Height, weight and BMI percentiles and nutritional status relative to the international growth references among Pakistani school-aged children.

BACKGROUND: Child growth is internationally recognized as an important indicator of nutritional status and health in populations. This study was aimed to compare age- and gender-specific height, weight and BMI percentiles and nutritional status relative to the international growth references among Pakistani school-aged children. METHODS: A population-based study was conducted with a multistage cluster sample of 1860 children aged five to twelve years in Lahore, Pakistan. Smoothed height, weight and BMI percentile curves were obtained and comparison was made with the World Health Organization 2007 (WHO) and United States' Centers for Disease Control and Prevention 2000 (USCDC) references. Over- and under-nutrition were defined according to the WHO and USCDC references, and the International Obesity Task Force (IOTF) cut-offs. Simple descriptive statistics were used and statistical significance was considered at P < 0.05. RESULTS: Height, weight and BMI percentiles increased with age among both boys and girls, and both had approximately the same height and a lower weight and BMI as compared to the WHO and USCDC references. Mean differences from zero for height-, weight- and BMI-for-age z score values relative to the WHO and USCDC references were significant (P < 0.001). Means of height-for-age (present study: 0.00, WHO: -0.19, USCDC: -0.24), weight-for-age (present study: 0.00, WHO: -0.22, USCDC: -0.48) and BMI-for-age (present study: 0.00, WHO: -0.32, USCDC: -0.53) z score values relative to the WHO reference were closer to zero and the present study as compared to the USCDC reference. Mean differences between weight-for-age (0.19, 95% CI 0.10-0.30) and BMI-for-age (0.21, 95% CI 0.11-0.30) z scores relative to the WHO and USCDC references were significant. Over-nutrition estimates were higher (P < 0.001) by the WHO reference as compared to the USCDC reference (17% vs. 15% overweight and 7.5% vs. 4% obesity) while underweight and thinness/wasting were lower (P < 0.001) by the WHO reference as compared to the USCDC reference (7% vs. 12% underweight and 10% vs. 13% thinness). Significantly lower overweight (8%) and obesity (5%) prevalence and higher thinness grade one prevalence (19%) was seen with use of the IOTF cut-offs as compared to the WHO and USCDC references. Mean difference between height-for-age z scores and difference in stunting prevalence relative to the WHO and USCDC references was not significant. CONCLUSION: Pakistani school-aged children significantly differed from the WHO and USCDC references. However, z score means relative to the WHO reference were closer to zero and the present study as compared to the USCDC reference. Overweight and obesity were significantly higher while underweight and thinness/wasting were significantly lower relative to the WHO reference as compared to the USCDC reference and the IOTF cut-offs. New growth charts for Pakistani children based on a nationally representative sample should be developed. Nevertheless, shifting to use of the 2007 WHO child growth reference might have important implications for child health programs and primary care pediatric clinics.

Family-based factors associated with overweight and obesity among Pakistani primary school children.

BACKGROUND: Childhood obesity epidemic is now penetrating the developing countries including Pakistan, especially in the affluent urban population. There is no data on association of family-based factors with overweight and obesity among school-aged children in Pakistan. The study aimed to explore the family-based factors associated with overweight and obesity among Pakistani primary school children. METHODS: A population-based cross-sectional study was conducted with a representative multistage cluster sample of 1860 children aged five to twelve years in Lahore, Pakistan. Overweight (> +1SD BMI-for-age z-score) and obesity (> +2SD BMI-for-age z-score) were defined using the World Health Organization reference 2007. Chi-square test was used as the test of trend. Linear regression was used to examine the predictive power of independent variables in relation to BMI. Logistic regression was used to quantify the independent predictors of overweight and adjusted odds ratios (aOR) with 95% confidence intervals (CI) were obtained. All regression analyses were controlled for age and gender and statistical significance was considered at P < 0.05. RESULTS: Significant family-based correlates of overweight and obesity included higher parental education (P < 0.001), both parents working (P = 0.002), fewer siblings (P < 0.001), fewer persons in child's living room (P < 0.001) and residence in high-income neighborhoods (P < 0.001). Smoking in living place was not associated with overweight and obesity. Higher parental education (P < 0.001) and living in high-income neighborhoods (P < 0.001) showed a significant independent positive association with BMI while greater number of siblings (P = 0.001) and persons in child's living room (P = 0.022) showed a significant independent inverse association. College-level or higher parental education as compared to high school-level or lower parental education (aOR 2.54, 95% CI 1.76-3.67), living in high-income neighborhoods as compared to low-income neighborhoods (aOR 2.13, 95% CI 1.31-3.46) and three or less siblings as compared to more than three siblings (aOR 1.75, 95% CI 1.26-2.42) were significant independent predictors of overweight. CONCLUSION: Family-based factors were significantly associated with overweight and obesity among school-aged children in Pakistan. Higher parental education, living in high-income neighborhoods and fewer siblings were independent predictors of overweight. These findings support the need to design evidence-based child health policy and implement targeted interventions, considering the impact of family-based factors and involving communities.

Dietary behaviors, physical activity and sedentary lifestyle associated with overweight and obesity, and their socio-demographic correlates, among Pakistani primary school children.

BACKGROUND: There is no data on diet- and activity-related behaviors associated with overweight and obesity among Pakistani school-aged children. The study aimed to explore dietary behaviors, physical activity and sedentary lifestyle associated with overweight and obesity, and their socio-demographic correlates, among Pakistani primary school children. METHODS: A population-based cross-sectional study was conducted with a representative multistage random cluster sample of 1860 children aged five to twelve years in Lahore, Pakistan. Overweight (>+1 SD) and obesity (>+2 SD) were defined using the World Health Organization reference 2007. Chi-square test was used as the test of trend. Linear regression was used to examine the predictive power of independent variables in relation to body mass index (BMI). Logistic regression was used to quantify the independent predictors and adjusted odds ratios (aOR) with 95% confidence intervals (CI) were obtained. Statistical significance was considered at P<0.05. RESULTS: Children skipping breakfast (8%), eating fast food and snacks≥once a week (43%) and being involved in sedentary lifestyle>one hour a day (49%) were significantly more likely to be overweight and obese while those participating in physical activity>twice a week (53%) were significantly less likely to be overweight and obese (all P<0.01). Skipping breakfast (P<0.001), eating fast food and snacks (P=0.001) and sedentary lifestyle (P<0.001) showed an independent positive association with BMI while physical activity showed an independent inverse association (P=0.001). Skipping breakfast (aOR 1.82, 95% CI 1.22-2.71), eating fast food and snacks≥once a week (OR 1.41, 95% CI 1.07-1.86), physical activity>twice a week (aOR 0.49, 95% CI 0.34-0.70) and sedentary lifestyle>one hour a day (aOR 1.56, 95% CI 1.19-2.03) were independent predictors of being overweight. Skipping breakfast had independent inverse association with physical activity (aOR 0.63, 95% CI 0.45-0.89) and eating fast food and snacks had independent positive association with sedentary lifestyle (aOR 1.79, 95% CI 1.49-2.16). Female gender was independently associated with skipping breakfast (aOR 1.50, 95% CI 1.04-2.16). Male gender (aOR 1.64, 95% CI 1.33-2.02), urban area with high SES (aOR 5.09, 95% CI 3.02-8.60) and higher parental education (aOR 1.74, 95% CI 1.12-2.68) were significant independent predictors of eating fast food and snacks≥once a week. Living in the rural area was independently associated (aOR 2.51, 95% CI 1.71-3.68) with physical activity>twice a week. Male gender (aOR 1.60, 95% CI 1.31-1.95), urban area with low SES (aOR 1.46, 95% CI 1.02-2.09), high-income neighborhoods (aOR 1.52, 95% CI 1.02-2.25), higher parental education (aOR 1.55, 95% CI 1.03-2.34) and fewer siblings (aOR 1.38, 95% CI 1.10-1.73) were independent predictors of sedentary lifestyle>one hour a day. CONCLUSIONS: Dietary behaviors, physical activity and sedentary lifestyle are independent predictors of overweight and higher BMI among Pakistani primary school children, and are significantly affected by the child's socio-demographic characteristics. These findings support the urgent need to develop a National strategy for diet and physical activity and to implement culturally relevant behavioral interventions in the resource-poor developing country settings.

Waist circumference, waist-hip ratio and waist-height ratio percentiles and central obesity among Pakistani children aged five to twelve years.

BACKGROUND: Central obesity has been associated with the risk of cardiovascular and metabolic disease in children and anthropometric indices predictive of central obesity include waist circumference (WC), waist-hip ratio (WHR) and waist-height ratio (WHtR). South Asian children have higher body fat distribution in the trunk region but the literature regarding WC and related indices is scarce in this region. The study was aimed to provide age- and gender-specific WC, WHR and WHtR smoothed percentiles, and to explore prevalence and correlates of central obesity, among Pakistani children aged five to twelve years. METHODS: A population-based cross-sectional study was conducted with a representative multistage random cluster sample of 1860 primary school children aged five to twelve years in Lahore, Pakistan. Smoothed percentile curves were constructed for WC, WHR and WHtR by the LMS method. Central obesity was defined as having both age- and gender-specific WC percentile ≥90th and WHtR ≥0.5. Chi-square test was used as the test of trend. Multivariate logistic regression was used to quantify the independent predictors of central obesity and adjusted odds ratios (aOR) with 95% CI were obtained. Linear regression was used to explore the independent determinants of WC and WHtR. Statistical significance was considered at P < 0.05. RESULTS: First ever age- and gender-specific smoothed WC, WHR and WHtR reference curves for Pakistani children aged five to twelve years are presented. WC increased with age among both boys and girls. Fiftieth WC percentile curves for Pakistani children were higher as compared to those for Hong Kong and British children, and were lower as compared to those for Iranian, German and Swiss children. WHR showed a plateau pattern among boys while plateau among girls until nine years of age and decreased afterwards. WHtR was age-independent among both boys and girls, and WHtR cut-off of ≥0.5 for defining central obesity corresponded to 85th WHtR percentile irrespective of age and gender. Twelve percent children (95% CI 10.1-13.0) had a WC ≥90th percentile and 16.5% children (95% CI 14.7-18.1) had a WHtR ≥0.5 while 11% children (95% CI 8.9-11.6) had both WC ≥90th percentile and WHtR ≥0.5. Significant predictors of central obesity included higher grade, urban area with high socioeconomic status (SES), high-income neighborhood and higher parental education. Children studying in higher grade (aOR 5.11, 95% CI 1.76-14.85) and those living in urban area with high SES (aOR 82.34, 95% CI 15.76-430.31) showed a significant independent association. Urban area with high SES and higher parental education showed a significant independent association with higher WC and higher WHtR while higher grade showed a significant independent association with higher WC. CONCLUSIONS: Comprehensive worldwide reference values are needed to define central obesity and the present study is the first one to report anthropometric indices predictive of central obesity for Pakistani school-aged children. Eleven percent children were centrally obese and strong predictors included higher grade, urban area with high SES and higher parental education. These findings support the need for developing a National strategy for childhood obesity and implementing targeted interventions, prioritizing the higher social class and involving communities.

Prevalence and socio-demographic correlates of stunting and thinness among Pakistani primary school children.

BACKGROUND: Child growth is internationally recognized as an important indicator of nutritional status and health in populations. Child under-nutrition is estimated to be the largest contributor to global burden of disease, and it clusters in South Asia but literature on under-nutrition among school-aged children is difficult to find in this region. The study aimed to assess the prevalence and socio-demographic correlates of stunting and thinness among Pakistani primary school children. METHODS: A population-based cross-sectional study was conducted with a representative multistage cluster sample of 1860 children aged 5-12 years in Lahore, Pakistan. Stunting (< -2 SD of height-for-age z-score) and thinness (< -2 SD of BMI-for-age z-score) were defined using the World Health Organization reference 2007. Chi-square test was used as the test of trend. Logistic regression was used to quantify the independent predictors of stunting and thinness and adjusted odds ratios (aOR) with 95% confidence interval (CI) were obtained. Linear regression was used to explore the independent determinants of height- and BMI-for-age z-scores. Statistical significance was considered at P < 0.05. RESULTS: Eight percent (95% CI 6.9-9.4) children were stunted and 10% (95% CI 8.7-11.5) children were thin. Stunting and thinness were not significantly associated with gender. Prevalence of stunting significantly increased with age among both boys and girls (both P < 0.001) while thinness showed significant increasing trend with age among boys only (P = 0.034). Significant correlates of stunting included age > 8 years, rural area and urban area with low SES, low-income neighborhoods, lower parental education, more siblings, crowded housing and smoking in living place (all P < 0.001). Significant correlates of thinness included rural area and urban area with low SES, low-income neighborhoods and lower parental education (all P < 0.001), and age > 10 years (P = 0.003), more siblings (P = 0.016) and crowded housing (P = 0.006). In multivariate logistic regression analyses adjusted simultaneously for all factors, older age (aOR 3.60, 95% CI 1.89-6.88), urban area with low SES (aOR 2.58, 95% CI 1.15-5.81) and low-income neighborhoods (aOR 4.62, 95% CI 1.63-13.10) were associated with stunting while urban area with low SES (aOR 2.28, 95% CI 1.21-4.30) was associated with thinness. In linear regression analyses adjusted for all factors, low-income neighborhoods and older age were associated with lower height-for-age z-score while rural area with low/disadvantaged SES was associated with lower BMI-for-age z-score. CONCLUSIONS: Relatively low prevalence of stunting and thinness depicted an improvement in the nutritional status of school-aged children in Pakistan. However, the inequities between the poorest and the richest population groups were marked with significantly higher prevalence of stunting and thinness among the rural and the urban poor, the least educated, the residents of low-income neighborhoods and those having crowded houses. An increasing trend with age was observed in prevalence of stunting and thinness. Smoking in living place was associated with stunting. Findings suggest the need to implement evidence-based child health policy and strategies, prioritizing the poor and socially disadvantaged population.

Prevalence and socioeconomic correlates of overweight and obesity among Pakistani primary school children.

BACKGROUND: Childhood obesity is becoming an equally challenging, yet under-recognized, problem in developing countries including Pakistan. Children and adolescents are worst affected with an estimated 10% of the world's school-going children being overweight and one quarter of these being obese. The study aimed to assess prevalence and socioeconomic correlates of overweight and obesity, and trend in prevalence statistics, among Pakistani primary school children. METHODS: A population-based cross-sectional study was conducted with a representative multistage cluster sample of 1860 children aged 5-12 years in Lahore, Pakistan. Overweight (> + 1SD) and obesity (> + 2SD) were defined using the World Health Organization child growth reference 2007. Chi-square test was used as the test of trend. Linear regression was used to examine the predictive power of independent variables in relation to BMI. Logistic regression was used to quantify the independent predictors for overweight and adjusted odds ratios (aOR) with 95% confidence intervals (CI) were obtained. All regression analyses were controlled for age and gender and statistical significance was considered at P < 0.05. RESULTS: Seventeen percent (95% CI 15.4-18.8) children were overweight and 7.5% (95% CI 6.5-8.7) were obese. Higher prevalence of obesity was observed among boys than girls (P = 0.028), however, there was no gender disparity in overweight prevalence. Prevalence of overweight showed a significantly increasing trend with grade (P < 0.001). Children living in the urban area with high socioeconomic status (SES) were significantly at risk for being overweight and obese (both P < 0.001) as compared to children living in the urban area with lower SES and rural children. Being in higher grade (aOR 2.39, 95% CI 1.17-4.90) and living in the urban area with higher SES (aOR 18.10, 95% CI 10.24-32.00) independently predicted the risk of being overweight. CONCLUSION: Alarmingly rapid rise in overweight and obesity among Pakistani primary school children was observed, especially among the affluent urban population. The findings support the urgent need for National preventive strategy for childhood obesity and targeted interventions tailored to local circumstances with meaningful involvement of communities.

Urban-rural inequities in knowledge, attitudes and practices regarding tuberculosis in two districts of Pakistan's Punjab province.

OBJECTIVE: The aim of this study was to explore inequities in knowledge, attitudes and practices regarding tuberculosis (TB) among the urban and rural populations. DESIGN: A cross-sectional study was conducted in two districts of Pakistan's Punjab province. The 1080 subjects aged 20 years and above, including 432 urban and 648 rural respondents, were randomly selected using multistage cluster sampling and interviewed after taking verbal informed consent. Logistic regression was used to calculate the crude odds ratio (OR) with 95% confidence interval (CI) for the urban area. The differences in knowledge, attitudes, practices and information sources between the urban and rural respondents were highlighted using Pearson chi-square test and Fisher's exact test. RESULTS: The study revealed poor knowledge regarding TB. The deficit was greater in the rural areas in all aspects. The knowledge regarding symptoms (OR 2.03, 95% CI 1.59-2.61), transmission (OR 1.93, 95% CI 1.44-2.59), prevention (OR 2.24, 95% CI 1.70-2.96), duration of standard treatment (OR 1.88, 95% 1.41-2.49) and DOTS (OR 1.84, 95% CI 1.43-2.38) was significantly higher in the urban areas (all P < 0.001). Although a majority of the subjects (urban 83.8%, rural 81.2%) were aware of the correct treatment for TB, less than half (urban 48.1%, rural 49.2%) were aware of the availability of the diagnostic facility and treatment free of cost. The practice of seeking treatment at a health facility (P = 0.030; OR 2.01, 95% CI 1.06-3.82), as soon as they realized that they had TB symptoms (P < 0.001; OR 1.72, 95% CI 1.26-2.35), was significantly higher in the urban areas. People in the urban areas were more likely to feel ashamed and embarrassed being a TB patient (P < 0.001; OR 2.03, 95% CI 1.50-2.76); however, they seem to be supportive in case their family member suffered from TB (P = 0.005; OR 1.53, 95% CI 1.13-2.06). Nearly half of the respondents, irrespective of the area of residence, believed that the community rejects the TB patient (urban 49.8%, rural 46.4%). Television (urban 80.1%, rural 68.1%) and health workers (urban 30.6%, rural 41.4%) were the main sources for people to acquire the TB related information. CONCLUSION: Respondents' knowledge regarding TB was deficient in all aspects, particularly in the rural areas. Intended health seeking behavior was better in the urban areas. Television and health workers were the main sources for TB related information in both the urban as well as the rural areas. Therefore, the area of residence should be considered in tailoring communication strategies and designing future interventions for TB prevention and control.

Socio-demographic correlates of the health-seeking behaviours in two districts of Pakistan's Punjab province.

OBJECTIVE: To explore socio-demographic correlates of the health-seeking behaviours among urban and rural population. METHODS: A population-based cross-sectional study was conducted in two districts of Pakistan's Punjab province with a random multi-stage cluster sample of 1080 individuals. Bivariate analysis using chi-square test and Fisher's exact test was used as the test of trend. Multivariate logistic regression was used to obtain adjusted odds ratio (OR) with 95% confidence interval (CI). Statistical significance was considered at P<0.05. RESULTS: Utilization of the public health facilities (74%) was associated with rural area (P=0.034) and poverty (P=0.001) while use of the private hospitals (41%) was associated with better education (P=0.002) and higher income (P<0.001). When simultaneously adjusted for area, income and education, the poor were more likely to use the public hospitals (OR 2.29, 95% CI 1.56-3.37) and less likely to attend a private hospital (OR 0.42, 95% CI 0.30-0.60). Main constraints in the public health facility use were cost (25%), dissatisfaction with quality of care (19%) and transportation difficulties (12%). Costs were more likely to be a problem among rural (P=0.010), illiterate (P<0.001) and poor (P<0.001) while dissatisfaction with quality of care was associated with urban area (P<0.001) and poverty (P=0.001). CONCLUSION: Socio-demographic factors significantly drive the health seeking behaviours among general population. After adjusting for all factors, the poor were more likely to use public hospitals. Costs and dissatisfaction with quality of care were main constraints in utilization of the public health facilities.

From their own perspective - constraints in the Polio Eradication Initiative: perceptions of health workers and managers in a district of Pakistan's Punjab province.

BACKGROUND: The success of the Global Polio Eradication Initiative was remarkable, but four countries - Afghanistan, Pakistan, India and Nigeria - never interrupted polio transmission. Pakistan reportedly achieved all milestones except interrupting virus transmission. This paper describes the perceptions of health workers and managers regarding constraints in the Polio Eradication Initiative (PEI) to ultimately provide evidence for designing future interventions. METHODS: A qualitative cross-sectional study using focus group discussions and in-depth interviews was conducted in the Nankana Sahib District of Pakistan's Punjab province. Study subjects included staff at all levels in the PEI at district headquarters, in all 4 tehsils (sub-districts) and at 20 randomly selected primary health centers. In total, 4 FGD and 7 interview sessions were conducted and individual session summary notes were prepared and later synthesized, consolidated and subjected to conceptual analysis. RESULTS: The main constraints identified in the study were the poor condition of the cold chain in all aspects, poor skills and a lack of authority in resource allocation and human resource management, limited advocacy and communication resources, a lack of skills and training among staff at all levels in the PEI/EPI in almost all aspects of the program, a deficiency of public health professionals, poor health services structure, administrative issues (including ineffective means of performance evaluation, bureaucratic and political influences, problems in vaccination areas and field programs, no birth records at health facilities, and poor linkage between different preventive programs), unreliable reporting and poor monitoring and supervision systems, limited use of local data for interventions, and unclear roles and responsibilities after decentralization. CONCLUSION: The study highlights various shortcomings and bottlenecks in the PEI, and the barriers identified should be considered in prioritizing future strategies.

Are we doing enough? Evaluation of the Polio Eradication Initiative in a district of Pakistan's Punjab province: a LQAS study.

BACKGROUND: The success of the Global Polio Eradication Initiative was remarkable, but four countries - Afghanistan, Pakistan, India and Nigeria - never interrupted polio transmission. Pakistan reportedly achieved all milestones except interrupting virus transmission. The aim of the study was to establish valid and reliable estimate for: routine oral polio vaccine (OPV) coverage, logistics management and the quality of monitoring systems in health facilities, NIDs OPV coverage, the quality of NIDs service delivery in static centers and mobile teams, and to ultimately provide scientific evidence for tailoring future interventions. METHODS: A cross-sectional study using lot quality assessment sampling was conducted in the District Nankana Sahib of Pakistan's Punjab province. Twenty primary health centers and their catchment areas were selected randomly as 'lots'. The study involved the evaluation of 1080 children aged 12-23 months for routine OPV coverage, 20 health centers for logistics management and quality of monitoring systems, 420 households for NIDs OPV coverage, 20 static centers and 20 mobile teams for quality of NIDs service delivery. Study instruments were designed according to WHO guidelines. RESULTS: Five out of twenty lots were rejected for unacceptably low routine immunization coverage. The validity of coverage was questionable to extent that all lots were rejected. Among the 54.1% who were able to present immunization cards, only 74.0% had valid immunization. Routine coverage was significantly associated with card availability and socioeconomic factors. The main reasons for routine immunization failure were absence of a vaccinator and unawareness of need for immunization. Health workers (96.9%) were a major source of information. All of the 20 lots were rejected for poor compliance in logistics management and quality of monitoring systems. Mean compliance score and compliance percentage for logistics management were 5.4 +/- 2.0 (scale 0-9) and 59.4% while those for quality of monitoring systems were 3.3 +/- 1.2 (scale 0-6) and 54.2%. The 15 out of 20 lots were rejected for unacceptably low NIDs coverage by finger-mark. All of the 20 lots were rejected for poor NIDs service delivery (mean compliance score = 11.7 +/- 2.1 [scale 0-16]; compliance percentage = 72.8%). CONCLUSION: Low coverage, both routine and during NIDs, and poor quality of logistics management, monitoring systems and NIDs service delivery were highlighted as major constraints in polio eradication and these should be considered in prioritizing future strategies.

Relationship of non-organic factors with malnutrition among children under three years of age.

OBJECTIVE: To study the association of socioeconomic and physical environmental factors with malnutrition among children under 3 years of age in four districts of Pakistan. DESIGN: Cross-sectional comparative study. PLACE AND DURATION OF STUDY: Selected MCH, Centres of Lahore, Jhang, Gilgit and Pallandri (AJK) providing preventive, promotive and curative services during the month of January 2004. PATIENTS AND METHODS: A total of 448 children under 3-years of age coming to selected MCH centers, during the study period, were examined for malnutrition. The children were divided into two groups (normal/malnourished) on the basis of standard WHO weight for age growth chart. The compared variables were weaning and breast feeding practices, gender, vaccination status, living conditions and parents' educational status. RESULTS: There were 238 (53%) male and 210 (47%) female children examined for malnutrition. The difference in weaning age, gender and vaccination status among normal and malnourished children were found to be statistically significant (p<0.001). A higher proportion of malnourished children (62.6%) was also found in families living in one room houses as compared to 2 or more room houses (p=0.01). There was an inverse association of educational status of both parents with malnutrition of children (p<0.001). CONCLUSION: This series showed a higher proportion of malnutrition among children, who were unvaccinated, weaned after seven months of age, not exclusively breast-fed for first six months, and lived in poor environmental conditions.