Epidemiology of childhood malnutrition in India and strategies for its control

By Dr Rakesh Kumar

Framework

1. Introduction

2. What is malnutrition

3. Magnitude of malnutrition

4. Determinants of malnutrition

5. Prevention and control

6. Nutritional programmes in India

7. References

Introduction

• Malnutrition makes children more vulnerable to disease and premature death

• India has the highest proportion of under-nourished children in the world

• Effective interventions are available to reduce stunting, micronutrient deficiencies, and child deaths

• Millennium development goal (MDGs) Target 2: to reduce the proportion of underweight children by half by the year 2015

What is Malnutrition

• A range of conditions occurring when intake of one or more nutrients doesn’t meet the requirements

• Protein Energy Malnutrition (PEM) is a malnutrition resulting from the deficiency of protein and/or energy in diet

• Etiological Theory: ‘Protein gap’ ‘Food gap’

Kwashiorkor: . Apathy, swelling (oedema) of the extremities, torso and face, cracked, peeling, infection-prone skin and unnaturally blond, sparse hair are its visible characteristics.

Marasmus: fat and muscle tissue are depleted, and the skin hangs in loose folds with the bones clearly visible beneath. Hyper-alert and ravenously hungry

Two polar forms of PEM

Interpretation of Nutritional Indices

Indicator AcuteMalnutrition

ChronicMalnutrition

Wt-for-age(Underweight)

Ht-for-Age (Stunting)

Normal

Wt-for-Ht(Wasting)

Normal

Grades of malnutrition

Magnitude of Malnutrition

Magnitude of Malnutrition

• Prevalence of malnutrition in World: Underweight:150 million (26.7%) Stunting: 182 million (32.5%) are stunted

• More than 70% of PEM children live in Asia, 26% in Africa and 4% in Latin America and the Caribbean

• Prevalence of malnutrition in India (NFHS-3) :

Moderate(Z-score < 2)

Severe(Z-score<3)

Underweight 43% 16%Stunting 48% 24%Wasting 20% 6.4%

Prevalence of stunting in children under 5 years

Countries with stunting prevalence ≥20% in children under the age of 5 years that together account for >80% of the world’s undernourished children.

The 20 countries with the highest burden of undernutrition

Prevalence of stunting among children under 5 years old in India by state

Inter state variation

Trends in Nutritional status in children

Determinants of Malnutrition

Conceptual Framework for determinants of Malnutrition

Infection and Malnutrition

Inadequate dietary intake

Disease: Incidence, duration, severity

Weight lossGrowth faltering

Lowered immunityMucosal damage

Appetite lossNutrient loss

MalabsorbtionAltered metabolism

Household- level Food security

National/ regional level food security

Age, Gender, Education, Income, Autonomy

Decision Maker

Household- level Food security

Agriculture production, Income, Effective trade, transport infrastructure

Effect of age on Malnutrition

Intergenerational cycle of malnutrition

Nutritional status at puberty

Girls nutritional status

Neonatal and infant nutritional status

Nutritional status of lactating women

Nutritional status of pregnant woman

Nutritional status of woman of child-

bearing age

The South Asian Enigma:

Why is undernutrition in South Asia so much higher than in Sub Saharan Africa?

• Explained by three key differences between South Asia and Sub Saharan Africa

1. Low birth weight - single largest predictor of undernutrition Prevalence of LBW in India is over 30% Indian babies (16% in Sub-Saharan Africa)

2. Women in South Asia tend to have lower status and less decision-making power than women in Sub-Saharan Africa.

3. Hygiene and sanitation standards in South Asia are well below those in Africa

Prevention & Control

Interventions that affect child undernutritionMaternal & Birth Outcome Infants & childrenMaternal supplements of balanced energy and Protein

Promotion of breastfeeding (individual and group counselling)

Iron -folate supplementation Behaviour change communication for improved complementary feeding

Maternal calcium supplementation Iron fortification and supplementation programmes

Maternal iodine through iodisation of salt Vitamin A fortification or supplementation

Maternal deworming in pregnancy Zinc supplementationZinc in management of diarrhoea

Interventions to reduce tobacco consumption or indoor air pollution

Periodic Deworming

Intermittent preventive treatment for malaria

Conditional cash transfer programmes (with nutritional education)

Insecticide-treated bednets Handwashing or hygiene interventions

Insecticide-treated bednetsTreatment of severe acute malnutrition

Interventions

Promoting appropriate feeding for infants and young children

• Promoting exclusively breastfeeding for the first six months

• Start complementary feeding (Timely , adequate, safe, properly fed) after six month while continuing breastfeeding up to two years of age

• Providing sound and culture-specific nutrition counselling to mothers and recommending the widest possible use of indigenous foodstuffs

• Helping women in paid employment to continue breastfeeding by providing with minimum enabling conditions e.g, paid maternity leave, part-time work arrangements, on-site crèches, facilities for expressing and storing breast milk, and breastfeeding breaks

• Food fortification and universal or targeted nutrient supplementation

GUIDING PRINCIPLES FOR COMPLEMENTARYF E E D I N G O F T H E B R E A S T F E D C H I L D

1. Practice exclusive breastfeeding from birth to 6 months of age, and introduce complementary foods at 6 months of age while continuing to breastfeed.

2. Continue frequent, on-demand breastfeeding until 2 years of age or beyond.

3. Practice responsive feeding, applying the principles of psychosocial care. Specifically: a) feed infants directly and assist older children when they feed themselves,

being sensitive to their hunger and satiety cues; b) feed slowly and patiently, and encourage children to eat, but do not force

them; c) if children refuse many foods, experiment with different food

combinations, tastes, textures and methods of encouragement;d) minimize distractions during meals if the child loses interest easily; e) feeding times are periods of learning and love - talk to children during

feeding, with eye to eye contact.

GUIDING PRINCIPLES ...

4. Practice good hygiene and proper food handling by – washing caregivers’ and children’s hands before food preparation and

eating, – storing foods safely and serving foods immediately after preparation,– using clean utensils to prepare and serve food, – using clean cups and bowls when feeding children, and – avoiding the use of feeding bottles, which are difficult to keep clean.

5. Start at 6 months of age with small amounts of food and increase the quantity as the child gets older, while maintaining frequent breastfeeding.

6. Gradually increase food consistency and variety as the infant gets older, adapting to the infant’s requirements and abilities.

GUIDING PRINCIPLES …

7. Increase the number of times that the child is fed complementary foods as he/she gets older. – If energy density or amount of food per meal is low, or the child is no

longer breastfed, more frequent meals may be required.8. Feed a variety of foods to ensure that nutrient needs are met. e.g, Meat,

poultry, fish or eggs should be eaten daily, or as often as possible. – Vitamin A-rich fruits and vegetables should be eaten daily. – Provide diets with adequate fat content. – Avoid giving drinks with low nutrient value, such as tea, coffee, soda.

Limit the amount of juice offered9. Use fortified complementary foods or vitamin-mineral supplements for

the infant, as needed. 10. Increase fluid intake during illness, including more frequent breastfeeding,

and encourage the child to eat soft, varied, appetizing, favorite foods – After illness, give food more often than usual and encourage the child to

eat more

Growth Monitoring & Promotion

Importance of Growth Monitoring :

a) To provide an opportunity for giving health education and advice for the prevention of malnutrition.

b) For early detection of abnormal growth and development.

c) To facilitate the early treatment or correction of any conditions that may be causing abnormal growth and development.

Child-care during Illnesses

• Home treatment: Give sick children appropriate home treatment for infections.

• Care seeking: Recognize when sick children need treatment outside the home, and seek care from appropriate providers.

• Appropriate practices: Follow the health worker’s advice about treatment, follow-up and referral.

• Feeding and fluids for sick children: Continue to feed and offer more fluids, including breast milk, to children when they are sick.

Management of Severe Malnutrition

Timeframe for management of severe malnutrition

Conceptual model of how interventions can affect early child development

Nutritional Programmes in India• Ministry of Social Welfare– ICDS programme– Balwadi nutrition programme– Special Nutrition programme

• Ministry of Health and Family Welfare– Prophylaxis against nutritional anaemia– Vitamin A prophylaxis programme– Iodine Deficiency Disorders Control programme

• Ministry of Education– Mid Day Meal programme

Interventions under ICDSServices Target Group Services ProviderSupplementary Nutrition& Growth monitoring

Children below 6 years; pregnant and lactating mothers

Anganwadi Workers (AWW) & AnganwadiHelper (AWH)

Immunization Children below 6 years; pregnant mothers

ANM/MO

Health Checkups Children below 6 years; pregnant and lactating mothers

ANM/MO/AWW

Treatment & Referral Children below 6 years; pregnant and lactating mothers

AWW/ANM/MO

Pre-School Education Children 3-6 years AWW

Nutrition & Health Education

Women (15- 45 years) AWW/ANM/MO

Integrated Child Development Services (ICDS) program

• Mismatch between the program’s intentions and its actual implementation

• Key mismatches are:

– Dominant focus on food supplementation– Service delivery is not sufficiently focused on the youngest

children (under three) – ICDS is only partially succeeding in preferentially targeting

girls and lower castes (who are at higher risk of undernutrition)

– The poorest states and those with the highest levels of undernutrition still have the lowest levels of program funding and coverage by ICDS activities

Redirecting ICDS

1. Resolve the current ambiguity about the priority of different program objectives and interventions

2. Emphasis on disease control and prevention activities, education to improve domestic child-care and feeding practices, and micronutrient supplementation

3. Better targeting towards the most vulnerable age groups (children under three and pregnant women)

4. Funds and new projects need to be redirected towards the states and districts with the highest prevalence of malnutrition

5. Supplementary feeding activities need to be better targeted towards those who need it most

Redirecting ICDS…

6. Growth-monitoring activities need to be performed with greater regularity, with an emphasis on using this process to help parents understand how to improve their children’s health and nutrition;

7. Involving communities in the implementation and monitoring of ICDS

8. Strengthening of monitoring and evaluation activities through collection of timely, relevant, accessible, high-quality information and this information needs to be used to improve ⎯program functioning by shifting the focus from inputs to results, informing decisions and creating accountability for performance

Will India reach MDG goal?

Different Intervention scenario needed for reaching MDG goal

References1. Gragnolati M, Shekar M, Gupta MD, Bredenkamp C and Lee YK. India’s

undernourished children: A call for reform and action. Washington DC. The International Bank for Reconstruction and Development / The World Bank. 2005.

2. Despite efforts, why does child malnutrition persist in India? International food policy research institute. [Electronic version]. Retrieved May 16, 2009. www.ifpri.org.

3. Nair KRG. Malnourishment among Children in India: A Regional Analysis. Economic and Political Weekly,2007:3797-3803

4. Turning the tide of malnutrition:Responding to the challenge of the 21st century, Nutrition for Health and Development (NHD) Sustainable Development and Healthy Environments (SDE). World Health Organization

5. National Family Health Survey India(NFHS-3)[online]. 2005-2006[cited 2008 July 12]; Available from :URL: http://www.nfhsindia.org

6. International conference on nutrition. Final report of the conference. Rome, Food and Agricultural Organization. World health organization, 1992.

7. Robert E Black. Maternal and child undernutrition: global and regional exposures and health consequences. Maternal and Child Undernutrition Series. Lancet 2008; 371: 243–60