Malnutrition In Indian context

“India against
Malnutrition : Current
Status and Government
Initiatives”
By
Dr Sanket V. Nandekar
JR, Dept. of Community Medicine
IMS-BHU, VARANASI

Background and Definitions
Medical component of Malnutrition
World Health Assembly 2012
Global Nutrition Report 2020
Current scenario INDIA, Uttar Pradesh, Varanasi.
Government Initiatives
Conclusion and suggestions
Outlines of the topic:

According to the World Health Organization (WHO),
‘Malnutrition’ refers to deficiencies, excesses, or imbalances
in a person’s intake of energy and/or nutrients. It can be
either ‘undernutrition’ or ‘overnutrition’.
Malnutrition Covers,
 Underweight (low weight for age)
 Micronutrient deficiencies / insufficiencies and over weight
 Obesity and diet-related non-communicable diseases
Malnutrition:

WHO Fact sheet 2021:
 1.9 billion adults are overweight or obese, while 462 million are under
weight.
 Globally in 2020, 149 million children under 5 were estimated to be
stunted (too short for age), 45 million were estimated to be wasted (too
thin for height), and 38.9 million were overweight or obese.
 Around 45 % of deaths among children under 5 years of age are linked to
undernutrition. These mostly occur in low- and middle-income countries.
At the same time, in these same countries, rates of childhood overweight
and obesity are rising.

Types Indicator SD score
 Stunting Height for Age < -2SD: stunted
< -3SD: severely stunted
 Underweight Weight for Age < -2 SD: underweight
< -3 SD: severely
underweight
 Wasting Weight for
Height/length
< -2 SD: wasted
< -3 SD: severely wasted
WHO Classification

Grade of malnutrition Weight for age of standard(%)
 Normal >80
 Grade I 71-80 (mild malnutrition)
 Grade II 61-70 (moderate malnutrition)
 Grade III 51-60 (severe malnutrition)
 Grade IV <50 (very severe malnutrition)
IAP classification of malnutrition

Severe Acute Malnutrition:
As per WHO, a child aged 6-59 month is classified as SAM if one
or more of the following present:
 Weight-for-length z-score (WLZ) < -3 OR
 Weight-for-height z-score (WHZ) < -3 OR
 Mid-upper arm circumference < 11.5 cm OR
 Bipedal edema (other cause of edema like nephrotic
syndrome, congenital heart disease should be excluded)

Anthropometry :
Standing Height = Recumbent Length - 0.7

 It is typical form of SAM
 Main sign is severe wasting
 Wasting often starts in Axilla & Groin (grade I)
 followed by Thighs & Buttocks (grade II)
 followed by Chest & Abdomen (grade III)
 Lastly the Buccal pad of fat (grade IV)
Marasmus :

No edema
Child may be active
No hepatomegaly
May have good appetite
Marasmus :
Baggy pant appearance in
Marasmus

Other findings: sugar baby appearance, hepatomegaly,
anemia, moon facies.
Skin changes: Indicates severe degree of malnutrition and
associated with very high mortality.
 Flaky paint dermatosis (pathognomic)
 Crazy pavement dermatosis
Hair changes: more changes at root of hair, loose luster, easily
pluckable, Flag sign.
Kwashiorkor :
Triad of essential
features of kwashiorkor:
 Edema
Growth retardation
 Mental changes

 Physical and mental exhaustion,
 Low weight in relation to height (wasting) and shortness for
age (stunted), Diminished skin folds,
 Exaggerated skeletal contours,
 Loss of elasticity of skin etc
General Symptoms of malnutrition :

WHO 10 Steps in the management of SAM:
There is an intervening transitional phase of treatment for 2-3 days
when dietary treatment changes from low calorie-low protein (F-75)
to high calorie-high protein diet (F-100).

In 2012, the World Health Assembly identified:
Target Topics
 Maternal nutrition
 Infant nutrition
 Young child
nutrition
Six Nutrition targets to be met by 2025.
Aim was to reduce:
1. Stunting by 40% in children under 5 years age
2. Prevalence of anemia by 50% among women in the
age group of 19-49 years
3. Ensure 30% reduction in low birth weight
4. No increase in childhood overweight
5. Increase the rate of exclusive breastfeeding in the
first six months up to at least 50%
6. Reduce and maintain childhood wasting to less
than 5%.

 Report on Global Nutrition, produced by the Independent Expert group
for the Global Nutrition Report.
 The Global Nutrition Report acts as a report card on the world's
nutrition globally, regionally, and country by country and on efforts to
improve it.
 It assesses progress in meeting Global Nutrition Targets established by
the World Health Assembly .
 The World Health Organization (WHO) is a Global Nutrition Report
Partner.
What is Global Nutrition Report?

India will miss targets for all four nutritional indicators for which there is
data available
1. Stunting among under five children,
2. Anemia among women of reproductive age,
3. Childhood overweight
4. Exclusive breastfeeding
What Global Nutrition Report 2020 says?

0
10
20
30
40
50
India Uttar Pradesh Varanasi
38.4
46.3 44.7
35.5
39.7
37.4
%
OF
UNDER
5
CHILDRENS
STUNTING
NFHS 4 (%) NFHS 5 (%)
1. Aim : Reduce Stunting by 40% in under 5 Children's

0
10
20
30
40
50
60
53.1 52.4 50.9
57
50.4
37.6
%
OF
WOMENS
(AGE
15-49
YEARS)
ANEMIA
NFHS 4 (%) NFHS 5 (%)
2. Aim ; Reduce Anemia by 50% among all
women's of Age group 15-19 Years

0
5
10
15
20
25
30
21
17.9
25.3
19.3
17.3
21
%
OF
UNDER
5
CHILDRENS
CHILDHOOD WASTING
NFHS 4 (%) NFHS 5 (%)
3. Aim : Reduce and maintain Childhood Wasting
to less than 5%.

0
10
20
30
40
50
60
70
54.9
41.6
23.5
63.7
59.7
47.5
%
OF
CHILDRENS
UNDER
6
MONTHS
EXCLUSIVE BREASTFEEDING
NFHS 4 (%) NFHS 5 (%)
4. Aim : Children under 6 months exclusively
Breastfed

0
0.5
1
1.5
2
2.5
3
3.5
2.1
1.5
0.9
3.4
3.1 3.1
%
OF
CHILDRENS
UNDER
5
YEARS
OVERWEIGHT
NFHS 4 (%) NFHS 5 (%)
5. Aim : No increase in Childhood overweight

Reasons for prevalent malnutrition in India:
 Monoculture agricultural practices
 Changing food patterns
 Poverty
 Migration
 Gender injustice
 Lacunae at policy level

 Food grain production has increased over five times since Independence,
still it has not sufficiently addressed the issue of malnutrition .
 India has focused on increasing food production, particularly staples (wheat
and rice). This led to lower production and consumption of indigenous
traditional crops/grains, fruits and other vegetables, impacting food and
nutrition security in the process.
 This intensive monoculture agricultural practices are indirectly degrading the
quality of land, water and the food derived through them.
Monoculture agricultural practices:

 Food consumption patterns have
changed substantially in India
over the past few decades, which
has resulted in the disappearance
of many nutritious local foods, for
example, millets.
Changing food patterns:

 Though poverty alone does not lead to malnutrition, it affects the
availability of adequate amounts of nutritious food for the most
vulnerable populations .
 Lack of sanitation and clean drinking water and dangerous hygiene
practices increase vulnerability to infectious and water-borne diseases,
which are direct causes of acute malnutrition.
Poverty :

Seasonal migrations have long been a livelihood
strategy for the poorest households in India, as a
means to access food and money through casual
labor .
However, children and women are the most
affected, suffering from deprivation during
migrations impacting their health condition.
Migration :

 There is a correlation between
gender discrimination and poor
nutrition.
 Malnourished girls become
malnourished adolescents who
marry early and have children who
become malnourished, and so the
cycle continues.
Gender injustice :

 There is a lack of real-time data that brings
all these factors together to show the
extent of India's malnutrition .
 Lax implementation of government
schemes at grassroots level.
 Lack of Strong leadership & Political will.
Lacunae at policy level:

Multi-sectoral approach :
 Include providing clean drinking water to all
 Reducing rates of open defecation
 Improving women's status
 Enhancing agricultural productivity and food
security
 Promoting nutrition-sensitive agriculture.
What is the Solutions???

Many management measures have been already implemented by the
Government of India to address nutritional status including,
 Reducing poverty
 Improving sanitation
 Fortification of foods with essential nutrients
 Enhancing women’s education
 Improving agricultural practices etc.
Management :

The following programs and schemes have been implemented
for improving nutrition and combatting malnutrition by the
Government of India.
 Integrated child development scheme (ICDS)
 National Food Security Act (NFSA), 2013
 Mid-day Meal Scheme (MDM)
 National Health Mission (NHM)
 Village Health Sanitation and Nutrition Committee
(VHSNC)
 Food Safety and Standard Authority of India (FSSAI)
 Rajiv Gandhi Scheme for Empowerment of Adolescent
Girls (RGSEAG) or Sabla Scheme
 Village Health Nutrition Day (VHND) and so on.

Integrated child development scheme (ICDS)
 India launched ICDS in accordance with the National Policy for Children in
India to fight malnutrition, ill-health, and to address gender inequality.
 One of the most comprehensive schemes for child development, started by
the Ministry of Women and Child Development in 1975, is funded partly by
the Central government of India and partly by the UNICEF.

 Its aim is to provide food and primary healthcare to preschool
children under 6 years of age their mothers and adolescent girls .
 Anganwadi centers provide Immunizations, Health education,
Health check-ups, Nutritious food, informal education and
referral services under this scheme.
Integrated child development scheme (ICDS)

Target Group Unit cost per beneficiary /
day
Caloric Value
Children 6 months to 6
years
Rs. 8.50/- 500 + Calories
Pregnant & Lactating
Mothers
Rs. 10.00/- 600 + Calories
Severely undernourished
children
Rs. 13.50/- 800 + Calories
Provisions under ICDS :

March monthly progress report of ICDS Chiraigaon Block :
No of 0-6 year
old Children's
35754
No of Pregnant &
lactating
women's
6748
Reported Live
Births in March
2022
315
Death in 0–6
years age group
in March 2022
0
3-6 year Age
group
2927 Boys
2789 Girls
Total no. of Out
of school girls
aged 11-14 years
40

Out of 32138 children's of age group 0-5 years , Height and Weight were taken
for 30889.
25158, 82%
5292, 17%
139, 1%
Nutritional Status of under 5 Children’s
Normal
Moderate Underweight
Severe Underweight
30135, 98%
681, 2% 73, 0%
Nutritional Status of under 5 Children’s
Normal
MAM
SAM

 Out of Total 30889 Children's 681 were having MAM & 73 were
having SAM.
 754 children's received treatment at community level on VHSND
(ie Village Health Sanitation and Nutrition Day).
 8 Children's were referred to PHC/CHC & 4 Children's referred to
NRC.

 In 1995, the Central Government started the National Programme of
Nutritional Support to Primary Education, popularly known as the Mid-
Day Meal scheme (MDM), to improve the nutritional status and
enhance enrolment and school attendance of children.
 The calorific value of a mid-day meal at primary stage has been fixed at
a minimum of 700 calories and 20 grams of protein by providing 150
grams of food grains (rice/wheat) per child/school day
Mid-day Meal Scheme (MDM)

National Health Mission (NHM)
 Launched in 2005, the National Health Mission covers both the National
Rural Health Mission (NRHM) and National Urban Health Mission (NUHM)
and aims to enhance the health programmes and health service delivery, in
both rural and urban areas, by improving maternal, neonatal child and
adolescent health, thus preventing diseases.

National Food Security Act (NFSA), 2013
 Launched on 10 September 2013, the National Food Security Act (2013) is an
Act of the Parliament of India intended to provide subsidized food grains to
approximately two-thirds of India’s 1.2 billion people.
 NFSA covers up to 75% of the rural population and 50% of the urban
population under Antyodaya Anna Yojana (AAY) and priority households (PHH).
 AAY households, which constitute poorest of the poor are entitled to 35 kg of
food grains per family per month while priority households are entitled to 5 kg
per person per month.

 NFSA defines the joint responsibility of the Centre and State/UT
Government.
 While the Centre is responsible for allocation of required food
grains to States/UTs, transportation of food grains up to
designated depots in each State/UT and providing central
assistance to States/UTs for delivery of food grains from
designated Food Corp. of India (FCI) godowns to the doorstep of
the Fair Price Shops (FPSs), the States/UTs are responsible for
effective implementation of the Act,

Priority Households :

Antyodaya Anna
Yojana (AAY)

Village Health Sanitation and Nutrition Committee (VHSNC)
 It allows ‘panchayats’ (village councils) to contribute to the governance of
health and other public services in villages.
 The VHSNCs monitor the work and contribution of community health
workers, such as Anganwadi Workers (AWW), Accredited Social Health
Activists (ASHA), and other public staff (from government entities such as the
Water and Sanitation department, Roads work, among others) in order to
maintain good sanitation and healthy environments in the villages.
Village Health Nutrition Day (VHND) and many more.

 Malnutrition is a complex and multi dimensional issue .
 It is primarily caused by several factors, including poverty, inadequate
food consumption, inequitable food distribution, improper
maternal, infant and child feeding, and care practices, inequity and
gender imbalances, poor sanitary and environmental conditions,
and restricted access to quality health, education and social care
services.
Conclusion :

Strong leadership & Political will is required to Fight against
Malnutrition
Promotion of nutrition-sensitive agriculture at all levels.
Traditional Cereals distribution should be added with Pulses to
improve Protein Consumption at mass level .
Strengthening implementation of government schemes at
grassroots level.
Need for Comprehensive real time data generation
Suggestions:

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