child

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CHILD NUTRITION
CHALLENGES AND OPPORTUNITIES Prema
Ramachandran Director, Nutrition Foundation
of India
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• Major nutrition-related public health problems
• Chronic energy deficiency and undernutrition
• Micro-nutrient deficiencies
• Anaemia due to iron and folate deficiency
• Vitamin A deficiency
• Iodine Deficiency Disorders
• Chronic energy excess and obesity

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• Low birth weight why is it remaining unchanged
  
• Why are we unable to ensure
• Exclusive breast feeding for the first six
  months
• Timely appropriate adequate complementary
  feed
• What is responsible for low dietary intake and
  high under-nutrition rates in preschool child
• What can we do to reduce anaemia in children
• Massive dose Vit A -Where do we go now ?
• Can we achieve universal access to iodised salt
  by 2010
• What should we do to tackle over- nutrition
• What are the priority areas for RD

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Low birth weight Why is it remaining
unchanged What is its impact on IMR What
happens to growth and development -are our
children short , thin but fat ? What are the long
term implications of low birth-weight and low
growth trajectory
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Trends in Low Birth Weight
Mean Gest
?
0.8W
0.3W
0
0.7W
20-15
14-10
Preterm
21-16
74g
Mean Wt
78g
52g
126g
?
1988
1962
1969
1969-73
1986
1989-93
1995
1994
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Multicentric Data

• National Neonatology Forum (1995/ 2002)
  Institutional Data on 37082 / 66512 Births
  LBW - 33 / 31.6 VLBW - 3.3 / 3.3
  Preterm - 12.3 / 14.7
• ? Overestimates Underprivileged and High Risk
  Population

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Time trends in IMR
Source RGI 2002
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Over the last three decades there is no
significant change in mean birth weight or
incidence of LBW However there has been a
steep decline in IMR If IUGR is major cause of
LBW improvement in BW is not essential
prerequisite for reduction in IMR
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• Birth weight and health
• In India about one third of all infants weigh
  less than 2.5 kg at birth.
• Low birth weight is associated with
• Low growth trajectory
• ?Increased risk of obesity, diabetes and
  coronary heart disease in later life

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Child nutrition begins with maternal nutrition
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Birth weights in relation to maternal BMI
Source Tenth Five Year Plan 2002
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• Improving maternal nutrition
• During the Tenth Plan efforts will be made to
  weigh all women as early in pregnancy as possible
  and to monitor their weight gain
• This is not being done at the national level
• Under the ICDS programme, food supplements are
  being provided to pregnant and lactating women
  who come to anganwadis.
• Coverage is between 15 and 20
• Women who receive supplements are not being
  chosen on the basis of their nutritional status

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• Tenth Plan strategy
• Operationalising universal antenatal care for
  all pregnant women
• ANC coverage is low content suboptimal Majority
  do not get weighed very few get Hb estimation
  done (NFHS -DLHS data).
• Operationalisation of nutrition interventions for
  the management of under-nutrition through
• targeted food supplementation and health care for
  those with under-nutrition
• Appropriate management of anaemia non existent

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• Tenth Plan -Improving maternal nutrition
• Women who weigh lt 40 kg should be identified and
  
• given food supplements consistently throughout
  pregnancy
• given adequate antenatal care
• monitored for weight gain during pregnancy and,
  if weight gain is sub-optimal, identify the
  causes and attempt remedial measures and
• given appropriate antenatal, intrapartum and
  postpartum care.
• Under NPAG in 51 poor districts
• all pregnant women were weighed
• those weighing lt40 kg given 6 kg of food
  grains/month
• Reported coverage high cost low
• Programme is getting evaluated

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• Low birth weight 10 Plan strategy
• anganwadi workers to report all births in
  village,
• weigh all neonates delivered at home soon after
  birth and
• refer those weighing less than 2.2 kg to a
  hospital with a pediatrician.
• Current status
• Feasibility demonstrated in small studies
• Anganwadis should have a 10kg tubular Salter
  scale for reasonably accurate weighing of
  neonate
• Need to have information about nearest hospital
  with a pediatrician
• Unfinished agenda - action will help in NNMR

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Over two decades there has been an increase in
fat fold thickness of neonates in boys and
girls in all birth weight categories
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Over two decades there has been an increase in
fat fold thickness of neonates in boys and
girls in all gestational age categories
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Birth weight, plasma glucose and insulin
concentrations in 4-year old urban children
Birth weight (kg) Number of children Plasma glucose (mmol/l) at 30 min Plasma insulin (pmol/l) at 30 min
lt 2.4 36 8.1 321
-2.6 36 8.3 337
-2.8 44 7.8 309
-3.0 42 7.9 298
gt3.0 43 7.5 289
All 201 7.9 310
P for trend 36 0.01 0.04
Source Yagnik et al, 1998
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Time Trends in nutritional status of Delhi cohort
Male Male Female Female
Age No. Weight(Kg) No. Weight (Kg)
At birth 803 2.890.44 561 2.790.38
2 yrs 834 10.31.3 609 9.81.2
12 yrs 867 30.95.9 625 32.26.7
30 yrs 886 71.814.0 640 59.213.4
Source Bhargava et al, 2004
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Current Status of Delhi cohort
Characteristics Male Male Female Female
Characteristics No. Value No. Value
Weight (Kg.) 886 71.814.0 640 59.213.4
Height (m) 886 1.700.06 638 1.550.06
BMI 886 24.94.3 638 24.65.1
WaistHip ratio 886 0.920.06 639 0.820.07
BMIgt_25 886 47.4 638 45.5
BMIgt_23 886 66.0 638 61.8
Central Obesity () 886 65.5 639 31
Impaired GTT 849 16 539 14
Source Bhargava et al, 2004
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Breast feeding protection from under and over
nutrition How far have we succeeded in
protection and promotion of breast feeding
Emerging challenges
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Improving Infant Feeding
Parameter NFHS1 (92-93) NFHS2 (98-99)
Excl BFlt4mo 51 55
Excl BF Median 1.4 mo 1.9 mo
Solid food 6 mo 17 24
Solid food 12mo 68 71
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Infant feeding practices -NFHS -2
Source NFHS 1998-99
Breast feeding is universal in India but
exclusive breast feeding upto six months and
introduction of complementary feeds at six months
is not common
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Prevalence of undernutrition (Weight for age
below -2 SD)
Source NFHS 1998-99
As a result there is steep increase in under
nutrition between 6-23 months of age
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• Tenth Plan- major focus on Prevention of
  undernutrition in infancy through
• promotion of exclusive breast feeding in the
  first six months
• nutrition education for the introduction of
  appropriate low-cost, energy dense (home
  available) complementary food at 6 months
• focus on nutrition education by AWW/ ANM during
  each contact. Yet to be operationalised under
  ICDS /NRHM
• Needed clear crisp messages AWW to district
  doctor should all say the same things repeatedly
  to bring about behavioral change
• Use of mass media as in NRHM - will it help in
  bring uniformity in messages of health and ICDS
  workers ?

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• The goals for the Tenth Plan are to
• enhance early initiation of breast-feeding
  (colostrum feeding) from the current level of
  15.8 per cent (as per NFHS 2) to 50 per cent
• enhance the exclusive breast-feeding rate for
  children up to the age of six months from the
  current rate of 55.2 per cent (as per NFHS 2) to
  80 per cent
• enhance the complementary feeding rate at six
  months from the current level of 33.5 percent (as
  per NFHS 2) to 75 per cent.
• Available data from DLHS and BPNI surveys
  indicate that these goals will not be achieved
  
• Operationalisation of this component should get
  major attention during 11th Plan

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Under nutrition in Preschool children Role of
poverty and poor caring practices Screening ,
early detection and effective management can
change the scenario
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Time Trends in Energy intake and undernutrition
in children (1-3 years)
Source NNMB reports
Even though there is no increase in energy intake
over time there has been a decline in severe
undernutrition perhaps because of better access
to health care
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Nutritional Status of children by Income
Source NFHS 1998-99
Undernutrition rates among poor in Kerala are
similar to undernutrition rates among the rich
in UP. Appropriate IYCF and caring can lead to
steep fall in undernutrition rates in
preschoolers
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Mean Energy Consumption- NNMB 2000
Age groups Males Males Males Females Females Females
Age groups Kcals RDA RDA Kcals RDA RDA
Pre-school 889 1357 65.5 897 1351 66.4
School Age 1464 1929 75.9 1409 1876 75.1
Adolescents 2065 2441 84.6 1670 1823 91.6
Adults 2226 2425 91.8 1923 1874 102.6
The gap between RDA and the actual energy
intake is greatest in preschool children and
lowest in adults Poor caring practices rather
than poverty appear to be the major factor
for low energy intake in children
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Over years there has been a increase in the
number of households where adults are getting
adequate food but children are not this
confirms that poor child feeding and caring
practices rather than poverty is becoming the
common cause of of undernutrition in preschool
child
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Over years there has been a decline in severe
under nutrition ( weight for age and height for
age) but not in wasting ( weight for height).
Health
implications of wasting are not well documented
Does low wasting rate explain the South
Asian paradox ?
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Energy Intake (INP) Undernutrition among
children (NFHS II)
Higher dietary intake will not lead to better
child nutrition unless infections are
controlled
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of severe underweight(lt4yrs) and under-5
mortality rate
Source NFHS 1998-99
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Nutritional Status of children by Income
Source NFHS 1998-99
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• Tenth Plan Goals
• Reduce prevalence of
• severe undernutrition in children in 0-6
  age group by 50
• Mild and moderate under-nutrition from
  current level of 47 to 40
• Tenth Plan recommended strategies for reduction
  of undernutrition have not been
  operationalised
• Available data from DLHS show that there is no
  major reduction in undernutrition since 1998-99.
  
• BUT
• Projects in Orissa, WB ,MP has demonstrated
  that if the suggested strategies are followed
• these goals are achievable with in the existing
  constraints

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• Capacity building in ICDS Tenth Plan
• enhancing the quality and impact of ICDS
  substantially through training, supervision of
  the ICDS personnel and improved community
  ownership of the programme
• concentrating on the improvement of the quality
  of care and inter-sectoral coordination and
  strengthening nutrition action by the health
  sector
• creating nutrition awareness through IEC at all
  levels (community, womens group, village-level
  workers, PRIs, programme managers and policy
  makers at the state and central levels) and
• establishing a reliable monitoring and evaluation
  mechanism
• Yet to be operationalised should receive
  priority

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• Convergence of services
• AWW can
• weigh neonates in home deliveries and refer those
  requiring care
• advise regarding exclusive breast feeding and
  complementary feeding
• identify undernourished pre-school children by
  weighing them at least once every three months
  and give food on priority to them
• act as depot holder for ORS.
• assist in emergency referral

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• Convergence of services
• ANM will
• Immunize all infants, pregnant women and children
  as per schedule.
• Screen children especially the under nourished
  ones for health problems and manage/ refer those
  with problems.
• AWW will
• Assist ANM in organizing immunization health
  check ups in anganwadi
• Assist ANM in administering massive dose Vitamin A

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Micronutrient deficiencies All effort for
combating anaemia Review Vitamin A
supplementation Universal access to iodised
salt
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Anaemia is a major problem right from childhood
it worsen during adolescence in girls Advent
of pregnancy further aggravates anaemia
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Combating anaemia Promote breastfeeding, improve
complementary feeding Dietary diversification
Double fortified salt Screen all children
where ever possible school health, hospitals
OPDs Detect and treat anaemia vigorously
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Vitamin A Deficiency

• Clinical Deficiency Marked Reduction
• Blindness 2 (1974) to 0.04 (1985)
• Bitot Spots ICMR (1969) 4.2
• DWCD (1996) 0.21
• NNMB 2 (1996), 0.7 (1990 1997)
• Isolated Areas Bihar, UP (DNP-ICMR 01)
• Night Blindness (lt4 yr) MICS 2000 0.6

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Coverage Under Massive dose of Vitamin A
Coverage can be improved -Orissa, UP But
overall coverage remains low
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Prevalence of Bitot spot has declined Is this
the right time to review the massive dose
vitamin A programme ?
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Huge installed capacity for producing iodised
salt This is under utilised. We supply iodised
salt to other countries who attain high rates
of iodised salt use
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Many coastal , salt manufacturing states with
good health indices have low iodised salt use.
Prevalence of goitre in these non endemic states
is relatively high
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There was a decline in household access to
iodised salt after the ban on sale of non-
iodised salt was lifted Reimposition of ban is
under way
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• Tenth Plan strategy
• Promotion of appropriate dietary intake and
  lifestyles for the prevention and management of
  obesity and diet-related chronic diseases
• Nutrition monitoring and surveillance to enable
  the country to track changes in the nutritional
  and health status of the population to ensure
  that
• existing opportunities for improving nutritional
  status are fully utilized and
• emerging problems are identified early and
  corrected expeditiously.

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• Tenth Plan strategy
• Research efforts to be directed towards
• review of the recommended dietary intake of
  Indians
• building up of epidemiological data on
• relationship between birth weight, survival,
  growth and development in childhood and
  adolescence
• body mass index norms of Indians and health
  consequences of deviation from these norms.

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NORMAL CHILD
WASTED CHILD
SHORT CHILD
SHORT AND WASTED CHILD
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A NORMAL CHILD
B TALL SLIM CHILD
A B have same bodyweight. B should get more
food to reach appropriate weight for his height
and continue linear growth
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A NORMAL CHILD
B SHORT FAT CHILD
A B have same weight. B is short and requires
more exercise to get to appropriate weight for
his height .
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BMI is the most widely used parameter for
assessment of nutritional status in adults but is
not used as an index to assess nutritional status
in childhood and adolescence. This is perhaps
because computation of BMI for age in growing
children appears complicated
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(No Transcript)
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Weight for age and BMI for age BMI which takes
into account the current height while assessing
the nutritional status is a sensitive index for
detection of under and over nutrition in
children. It worth while to put in the additional
effort to compute BMI for age to assess
nutritional status in children adolescents
because it will enable early detection of both
under and over nutrition and appropriate
management so that these children grow into
healthy adults.
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Indices to be monitored Rationale for
monitoringassess progress, identify problems
and take mid course correction Process
indicators are to be monitored as per the
NRHM/ICDS formats. In addition 100 Civil
registration- reconciled at village level
Births- check with No of pregnant women

Deaths- assess MMR, neonatal, infant and
child mortality rates Monitor- infant and child
feeding practices Under-nutrition rates in
children reconcile with the DLHS data after
converting data to IAP classification
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THANK YOU