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Malnutrition highest in four States, Nutrition Mission likely to build momentum: Lancet

The focus brought on malnutrition by the National Nutrition Mission effort is likely to build momentum towards the more rapid reduction of malnutrition in India, a paper published in the latest edition of The Lancet has said. 

“It is encouraging that India has set ambitious targets to reduce malnutrition through NNM. The trends up to 2017 indicate that substantially higher rates of improvement will be needed for all malnutrition indicators in most states to achieve the Indian 2022 and the global 2030 targets,’’ says the paper “The burden of child and maternal malnutrition and trends in its indicators in the states of India: the Global Burden of Disease Study 1990–2017.’’

Malnutrition was the predominant risk factor for death in children younger than 5 years of age in every state of India in 2017, accounting for 68·2%  of the total under- deaths, and the leading risk factor for health loss for all ages, responsible for 17·3% of the total disability-adjusted life years (DALYs). The malnutrition DALY rate was much higher in the low socio-demographic index (SDI) than in the middle SDI and high SDI state groups. This rate varied 6·8 times between the states in 2017 and was highest in the states of Uttar Pradesh, Bihar, Assam, and Rajasthan.

The prevalence of low birth weight in India in 2017 was 21·4%, child stunting 39·3%, child wasting 15·7%, child underweight 32·7%, anaemia in children 59·7%, anaemia in women 15–49 years of age 54·4%, exclusive breastfeeding 53·3%, and child overweight 11·5%. 

If the trends estimated up to 2017 for the indicators in the NNM 2022 continue in India, there would be 8·9% excess prevalence for low birthweight, 9·6% for stunting, 4·8% for underweight, 11·7% for anaemia in children, and 13·8% for anaemia in women relative to the 2022 targets. For the additional indicators in the WHO and UNICEF 2030 targets, the trends up to 2017 would lead to 10·4% excess prevalence for wasting, 14·5% excess prevalence for overweight, and 10·7% less exclusive breastfeeding in 2030. The prevalence of malnutrition indicators, their rates of improvement, and the gaps between projected prevalence and targets vary substantially between the states.

The research was funded by The Bill & Melinda Gates Foundation; Indian Council of Medical Research, Department of Health Research, Ministry of Health and Family Welfare, Government of India.

Low birthweight, the largest contributor to the malnutrition DALYs in India, had a prevalence of 21% in 2017, which showed a modest declining trend. Within child growth failure, the highest  contribution to DALYs was from wasting, the prevalence of which declined only moderately in India during 2010–17. The prevalence of stunting and underweight has been decreasing, however, the prevalence has remained very high in India at 39% and 33%, respectively, in 2017. The prevalence of anaemia has been extremely high in India at 60% in children and 54% in women in 2017, with only moderate decline during 2010–17. However, the prevalence of child overweight has increased considerably in India in the past decade, with a prevalence of 12% in 2017. The prevalence of exclusive breastfeeding was 53% in India in 2017, with a moderate increase during 2010–17, the paper says. 

Substantial state-level variations exist in the prevalence for each of the malnutrition indicators. The findings in this report indicate that, if the trends up to 2017 continue, the NNM 2022 and the WHO and UNICEF 2030 targets will not be achieved in most states of India, except for low birthweight and stunting in a few states and exclusive breastfeeding in several, The Lancet says. 

Because low birthweight was the largest contributor to child malnutrition DALYs in India, its slow decline should be addressed as a priority. South Asia, with India as its largest component, is estimated to have the highest prevalence of low birthweight for any region in the world. A major issue with tracking low birthweight is the poor quality of birthweight data in many low-income and middle-income countries, including India. Low birthweight adversely affects not only child health but also increases the risk of chronic diseases later in life.

Weight at birth is an intergenerational issue dependent on an interplay of various factors, including maternal undernutrition, intrauterine growth, gestation at birth, birth spacing and order, and maternal age. The higher proportion of underweight women in the reproductive age group in India compared with sub-Saharan Africa has been suggested to contribute to a higher prevalence of low birthweight in India, even though sub-Saharan Africa is poorer. Chronic energy deficiency in women of reproductive age is a manifestation of long-standing malnutrition reported to be common in India, which increases the risk of preterm births and infants with low birthweight. Improving the nutritional status of girls in general and that of women in the preconception period and during pregnancy and provision of quality antenatal care, including the treatment of pregnancy complications, would positively affect low birthweight and extend the benefits to the next generation.

Substantial improvements across the malnutrition indicators in the states of India would require an integrated nutrition policy to effectively address the broader determinants of undernutrition across the life cycle. These improvements include providing clean drinking water, reducing rates of open defecation, improving women’s status, enhancing agricultural productivity and food security, promoting nutrition-sensitive agriculture, coupled with the harmonisation of efforts across ministries and sectors, political will and good governance, and strategic investments in a multisectoral approach, the report points out. 

According to the paper, of the 1·04 million under-5 deaths in India in 2017, 706 000 or 68·2%, could be attributed to malnutrition. Although all causes under-5 death rate in India decreased from 2336 per 100 000 in 1990 to 801 per 100 000 in 2017, the proportion of under-5 deaths attributable to malnutrition changed only modestly from 70·4% in 1990 to 68·2% in 2017. Similarly, the DALY rate attributable to malnutrition in children younger than 5 years reduced by 65·8% from 147 956 per 100 000 in 1990 to 50 627 in 2017, but the proportion of total DALYs in children younger than 5 years attributable to malnutrition changed only slightly from 70·1% in 1990 to 67·1% in 2017, making it the predominant risk factor for health loss. 

By TIS Staffer
the authorBy TIS Staffer

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