|DR K N RAO MEMORIAL ORATION
|Year : 2020 | Volume
| Issue : 3 | Page : 216-222
Breaking the chain of malnutrition: Opportunities, challenges and actions
Executive Director, All India Institute of Medical Sciences, Bibinagar (Hyderabad), Telangana, Indiaia, India
|Date of Submission||01-Jul-2020|
|Date of Decision||01-Jul-2020|
|Date of Acceptance||01-Jul-2020|
|Date of Web Publication||22-Sep-2020|
All India Institute of Medical Sciences, Bibinagar, Hyderabad - 508 126, Telangana
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Nutrition continues to be a major challenge in India. Children, Adolescents, Pregnant and Lactating women have various nutrition related public health issues which needs accelerated efforts. Department of Community Medicine & Family Medicine, AIIMS, Bhubaneswar undertook various community-based nutrition interventions and initiatives in Odisha and documented the good practices and results. This article captures multiple nutritional programmes implemented in Odisha with support of Government and other organizations.
Keywords: Anaemia, interventions, malnutrition
|How to cite this article:|
Bhatia V. Breaking the chain of malnutrition: Opportunities, challenges and actions. Indian J Public Health 2020;64:216-22
|How to cite this URL:|
Bhatia V. Breaking the chain of malnutrition: Opportunities, challenges and actions. Indian J Public Health [serial online] 2020 [cited 2021 Jun 23];64:216-22. Available from: https://www.ijph.in/text.asp?2020/64/3/216/295799
| Introduction|| |
Recent years have seen greater impetus in stronger nutrition governance mechanisms for multi-sectoral nutrition actions. Nutrition is high on the political agenda, governance, and equity-focused policy and programming.
Many such concerted and synergistic efforts have led to significant improvements in the health and nutrition outcomes in India over the past one decade. Infant mortality rate (IMR) has reduced from 65 per 1000 live births in 2005–2006 National Family Health Survey 3(NFHS-3), to 41 per 1000 live births in 2015–2016 (NFHS-4). Likewise under-five mortality rate has declined from 91 per 1000 live births in 2005–2006 (NFHS-3), to 50 per 1000 live births in 2015-2016 (NFHS-4). As per the NFHS-4 (2015–2016), there is commendable progress in terms of stunting decline as compared to NFHS-3 (2005–20060), i.e., from 45% to 34.1%. However, despite progress in malnutrition reduction, 35.8% of children under 5 years of age remain underweight and 38.4% remain stunted (NFHS-4, 2015–2016).
The health impacts of micronutrient deficiency or “hidden hunger” are not always acutely visible. Micronutrient deficiencies form an important health issue, with malnutrition affecting key development outcomes including poor physical and mental development in children, vulnerability to diseases, mental retardation, blindness, and general losses in productivity and potential. For example iron deficiency causes anemia which is a significant public health challenge. Anemia is correlated to higher occurrence of prematurity and low birth weight (LBW) newborns, poor academic performance among children, inadequate physical achievement among adolescents and more morbidity and mortality among all vulnerable age groups. Thus, it is the vicious cycle of anemia and its consequences contributing to higher IMR and maternal mortality ratio (MMR). With growing understanding of the complexity of malnutrition and its multi-factorial causes, there is a compelling need to move toward adopting and promoting a multi-sectoral approach to achieve better nutrition outcomes.
A host of sociocultural norms and gender norms play against the nutrition agenda. Critical among them is child marriage. In India, about 26.8% of girls get married before the age of 18 years, more so among scheduled tribes. Around 7.9% girls aged 15–19 years are already mothers or pregnant. The widely accepted norm favoring early marriage, teenage pregnancy, and early childbirth tremendously increases the risk of low-birth weight babies that perpetuate the life-cycle of under-nutrition.
Health services especially in interior areas of tribal blocks are affected by poor staff availability and skills. High staff turnover and absenteeism are a constant feature, constraining basic services delivery, and further perpetuating the undernutrition scenario. Service delivery in these areas of course is further deterred by poor infrastructure and communications connectivity.
Community demand for nutrition programs, barring a few, historically remains low. As communities constantly struggle to make ends meet, issues around livelihoods and land rights take higher priority, leaving nutrition, health, early development of young child a distant agenda. In a society, where child care remains solely the responsibility of mothers, who themselves have limited education and no decision-making power, the delivery of maternal and child nutrition services, as well as raising the awareness and practice around early child stimulation, continues to be a challenge.
The Odisha scenario
The India Fact Sheet of the NFHS-4 released in 2017 shows that the State of Odisha has shown outstanding progress in almost all nutrition indicators from 2005 to 2006.
With an IMR of 40 in 2015–2016 vis-a-vis National average of 41, there has been a 25 point decline in IMR from 2005 to 2006 and it is lower than the national average. Similarly MMR has reduced from 367 in 1998 to 180 in 2012–2013. In these 10 years, there has also been significant improvement in the nutrition indicators such as underweight children (0–5 years) and Stunting among children (0–5 years). The NFHS-4 (2015–2016) state factsheet for Odisha has shown 34% of children under 5 years of age are underweight, 34.1% remain stunted (NFHS-4, 2015–2016) and 20.4% are wasted. Cuttack and Puri have figured among the top 10 districts in the country with lowest levels of Stunting.
Odisha has shown varied progress in terms of the different determinants of stunting. Early initiation of breastfeeding (within 1 h of birth) has improved by around 25% up from 55% in 2005–2006 to 68.6% in 2015–2016, while exclusive breastfeeding in the first 6 months has risen by around 29%, increasing from 51% in 2005–2006 to 65.6% by 2015–2016, showing good progress. However, complementary feeding practices have deteriorated over the past 10 years, with only 55% children being introduced to complementary foods at 6–8 months, and as low as 26% meeting minimum dietary diversity (Rapid survey of Children 2013–2014).
Undernutrition and anemia affect over 50% of adolescent girls in Odisha, particularly girls from poor socioeconomic backgrounds and there has been little improvement over the past 10 years [Figure 1] and NFHS 4 indicates that in Odisha, 41% of adolescent girls are moderate to severely thin with body mass index <18.5 and 51% are anemic. In chronically undernourished women, pregnancy and lactation have an adverse effect on maternal nutritional status. Low pre pregnancy weight and low pregnancy weight gain are associated with LBW and all its attendant adverse consequences. Childbearing occurs mostly at ages 15–25 when Indian women are most likely to be underweight or anemic. This is combined with an average weight gain of 7 kg for a full term pregnancy, which contributes to a high incidence of LBW, wasting, and stunting in their children. The decrease in the prevalence of underweight and anemia among adolescent girls in Odisha over the past 10 years has been slow [Graph 1] shows indicators of india and odisha.
|Figure 1: Anemia among women of reproductive age in Odisha in 2016 (NFHS 4) by district.|
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| Initiatives by the Department of Community Medicine and Family Medicine, All India Institute of Medical Sciences-Bhubaneswar|| |
The Department of Community Medicine and Family Medicine (CM and FM) started from August 14, 2012, is an enthusiastic and dynamic environment where faculty, residents, staff, and students are engaged in learning, work in collaboration and committed to improving the health status of communities. The department is consistently working toward discovery of new knowledge in domain of public health, advocacy for the application of new ideas in health care of population thereby creating footprints of community health programs in 25 of the 30 districts of Odisha.
Department started Indian Journal of Community and Family Medicine under the Aegis of Ministry of Health and Family Welfare, Government of India to promote research since 2015.
The department also offers educational and research opportunities for individuals pursuing careers in the patient-care professions, strong community-based health activities, public health, advancing knowledge through epidemiological, bio statistical, behavioral and socio-clinical, ethical research. The department organizes training programs, develops policy, and plans and executes academic activities. These activities encompass undergraduate programs for medical, nursing, and paramedical courses, MD programs, and fellow program with an aim to produce high quality public health professionals. This apart, a number of initiatives have been taken up by the department to further strengthen and support the public health and nutrition initiatives in the state as enumerated below:
Establishment of a resource center for advancement on public health nutrition
Under the aegis of the Department of CM&FM, All India Institute of Medical Sciences (AIIMS)–Bhubaneswar, a Resource Centre for Advancement on Public Health Nutrition (RCAPHN) has been established in partnership with UNICEF on March 2019. This Resource Centre is supported by four senior consultants who also support the Government of Odisha through the CM and FM Department to improve program implementation and monitor outcomes for maternal and child nutrition through better technical handholding, knowledge management, CME programs on nutrition and allied areas, organize media sensitization workshops, capacity development of key stakeholders, development of resource and advocacy materials, establish linkages between different national and international institutions, periodic publication of resource materials, quality papers and journals, and policy dialogues.
Fellowship in public health nutrition
A fellowship in public health nutrition program has been rolled out through RCAPHN and dedicated to researchers and development professionals who desire to continue with scientific training and pursue their research interests with a long-term commitment in the field of public health and nutrition. The objective is to create an exceptional training program that will serve to develop leadership and expertise for working with disadvantaged and vulnerable populations, women, children and elderly. The main purpose of the fellowship is to enable the holders derive from their training, the knowledge and professional competence which will enable them to participate more actively in improving the health and nutritional scenario in the State. This is a first of its kind initiative in the state through any medical institution or may be among first in the medical schools in India. The course commenced on October 2019 and regular session is underway as per course curriculum.
Self-learning modules developed on basics of nutrition, severe acute malnutrition, women's nutrition, micronutrients, and national programs have been developed as course materials. [Figure 4].
Baseline survey of Swabhimaan pilot
A pilot on improving nutritional status of girls and women (before, during, and after pregnancy) using the women collectives is being implemented in the state through the State Rural Odisha Livelihoods Mission (OLM) in the districts of Angul and Koraput. The baseline survey prior to implementation of the pilot was supported by AIIMS in partnership with IIPS, Mumbai and UNICEF, right from recruitment of the field investigators/surveyors, capacity building of the staff, logistical arrangements, monitoring, and data collection to data analyses. Cross-sectional block surveys were undertaken in (Koraput Sadar and Pallahara blocks) during October 2016–January 2017. The baseline findings highlighted some interesting data: 11% of pregnant women in Pallahara and 5% in Koraput were severely malnourished (MUAC <21 cm).
Almost 15% of the total surveyed pregnant women in both the blocks were adolescent girls. Half of the total pregnant women in Pallahara and 40% in Koraput were found to have a low Diet Diversity (<5 out of 10 food groups). Among the pregnant women in both the blocks, only 30%–40% were found to have sought ANC services in the first trimester. A very low proportion of pregnant women consumed deworming tablets.
Swabhimaan has been successfully implemented in the 2 districts of Odisha and has been proving effective in improving the key nutritional indicators in girls and women. Various interventions were implemented such as efficient convergence between the 3As (ANMs, ASHAs, and AWWs) and the women collectives, screening and identification of nutritionally “at risk” women', linking communities with key services through increased demand generation and strengthening of systems.
Implementation of JibanSampark to improve health and nutrition among the Particularly Vulnerable Tribal Groups in Odisha
There are 75 centrally recognized particularly vulnerable tribal groups (PVTGs) in the country (on the recommendations of the Dhebar Commission in 1975). Communities identified by Tribal Research Institutes of the respective state governments and listed as PVTGs. Odisha is a home to 13 PVTGs, highest among all the states. These groups are characterized by distinctly social, cultural, and occupational practices with preagricultural economy, extremely low levels of literacy and isolated habitation. The major challenges in reaching these groups include, language barrier, hard to reach areas, unwillingness to adopt modern newer health-care services and scarcity of health-care providers in PVTG areas as well as unwillingness of service providers to work in remote areas. These factors lead to extreme low literacy levels, high IMR/MMR, poor health and nutrition status, scanty economic and employment opportunities, and issues of land rights. Therefore, to reach out to these groups, Jiban Sampark program is being implemented by the state government in partnership with UNICEF and AIIMS. The major strategies are: (a) capacity building of formal and informal health service providers on technical and communication skills; (b) Community mobilization through capacity building of community-based platforms and stakeholders for positive behavior changes; (c) quality improvement of outreach of services during home visits; and (d) partnership with civil societies. The department of CM and FM has been instrumental in taking development of six thematic training modules for Training of Trainers, a comprehensive FLW training module in Odia along with tools for monitoring of FLW trainings [Figure 2]. 198 officials from Women Child Development and Mission Shakti Department, OLM, OPELIP and Central Statistics Office (CSO) partners have been trained in these modules.
JibanSampark has been able to reach out to these vulnerable groups in an extremely positive way. CSO partners have been the key facilitators in taking this ahead into the community through various social behavior change communication strategies to bring in the desired improvement in behavioral practices so as to improve their health seeking behavior and nutritional status [Figure 5].
Facilitation of Anemia Mukt Bharat
Anemia is the most common micronutrient deficiency and a major public health problem. Studies show that more than 50% of the women and children in the country are anemic. India's National Health Policy (2017) recognizes anemia as a deterrent to maternal and child survival and overall productivity of the nation. Hence, it is highly imperative to intensify and strengthen the ongoing National Iron Plus Initiative (NIPI) which is the major objective of Aemia Mukt Bharat. Improving the anemia levels across life cycle can prove to be one of the most important strategies to improve maternal and child health outcomes. NIPI was launched in 2014 in Odisha which provisions for iron supplementation in a life-cycle approach involving 3 main departments, Health and Family Welfare, Women and Child Development and School and Mass Education. The key components of the program include, a. Iron folic acid (IFA) supplementation b. Biannual provision of deworming. Promotion of iron-rich diets and hygiene practices.
In order to assess the status of NIPI implementation in Odisha, AIIMS-B in partnership with UNICEF had undertaken a detailed process documentation exercise with an objective to document key state and district experiences in implementing the NIPI program in Odisha; document the critical success factors, challenges, bottlenecks to ensure effective implementation, explore the programmatic lapses to improve program performance and suggest recommendations for future actions. The report was published in November 2017. The survey was done using both qualitative and quantitative methods in one district from each revenue division based on poor performance indicators (3 districts) and one best performing district based on AHS 2012–2013 including hemoglobin tests using hemocues. The districts were Bhadrak, Jagatsinghpur, Kalahandi, and Keonjhar [Figure 6].
These prevalence estimates are consistent with the number of pregnant and lactating women, frontline workers, and other officials who reported during the qualitative study taking a double dose of IFA tablets during pregnancy following Hb assessment indicating anemia. It is notable that the prevalence of anemia among adolescent boys is not far behind that of adolescent and adult women. Results showed that anemia is high among all beneficiary groups and frontline workers whose Hb were assessed in the survey.
Among beneficiaries, it was most prevalent among lactating mothers (77%), followed by WRA (71%), pregnant women (69%), and adolescent girls (68%) [Graph 2]. Among the frontline workers, anemia was the most common among ASHAs (69%), followed by AWW (62%), and ANMS (53%). Fortunately, the prevalence of severe anemia is low (1%–3%), but the prevalence of moderate anemia (7%–20%) and of mild anemia (39%–58%) is very high.
Further steps were also taken to facilitate Anemia Mukt Bharat interventions. Several test, treat and talk camps were organized in Khurda and Balasore districts for 44 days. Seven thousand Five hundred and thirty five people were tested and counseled during the campaign [Figure 3] and [Graph 3].
Detailed report has been compiled on the Test, Treat, and Talk campaign in Odisha. Beneficiaries were reached through outpatient department, village health and nutrition day sessions and AWCs.
Anemic beneficiaries were counseled for dietary modifications and appropriate pharmacological interventions were advised. Beneficiaries were found to be suffering mainly from mild (20.8%) and moderate anemia (11.1%) and few (0.8%) suffered from severe anemia. Among the beneficiaries tested (excluding pregnant women), more females were diagnosed with any anemia (19.3%) as compared to males (12.7%). About one-third (33.7%) of pregnant women were found to be anemic, mild (17%) and moderate (15.5%) [Graph 3].
The efforts to reduce burden of anemia in the state has been recognized by Ministry of Women and Child Development and NITI Aayog.
Study on consumption pattern of food and food products/items high in fat, salt, and sugar among selected cities/towns and rural population of India
Under the guidance and support of ICMR, New Delhi, a multicentric study was undertaken in 15 sites:
Urban: 7 (Delhi, Bhopal, Kanpur, Srinagar, Bengaluru, Nagpur, Ludhiana)
Rural: 7 (Jaipur, Trivendrum, Rishikesh, Gujrat, Jorhat, Dibrugard, Tripura)
Odisha: 2 blocks (1 each in Cuttack and Kandhamal districts). The study gave an estimation of the percentage of people with elevated random blood sugar and lipid profile besides food habits.
Overall, the population of Tangi, Chowdwar appeared more predisposed to an abnormal blood glucose and lipid profile. The findings might be indicative to an unhealthy lifestyle, diet rich in high fat sugar and salt and lack of physical activity. A higher inclination towards urbanization might be another explanation [Graph 4].
| Conclusion|| |
Public health nutrition plays a crucial role in improving the maternal and child survival and nutrition outcomes in the most vulnerable populations. The trend of improvement has been quite positive in the recent years. The strategy needs to catch the low hanging fruits such as robust supply chain management, real time monitoring, regular updation of knowledge and skills of service providers, improved demand generation through community mobilization, convergence between line departments, and strengthening regular reporting and compliance. These ongoing initiatives, if managed and monitored well, may have the capacity to bring in long-term effects. The CM and FM Department AIIMS-B have been totally proactive in understanding the issues and taking appropriate actions in the direction. With these efforts, we are hopeful that Nutritional status of community in Odisha will show good results.
At the foremost, I express my sincere gratitude to the entire team of CM and FM Department of AIIMS, Bhubaneswar, without whom such large scale initiatives would not have been possible. Their relentless support and perseverance helped the department scale new heights.
Thanks to all Faculty, Residents and staff particularly to Dr. Swayam Pragya Parida who worked with me in all nutrition related programs, Dr. Prajna Paramita Giri for RCAPHN and PVTGs. Dr. Binod Kr. Behera in RCAPHN, Dr Manish Tayawade for PVTGs I also extend my special thanks to Mr. Manoj Satpathy and Ms. Smiti Senapathy for their contribution to the Jiban Sampark project. My appreciation to team of consultants of RCAPHN, Ms. Sonali Sinha, Ms. Prajna Chowdhury, Ms. SanjeetaRaut, Ms. Kasturi Panda, staff: Ms. Jasmine Mohanty and Mr. Soumya Ranjan Samal for leading ahead the project successfully. I am grateful to all the donor agencies, UNICEF (Mr. Sourav Bhattacharjee and team), ICMR, New Delhi (Dr G. S. Toteja and team) for all the support.
My heartfelt gratitude to Dr. Gitanjali Batmanabane, Director, AIIMS, Bhubaneswar and Government of Odisha and all the communities for their support to embark on every initiative with great success.
I express my sincere thanks to IPHA in recognizing the efforts made by the Team of CMFM, AIIMS Bhubaneswar and conferred with Dr K.N. Rao Memorial Oration” at 64th IPHACON 2020 held at AIIMS, New Delhi.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
National Family Health Survey (NFHS) 4, Report. Indian Institute of Population Sciences, Deonar, Mumbai; 2015-16.
Anemia Mukt Bharat. Operational Guidelines for Programme Managers. Ministry of Health and Family Welfare, Government of India; April, 2018.
Process Documentation on National Iron Plus Initiative in Odisha, Department of CM FM, AIIMS B & UNICEF, Odisha; September, 2017.
Anemia Mukt Bharat. Test & Treat Campaign in Odisha, Department of CM & FM, AIIMS B & UNICEF, Odisha; 2018.
Stop Stunting in South Asia: A Common Narrative on Maternal and Child Nutrition. UNICEF South Asia, Strategy; 2014-2017.
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]