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Unravelling the real story behind malnutrition in India

Unravelling the real story behind malnutrition in India

The 2019 Global Hunger Index report should be an eye-opener for India as it has placed India at 102nd   place out of 117 countries. The Global Hunger Index (GHI) is a tool that measures and tracks hunger globally, by region, and by country. 

On the other hand, UNICEF 2019 report highlights that malnutrition remains alarmingly high in India. Nearly half of all deaths in children under 5 are attributable to under nutrition.  The national report on Food and Nutrition Security Analysis, 2019, also brings out the paradox in a food-grain surplus India. While the food-grain production is rising in India, the malnutrition is not decreasing.  Indian is producing enough food-grains, making the country self-sufficient. Unfortunately, it does not reach the poorest 30% of the population doing hard physical works who consume 500 calories less than required norms. 

What this means is that there are capacity and demand, but faulty distribution and low supply to needy population. Should we be worried? Correspondingly energy and protein intake from cereals has decreased. According to report of National Nutrition Monitoring Bureau, there is inadequate quantity & poor quality of food intake by children, pregnant and lactating mothers. As high as 70% pre-school and school children have deficient proteins, calorie and micronutrients.

Under-nutrition affects immunity adversely, increases the frequency and severity of infections, leading to increased number of deaths.

Speaking of deaths, neonatal mortality rate of our country is 30 per thousand live births. Almost equal numbers are born dead. Out of 1000 live newborn 40 infants die before celebrating first birthday, and 50 of them are not alive till their 5th birthday. The number of fatalities in mothers during delivery, is whopping 250 deaths per 100000 deliveries, as per National family health survey 4th report.

At the current pace of disjoined actions on the demand and supply of adequate nutritious food, and inadequate coverage of primary health care in rural/tribal regions, have we headed to a state of a public health emergency?

Wasting is a form of acute malnutrition. In an acute catastrophe like infection, energy requirement is met by burning muscle and fat tissue and they are wasted away.  Acute malnutrition is attributable to 15% of all child deaths. Children under five years having a “weight-for-height” ratio 2 or more standard deviations below the median are suffering from wasting or acute malnutrition. The severe acute malnutrition (SAM) may have presence of bilateral edema in addition to weight-for-height score less than 3 standard deviations from the mean weight of a reference population of children of the same height.  Every 5th child is wasted in our country. 

Stuntingis a form of chronic malnutrition. The under-fivers scoring “height-for-age” ratio, 2 or more standard deviations below the median, are stunted. It is associated with an underdeveloped brain, poor learning capacity. India has an inter-generational cycle of under-nutrition. The prevalence of chronic malnutrition in India is among the highest in the world and is nearly double than that of Sub-Saharan Africa and has dire consequences of mortality, morbidity, educability, and productivity. Around 55% under five children are stunted. 

Underweight children score, 2 or more standard deviations below the median in “weight-for-age” ratio. We have prevalence of 52% underweight children in India.

Malnutrition in mothers: Every forth Indian woman has low (< 18.5 kg/m2) body mass index (BMI). Children born to women with low BMI are more likely to be malnourished at birth. The malnourished adolescent girls become the genesis of neonatal low birth weight. Therefore, appropriate nutrition in adolescence, pushing ahead the age of marriage and first pregnancy, nutrition during pregnancy are the keys to reduce low birth weight.

A most important period of 1,000 days from pregnancy until a child turns two years is a critical time for both, physical growth and brain development. Vision, hearing, receptive language, and higher cognitive functions like decision-making, emotional and social regulations are either developing rapidly or falling behind during this period. For this, some critical measures that need to be taken are: 

Newborns should have exclusive breastfeeding for 6 months, followed by complementary feeding. Complementary food should have high calorie density, must be semisolid, given in adequate amount, at least 3 to 4 times a day. There should be inclusion of cereals, pulses, fruits, roots and tubers. Our socio-cultural weaning practices of complementary feeding are grossly faulty. Intensive “community behavior change communication” program is need of the hour.

If the present nutrition situation prevails, it appears that 40% of our future workforce will not be able to achieve their full physical and cognitive potential. Unless nutrition is brought centre stage, India will miss out on its window of opportunity by failing to capitalize on its demographic dividend.

Indian Council of Medical Research report 2017, states that India has unacceptably high risk of child and maternal malnutrition. In stark contrast, the disease burden due to child and maternal malnutrition in India was 12 times higher per person than in China in 2016. This situation after decades of nutritional interventions in the country must be rectified by systematic and consistent interventions making adequate nutrition as one of the highest priorities for health improvement in India. 

The multipronged approach, that India needs to follow urgently to overcome the challenge of malnutrition include adequate supply of nutritious food, clean and safe water, sanitation and hygiene (WASH) practices and behavioural change. 

Equally important is the fact that three fourth Indian population is rural/tribal. As many as 66 % of rural Indians do not have access to the critical medicines and 31 % population travels more than 30 kms to seek health care in rural India. Rural Health centers are critically short of trained health medical persons. We have 25% home deliveries, 60 % newborns do not have postnatal checkup by doctor in rural/tribal area and early marriages are a common feature, family planning measures are not followed hence big families is the scenario. 

In the context of the above observations prompt expansion of health-care providers in India is needed in rural/tribal region. Successful experiment in Melghat tribal region of Maharashtra have shown that the community health workers trained with focused, abbreviated intensive training with regular refresher training can conduct safe and clean home deliveries, community newborn care, treat diarrhea, pneumonia,  can conduct sessions for behavior change and can manage malnutrition in the community. The model should be replicated in larger regions.

(The author is MD; DCH, Ex-Dean & Professor of Pediatrics Consultant at “MAHAN” (Meditation, Addiction, Health, AIDS, Nutrition), Melghat, India. The views mentioned in the piece are personal.)

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