Characteristics and determinants of child nutritional status in Nepal

This series of unrefereed Discussion Papers Is intended to provide an initial circulation of work prepared under the auspices of the Population and Rtman Resources Division, Comments are therefore very welcome. The papers should not be cited * 'vIthout eleLrance by the author. The vieve expressed are not nectssarily those of the World Back Group. Population and Human Resources Division Discussion Paper No. 82-15 CBARACTERISTICS AD DETERMINANTS OF CHILD NUTRITIONA. STATUS IN NEPAL December 1982 Prepared by: Reynaldo Martorell, Food Research Institute, Stanford Univeristy Joanne Leslie, Econ-3mic Development InsLitute, World Bank Peter R. Moock, Teachers College, Colutbia University Prepared for: a e This paper vas prepared as part of World Bank Research Project RPO 672-10, -Health and Rural Development in Nepal.- The World Bank Washington, D.C. 20433 U.S.A. CRARACTERISTICS AND DETERMINANTS OF CHILD NUTRITIONAL STATUS IN NEPAL Abstract The limited data available suggest that the prevalence of poor health and malnutrition In Nepal is as high as anywhere in the world. This paper focuses on child malnutrition in the Terai or southern plains region of Nepal. The data were obtained from a survey of rubsistence farm households In the Terai districts of Bara and Rautahac. Although the data are regional in scope, their richness allows for an in-depth characterization of the growth pattern of Nepalese children and for the identification of some of the key determinants of antritional status in this population. The sample studied consists of 510 children ranging to age from 3 to 10 years. These children had been 0 to 7 years old in 1977 when they were first surveyed as part of a World Bank research project concerned with- the effects of education on farmer productivity, fertility, child survival and child nutritional status. However, the data analyzed in this paper all come fror. the most recent survey (December 1980 through January 1981) which particularly emphasized nutritional status and included detailed anthropocetric, hemoglobin and dietary intake measures, as well as questions on family socioeconomic characteristics. When compared with a U.S.A. reference population, the NepalL children in this sample were found to have extremely low weights and heights; 65% were stunted (< 90% NCRS median height-for-age), 4% were wasted (< 80% NCHS median weight-for-height), and 122 vere Comes 3 (< 60% NCHS median weight-for-age). When arm mauscle and arm fat areas were plotted against height, average arm muscle was found to be low but within the normal range, while arm fat area was well below the U.S.A. 5th percentile. Average hemoglobin levels were also low, particularly for girls. A multiple regression analysis to identify the variables associated with malnutrition found that age, district of residence, household incoml, breastfeeding and several specific food items were significant predictors of nutritional status. Both household income and residence in Bara district were found to be positively and significantly associated with almost all :peasures of nutritional status. The relationship between age and nutritionalgstatus was U-shaped, with both the youngest and the oldest children in the 'sample being somewhat 4ess malnourished. Longer duration of breastfeeding yas associated witbgreater fat stores, but with reduced stature and 104 hemoglobin values. It is worth noting that the reported average duration of breastfeeding in this population was 34 months. Among the diecary factors considered, consumption of roti and pigeon peas tended to be positively associated with nutritional status, whereas consumption of sweet potatoes and turnips tended to be negatively associated. CHARACTERISTICS AND DETERWINANTS OF CHILD NUTRITIONAL STATUS IN NEPAL Page No Abstract Introduction * * * * %* * * * * * * I Methods . . . . . . . . * * * * * * * * * * * * * * * * * 2 Results . . . . . . . . . q * . . . 0 * 0 * 0 * . . . . 7 DiscussioR o * * * * * * * * * * * * * * * * * * * * * * * 24 References . . . . . % * . * . * * . * * . . . . . . 35 List of Tables 1. Means and Standard Deviations for Anthropometric Measures in Nepalese Boys and Girls (n - 510) . . . 8 2. Variable Definitions, Means, and Standard Deviations for Variables Used in Multiple Regressions (na - 461) 18 3. Significant Correlations Between Dependent and Independent Variables (n - 461) . . . . . . . . . . 19 4. Detetminants of Anthropometry and Hemoglobin (n 461) 21 5. Distribution of Categories of Nutrition Status by Categories of Total Value of Crops (CRPVL) . . . . . 23 List of Figures 1. Anthropenetry Z-Scores in Nepalese Children . . . . 10 2. Weight vs. Height in Boys . . . .. . . . . . . . 11 3. Arm Circumference: Males . * . . . * . . . . . . . 12 4. Triceps Skinfold: Males . . . . . . . . . . . . . . . 13 5. Arm Muscle and Arm Fat Area Plotted on Height f o r ! a l e s . . . . . . . . . . . . . . . . . . . . 1 5 6. Mean Hemoglobin Values in Nepalese Children Plotted on U.S.A. Sea-Lavel Standards . . . . . . . . . . . 16 . 7. Response of Anthroponetric Indicators lb Varying Levels of Food Intake . . . . . .. . . . . . . . . 29 CHARACTERISTICS AND DETERMNANTS OF CHILD NUTRITIONAL STATUS INI NEPAL By Reynaldo Nartorell Joanne Leslie Peter R. Noock Tntroduction '7p Tin on of venal is a landlocked nation of 1w0,798 square kilometers situated between Tndia to the south and China to the north. Nearly an percent of its estimated 15 million inhabitants are Mindu, 7.5 percent are RuAdhists, and I percent are !Auslins. Pthnicallv. four-fifths are of Indo- Aryan ortain, and the rest are of 'tibto-Nepalese ancestry. lepal was fairly isolated from the world till tQ51 when the Rana government was overthrown and oower was restored to the king. The reported average per capita income for Vepal is anonR the lowest in the world, S1W0 per year as of 1980 (World Bank, loR2) Tnfant nortality has been estizated to be about 165 per thousand for the 'erai region using 1Q7& child survivorship data (Thapa and Rutherford, IQA2). other developnent indicators are as follows: adult literacy is IQ vercent (1477 estimate), life expectancy at birth is 64 years (19A0 estimate), vercent of the ooulation has access to safe water (1975 estimate), and the average ver caoita daily suoply of food energy is 2,00n2 calories or 89 percent of the requirement (1977 estimate) (World Rank, 1982). Data on health and nutrition in Nepal are limited. The first .comrebensive health surver was carried out in 196i by the University of navaii (Worth and Shah, 1O9). Dietary but no anthropnetric data were - .collected in this clinically-oriented study. Recently, the Centers for - Disease rontrol (ME) and the United States Agency for International neveloomenc (USAtM) assisted the rovernment of Nepal in carrying out a national nutrition survey on children that included anthropometry and hemoglobin deterninations (%rink et al., 1976). -2- The objective of this paper is to report on the analysis of health and nutrition data obtained as part of a World Bank research project undertaken in the Terat region of Nepal. The data are regional in scope but their richness allows for an in-depth characterization of the growth pattern of Nepalese children and for the identification of some of the key determinants of nutritional status in this population. Methods The data reported in this paper were obtained from a survey of rural households in two of Nepal's 75 administrative districts. The districts, Bara and Rautahat, are located in the Nepal Terai. Nepal is divided into three geophysical zones running in parallel strips from east to vest. The northernmost zone runs along the border between Nepal and China (Tibet) and consists of the Himalayan range. The middle zone, which includes Kathmandu and the Kathmandu Valley, is known as the Hill region and ranges in altitude from 1,000 to 4,000 meters. The Terai to the south is a flat, fertile area straddling the border between Nepal and the Indian s"mtes of Bihar and Uttar Pradesh. The inhabitants of the Terai on the two sides of the India-Nepal border are primarily agrarian and share many cultural and economic characteristics. The sample aL%died is a random sample of households in six panchayats of Bara (out of 109 panchayats in the district) and six panchayats of Rautahat (out of 132). A list of owners of all dtellings in each panchayat was obtained from the local rural health workers. Using a three-digit random number table, households to be ntprviewed were selected randomly within panchavats until a 15 percent samole of households had been chosen in each Panchavat. The households chosen for study were interviewed on four separate occasions etinnint in October 1477 as oart of a World Bank study of education, aericultural productivity, and rural development. Fach survey varied in content and emphasis but was hased on essentially the same households and individuals. This report ts largely limited to the data collected durtnt the most recent survey carried out from necember 180 to January 1GRI and includes 510 children rzni4nx in age from 3 to 10 years of ace (0 to 7 years in 1477, the first survey vvar). The 1980-A1 survey emphasized nutrition data collection and included anthropometry and hemoglobin deterninations as well as dietary freQuency ouestions. The ponulation of the Rara/Rautahat research site is composed nrinarilv of middle- and low-caste Rindu households from the business, farmina, and occuoational castes. M'uslins constitute 10 percent of' the nooulation of ara and 14 percent of that of Rautahat, but muslim households were not included in the sample. Rousehold caste was coded as high ca-ste (Rrahmin (Jhal, Chhetri, Kayastha, and Jaisaual): middle caste (Yadav (Ray, Ahir, Raut, Xdrmil, Saaa [Tanu, Kaluar, Raniya, Telil, Xahatd fKdiri, Nuniyal and Chaudhari (Tharul: and low caste (Thakur Prajan, Loharl, Mahara (Chanarl, Uaihi ["Asahar7, %Vdhiya [Sonar, nhobi, Bur, and.thersl, Das (Tatwal, Hazara Inusadh), riri (rosai, ciri, Sirvang], and Kohar_jPadit]). Five percent of the children were found to come from high caste Mmilies, 59.6 percent were from middle caste families, and 35.6 percent were from low caste families. The caste of a household, it should be noted, designates its ancestral affiliation and occunational status (e.g. middle caste.as "business" and "farning" castes) but does not necessarily correspond to actual economic activity or occupational status today. Tn fact, all of the households were subsistence farn households. lhe field workers who collected the data were secondary school graduates and spoke both Vepali (the Language in which the instruments were written) and Rhojpuri (the languate of respondents). Nepali and Rhojpuri are clonelv related languagas of the Indo-Aryan group, and the questions were translated from Neoali to Ihojpuri in the field. cur anthroponetric measures were collected following standard technioues: height, weight, arm circumference, and triceps skinfold. Height was reasured to the nearest millimeter with a locally constructa4 wooden neasuring board, and weight was measured to within n.1 kg. using a portable beam balance scale. The Parvenden skinfold caliper was used to measure triceps skinfold, and the 7erfas insertion tape to measure arm circumference, both to the nearest am. Capillary blood was collected*y finger prick and analyzed in the field. Rlood was put directly on a slide, stirred with a reagent and the slide inserted into a reading chamber (method of American Optical Company* Values were not corrected for altitude since the Terai, unlike the rest of Menal, is flat. Mothers were also asked about their children's diarrheal and respiratory illnesses during rhe preceding week and about the frequency of consumption of major foods during the same period. Information about the duration of breast feeding and the timing of the introduction of solid foods was also obtained for each child. Socioeconomic and other data including age and sex structure of the family, caste, land ownership, agricultural production, and level of schooling were obtained through standardized questionnaires. The field workers encountered considerable difficulty in obtaining age information. Written birth records were not generally available for the children. Although for young children mothers were reasonably confident in stating their ages, the field workers did assist some by reference to annual festivals and important local events. Inspection of the data shows that 83 percent of the children had reported ages that were multiples of 12 months. There is clearly an excessive tendency towards "heaping" around completed years since, if age were randomly distributed, only 8 percent of the children would be expected to have ages divisible by 12. Mothers are believed to have rounded upwards, and many children may be several months younger than reported. This would lead to an overstatement of the proportion of children . reported as malnourished, although the indicators are less sensitive to small errors in age than would be the case had the children been younger. One of the moust significant predictors of nutritional status was found to be a variable named CRPVL. The variable CRPVL represents an attempt to reduce the number of agricultural production variables and is a crude - 6 - measure of household income during 1980. It was computed as the sue of the outputs of the paddy and wheat crops weighted by the respective farz-gate prices of these two cereals. By taking the gross value of paddy and wheat produced as the sole measure of household income, the costs of producing these crops and the net returns accruing to other agricultural enterprises and to any off-farm employment engaged in by members of the household were ignored. Although most households did produce other crops and kept some livestock, paddy and wheat were the principal farm enterprises in this part of the Terai. Virtually every farm (91 percent) cultivated paddy in the 1980 growing season, and a smaller number (62 percent) cultivated wheat. Paddy and wheat together accounted for 1.0 ha. of land usage that year on the "typical farm" out of a total of 1.3 ha. available. There is ample justification for ignoring off-farm income sources because most households (88 percent) reported no such income and, for those that did, the amount was relatively insignificant (Rs. 213 on average; 12 Rs. equal $1 U.S.A.). Subroutines obtained from the Centers for Disease Control (CDC) were used to generate percent of median values and Z-scores for weight, height, and weight-for-height. These calculations use data from the National Center for Health Statistics (NCBS) as the reference or standard (Hamill et al., 1979). Arm muscle area and arm fat area were calculated as recqmmended by Frisancho 4 (1981). Fifty-six food items were included in the dietary questionnaire. To reduce the number of variables in the analyses, the ten most variable items (i.e., large variance) were selected. This procedure excludes foods that are -7- consu"ed either only occasionally (e.g., seasonal fruits) or very frequently (e.g., rice). Only six of the ten "high variance" dietary variables were included in the final regression eauntions since earlier analyses showed that the other four consistently failed to be significant predictors of any measure of nutritional status. The dietary variables were re-coded for the purposes of this analysts into three careiories: I - not eaten last week, 2 - eaten . occasionally last week, 3 * eaten dativ. All data were scanned for outliers and a amall percentage (less than I percent) of cases with inconsiste-t or iprobable values were deleted. A core sample of SI1 cases was available for the analysis. These 510 cases had conolete data for height, faight, ate, sex, di.-trict, crop value, and for weaning, df.etary, and disease variables. 'Iwe"er, there were some missing values for other variables, which resulted in our using just 461 cases in the final regression eauationt. The SPSS software pack&e wau used for all Vesults Samole sizes, means and standard deviations for height, weight, arm circumference, triceps skinfold, and hemoglobin are shown in Table 1, senarately for boys and girls, and for eight age groups. Age 3 includes children T0 to 47 nonths of age, age A includes the range 48 to 59 months and vo on. Recause the maicrty of children have ages that are multiples of twelve nonths, the averageage of each group is close to the starting month (e.g., T0A.6 nonths for grotp T6 to 47, 4A.R months for group 4R to 59, etc.). - 8 - -;ь1. д: ���cs �tiэ ��'�►эn д�т:.л::�s �3 �к:�tгат��t "�_.aSr3SS :� �э1:.f.3� S'r.5 .� �.3_5 Sa • 3.А) �►sa ctrre�- :Уlсsрв • �елоЬiоЫа Яе�Ьс (о.) �te1�c ('�.) '.гrке (о.) s7c:aSab3 ��.) (а.Од�0 31.) 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'?*here are no statistically significant differences in Z-score values associated with sex. 'r%o ,sge pattern in 7-score values zhown in Figure I seems to IrAlcate prozrossive stuntIr4t till about 5 years of age with the situation stabiltrinz or sliahtly inproving thereafter. ',Mean weigbts are Plotted atainst mean hefithts for Vep4lese and NCHS boys in Figure 2. ThIs analvsis revealk that Veoalese children are I to 1.5 kq. lighter umen compared to FT.1q.A. children of the same height. A very similar pattern is evident for stirls. Prtsancho (IORI) has recently published !,norms for arm circumference, triceas skInfold. and uoper arm fat and muscle areas. 11hese data come from the same *ovulation as the 'WHS norms for MUM :and weight. At present. no suSroutines are available to the public for calculating '-score values- In Figures 3 and 4, the VCHS 500 &ad 5th percentil-as and the Nepalese mea are vlotted for trtcevs and arm circumference respectively for 'the sample of boys (sanple sizes as In Table 1). Art circumference: shows a steady rise vtth age in TT.S.A. and Nevalese chUdren as shown in Fii 1 ,ture 1. In contrast, vaLlnes for triceps skinfold are nearly constant in the age range under study, ar- ewident Ir rIRure 4. Also shown clearly in vigures 3 and 4 is that Vepalese chl1dren have verv small2arn circumferences and skinfolds. The pattern in gifts was FounA to be similar. - 10 - gure 1: APR Z-SCORS IN NE?ALESE CHLDREN 0 33 51 101 90 90 62 55 24 for hoght - . . .. - Z-scores UIght H.eight -3- - 6 7 8 9 i0 Age (years) 由口口口口口口口■■■細■■•■一 •…‘ !_2．一’: -－一－一一－■一－一－&‘■一－一－－■－-－一．••■■■“dd■自■■■■■■■‘-j口勵•口h■hh勵口h口h■口自勵d口口j口口口口口口口■■■■■j細騙細口口口h■■■■■•自■自自d州么■自■■．■d己由己自h■必口曲■．■■■■■■■由呂■曲•－-------- 山bーーーーーーーーーーーーーー― ._:-＿・，,-1_―・ り国国国日日国日園国日国園国■■ . &’『 ，「―，、・－!--’一一’, .he small arm circumference of Nepalese ch!ldren should in pert reflect the small average body size of these children. To Investigate the extent to which this is the case and also to explore whether fat area and muscle area are differentially affected, am muscle area and am fat area have been plotted against heights as shown in Figure 5. 4eans for am muscle and fat area are plott*d against mean height in the case of the Nepalese sample. For comparison, the 50th and 5th percentiles of arm muscle and fat area are plotted against median heights in the case of the XCHS sample. Relative to height, the average am muscle area of Nepalese children is somewhat low in comparison with the NCHS noms but well within the normal distribution (i.e., between the 50th and 5th percentiles). -.his is in marked constrast to arm fat area, in which case Nepalese values are substantially below the NCHS 5th -percentile. As would be expected from these relationships, the percent of arm area which is muscle Is considerably greater in the Nepalese sample than in the NCHS sample. As was the case for other figures, patterns for girls wera similar to those for boys. Figure 6 indicates--that the hemoglobin values of the Nepalese rphildren are very low when compared to U.S.A. seo-level norms. For Nepalese girls, mean values fall below the 3rd U.S.A. percentile while for boys they vary between the 3rd and the 10th percentile. Hemoglobin values do not rise with age in the Nepalese sample as is observed in the USA population. - 15 - Figure 5: AM MLSCLE ASD AM FAT AREAN ?LOTTED 0N FEIGHT FOR .ALES (ages in parentheses) 20 NCHS muscle, 50th percen N Nepal muscle, mean 15 ,NCS muscle, 5 percent. Area S 10- (cm') - NCHS fat, 50 percentile 51 (2.5) (35) (4.5) (5.5) - CHS fat, 5th percentile (6.5)(75 (3.1) (4.1)(5.1) (6.1) -,.---* Nepal fat, mean (7.0) (8.1) (9.0) (10.3) .0-, I I I I I 80 90 100 110 120 130 Height (cm.) *3 - 16 - Figure 6: MEAN hiMOGLOBIN VALUES IN NEPALESE CHLLDREN PLOTTED ON U.S.A. SEA-LEVEL STANDARDS e.olobin. Peentiles+ ,16 97 14 - 015 G/DL13 13 12 3 12 11I 97 17 0 16 Boys 16 15 14 0 14 13 13 GIDL 12 :11 I__________ 2 6 8 10 i2 14 16 Age (years) +Percencile grid prepared by Dallman and Siimes (1979). - 17 - "ultivariate analvses were conducted to iVentify the nosv important determinAnts of nutritional status in the study sample. Verressions were carried out for both Z-scores and Percents of median values for heimht, WeIRht and velght-for-hetiht. gince siilar results were obtained for both CyDeS of dependent variables and since Percents of nedian values have been used more often in previous studies, results for the ?-score regressions are not revorted here. variable definitions, sanple sizes, and mean and standard deviations for the dependent, backtround, dietary, and mortidity variables used in the multiple regressions are given in Table ?. Cases with missing values for one or uore variables have been eliminated through list-wise deletion and all calculations are based on the remaining 461 cases. Mean percents of median values are RR for height, 73 for weight, and q3 for weight- for-height. *he sample is approxitately evenly divided both by sex and district. Families had access to very limited amounts of land and their total aaricultural production was very low. fnly 20; oercent of fathers and 7 percent of mothers had ever been to school. Mothers reported that chldren were breast fed for nearly three years on average and solids were not introduced till about IR months. vighteen percent of the children were reported to have had diarrhea the previous week and 41 percent were said to have had resoiratory infections. "%st of the independent varlables are significantly related to one or nore of the dependent variables in to expected direction as shown in Table 3. Greater values for the variables LANn and CRPVL are associated with better growth as measured by all of the anthropometric variables except triceos skinfold and fat area. Children fron Rara appear to be better off, - 18 - Table 2: VARIABLE DEFINITIONS, MEANS, AND STANDARD DEVIATIONS FOR VARIABLES USED IN MULTIPLE REGRESSIONS (n 4 661) Standard Variable description Mean deviation Dependent variables HA Percent of median height 88.47 6.43 WA Percent of median veight 73.22 11.89 WH Percent of median weight for height 92.97 8.44 AC Am circunference (cm.) 14.19 1.07 TRICEPS Triceps skinfold (cm.) 3.04 0.75 MAREA Muscle area ( . 2)/10 138.41 231.6 FAREA Fat area (Co. ) /10 20.54 51472 HG Hemoglobin (g./dl.) 11.32 1.77 Background variables AGE Age of child (months) 76.67 22.41 AGESQ Age of child squared 6,379.18 3,578.17 SEX 1 - male, 2 - female 1.49 0.50 DISTRICT 1 * Bara, 2 * Rautahat 1.56 0.50 CRPVL Value of crop output (100 Rs.) 23.96 32.92 LAND Land owned (Bighas) + 2.07 3478 MOAGE Age of mother (years) 33.80 8.11 HICST High caste (1 high, 0 - others) 0.05 0.23 LWCST Lov caste (1 low, 0 * others) 0.36 0.48 MOSCR Mother ever been to school (1 * yes, 0 - No) 0.07 0.25 FASCR Father ever been to school (1 - yes, 0 - No) 0.26 0.44 Dietary variables NBF Months of breast feeding 34.19 11.26 MEBF Months of exclusive breast feeding 18.20 7.73 BRICE Beaten rice last week (1 - none, 2 - some, 3 *daily) *1.83 0.69 ROTI Plti last week (1 - none, 2 - some, 3 - daily) 1.52 0.61 PPEAS Pigeon peas last week (1 - none, 2 - some, 3 - daily) 1.34 0.64 SWPOT Sweet potatoes last week (1 - none, 2 - some, 3 - daily) 2.15 0.61 SUGAR Sugar or molasses last week (1 - none, 2 - some, 3 - daily) 1.87 0.74 TURNIP Turnips last week (1 - none, 2 - soda, 3 - daily) 1.93 0.63 Morbidity variables RESP Respiratory infection last week (1 yes, 0 - no) 0.41 0.49 DIARR Diarrhea last week (1 - yes, 0 - no) 0.18 0,39 1 Bigha - 1.6 acres - 0.6 ha. - 19 - Table 3: SICEFICAS COUL,ATIMS 3-41 DEFMENT A M ErE T TALI.~A(LZ 461) HA MleA TIICES jRA FAR~A k¢ ( ofl ( of (*. of (ara median mdian median circam- (triceps (muscle (fat (hymo- ,ables height) weight) M/U ) terenc*) skiatold) area) ar*a) tlobio) Age -0.297 c -0.226 c 0.356 c -0.559 c 0, c -0.432 1,. 0.089 a Sex -0.077 & -0.089 & -0.220 C .ICT District -0.112 b -0.137 b -0.258 -0.252 * Crop output value 0.157 c 0.169 c 0.214 c 0.205 0.083 a a 3 Land 0.142 c 0.135 c 0.199 c 0.201 c E Hother's age 0.176 c -0.101 & 0.196 c 0.080 a ST Righ caSte 0.109 b 0.109 b ST La cast. -0.092 a -0.116 b S School (mother) 0.08W & 0.088 & 0.103 & 0.099 a 0.08' a School (father) 0.078 & 0.078 a 0.093 a 0.090 & bcG. reast fed -0.096 & Moe. ay breast 0.107 & 0.154 c 0.139 c -0.106 & U.atem rice 0.098 a 0.137 b 0.087 a 0.130 b 0.105 c 0.108 b 0.139 b S Roti 0.089 a 0.083 a AS aigeoa peas 0.080 a 0.102 a 0.135 b 0.119 b 0.102 a Or Smeet potatoes 0.077 a A Sugar/molasses 0.124 b 0.115 b 0.155 e 0.150 e SI Turnips Respitatory S Diarrhea 1-0.078 a p < .05, b p < .1 p < .001. - 20 - and except for arm circumference and auscle area, older children tend to be worse off in terms of the anthropometric measures. Increased parental age and schooling are associaed with improved growth, and caste is related to growth in the expected direction, with high caste status being associated with greater fatness, and low caste with smaller heights and weights. No significant associations with diarrhea are observed, and except for a positive association with triceps and fat area, neither is any found for respiratory illnesses. Prolonged breast feeding in the past is associated with shorter heights, and months of exclusive breast feeding (i.e., late introduction of solids) is associated with greater fatness (increased triceps, fat area, and weight-for-height) and with lower hemoglobin values. Hore frequent consumption of foods, particularly beaten rice, roti, pigeon peas, and sugar, is associated with better growth. Multiple regression equations are shown in Table 4 for all of the anthropometric variables and for hemoglobin. The variable LAND is highly correlated with CRPVL (r - 0.820, n - 461, p < .001). Since both variables were thought to measure the same construct and since CPRVL was found to be related more consistently to the anthropometric variables (see Table 3), LAND has been deleted from the list of independent variables. The results in Table 4 indicate that age is a significant predictor of the anthropometric variables. The fact that the coefficient foif age squared is positive and statistically significant in a number of the regra'sions suggests that the relationship betwen age and the anthropometric variailes is not linear but U-shaped, as was evident for height in Figure 1. District is negatively associated with all of the anthropometric variables, suggesting that children from Rara are � М � т.�i� А� ог;тrrиlемlп3 а ultlaoг�Owcпr А11и rcw�clл/1r /a • и1) , . д_ 1и иА rи дс п1<��3 1иw► i+ьw� nc v.r1.e1.• е е � с ► е ► е ► е ► с е � е е �`гМ! 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(о.и) о.и/ (1./1f -о.оо1 to.lы мr/r .о.он lo.�i) -о.ои (о.ц) о.о�/ (1.о!) -о.оа �о.и> о.0а U.�/1 -1.<.!� и.») о.�и с1.и► -о.о» ct.1r) � ига о.гог (о.и> о.3и и.о/) о.а» со.и) о.а1 �o.3s> о.оl1 (о.и) ►.Оа со.и) 3.1n со./r) о.а! с0.Аа) /етг -1.o3s/,�.рг,) F��;го (1.lо) о.Ап (1.а) о.1г1 и.3А) о.оЧ eo.3s) lt.t3/ и.м) •.!!/ и.l1) о.13+ ea.vA) rrrлs -4.1i1 i» и(ал3) 1.1ю c1.w> о.1» с1.м> о.ои и.ц) li.133 и.эв) •.►эь и.и) о.о� соли) s�►от -о.А31 (1.l1) -1.а1 c1.1s) -о.lи (о.)» -о.оо3 (o.ot) о.оlг (о.и) �г./0/ со.1» 1.мо со.и> о.о33 со.31) 3UСАв 0.1�1 (1.�1) 0.«� (0.)!) -0.1Ч (1.0�) '0.01) 10.t1) 'O.O1i (0.<1/) О.ОЧ (0.00) 'l.�1в (0.l�) -0.401 (O.QU) ти/иtг -о.гю (о.�и -1.1и (1.з1> -о.�м л.�1> -о.!!� (!м) -o.oit со,�lJ -+..ж �!./�) -+.yw �1л» -о.ои со.») мигеlаlе� �сsг O.srt (о./:) 1.�и (1.») о.�1� (о.�!) о.1н c1.at) о.ооо �о.оо) эь.�1о (1.в» т.»r со.ц1 -о.l�� t1.��1 о1А�к -0.111 �u.fr) -о.ы � (о.И) o.o0f (О.оо) -и.оо/ �о.о�) -о.а! (о./�) f.of/ lо.ю) -�ь.ьь1 (о./О) -о.Оь0 tо.га) - ео,,.е.ае 1оо.о» и.lw - �3./1! 1A.o3r 3.3и 1.llь.эь iю.nl 11.3и � о.03А ;�'� о.1и ' о.м/ о.3ю оли о.юь о./а/ о.wг - - __-� � - - т,��..��_ ,�,� lА.и� �/говlоа сие111е1мев ��'в /lvва 11гве tellew� еу t vвlигв 1а ,+rеаtlивев. "better off" in ways not captured by the included background measures. nle sec of the child is not an important predictor of any of the anthropometric variables; Soys, however, are seeu to have significantly greater hemoglobin, values than do girls. Except for a negative association between F.kSCH (father's school attendance) and triceps skinfold, the associations observed previously in the table of simple correlations (Table 3) for caste (HICST and LWCST) and schooling (FASCH and MOSCH) are not statistically significant in! the multiple regressions. A longer duration of breastfeeding (4,BF) is associated with reduced stature (HA) and gredtar fatness (TRICEPS and FAREA). This pattern Is consistent with negative associations between stature and fatness in the sample (RA and TRICEPS: r - --0.18, p < .001; RA and FAREA: r - -0.07, p < .10). Similarly, the lor%ger the duration of exclusive breastfeeding (MEBF), the greater are the fat stores and, curiously, the lower are the hemoglobin values. %tile children who 'consume more sugar tend to be taller, consumption of roti has the opposite effect. Turnip consumption is: negatively related to all dependent variables while associations w:ith beaten rice and pigeon peas are positive. The regressions also suggest that chlildren reporting respiratory illnesses the previous we'ek.have larger arm circumferences and arm muscle areas, but lower hemoglobin levels., CRPVL is ine of the variables in Tables 3 and 4 that show consistent associations with the anthropometric variables and hemoglobin. Table 5 Z presents additional analyses and shovs how the distribution of children classified as havings"poor nctritional status" varied by terciles of CRPIO The indicators of nu:ritional status used here are among those widely usedjn 1 �♦ � • � � '1'вLle 9� "B1e71tUUT1AN 01 CA7:GOS16f Ор M1Rt1T10MAL еТАТ1lе еУ САУ'е00е1йi OI 1'OTAL YAW6 ОР qtOK (СП1'VL) Ув1ив nt � Увв м An Сlгеwtвгооеа Qеввв Гitв агtга Ави1+ ltov sгорв вв вв гваа а ои ги г а г а г в вгвtа�� totвl ю 1)ь 1ds t1 1:е и 1о ) 9: ц :1 11о и :, s ыw (ге.�� Ot.ы (9�.е) (ь.�) Oo.s) (к�л� (s.)) (�.о� (».s) (ц�s) u1.t) (�:.s) (по.�) (ь.г� (г.о� 1)� Sl 10t !« 9 !tA х! 1! 1� Ч )i ?0 1е 29 1) 1 M1JJ1a (7х.х) (бб.)) (9�.1) (!.9) ()1.9) (!0.)) ().е) (i.S) (3).S) 51.0 1�.t il.е 11.0 19.о 4.6 lS1 )t 1ns teo 1 1ц го ) го и 1у )о 1a ю ss � иlел (��.ц (s�.�) (st.�) ro.�� (e�.i) (i1.o� г,�.9) U1.o) (��.�) и.в u.n и.� �`.• 1s.e г.г iei Colura toul !)! 711 4е9 2l )ее 9� 29 е0 l9i tSl 61 l)f, 1) 1) 1f, 31П � �� ы СМ/ lqивгв •.)! Iв 9,.0� I. 17.ei /� 1.« tЛt � � r � MT.t/t Nov pareeaca аге еlvвд 1д рвгвеthггив. Daflolrl011• v.lua ot ern?rc l.ои (смvь с 9.��. мiвиа (s.d < смv1. < xo.s). У!е<, (с*rrг. > xo.s) I 5cuatlaet Ио (НА > 90 1U), Уаа (МА < 9о ИА) • и.вгlае� ио (Уи > ео ми�, Уа. п+У r ео� - - -' � - -��-- - Аг■ еlгсив(агаnси бгвеn ( Ас > 17.�), Уа11оу (12.! < At С 17.А). Red (АС < 12.5) Савва свtrеогlен Morsal (УА � 90.0), Qrвda-l O!.0 < УА < е9.9), Сгв1ь 2(f,0.0 < МА <)е.9). Gгв1а У(УА К f9.9i Аав.la иом (110 > 1l.о), и! и(1о.0 < ИО t 1ол). моеагвг! (е.о < �а < 9.1). !е•ега (Мб с).9) - - - в/ р<.113, Ь/ р<.01 --- - -- 24 public health. The table consists ot five indicators of nutritional st4tus.* stunting, wasting, the "Color codes" of am circumference, the Gomez classifications of weLght-for-age, and anemia classifictions. (See Table 5 for pcecise def%nitions of all of the indicators.) A very large percent of the sample is stunted (64.9 percent); however the prevalence of stunting significariLly decreases as CRPVL increases. Uasting is seen to exist for 4.1 percent of the sample, but whereas it is 6.3 percent for those in the low tercile of CRPVL, it diminishes to only 0.6 percent in the uppev ttrcile. The yellow and red zones for am circumference are categories intended to indicate moderate and severe nutritional deprivation. A child in the green zone is coasLdtrod not to to qt risk. 'While 29.6 percent of the children whose families had low CRP%L values fall into yellow and red categories, only 14.9 percent do so in the case of those whose families were in the high CRPVL group. The percent of children classified as either moderately or severely malnourished according to the Gomez categories of weight-for-age is 66.4 percenc for the bottom tercile, 64.2 percent for the middle tercile, and 54.6 percent for the top tercile of CRP%L. Finally 36.1 percent of the children shc,.r some degree of ane2la, but no relationship with CRPVL is evident. Discussion The extent of malnutrition found among the children of the eara/Rautahat sample is awng the highest that has been reported outside Sf extraordinary deprivations occurring during events such as wars and famines. :he 1980-81 survey, which provided the data for this analysis, found that 65 percent of the children were stunted, 4 percent were wa3ted, and 12 percent uvre Gcxmez 3 (less than 60Z of weigh t-!or-age). Earllzr s,:-,-veys, done in the sane Popilation when this cohort of chil4ren was 6 nonths to 4 years of aRe found that in the fall of 1,77, S5 percent were stunted, ZO percent were wasted and 2? oercent were romez 1. gix months later, in the spring of 197R, 54 percent were found to be stunted, 13 percent were wasted and 11 percent were ronez I (Leslie, tal4ya and 4anduant. 19O1). The extreeely high rate of wa%tinR reoorted for the fall of 1977 nay reflect a seasonality in malnutrition: the 1077 survey was carried out it the period just before the main annual rice harvest. The period is usually one of extreme hardship and was particularly severe in 1477 since it followed two successive years of Orought (Leslie, 147R). Rathroa scales were used to measure weights in the 1077 survey and beam balance scales were used in later surveys. This nethodological difference, however, is unlikely to explain the lower recorded weights. Rathroon scales are less precise tl;.n beam balance scales but would not necessarily lead to systematic (i.e., lower) differences. The higher rate of stunting found in the 19RO-M1 survey compared with the surveys done in 1977 and 1Q78 was to be expected, since stunting is a cumulative process, and the children were three years older in the most recent survey. A national nutrition survey coordinated by the Centers for Disease Control (Brink et al., 1976) also reported high rates of malnurition in a sanole of 'erai children 6 nrnths to 6 years of age: 65 percent of the CDC sanole was found to be stuntid and 9 percent to be masted. These figures inly sonewhat less stunting rnd about the same rate of wasting than reported here for Rara and Rautahat at the time of the 1978 survey. 'e rn-coordinated survey also included a Vepal urban population for comparison. .uenty-nine nercent of this sample uas found to be stunted, and two percent was found to be wasted (Rrink et al., 1Q74). SimilArly, varouharson (IQ76) measured a rural "well-,o-do" group chosen fron among children attendina private clinics or schools and from among the children of health workers. Vist-al inspection of the growth curves prepared by Farouharson (lQ0) shows that relatively affluent rural children grow better than do their poor counterparts. 14eans for the well-to-do were plotted between the lIth and the 50th percentile of the Rritish standards, while those for the poorer children fell far below the 10th percentile. Few details were Drovided by Rrink et al. (1Q70) and Farquharson (1976) on the characteristics of the well-to-do samples, and it is difficult to assess whether their results represent the genetic votential of the Nepalese. Studies from northern India. for example, show that elite Pindu children have the same anthropometric characteristics as Rritish and American children (t1dani, 1963; Ranik et al.. 1472: Currinbhov, l63). "e he.uxicbin values of the Rara/Rautahat sample were very low. Fauallv low values have been reported for Nepalese children by Brink et al. (076), as well as for Indian children (Rao et al., 19R0; nevadas et al., loan: wherol et al., 1072: r,hat et al., 1970). Other investigators have also encountered considelable difficulty in ohtainine accurate age information in Nepal (Farquharson, 1976). In all likelihood, mothers of the children in the Sara/Rautahat sample rounded uowards when as?ted their chidlren's ages. The consequence of this is that - 27 - many of the analyses have compared younter Nepalese children to older children in the ViCug sample and thus overestimated the mai-itude of retariation in ace- dependent measures such as height and arm muscle area. As the average age of the study sample is underestimated by no more than six months, however, the bias introduced is small. Indeed, analyses of variance showed no difference in helcht, weight or weitht-for-height between "heapers" and "non-heapers." Also, the two troups were evenly distriuted across sex and district lines and showed no socioeconomic differences (e.g., CRPVL, LAID). "ike malnourished children from Latin America (Yarbrough et al., 175: Leslie, 19A2), Nepalese children are not able to maintain normal weight- to-height relationships but are instead I to 1.5 kis lighter when compared with well-nourIshed children of the same height. Relative to height, am muscle area in the NeDalese samole is smaller than in the NrMS sample, while muscle areas in Latin American children are normal once size is taken into account (Martorell et al., 1974: teslie, IQt2). Vepalese and Cuatemalan children show markedly lower arm fat areas when compared to NCHS children of the same size (Martorell et. al., 1976); howepr, Rrazilian children show fat areas closer to U.S. noras (Leslie, 19R2). We hypothesize that the growth patterns in Kepal, Cuatemala and Rrazil reflect different degrees of severity of the same underlying response to protein-energy malnutrition. We hypothesize that the severitp of protein-energy malnutrition is greater in Vepal than in Cuatemala and Rrazil, and that these latter children were able to cove with the stress of malnutrition by growing less in hody size but without alterin weight/height ratios. The situation in Nepal May reflect nore severe conditions which demand more powerfal adaptive mechanisms. In - 28 - Nepal, growth in height is affected to an even.greater degree, and weight-for- height ratios are diminished as well. This is precisely what happens to individ'al children as they develop severe protein-energy malnutrition; linear growth is reduced at first, and eventually wasting begins. Similarly, it hAs been shown that children recovering from malnutrition first recover in terms of weight, and only when relatively adequate weLght-for-height has been achieved, does linear growth begin to recover (Cheek et al., 1970; Graham et al., 1969). The hypothesis is presented In schematic form in Figure 7. The Nepalese sample is located in the area between A and B uhich is characterized by linear growth reduction and astcing, whereas the Guatemalan and Brazilian samples are between B and C and experience only linear growth reduction. Between C and D Unear growth is only minimally affected if at all, whiLe weight for height changes dramatically. The Nepalese data presented here are also informative of the correlates of nutritional status measures. Caste was one such variable investigated. High caste was associated with increased skinfolds and fat areas, and low caste was associated with reduced heights and weights (Table 3). Once other socioeconomic indicators were taken into account, however, all assoclatiobs with caste lost their statistical significance (Table 4). Brink et af. (1976) found caste to be essentially unrelated to nutritional status in the lepal national nutrition survey. Also, Brown et al. (1968) reported there were -no marked differences in nutrient intakes associated with caste in poo r rural families of Nepal. On the other hand, two Indian studies in the Punj ab found caste z3 be a significant predictor of child nutritional status. Data from the Narangwal project showed that caste and income were the two most - 29 - Figure 7: RESPONSE OF ANYTHROPOKETRIC IN.DICATOR?S TO VARYING LEVr.S OF FOOD INTAKE D Normal C , B w Fo None Fo Very Moderately Normal Excessive' utake deficient deficient Obesity D Food Normal Intak Very Moderately deficient deficient lormal ieessive - 30 - significant variables distintuishint the well-nourished from the malnourished children (vielnann et al., 176). The results of the Morinda study found malor differences in chillren's nutritional status by cast,: income effects, however, were not investigated in this study (Levinson, 1976). It is noteworthy that there were no differences between boys and eirls in the degree of growth retardation relative to the NCHS norms. There was a difference, however, for hemonlobin. While girls had hemoglohin values that are below the 3rd percentile of aqe-sex*specific standards, boys had slightly higher values, between the 3rd and 10th percentiles. The lack of clear differences between the sexes in anthroponetric Indicators of nutritional status argues that differential treatment favoring boys over girls may not be as marked as reported for India (Levinson, 1974). District was a variable consistently associated with nutritional status. rhidren fron Rara vere better off than those from Rautahat. These differences, it should be recalled, persist after controlling for other independent variables. Although somewhat difficult to interpret, the finding of better nutritional status for the children in Sara compared vith the children in Rautahat is consistent with nutritional status data from the earlier surveys (Leslie, Raidya and M.ndwani, 1981) and with other studies from the same research project. The location of the Bara relearch site, which is closer to a reasonably large toun (Rirgunj) and closer to-a main road, seems td give the inhabitants an advantage that results in higher crop yields (Janiso' and "Yock, laP1), lower fertility rates (Cochrane, 1981), better school progression (Moock and Leslie, 1982) and, as seen in this paper, better nutritional status. -31- Nepalese babies are breast fed for long periods of time. Farquharson (1976) states that most are breast fed ir at least two years and frequently longer. Brown et al. (1968) found that nearly all children were breast fed for over 18 months, and over half were breast fed longer than two years. The duration found in this study was 34 months, which does not seem unreasonable in view of previous findings. Solids tend to be introduced to the diets of Nepalese infants at later ages than in many areas of the world. Though the traditional "rice feeding" ceremony in rural areas takes place around six moths, it is said to be no more than a ritualistic feeding in many instances. For many children, solids are not introduced as part of the regular diet till it becomes obvi"us to the parents that the child is losing weight on breast milk alone. Breast-f.td children receiving other supple- mentary milks may have a later introduction to solids (Farquharson, 1976). Farquharson (1976) reported that no infants were on breast milk alone after I year of age and that very few were receiving milk but no solids after 1 year of age. According to Brown et al. (1968), many women introduced solids between 3 and 6 months, 20 to 30 percent between 6 and 12 months, and only a small fraction waited beyond I year of age. Uhile there may be a tendency to introduce solids late in Nepal, the finding in this study that the average duration of exclusive breastfeeding is 18 months is probably an exaggeration. Perhaps, the question was not properly understood and instead the results refer to the timing of the full establishment of the regular adult diet. There is no way of confirming this possibility with our data. The variable MEBF (months of exclusive breastfeeding) was found to be positively associated with greater fatness (i.e., skinfold, fat area, and wetzht for hei2ht). rven after controlling for other variables, the later that nothers clatied they introduced solids, the more likely their infants were to have larger skinfolds. The duration of exclusive breastfeeding is associated negatively, however, with the level of hemoglobin, a finding that night suggest a difficulty in recovering good iron status in this population, even several years after the introduction of food soliAs. The total length of breast feeding (KRF) was not found to he related to physical growth measures in bivariate fashion but, after controlling for all other independent factors, the duration of hreast feeding is associated with a greater degree of stunting and with larger skinfolds and fat areas. This is a population reporting universal breast feeding, and the association with stunting should he interpreted with caution. The analysis of the 1477 and 1978 survey data pointed to a significant negative association between infectious disease and nutritional status, particularly between diarrhea and low weight-for-height (Leslie, Raidya and Mandwant, 1081). This sane association was not found in the analysis of the 1QRO/R1 data. Although rates of upper respiratory illness ,;etre sinilar in all surveys -- 4n% to 50% prevalence - the rates of diarrheal disease were much lower in the 1980/R1 survey, which is consistent with the older age of the children. The fact that the children in the 1980/81 survey were vast the age of peak diarrheal illness, combined with the fact that the a diarrhea data referred only to the previous week, probably explains the findine of no association between diarrhea and nutritional status. As far as upper respiratory illness (URI) is concerned, the findings were - 33 inconsistent. In nost cases there %as no association betveen LRI and nutritional status. Qowever, significant positive associations vere found between tT and arm circunference and between URI and arm muscle area, other things held constant. In addition, a significant negative association was found between IIRT and hemoglobin. The short period of time covered by the diqease data is a severe linitatien of the study and does not provide a fair test of the role of infection in Oetersimins malnutrition in these ccncunities. The usual diet of the nepalese Terai population consists primarily of rice, Ahal (cracked legumes cooked to a soup-like consistency!), a vegetable curry (made predominantly of potatoes and a variety of coarse spinaches), small amounts of ailk, and occasional fruits and vegetables (3rown et al., 140R: 7arquharson, 1476). Many families follow the Rindu prohibition against eat. nietary data in this study were limited to the frequency of consumption of varticular food items. The ten most variable dietary variables were considered in the analyses and it was found that a number of them were consistently related to nutritional status. Pigeon peas, beaten rice, and sugar, for example, shoved positive bivariate correlations with several anthroponetric variables. '6st of these associations were considerably attenuated after controlling for 3ther factors in multivariate analyses. Some variables weya negatively related to growth in the multivariate analyses: roti (with htight) and turnips (with arm circumference, and muscle area). Uhile never asnificant, associations involving sweet potatoes were often negative. Sweet potatoes and turnips are known to be foods that are consumed nore frecuently by coorer families. Also, the code of Manu forbids the higher castes from eating turnips (Lowenberg et al., 1979). %He found that CRPVL was positively associated to the dietary variables, which tOemselves showed Dositive associations with nutritional status, but was either unrelated or negatively related to sweet potatoes, roti, and turnips, dietary variables that were negative Predictors. Iecause maternal qize information was available for only a limited number of cases, it was not included in the regression analyses reported 1 Tables 1 and A. Analyses were carried out, however, vith a reduced sample, and maternal stature and weight were found, as in many other studies aroun4 the world, to be significant predictors of the nutritional status of children. This confirms the value of maternal anthropometric in4icators to select infants and children at high risk of malnutrition and mortality. maternal age was also found to be an important positive predictor of nutritional status in children even after controlling for all other variables. rinally, socioeconomic variables (CRPVL and LAND) were found to e significant determinants of nutritional status. Studies in India (Kielman et al., 1076; Levinson, 197&: Devadas et al., 198n) and Latin America (ValverAe et *l., 1QR) have found that income, for which CRPVL &s a proxy in this study, is one of the nost significant predictors of nutritional status. Mhildren in the lover third of the distribution of CPRVL were twice as likely to have reduced arm circumferences (smIller than 13.5 cm. - yellow and red categories in Table 5) as were childreg in the upper third of the distribution. For wasting (weight-for-height less than 8 percent) the differences between the lower third and the upper third of the distribution - 35 - were even greater. The amount of land available to the family is another important variable predictive of nutritional status, a: has been shown in other studies as well (lesai, 9tandard and Miall, 147n: Rawson and Valverde, 1Q7A: valverde et-al., 1977: Nctowell and qoowes, 1977). These findinis reinforce the views that Protein-enerxy malnutrition is a probles of pove ty ant that substantial inorovement is likely to came only fron raisin the standard of living. -36- RFFRF'CES Ranik, V.n.n., Vayar r., Krishna, R., Ral, L. "The Pffect of %utrition on rrowth of Pre-School Children in nifferent Comunities in Delhi." Indian Pediatrics, 9, 1Q72: pp. 460-466. Rrink, R.W., Khan, I.R., Solitter, J.L., Rtachlink, T.. Lne, J.M., Vichanan, ".Z. "Nutritional Status of Children in Nepal." URO Bulletin, 54, 107A: pp. 111-31R. Rrown, M.L., tiorth, R.N., Shah, '.X. "Food Rabits and Food Intake in Nepal". Troo reomr "ed, 20, loMR; pp. 217-224. Cheek, D.A., Mill, 1I.F., Cordano, 4., r.rahan, C.C. "walnutritirna in Tnfancy: Changes in Muscle and Adipose Tissue Refore and After Rehabilitation". Pediatric Research, 6, 1970; p. 135. Cochrane, S.M. "The Determinants of Fertility and Child Survival in the Iepal Teral". Mashington DC: The Uorld Rank (Population and Human Resources Division Discussion Paper go R1-34), 191. Currinhhov, 7. "Crowth and Development of Roubay Children." Indian J. Child ith, 106lo4: op. A7-651 nallnan, D.P., 9ines, M.A. "Iron Deficiency in Infancy and Childhood." Report for the International %tritional Anemia Consultative Croup, Rashington DC.: The vutrition Foundation, 179. nesdi, 0., Standard, K.L., %liall, M.F. "Socioeconomic and Cultural Tnfluences on Child rrowth in Rural Jamaica". Journal of Biososcienoes, 2, 1q7n: pp. 133-161. D)evadas, R.O., Rajalakshni, R., Kaveri, R. "Influence of Family Income and Parent's Oducation on the Nutritional Status of Pre-School Children." Indian J. -utr Dietet, 17, 1980; pp. 237-246 rarquharson, S.M. "Crowth Patterns and Nutrition in Vepalt Children." Archives of niseases in Childhood, 51, 1976: pp. 3-12. Frisancho, A.R. "Vew 1brns of Upper Linb Fat and %%scle Areas for Assessmnt of Nutritional Status. American Journal of Clinical Nutrition, 34, 1981; op. 2560-2565. Chai, O.P., Chaudhuri, S.N., Kapur, S., Jaisual, V.V., Sinclair, S. "Vutritiinal Assessment of Pre-Sbool Children of a Rural Area. Indian Journal of medical Research, 58, J970: pp. 1621-1628. rrahan, C.r., Cordano, A., Blizzard, R.M., Cheek, D.R. "Infantile Malnutrition: Changes in Body Composition During Rehabilitation:. vediatric Research, 3, 196Q; 9. 57Q. - 17 - =anill, P..V., Prizd, '.A., Johnson, C.L., Reed, R.R., Roche, A.r., voore, 1W.". "Physical Crowth: Xational Center for Realth Statistics Percentiles. Anerican Journal of Clinical Vucrition, 32, 1979: pp. 607- Jamison, P.T., %oock, P.R., "Parner rducation and Parm Pfficiency in Nepal: The Role of Schooling, fxtension Services, and Cognitive Skills". Mashington, D.C.: The World Rank :Population an Human Resources Division iscussion Paper So. Al-60), 194!. Tielmann, V.S., Xtelnann, A.A., Crewal C.K. "Etiological tremtvnce r: Protein Calorie Pndernutrition in a Rural ChilA Conunity." Acta rrooica, T3, 1476: pp. 142-368. Leslie, J., Raidya, S.., anduani, K. "Prevalence and Correlates of Childhood Malnutrition in the Terai Region of Nepal". WashITteon DC: The World 'ank (Population and Ruman Pesources Division Discussion Paper No. RI-35), 1981. Leslie, J. "Child Malnutrition and Diarrhea: A Longitudinel St y from Northeast Rrazil." n.Sc. Thesis, Johns Ropkins School of HRfiene and Public Pealth, 19R2. Leslie, J. "Family Characteristics and the Nutritional Status of Children in the Terai Reion of .1epal." X.Sc. Thesis, Johns Hopkins Iniversity, qchool of Ryiene and Public Pealth, 1978. Levinson, P.J. "Morinda: An Econoic Analysis of Malnutrition A ong Young Children in Rural India." Cambridge, Mass.: Cornell-KIT International Nutrition Policy Series, 1976. Lomenber, N.E., Todhunter .d., ilson, E.n., Savage, J.R. Luba ki, J.L. Food and People. 3rd ed. New York: John Wiley and Sons, 1979. artorell, R., Yarbrough, C., Lechtig, A., Delgado H., Klein, R.E. "Upper Arm Anthroponetric Indicators of Nutritional Status", Amerthan Journal of Clinical Nutrition, 29, 1976: pp. 46-53. McDovell, I., Voorweg, J. "Fnvironmental Risk Factors in Outpatient Recovery from !alnutrition". fcology of Food and N'trition, 6, 1977: pp. 23-30. "bock, P.R., Leslie, J. "Childhood Malnutrition and Schooling i the T-rai Region of Iepal". Washington DC: The World Rank (Population and Human Resources Division Discussion Paper Mo 82-14) 1987. Rao, K.V., Radhaiah, C., Raju, S..S. "Association ofrrowth St tus and the Prevalence of Anemia in Pre-School Children". Indian J Ned Res, 71, 19PO: pp. ?137-240. * 38 - Rawson. I.G.. Valverde, V. "The Ztiology of Malnutrition Among Preschool Children to Costa Rica". Env Chld Rlth, 22, 1976 pp. 12-17 Thapa. S., Rutherford, R.D. "Infant Mortality Estimates Based on the 1976 Nepal Fertility Survey". Population Studies, 36, 13G2: pp. 61-80. Uberot, X.S., DeSweeser, C., Taylor, C.E. "A Study of Anemia Among Rural Puniabi Children". Indian Journal of Medical Research, 60, 1972; pp. 793-611 Uberol, P.M., "Physical Growth of Children in V11ftrent Socio-econoi Croups in Bombay". Indian J Child Rlth, 12, 1963: pp. 593-611. Valverde, V., artorell R Mjia-Pivaral, V., Delgado, H., Lechtig, A., Teller C., Klein, R.E. "ReLationship Between Family Land Availabili .y and Nutritional Status". Ecology of Food and Nutrition 6, 1977-pp. 1-7. Valverde, V., .ajia-Pivaral V., Delgado, ., Belisan, J., Klein, R.E., artorell, R. "Income and Growth Retardation in Poor Families with Similar Living Conditions in Rural Cuatemala". Ecology of Food Nutrition, 10, 1981; pp. 241-248. Waterlow, J.C., Busina, R., Keller, U., Lane, J.M., Nichaman, M.Z, Tanner, J.M. "The Presentation and Use of Height and Weight Data for Comparing the Nutritional Status of Groups of Children under the Age of 10 Years". WHO Bulletin. 55, 1977: pp. 489-498. Worth R H., Shah, N.K. Nepal Health Survey, 1965-1966. Honolulu: University of Eamali Press, 1969. Yarbrough, C., Habicht, J-P., Malina, R.M., Lechtig, A., Kellan, R.E. "Length and Weight in Rural Guatemalan Ladino Children: Birth to Seven Years of Age." American Journal of Physical Anthropology, 42, 1975: pp. 439-448. World Bank, World Developmen Re ort, 1982. New York* 'Oxford University Press, 1.982. Z POPULATION & H MAN RESOURCES DIVISION DISCUSSION PAPERS [A * by the number indicates the paper is Bank-confidential or otherwise restricted.] 81-1 Oey A. Meesook, "Demographic Characteristics of Individuals and the Measurement of Lifetime Income". February 1981. 81-2 Susan H. Cochrane, The Economics of Fertility with Examples from Asia". February 1981. 81-3 Rashid Faruqee, "Social Infrastructure and Services in ZLmbabwe". February 1981. 81-4* Richard Sabot, A. 3urry, A. Bazlevood, J. Knight, J. Armitage and N. Boissiere, "Cognitive Skills: Their Determinants and Influence on Earnings in Two Poor Urban Economies." February 1981. 81-5 Dean T. Jamison, Barbara Searle, Stephen Heyneman, and Klaus Calda "Improving Elementary Mathematics Education in Nicaragua: An Experimental Study of the Impact of Textbooks and Radio on Achievement". March 1981. 81-6 Rashid Faruqee, "Analyzing the Impact of Health Services: Narangual and Other Experiences". March 1981. 81-7 J. B. Knight and R. H. Sabot, -Labor Market Discrimination in a Poor Urban Economy". March 1981. 81-8 Oey A. Meesook, "Interrelationships between Demographic Factors and Income Distribution: Problems of Measurement, Description and Interpretation". April 1981. 81-9 Susan H. Cochrane, Nirmala Joshi and Kalpana Nandwani, "Fertility Attitudes and Behavior in the Nepal Terai". April 1981. 81-10 J.B. Knight and Richard Sabot, -The Role of the Firm in Wage Determination: An African Case Study". April 1981. 81-11 J.B. Knight and Richard Sabot, -The Returns to Education: Increasing with Experience or Decreasing vJ#h Expansion?". March 1981. 81-12 J.B. Knight and Richard Sabot, Urom Migrants to Proletarians: Employment Experience, Mobility4nd Wages in Tanzania". March 1981. 81-13 A. Berry and Richard Sabot, "Unemployment and Economic Development". April 1981. 81-14 Rashid Faruqee and Ethna Johnson, "Health, Nutrition and Family Planning: A Survey of Experiments and Special Projects in India-. April 1981. 81-15 Francois Orivel and Dean T. Janison, -The Cost-Effectiveness of Distance Teaching Projects". June 1981 -2- 81-16 Richard Sabot, -Labor Force Growth, Employment and Earnings in Egypt: 1966-1968". May 1981. 81-17 K.C. Zachariah, "Anomaly of the Fertility Decline in Kerala: Social Development, Agrarian Reforms, or the Family Planning Program". may 1981. 81-18 Richard Sabot, A. Berry, A. Hazlwood, J. Knight, P. Collier, J. Araitage, H. Bolssiere, -Education Expansion and Labor Market Adjustment in Kenya and Tanzania - A Background Paper". May 1981. 81-19 Nancy Birdsall and Oey Meesook, 'Child Schooling, Number of Children and Intergenerational Transmission of Inequality: A Siulation'. May 1981. 81-20 Francois Orivel, 'The Impact of Agricultural Extension Services: A Review of the Literature". July 1981. Also available in French as iL'Impact des Services de Vulgarisation Agricole: Revue de Is Litterature". 81-21 Nancy Bird,all and H. Louise Fox, -Why Males Earn More: Location, Job Preferences and Job Discrimination Among 3rauilian Schoolteachers. Hay 1981. 81-22 Althea Hill, -The Demographic Situtation in Sub-Saharan Africa: A Discussion Paper-. Kay 1981. 81-23* R. Sabot, A. Berry, A. Hazlewood, J. Knight, J. Araitage, H. Boissiere 'Does the Expansion of Education Compress the Structure of Wages and Reduce the Inequaliti- of Pay? A Preliminary Analysis-. July 1981. 81-24* Nancy Birdsall and Dean T. Jamison. -Income and Other Factors Influencing Fertility and Mortality in China". October 1981. 81-25* Nancy Birdsall, Sulekha Patel and K. C. Zachariah, 'Alternative Projections of the Chinese Population". June 1981. 81-26* Dean T. Jamison, T.J. Ho, and F.L. Troubridge. -Food Availability and the Nutritional Status of Children in China". Septemter 1981. 81-27* Dean T.-Janison. -Child Malnutrition and School Retardation-in China-. Septqpber 1981. - 81-28 Deborah Lhamon Macmillan. -Language Policies for African Primary Education: Sumary of the Anglophone Research Literature.- July 1981. 81-29 Tania Thevenin. -Les Implications Pedagogiques des Politiques de langues dans 1'enseigcnent en Afrique: Une revue de La litterpture Francophone. June 1981. Also available in English as -Pedagogical Implications of Language Policy in African Schools: A Review of the Francophone Literature. -3- 81-30 Vicente Paqueo. "A Household Production*Model of School Enrollment: A Probit Analysis of the 1978 Bicol Multipurpose Survey Data". June 1981 81-31 Bryan L. Boulier and Vicente B. Paqueo. 'On the Theory and Measurements of the Determinants of Mortality". June 1981 81-32 Reynaldo Martorell. "Nutrition and Health Status Indicators: Suggestions for Surveys of the Standard of Living in Developing Countries". June 1981. 81-33* R. Sabot, A. Berry, A. Hazelwood, J. Knight, J. Armitage, and M. Boissiere. 'Correlates of Educational Attainment in Tanzania". July 1981. 81-34 Susan H. Cochrane. "The Determinants of Fertility and Child Survival in the Nepal TeraL". July 1981. 81-35 Joanne Leslie, B.G. Baldys, and K. Nandwant. 'Prevalence and Correlates of Childhood Malnutrition in the TeraL Region of Nepal". July 1981. 81-36 R. Hansell Prothero. "Perspectives on Population Mobility in West Africa". August 1981. 81-37 Timothy King. -Population Growth, International Resource Transfers, and International Migration". August 1981 81-38 Timothy King. -Iangration from Developing Countries: Some Philosophical Issues". August 1981. 81-39 R. Sabot and J. Knight. *Why Wages Differ: Earnings Functions in a Poor Urban Economy". August 1981. 81-40 Joao Batista de Araujo e Oliveira and Francois Orivel. 7a-Service Teacher Training System: Logos I in Brazil". August19.91. 81-41 R. Sabot, A. Berry, A. Hazlewood, J. Knight, J. Armitage and M. Boissiere. -Correlates of Educational Attainment in Kenya*. August 1981. 81-42 Peter Fallon. "Incomes, Poferty and Income Distribution in Rural Botswana: A Synthesis of Evidence Based on the Rural Income Distribution Survey." September 1981. 81-43 Barbara Watanabe and Eva Mueller. "A Poverty Profile for Rural Botswana.' October 1981. 81-44 Eva Mueller "The Value and Allocation of Time in Rural Botswana." November 1981. -4- 81-45 Robert E.B. Lucas. "The Distribution and Efficiency of Crop Production in Tribal Areas of Botswana." September 1981. 81-46 Robert E.B. Lucas. "The Distribution of Wages and Employment In Rural Botswana." Septeaber 1981. 81-47 Dov Chernichoavsky. "Socioecononc and Demographic Aspects of School Enrollment and Attendance in Rural Botswana." October 1981. 81-48 Dov Chernichovsky. "Socioeconomic Correlates of Fertility Behavior in Ru.al Botswana." October 1981. 81-49 Sherri Kossoudji and Eva Mueller. -The Economic and Demographic Status of Female Headed Households in Botswana.- October 1981. 81-50 Francois Orivel. -La Tlfivision Scolaire du S&ngal: Evaluation Economique et Perspectives." Aout 1981. (Summary available In English.) 81-51 Rillary Perraton, Dean T. Jamison and Francois Orivel. -Mass Media for Agricultural Extension in Halavi. September 1981 81-52 Thomas W. Merrick. "The Impact of Access to Piped Water on Infant Mortality in Urban Brazil, 1970 to 1976." August 1981. 81-53 N. Krishnan Naaboodiri. -Determinants of Fertility in Sri Lanka.' September 1981. 81-54 N. Krishnan 'Naaboodirt. 'Age at Marriage in Sri Lanka.- October 1981. 81-55* R. Sabot, A. Berry, A. Hazlewood, J. Knight, J. Armitage, M. Boissiere. "The Structure of Wages in Kenya and Tanzania: What Role Has Pay Policy Played?" Octobee 1981. 81-56* R. Sabot, A. Berry, A. Hazlewood, J. Knight, J. Armitage, M. Boissiere. -Wage Dynamics In Tanzania and Kenya: Policy Simulations." October 1981. 81-57 Dov Chernichovsky and Oey A. Meesook. "Female Labor Force Participation r in Indonesia." October 1981. 81-58 Dov Chernichovsky and Oey A. Meesook. "Poverty in Indonesia: A Profile." November 1981. 81-59 Susan H. Cochrane and Kalpana Nandvani. "The Determinants of Fertility to 22 Villages of Northern Thailand." December 1981. 81-60 Dean T. Jamison and Peter R. Moock. "Farmer Education and Farm Efficiency in Nepal: The Role of Schooling, Extension Services, and Cognitive Skills." December 1981. - 81-61 Susan H. Cochrane and Dean T. Jamison. -The Determinants and Consequences of Educational Achievement in the Rural Chiaeg Mai Valley." December 1981. 81-62 Rashid Faruqee, Carl Taylor, R.S.S. Sarua, Robert Parker and illia Reinke. "Benefits of Integrating Family Planning with Health Services: The Narangwal Experiment". December 1981. ** -6- 82-1 Hilary Perraton. "Mass Media, Basic Education and Agricdtural Extension". Jauary 1982. 82-2* R.C. Zachariah and Sulekha Patel. -Trends and Determinants of Infant and Child Mortality in Kerala". January 1982. 82-3 Soe Pudasaini. "Education and Agricultural Efficiency in Nepal". January 1982. 82-4 Katherine Blair. "Economic Self-Sufficiency and the Effects of Economic Development on Village Housing in Nepal". Jan ary 1982. t 82-5 Meena Acharya. -Time Use Data and Living Standard Measu ement Study". March 1982. 82-6 Nancy Birdsall. "Child Schooling and the Measurement of Liviag Standards". February 1982. 82-7 Teresa J. go. "Measurin4 Health as a Component of Living Standards". March 1982. 82-8 Nancy Birdsall. -The Impact of School Availability and qua&!.y on Children-s Schooling in Brazil". March 1982. 82-9 J. M. Sullivan, S. H. Cochrane and W. D. Kalsbeek. "Procedures for Collecting and Analyzing Mortality Data in LSMS.1 April 1982. 82-10 Nancy Birdsall and Jere Behrman. -Income Returns to Quantity and Quality of Schooling in Brazil: Is Quantity Alone Misleading?- January 1982. 82-11 Meena Acharya and Lynn Bennett. -Women and the Subsistence Sector: Economic Part cipation and Hoasehold Decision-Making in Nepal". April 1982. 82-12 Tania Catz-Thevenin. .L'Impact des Langues Maternelles Dans Les Projets d-education Rurale Utilisant les Mass-Media". April 1982 82-13 Dean T. Janison and Marlaine,,ockheed. -Participation n Schooling: Determinants and Learning Outcomesin Nepal-. (forthcoming). 82-14 Joanne Leslie and Peter R. MVck. "Childhood Malnutrit on and Schooling in the Teral Regnn of Nepal". December 19Q2. 82-15 Reynaldo Martorell, Joanne Leslie, and Peter R. Moock. "Characteristics and Determinants of Child Nutritiona Status in Nepal". December 1982.