|Year : 2011 | Volume
| Issue : 1 | Page : 1-6
Evidence-Based preventive interventions for targeting under-nutrition in the Indian context
Sandip Kumar Ray
Chief Editor, Indian Journal of Public Health, Professor and Head, Department of Community Medicine, KPC Medical College, Kolkata, India
|Date of Web Publication||30-Jun-2011|
Sandip Kumar Ray
Chief Editor, Indian Journal of Public Health, Professor and Head, Department of Community Medicine, KPC Medical College, Kolkata
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Ray SK. Evidence-Based preventive interventions for targeting under-nutrition in the Indian context. Indian J Public Health 2011;55:1-6
|How to cite this URL:|
Ray SK. Evidence-Based preventive interventions for targeting under-nutrition in the Indian context. Indian J Public Health [serial online] 2011 [cited 2020 Apr 5];55:1-6. Available from: http://www.ijph.in/text.asp?2011/55/1/1/82531
Under-nutrition includes both protein-energy malnutrition and micronutrient deficiencies. Since the country's independence in 1947, there has been a substantial improvement in the health and well-being of the people, but under-nutrition remains in the background as a silent emergency. Almost half of all the children under the age of three are underweight, 30% of the newborns are born with low birth weight, and 52% of the women and 74% of the children are anemic  Other major nutritional deficiencies of public health importance in the country are Vitamin A deficiency and iodine deficiency. Productivity losses to individuals are estimated at more than 10% of the life time earnings, and gross domestic product (GDP) loss due to malnutrition runs as high as three to four percent.  According to NFHS 3 report  almost half of the children under five years of age (48%) are stunted and 43% are underweight. The proportion of children who are severely undernourished (more than three standard deviations below the median of the reference population) is also notable - 24% according to height-for-age and 16% according to weight-for-age. Wasting is also quite a serious problem in India, affecting 20% of the children under five years of age. Very few children under five years of age are overweight. The proportion of children who are stunted or underweight increases rapidly with the child's age, through the age of 20 - 23 months. Under-nutrition decreases thereafter for stunting and levels off to underweight. Overall, girls and boys are almost equally undernourished. Under-nutrition is generally lower for first births than for subsequent births and consistently increases with increasing birth order, for all measures of nutritional status. Short birth intervals are associated with higher levels of under-nutrition, except in the case of wasting. 
Under-nourishment not only affects the physical appearance and energy levels, but also directly affects many aspects of the children's mental functions, growth, and development, which have adverse effects on children's ability to learn and process information. A better nutritional status helps the child to grow into an adult, who can be productive and contribute to members of the society.  Under-nutrition is also the underlying cause for 53% of the under five mortality  [Figure 1].
In 1998, the World Bank estimated that India was ranked second in the world with regard to the number of children suffering from malnutrition, after Bangladesh, where 47% of the children exhibited some degree of malnutrition. The prevalence of underweight children in India is among the highest in the world, and is nearly double that of the Sub-Saharan Africa with dire consequences for morbidity, mortality, productivity, and economic growth.  The UN estimated that 2.1 million Indian children die before reaching the age of five years, every year, that is, four every minute - mostly from preventable illnesses such as diarrhea, typhoid, malaria, measles, and pneumonia. Every day, 1,000 Indian children die because of diarrhea alone. 
According to the World Food Program and the M.S. Swaminathan Research Foundation (MSSRF) - over the past decade there has been a decrease in stunting among children in rural India, but inadequate calorie intake and chronic energy deficiency levels have remained steady.  On the contrary child malnutrition is prevalent only in 7% of the children under the age of five years in China and 28% in the sub-Saharan Africa compared to a prevalence of 43% in India. ,
Under-nutrition is the underlying cause of about 50% of the 2.1 million under-five deaths in India each year. The prevalence of under nutrition is the highest in Madhya Pradesh (55%), followed by Bihar (54%), Orissa (54%), Uttar Pradesh (52%), and Rajasthan (51%), while Kerala (37%) and Tamil Nadu (27%) have the lowest. 
Under-nutrition is found mostly in rural areas and is concentrated in a relatively small number of districts and villages with 10% of villages and districts accounting for 27 - 28% of all underweight children. 
Evidence from the studies conducted by the author also suggested the following facts in regard to malnutrition in the under-five population ,,,,, [Table 1].
|Table 1: Prevalence of overall and severe degree of undernutrtion in different study areas|
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There are evidences that suggest a link between nutrition and infection among children under five years of age. Taylor et al.  in their experiment at Narangwal observed that the prevalence of respiratory infection, diarrheal, and other diseases tended to be highest when the child was nutritionally vulnerable and the immune capacity significantly reduced due to sub-clinical, under-nutrition. Similarly the studies carried out by the author in Nimpith as well as among pavement dwellers revealed these facts. , These studies indicated the fact that more the number of episodes of illnesses in the past 15 days, more would be chances of the under-five year children suffering from malnutrition and growth faltering [Figure 2].
- Under-nutrition was more prevalent in the age group of 12 - 23 months, females, where family size had more than three or more children.
- Children born after a short birth interval were more likely to be undernourished than other children.
- Children belonging to minority community were considerably more likely than other groups of children to be underweight and stunted, and they were slightly more likely to be wasted. However, a study showed that severe degree of malnutrition was higher among the Hindus (17.16%) than among the minority community (14.62%), but the differences were not statistically significant (P > 0.5) among an underserved community.
- Similar findings was also observed in Nimpith, where Hindus (63.32%) had more prevalence than minority community (57.59%), but a severe degree of malnutrition was higher in minority community (4.95%) community than in Hindu (2.77%)
- Children belonging to the scheduled caste and scheduled tribes had higher levels of under-nutrition than other children on all three measures.
- The prevalence of a severe degree of malnutrition was significantly higher among Non-Bengali linguistic groups (23.28%) than Bengali groups (13.79%), as observed in a study among pavement dwellers.
- The overall prevalence of malnutrition in a severe degree was higher when the interval between two births was less than 36 months.
- With bigger family size under-nutrition was found to be more prevalent as there were 'more mouths to be fed'. Young children in families with four or more siblings were nutritionally the most disadvantaged as observed in these studies.
- Children born after a short birth interval were more likely than other children to be undernourished.
- Under-nutrition was relatively low for children whose mothers had not worked in the past 12 months. The study at Ausgram tribal area revealed that severe degree of malnutrition was > 11% among those children whose mothers were working outside, in comparison to those whose mothers were only housewives (1.37%). PM Shah also reported 50 - 60% undernourishment among children whose mothers were working. 
- Under-nutrition was more common in children of mothers whose height was less than 145 cm or whose body mass index was below 18.5, than in other children.
- Children from households with a low standard of living were two to three times more likely to be underweight or stunted than children from households with a high standard of living.
General under-nutrition, characterized by under-weight among children is more prevalent among rural children, scheduled castes, and tribes, and among children with illiterate mothers. The contributing factors for under-nutrition are household food insecurity and intra-household food distribution, imbalanced diet, inadequate preventive and curative health services, and insufficient knowledge of proper care and infant feeding practices. ,
Malnutrition among women is one of the prime causes of low birth-weight babies and poor growth. Low birth weight is a significant contributor to infant mortality. Moreover, low birth-weight babies who survive are likely to suffer growth retardation and illness throughout their childhood, adolescence, and adulthood, and growth-retarded adult women are likely to carry on the vicious cycle of malnutrition by giving birth to low birth weight babies.
Household food security means, 'Access by all people at all times to enough food for an active and healthy life (World Bank). Access implies entitlement to food'. It is a matter of grave concern that even after four decades of planned development, two decades of poverty alleviation programs, and five decades of the public distribution system (PDS), household security continues to remain a question for a large section of our population especially in the tribal and drought-prone areas of India. The study by the author and his co-workers reveals that consumption of cereals and starchy food was higher (more than one-third for cereals and one-half for roots and tubers). Intake of protein-rich food like pulses, milk, and protein-rich products was found to be much less than the Recommended Dietary Allowance (RDA), similarly for oil and sugar. Poor support from Public Distribution and Fair Price Shops, along with a poor quality of foodstuff needs attention. It has also been observed that 11% of the calories were contributed by alcohol, in a tribal area of West Bengal. In the studied Tribal area, household food security was much higher, that is, 52%, with 9% severe malnutrition, while at the riverine area of Sunderban, with comparatively less household food security of 44%, there was only 4% severe malnutrition. The reason for better food security in the tribal area was due to the fact that 11% of the total calories in family diet was contributed by alcohol. In the family food the benefit of such calories was received only by the adult population and the children under-five years of age remained deprived and became under-nourished.  After going through all of the above-mentioned evidences, it can be concluded, with the help of the diagram given herewith [Figure 3], how under-nutrition occurs.
The above-mentioned discussions highlight the evidences, based on which actions should be proposed. It may be pertinent to comment that poverty is the root cause of under-nutrition, but not the only cause.
Mahatma Gandhi's statement, 'For the hungry, God is bread,' is relevant for vast sections of the Indian population even today. Preventing under-nutrition has emerged as one of the most critical challenges to Indian health planners.  Today, whatever has been chosen for preventing under-nutrition is chosen on an adhoc basis. The evidence-based research findings have already suggested simple actions that should have been undertaken for the prevention of under-nutrition. In the early 90s UNICEF and the State and Central Government were committed to promote Baby Friendly Hospital Initiatives (BFHI) in the hospitals, continued feeding during illness, exclusive breast feeding, and timely complementary feeding, care of pregnant women, and so on. An attempt to implement these initiatives continued in some states for some period of time, but thereafter, it was never sustained or was sustained in a half-hearted manner, when all of these were incorporated into newer National Programs for mother and child healthcare, like RCH, National Rural Health Mission (NRHM), and so on. These laid less emphasis on nutrition-related issues. It was felt that actions like BFHI, Joint training program on health and nutrition, involving an Integrated Child Development Scheme (ICDS), Health and Panchayat functionaries on key issues for prevention of under-nutrition, should have been continued with enthusiasm and vigor rather than making it less prioritized. Addressing the children under two years of age for growth monitoring to detect and treat early severe under-nutrition; advocating continued feeding during illness; de-worming; immunization under the Universal Immunization Program (UIP); exclusive breast feeding; timely initiation of complementary feeding; continuing feeding during illness; removing gender disparity in regard to care of the female child; preventing too early, too close, and too many pregnancies; adequate rest and sleep; one extra meal, and no heavy work during pregnancy; regular consumption of IFA tablets (small and large) for prevention of anemia in pregnant women, lactating mothers, children, and adolescents; vitamin A prophylaxis and therapeutic program; consumption of only iodized salt; attending the Anganwadi center for growth monitoring and availing food supplementation; and regular availability and utilization of PDS, should have been continued in spite of bringing a newer attempt, with lesser priority on these key issues on nutrition. Fair Price Shops should be established to provide good quality essential food items on a regular basis to the poorer and underserved population. Counseling of parents regarding caring for sick children and inculcating proper feeding habits will go a long way in addressing malnutrition in small children; this should be continued in a planned way throughout the country integrating with other National programs of similar natures.
Started by the Government of India in 1975, the Integrated Child Development Scheme (ICDS) has been instrumental in improving the health and well-being of mothers and children under six years of age, by providing health and nutrition education, health services, supplementary food, and pre-school education.  The ICDS program is one of the largest national development programs in the world. It reaches more than 34 million children, aged zero to six years and seven million pregnant and nursing mothers. Does it really reach out in the true sense? The government of India intends to universalize ICDS in the near future. Other programs impacting on under-nutrition include the National Mid-day Meal Scheme, the National Rural Health Mission, and the Public Distribution System (PDS). The challenge for all these programs and schemes is how to increase the efficiency, impact, and coverage. It has been observed by the author, during his studies (un-published data) that weight recording on a growth chart iwas done for only 30% of the under-five children; while almost all of them belong to the age group of three to five years, and are attending Anganwadi centers for non-formal, pre-school education and food supplementation. However, the above-mentioned studies reveal that a severe degree of under-nutrition occurs mostly in children under two years of age. ,,,, Furthermore, it is a fact that neither do mothers or caregivers of child beneficiaries understand the exact meaning of growth monitoring, nor do care-providers explain its importance to them. Growth monitoring in the true sense means:
Presently, the weight of the child is only recorded and plotted. Other activities were totally ignored. Thus, in a true sense it was only weight recording (data collection). Studies by the author in some blocks of West Bengal found out that a majority of the mothers or caregivers understood that growth monitoring meant recording of weight, which was carried out mainly from an ICDS center. However, they hardly understood the importance of this service (only around 3 - 4% knew it as an important tool to identify faltering of growth). Thus, the concept of monitoring should be replaced by growth surveillance with emphasises on the action part, that is, all the activities (1 - 4 stated above) related to it. It should be undertaken to make growth monitoring popular and acceptable to the mother or caregiver and also explaining to the mother how growth monitoring helps them to understand their children's growth status, as well as, how growth faltering could be prevented. During the 1971 war, when people had to shift to the West Punjab war front hurriedly, they left many things, but they never forgot to take with them the growth chart of their children. This meant that the care providers followed all the above four steps or in another sense they did growth surveillance, as surveillance meant data collection for action. This was not only a nutrition-related activity, but also a health-related activity, which needed to be supervised by both the ICDS and health functionaries. However, there was no integration between these two departments. Either these departments should integrate and coordinate, or the ICDS should come under the Department of Health for the betterment of the mother and children health and nutrition components. The major activity of the ICDS was improvement of Maternal and Child Health. The under-privileged section of the community should be given top priority in regard to Maternal and Child Health services.
- Correct and regular recording of weight of an under-five child following '0' adjustment of the weight machine
- Plotting the weight against the appropriate age, in months, of the under-five children
- Showing it to the mother or caregiver to explain the status of growth
- Taking measures such that growth faltering is prevented or controlled.
In the area of Child Development and Nutrition, UNICEF assists the Government to further expand and enhance the quality of ICDS, by improving the training of childcare workers, by developing innovative communication approaches with mothers; helping to improve monitoring and reporting systems; providing essential supplies, and developing effective community-based early childcare interventions. UNICEF also supports iron folic acid and Vitamin A supplementation for adolescents and young children, respectively. Another priority is collaboration with the government and others to increase the use of iodized salt. 
The discussion finally concludes by stating that all health- and nutrition-related activities, with the background of evidences, as observed, should be continued and sustained in an integrated, coordinated, and sustainable manner, where both Health and ICDS should participate together or both these Departments should be under one umbrella or one boss at the grass-root level. Anganwadi workers should act as the daughters-in-law of the area. They should not be utilized by the administrative authority for other purposes, other than ICDS services. This is possible if they come under the Department of Health. It is also felt that there is poor supportive supervision for these groups of functionaries. Supportive supervision is an essential component of better functioning.
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[Figure 1], [Figure 2], [Figure 3]