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Overcoming Malnutrition in India

Malnutrition: How to overcome in India

Focussing on women’s education, Access to sanitation & potable water, diet rich in proteinaceous foods and biofortification of grains can curb malnutrition

President Donald Trump applauded India’s achievements in his address at the crowded Motera stadium. These ranged from religious freedom to reducing poverty to the giant emerging economy. This should have made every Indian feel proud, except that only in the next three days, riots in Delhi made us feel ashamed of our poor governance, lack of communal harmony, and intolerance of opposing ideas. In this piece, however, we want to focus on the UN’s top three Sustainable Development Goals (SDGs), namely poverty elimination, zero hunger, and good health and well being by 2030.

The World Bank’s estimates of extreme poverty, defined as $1.9 per capita per day at the 2011 purchasing power parity, show a secular decline in India from 45.9% to 13.4% between 1993 and 2015 (see graphic). If the overall growth process continues, as has been the case since, say, 2000, India may succeed in eliminating extreme poverty by 2030, if not earlier. Also, given the overflowing stocks of foodgrains with the government, and a National Food Security Act (NFSA) that subsidises grains to the tune of more than 90% of its cost for 67% of the population, there is no reason not to believe that India can also attain the goal of zero hunger before 2030.

The real challenge for India, however, is to achieve the third goal of good health and well being by 2030. India’s performance in this regard, so far, has not been satisfactory.

In 2015-16, almost 38.4% of India’s children under the age of five years were stunted, 35.8% were underweight, and 21% suffered from wasting, as per National Family Health Survey (NFHS) 2015-16. The situation is some states like Bihar, Jharkhand, and Uttar Pradesh is even worse (see graphic). No wonder, the Global Hunger Index (GHI) ranked India 102nd out of 117 countries in terms of severity of hunger in 2019.

How can India overcome this colossal challenge of malnutrition? The National Nutrition Strategy 2017 aims to reduce underweight prevalence in children (0-3 years) by 3 percentage points from the NFHS 2015-16 estimates every year by 2022. This is an ambitious target given that the decadal decline in underweight children from 42.5% in FY06 to 35.8% in FY16 amounts to less than 1% annual decline. Similar targets have been set by the National Nutrition Mission (renamed POSHAN Abhiyaan) 2017 for reducing stunting, undernutrition, anaemia (among young children, women and adolescent girls), and low birth weight by 2%, 2%, 3%, and 2% per annum, respectively.

Our research at ICRIER tells us to focus on four key areas if India has to make a significant dent on malnutrition by 2030. First and foremost is women’s education as it has a positive multiplier effect on child care, and access to health care facilities. It also increases awareness about nutrient-rich diet, personal hygiene, etc, and can help contain family size in poor, malnourished families. Thus, a high priority to female literacy, in a mission mode through liberal scholarships for the girl child, would go a long way to tackle this problem.

Second, is the access to improved sanitation and safe drinking water. From that angle, the Swachh Bharat Abhiyan and Jal Jeevan Mission would have positive outcomes in the coming years.

Third, there is a need to shift dietary patterns from cereal dominance to consumption of nutritious foods like livestock products, fruits and vegetables, pulses, etc. But, they are generally costly, and their consumption increases only with higher incomes and better education. Diverting a part of the food subsidy on wheat and rice to more nutritious foods can help.

Lastly, India must adopt new agricultural technologies of bio-fortifying cereals—zinc-rich rice and wheat, iron-rich pearl millet, and so on. The Indian Council of Agricultural Research has to work closely with Consultative Group of International Agricultural Research’s The Harvest Plus programme to make it a win-win situation and curtail malnutrition in Indian children at a much faster pace and a much lower cost than a business-as-usual scenario would achieve.

Global experience shows that with the right public policies focusing on agricultural, improved sanitation, and women’s education, a country can have much better health and well being for its citizens, especially children. In China, agriculture and economic growth significantly reduced the rates of stunting and wasting among the population, and lifted millions of people out of hunger, poverty, and malnutrition. According to the Food and Agriculture Organization, Brazil and Ethiopia have transformed their food systems, and have targeted their investments in agricultural R&D, and social protection programmes to reduce hunger in the country. Despite India’s improvement in child nutrition rates since FY06, it is way behind the progress experienced by China and other countries. According to the Global Nutrition Report 2016, at current rates of decline, India will achieve the stunting rates currently prevalent in China by 2055. India can certainly do better, but only if it focuses on this issue.

Global Hunger Report 2019- child-wasting-Pristine Premixes

Child wasting in India at an alarming rate – Global Hunger Report 2019

India has slipped to 102 position in the Global Hunger Report 2019 out of 117 countries, slipping from its 2018 position of 95 and behind its neighbours Nepal, Pakistan and Bangladesh.

Seventeen countries, including Belarus, Ukraine, Turkey, Cuba and Kuwait, shared the top rank with GHI scores of less than five, the website of the Global Hunger Index that tracks hunger and malnutrition said on Wednesday.

India slips to 102nd rank in Global Hunger Report 2019

The report, prepared jointly by Irish aid agency Concern Worldwide and German organisation Welt Hunger Hilfe termed the level of hunger in India “serious”. In 2000, India was ranked 83 out of 113 countries. Now, with 117 countries in the fray, it has dropped to 102 rank. Its GHI score has also decelerated — from 38.9 in 2005 to 32 in 2010 and then from 32 to 30.3 between 2010 and 2019.

The share of wasting among children in India rose from 16.5 per cent in the 2008-2012 period to 20.8 per cent in 2014-2018, according to the report. Just 9.6 per cent of all children between 6 and 23 months of age are fed a “minimum acceptable diet”, it said. “India’s child wasting rate is extremely high at 20.8 per cent, the highest for any country in this report,” it said.

Countries like Yemen and Djibouti, which are conflict ridden and facing severe climate issues respectively, fared better than India on that front, according to the report. Neighbouring countries like Nepal (73), Sri Lanka (66), Bangladesh (88), Myanmar (69) and Pakistan (94) are also in the ‘serious’ hunger category, but have fared better at feeding its citizens than India, according to the report.

China (25) has moved to a ‘low’ severity category and Sri Lanka is in the ‘moderate’ severity category. However, India has shown improvement in other indicators such as the under-5 mortality rate, prevalence of stunting among children and prevalence of undernourishment owing to inadequate food, the report said.

 

Source : https://www.thehindubusinessline.com/news/india-slips-to-102nd-rank-in-global-hunger-report-2019/article29698494.ece

Image credit : http://www.asianews.it/

Lychee toxin yet another hazard for undernourished children - Pristine Premixes

Lychee toxin yet another hazard for undernourished children

Acute Encephalitis Syndrome: Is Lychee Fruit the real Reason for Children Deaths?

Muzaffarpur in Bihar has been hit by curious cases of Acute encephalitis syndrome (AES) for the past few months.  The cases that happened in Bihar’s Muzaffarpur, Vaishali, Sheohar districts have claimed more than 100 lives. Around 100 children have been admitted to various hospitals. The immediate reason behind the death has been attributed to Hypoglycaemia, i.e. low blood sugar level. Most of the cases have been reported from areas near Lychee orchards. 

According to a study, it may be due to the eating of Lychee among malnourished children. Lychee contains chemicals and substances that are kind of similar to Ackee, a Jamaican fruit. This fruit is the main reason for childhood acute encephalopathy disease named Jamaican vomiting sickness (JVS). 

What is AES?

AES is a common term to a condition affected to children with clinical neurological manifestations, which include mental confusion, disorientation, convulsion, or even coma. Meningitis caused by virus or bacteria, encephalitis caused by a virus, encephalopathy, cerebral malaria and scrub typhus caused by bacteria are collectively called acute encephalitis syndrome. Encephalopathy is biochemical in origin and is different from the rest. Even though there are different types of encephalopathy, in Muzaffarpur case, it is associated with hypoglycemia and hence called hypoglycaemic encephalopathy.

As per the study conducted by T Jacob John, virologist and pediatrician from Vellore and Mukul Das of Indian Toxicology Research, Lucknow, the clinical features of Ackee poisoning and Muzaffarpur AES are similar. The clinical features in these patients are stereotypical: Inconsistent presence of fever, brain oedema, absence of inflammatory cell response in cerebrospinal fluid and hypoglycemia, and sudden onset with prodromal phase. The clinical features and the preliminary epidemiological findings have supported that it may be due to acute non-infectious encephalopathy and not viral encephalitis. The children who are diagnosed with this condition are well and good till evening, but their condition worsens the next morning with brain function derangement and seizures. Malnutrition is considered as the main associated factor for kids affected by this condition. 

Is Lychee seed the real villain?

Lychee seeds contain a lower analog of hypoglycin A, namely methylene cyclopropyl-glycine (MCPG)14. MCPG is not found in the ripe or unripe lychee fruit, but it’s found to cause hypoglycemia and derangement of fatty acid β-oxidation in liver cell mitochondria in experimental animals.  As per reports, it is due to the toxicity of MCPG that has killed the children and this toxicity is due to the formation of MCPF-CoA, which in turn inhibits several dehydrogenases responsible for gluconeogenesis, causing depletion of glucose reserve in the body.

Usually, in the early morning, it is normal for the blood sugar to dip since there is no food intake for several hours. Malnourished children who had gone to sleep without a meal at night develop hypoglycaemia. The brain actually needs a normal level of glucose in the blood to function properly. And in this condition, the liver is unable to supply it and hence the alternate pathway of glucose synthesis (fatty acid oxidation) is turned on. This pathway is blocked by MCPG and ends up in death. The study says that in malnourished children, who had eaten lychee fruits the previous night on empty stomach, the situation proves fatal.

In another study done by Arun Shah of the Indian Academy of Paediatrics and appeared in Lancet Global Health journal in 2017, the children in the affected villages fell ill the next morning after eating them the previous night with symptoms like high fever, brain function derangement, and seizures. The doctors also say that the disease can be treated through an infusion of dextrose within four hours of the onset of the illness. Another technique is to ensure that no child goes to bed without a meal. The Lancet report had suggested the Bihar Government to keep children away from orchard gardens during April-June and also urged ministers to tackle the malnutrition in the various families.

 

Bibliography

www.downtoearth.org.in

https://www.downtoearth.org.in/news/lychee-a-probable-reason-for-acute-encephalitis-syndrome-44304

https://www.currentscience.ac.in/Volumes/106/09/1184.pdf

https://www.thehindu.com/sci-tech/health/explainer-how-is-litchi-toxin-causing-deaths-in-undernourished-children-in-muzaffarpur/article28075727.ece

https://www.theguardian.com/global-development/2019/jun/19/malnourishment-blamed-for-rise-in-encephalitis-in-bihar

 

Malnutrition in India - a mother feeding her child

Malnutrition in Children: India Has 22 million Wasted Children

India Has 22 Million Wasted Children; Poshan Abhiyaan Signals Govt’s Strong Commitment To Tackle Malnutrition in Children: Experts

An estimated 26 million children aged under five years are wasted in South Asia, which is over half  of the global burden of wasting. India is home to four out of five of these children and lies at the epicentre of this global public health problem, with 22 million children wasted, and over eight million severely wasted at any one time, according to the UNICEF, WHO and World Bank Group, 2018.

Malnutrition in Children- India has the highest level of child wasting in south Asia

In 2015 India committed to reducing the proportion of children suffering from wasting to less than 5%, a nutrition target of Sustainable Development Goal (SDG) 2. However, the prevalence of wasting (21.0%) and severe wasting (7.5%) remain very high in the country (National Family Health Survey-4 2015-2016) and have not fallen in the past decade, despite a 10 percentage point decline in stunting during the same period. This lack of progress towards the wasting target, and the persistently high numbers of children with wasting, is of immense concern.

In India, the prevalence of wasting is witnessed highest at birth (37%) and declines with age, a pattern seen in other South Asian countries such as Bangladesh. Over 30% of infants aged less than six months are wasted  in India, underlining the imperative to address growth failure in early life. In comparison, data from selected countries in West and Central Africa show the prevalence of wasting is relatively low at birth and increases in infancy, reaching a peak at around 12 months of age.

These contrasting patterns suggest that poor maternal nutrition and health may play a larger role in the causes of wasting in early life in India (and Bangladesh) than it does in other settings. Almost one quarter (23%) of women of reproductive age in India are thin (body mass index (BMI) <18.5 kg/m2), 11% have a low stature (height

Maternal thinness, low stature and anaemia predict low birth weight (LBW) and wasting in India. These findings indicate that a comprehensive response to wasting in India must include a strong focus on the prevention and management of growth faltering in infants under six months, including interventions to improve the nutritional status of women before and during pregnancy.

Another significant finding is the relationship between wasting and mortality in India and South Asia, which appears to be affected by different factors than in other regions of the world. The prevalence of wasting and severe wasting is higher in India and South Asia than in other regions, yet the Under-Five mortality rates are comparatively lower. These comparisons need careful interpretation and more research is needed to understand the relationship between mortality and wasting in India.

 

India has an array of government schemes and programmes to counter malnutrition and its underlying causes. However, it is evident from the continuing high prevalence of wasting that these schemes and programmes are not designed to address the burden adequately, or are not functioning optimally.

Currently the main approach to treat severe wasting in India is facility-based treatment, known as F-SAM. The guidelines for F-SAM, which provides inpatient treatment of SAM (Severe Acute Malnutrition) with medical complications, were released in 2011. A network of 1,151 nutrition rehabilitation centres (NRCs) has since been established across the country and these manage approximately 180,000 cases annually, which represents a small fraction of the annual caseload.

This existing inpatient infrastructure is neither sufficient nor intended to manage all children with severe wasting. Approximately 85-90% of children with severe wasting do not have medical complications and can safely be managed at community level. Indeed, the national guidelines on F-SAM recognise the need for the community-based management of severe wasting without medical complications. However, community-based management has been challenging to operationalise in the absence of national guidelines, which are currently in the process of being developed by the Government, although their content remains unclear.

India has well designed community-based public health systems and delivery platforms at facility and community level that can be leveraged by POSHAN Abhiyaan to support a comprehensive response to severe wasting. This should include four components: (i) the prevention of wasting and severe wasting, including relapse after successful treatment; (ii) early case detection of wasting through active screening; (iii) facility-based management of severe wasting with medical complications; and (iv) community-based management of severe wasting without medical complications.

Many nutrition-specific interventions to prevent wasting and other forms of malnutrition are delivered at community-level in India through Anganwadi Services under the umbrella of the Integrated Child Development Services (ICDS) scheme. Anganwadi centres, a nationwide network of rural community centres, provide health and nutrition services and pre-school education to a population of up to 1,000.

There are a host of schemes, programmes and services that target pregnant and breastfeeding women (PLW) with nutrition interventions. These include a take-home ration from Anganwadi centres; anaemia prevention and control under the Anaemia Mukt Bharat programme; antenatal care services, including dietary counselling through VHSNDs; and schemes such as Pradhan Mantri Surakshit Matrutva Abhiyaan that provide quality antenatal check-ups. Institutional deliveries are promoted through conditional cash-transfer schemes (Janani Suraksha Yojna and Pradhan Mantri Matru Vandana Yojna) and free services for delivery and early neonatal care (Janani Shishu Suraksha Karyakaram), and provide an important opportunity to support mothers in establishing good breastfeeding practices.

Under POSHAN Abhiyaan there is huge ambition to eliminate malnutrition in children and ensure that every child has access to quality services to address wasting across the continuum of care. This requires a cost-effective, integrated and sustainable approach that successfully prevents the development of wasting and provides care for those with wasting.

The infrastructure to deliver a comprehensive, community-based programme to prevent and treat wasting already exists in India; a vertical programme to address wasting is therefore unnecessary. There is an extensive network of community-based Anganwadi centres and community-health workers, together with health and nutrition schemes and programmes, into which components of a comprehensive approach can be integrated at scale.

Context-specific solutions to prevent malnutrition in children, particularly from developing wasting must be the priority. These solutions should be grounded in an understanding of the specific causes and drivers that lead to wasting. The high prevalence of wasting at birth in India suggests the need to improve the nutritional status of women before and during pregnancy and to ensure mothers have access to skilled support for early and exclusive breastfeeding. From six months of age, counselling on complementary feeding and continued breastfeeding and the prevention and treatment of diseases become important components of preventive approaches. These interventions are already part of existing health and nutrition schemes and programmes, but are not reaching children and women with the desired Coverage, Continuity, Intensity and Quality (C2IQ).

The introduction of monthly height measurements for all children during growth monitoring at Anganwadi centres will increase opportunities for the early detection of malnutrition in children. However, it is necessary to ensure that community health workers have the capacity (equipment, skills, time and motivation) to add this responsibility to their roles and increase community demand for services.

The Anganwadi centres currently cater to children with severe underweight and any children identified by health workers as having severe wasting with medical complications are admitted to inpatient care. The forthcoming community-based guidelines on the prevention and management of wasting will guide how treatment reaches children with severe wasting without medical complications at community level. Optimising the quality, production and distribution of rations under the Supplementary Nutrition Programme (SNP) and identification of the nutritional treatment that will be used to manage severe wasting at community level are needed so that treatment puts children back on the path to healthy growth. A strong referral system and tracking of individual children across the different programme components, from the community through to the inpatient facility, are also essential to ensure that children receive the full continuum of care on offer.

It is important to build the evidence base around this comprehensive approach to managing children with acute malnutrition in India and delivering services across the continuum of care. This learning could inform both India and other country contexts with a similar profile of wasting. Key evidence questions include a context-specific understanding of wasting in India; how to scale up screening using Weight For Height (WFH) at community level effectively; the modalities of managing growth failure in infants under six months old; and the cost-effectiveness of forthcoming guidelines to care for children with severe wasting at community level. In addition, a better understanding is needed of how to address challenging issues such as linkages and referrals between various programmes and schemes to ensure a continuum of prevention and care.

(This article has been edited by Outlook. The authors of the piece are:  Arjan de Wagt, Eleanor Rogers, Praveen Kumar, Abner Daniel, Harriet Torlesse and Saul Guerrero)

(Arjan de Wagt is Chief of the Nutrition section, UNICEF India; Eleanor Rogers is a Nutrition Specialist in the Nutrition Division of UNICEF India; Dr Praveen Kumar is a paediatrician and Professor of Paediatrics at Lady Hardinge Medical College and Kalawati Saran Children’s Hospital in New Delhi; Harriet Torlesse (PhD) is Regional Nutrition Advisor at the UNICEF Regional Office for South Asia; Saul Guerrero is a Nutrition Specialist at UNICEF HQ; Abner Daniel is a medical doctor with an MD in Community Medicine,  working as Nutrition Specialist in UNICEF, New Delhi. The findings, interpretations and conclusions in this article are those of the authors. They do not necessarily represent the views of UNICEF).

 

Source: outlook magazine 

Image credit: UNICEF

 

 

Malnutrition

India loses 4% of GDP to malnutrition, say experts ahead of budget

A diverse set of processes link health care, education, sanitation, hygiene, access to resources and women empowerment

Nearly 4 percent of India’s GDP is estimated to have been lost due to malnutrition and certainly women and children deserve a better deal in expenditure outlay, since the country hosts 50 percent of undernourished children of the world and women and girl children fall last in the household food serving, said an ASSOCHAM-EY joint paper ahead of the union budget that will be presented on Thursday.

Quoting data from the National Family Health Survey-4, the ASSOCHAM-EY paper noted with concern that close to 60 percent of our children aged between 6 – 59 months are anaemic. It is only about 10 percent of the country’s total children who are receiving adequate diet.
The women and girl child, for whom the NDA government has launched flagship programmes, are no better in terms of their daily nutrition intake. About 55 percent of non-pregnant women and 58 percent of pregnant women aged between aged 15-49 years are anaemic.
“A large part of India continues to consume non-nutritious, non-balanced food either in the form of undernutrition, overnutrition or micronutrient deficiencies. It is important to understand that malnutrition derives not just from lack of food but from a diverse set of inter-linked processes linking health care, education, sanitation, hygiene, access to resources and women empowerment,” it said.
Assocham secretary general DS Rawat said, the government needs to pursue policies which “focus on removing health and social inequities. Programmes and policies that aim to address the nutrition burden present a double – win situation”.
Ernst and Young LLP Partner Amit Vatsyayan said: “While sub-optimal nutrition impacts the overall health and quality of life of people, it also adversely impacts the productivity of the country. It is estimated that that nearly 4 percent of the GDP is lost due to different forms of malnutrition.”
The adverse, irreversible and inter-generational impacts of malnutrition make optimal nutrition critical to the development of the country as a whole and all its citizens.
The paper said that in order to cater to the large unmet needs of micronutrients, it is imperative to focus on production diversity as well as food fortification at a macro level.
“For instance, millets are three to five times more nutritious than rice and wheat in terms of proteins, minerals and vitamins. They are cost effective crops as well; yet considered as poor people’s crop while rice and wheat are preferred over them. Millets are rich in Vitamin B, calcium, iron, potassium, magnesium, zinc and are gluten-free. They are suitable for people with gluten allergies or those with high blood sugar levels”.
RUTF Food

What Is Ready-To-Use Therapeutic Food? (RUTF)

RUTF is a tasty, energy-packed paste made from peanuts, oil, sugar, milk powder and vitamin and mineral supplements, it is the most effective tool for treating acute and severe acute malnutrition (SAM), which, every year, threatens millions of children worldwide.

RUTF is easy to ship and administer. It doesn’t require refrigeration and stays fresh for up to two years. Best of all, no mixing with potentially contaminated water is required. Each 100-gram single-serving packet comes ready-to-eat. All parents have to do is what comes naturally: Open the packet, feed their children and watch them grow healthy and strong.

UNICEF is the global leader in RUTF procurement, purchasing and distributing eighty percent of the world’s supply. UNICEF works with manufacturers to increase supplies of the product and keep prices down. One carton of RUTF contains 150 packets, enough for one six- to eight-week course of treatment to restore the health of a severely malnourished child.

Today, the global need for RUTF is greater than ever before as an unprecedented humanitarian emergency looms across 3 regions and 13 countries in Africa and the Middle East. The lives of 80 million people — more than half of them children — are threatened by alarming levels of food insecurity.

War, displacement, climate change and drought have created unprecedented food emergencies that affect children in the following countries:

  • Lake Chad Basin: Cameroon, Chad, Niger and Nigeria
  • Eastern Africa: Democratic Republic of the Congo, Ethiopia, Kenya, Somalia, South Sudan, Sudan and Uganda
  • Middle East/Northern Africa: Djibouti and Yemen

The advantage of RUTF is that it is a ready-to-use paste which does not need to be mixed with water, thereby avoiding the risk of bacterial proliferation in case of accidental contamination. The product, which is based on peanut butter mixed with dried skimmed milk and vitamins and minerals, can be consumed directly by the child and provides sufficient nutrient intake for complete recovery. It can be stored for three to four months without refrigeration, even at tropical temperatures. Local production of RUTF paste is already under way in several countries including Congo, Ethiopia, Malawi and Niger.

Source: Unicef

Some of our interventions for the management of acute and severe acute malnutrition

RUTF Biscuit (Bar) – Poushtik Nutri Bar

RUTF Biscuit (Bar) a high-energy fortified food. This RUTF Bar follows the WHO/WFP/ UNSSCN/ UNICEF joint statement on Community-based Management of Severe Acute Malnutrition for children and adults.

F-75 and F-100 Therapeutic Milk Powder  

F-100 and F-75 are therapeutic milk products designed to treat Severe Acute Malnutrition (SAM). They are used in therapeutic feeding centers where children are hospitalized for treatment.

Poushtik High Energy Biscuits (HEB)

Poushtik High Energy Biscuits are fortified with Vitamins & Minerals and are developed as an intervention for treating severe, acute malnutrition as per the World Food Program(WFP) guidelines.