, Tippapuram, Yampuram and Puttapalli. These mobile clinics are in hard to reach remote hilly tribal villages with poor infrastructural facilities. In addition to MUAC screening, all children attending the mobile clinics with or without health problems were also screened for estimated age which was determined by noting the birth date recorded on the child's vaccination card. We have limitation on the availability of data for yellow and green colour measurements.

Results
Among the children between 6 and 23 months of age the severe malnutrition (indicated by the red colour) was 3.8%, whereas in children between 24 and 59 months of age was relatively much lower (0.59%). Similarly, moderate malnutrition among the 6-23 months aged children was almost 22%, significantly higher compared to 24-59 months aged children, which was only 4.8%. The cumulative malnutrition rate among the 6-23 months aged children was 25.8% and among the children between 24 and 59 months of age was 5.4%. However, the overall malnutrition among all screened 6-59 months aged children (4502) was 15.2% (Table 3).

Discussion
The severe malnutrition rates reported in this study are relatively lower compared to figures reported by National Family Health Survey-3 (NFHS 3) (6.8%), which was carried out across the country among the same age group of children. However, the under nutrition rates reported in this study is still high which may have significant negative impact on health, education and productivity of the children. Persistent undernutrition is a major obstacle to human development and economic growth in India, especially among the rural poor and vulnerable areas, where the prevalence of malnutrition is the highest 9 . Illiteracy, poor health seeking behaviour, unavailability of health care services and poor infrastructure might be other contributing factors of malnutrition among these tribal populations.
The advantage of using the MUAC measurement compared to other nutritional indices is that it is simple to use and it is good to identify the high risk children who need urgent treatment, facilitating the better coverage at the screening and/or diagnostic stage, which is a key component of program success 11 . The revision of the MUAC cut off by WHO to identify severe malnutrition is useful in early diagnosis in less severe state of malnutrition whereby it reduces the duration of treatment in therapeutic feeding centres 6 .
The government of India is implementing various nutritional interventions including ICDS (Integrated Child Development Services) to address the malnutrition problem among children 9 . The ICDS program is a well designed and well placed program to address the child undernutrition in the country. However there was more emphasis on coverage rather than on the quality of the program which resulted in limited impact in addressing the malnutrition problem 9 . Hence, it is necessary that the current ICDS program focuses on improving the quality of tools used to fight the persistent malnutrition among the under-five years old children.
Faulty feeding practices negatively affect the children's nutritional status, and the current nutrition programs have been unable to make much progress in dealing with these serious issues 11 . We believe that public health interventions for severe malnutrition must simultaneously focus on preventive and promotive aspects, and therapeutic interventions in the community. There is a paucity of local evidence especially in tribal areas which lack clarity about the possible therapeutic protocols to implement community-based management of severe malnutrition. Evidence from other countries may not be relevant to a very diverse and vast country like India. Research organizations and funding agencies need to prioritize the research further and build a valid evidence base to implement community based malnutrition programs.

Data availability
MSF obtained data pertaining only to orange and red colour measurements, as the purpose of MUAC screening at mobile clinics was to detect only those children who were malnourished enough to be included in ATFP [Ambulatory Therapeutic Feeding Programme]. For children to qualify for this programme their MUAC measurements should be <118 mm. Hence, only orange and red color measurements data were collected. MSF did not record green and yellow colour measurements for the above mentioned reason.

Ethical considerations
Data were obtained from MSF mobile clinic databases and as a retrospective study, ethical clearance was not necessary. We thank MSF for providing such data.
Author contributions SBK and IQ conceived and designed the study. MQ, IQ, SA, SBK analysed the data. SBK and IQ interpreted the data. SBK and MQ drafted the article. All authors revised the article and gave the final approval for publication.

Competing interests
No competing interests were disclosed.

Grant information
The author(s) declared that no grants were involved in supporting this work. This is an important topic and data collected in field operations can be potentially informative to practitioners in India and elsewhere. The main results are given as the prevalence of moderate and severe malnutrition determined by MUAC at 7 mobile clinics in an area affected by chronic insurgency. The paper would be considerably strengthened by a more detailed description of research question being asked, the population and how they were sampled. As currently written, no data on treatment and its outcomes are given. Without these, it will be difficult to draw policyrelevant conclusions.
In the Introduction, it would be helpful to clarify some of the terminology for readers: In 'However a higher cut off point of 115  Are there any data on outcomes of treatment? This would make the manuscript much stronger.

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In the Discussion: It is not possible to make comparisons with the NFH without the study design having aimed to collect community rather than clinic-based populations. This needs to be clarified above. If the population is representative of clinic attendees, then this comparison should be deleted.

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For the sentence 'evidence from other countries may not be relevant to a very diverse and vast country like India.', please be much more specific. Do the authors mean anthropometry (posing a challenge to the WHO 2006 findings that advantaged children grow the same in ○ The benefits of publishing with F1000Research: Your article is published within days, with no editorial bias • You can publish traditional articles, null/negative results, case reports, data notes and more • The peer review process is transparent and collaborative • Your article is indexed in PubMed after passing peer review • Dedicated customer support at every stage • For pre-submission enquiries, contact research@f1000.com