Malnutrition, an Emergency: What it Costs the Nation

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Economics of Malnutrition Combating
Malnutrition in the Inter-generational Context
Veena S Rao
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Introduction

• India, today is one of the most malnourished
  countries in the World.
• More than 40 of the Worlds under weight
  children below five years live in India (Global
  Hunger Index 2007)
• The latest NFHS 3 asserts that not much progress
  has been achieved in improving human resources.
• Poverty is a major, but not the only cause of
  malnutrition
• Percentage of population suffering from various
  forms of malnutrition, far exceeds the percentage
  below poverty line
• After National Nutrition Policy 1993 and National
  Plan of Action, 1995 no national programs or
  policies for eradicating malnutrition have
  appeared.
• Today, India has no national programme to combat
  malnutrition

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Indicators for Assessing the Nutritional Status

• Indirect Indicators
• Access to Hygenic Sanitation and Toilet
  Facilities
• Access to Safe Drinking Water
• Female literacy

• Direct Indicators
• Low Birth Weight
• Infant Mortality Rate (IMR)
• Under 5 Mortality Rate (U5MR)
• Stunting/ Wasting/ Underweight
• Anaemia
• Immunization
• Maternal Mortality Rate (MMR)
• Chronic Energy Deficiency and Anaemia among adults

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Chronic Energy Deficiency (CED)and Anaemia among
Women
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Nutritional Status of Men in India

• Male malnutrition intrinsically begins with
  maternal malnutrition
• 28.1 of the men in India have Body Mass Index
  below normal
• Stunted stature and low body weight of men due to
  malnutrition results in Chronic Energy Deficiency
• 24.3 of the men in India are anaemic
• Anaemia reduces work capacity and results in low
  productivity
• Percentage of men suffering from anaemia ranges
  from 7.1 in Kerala to 44.6 in Assam
• Percentage of men having below normal BMI and
  suffering from anaemia is higher in SC and ST
  population.

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Cont
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Economics of Malnutrition

• Prof RW Fogel NBER Working Paper 16- Conquest
  of High Mortality and Hunger in Europe and
  AmericaTimings and Mechanisms
• The first law of thermodynamics applies as
  strictly to the human engine as to mechanical
  engines. Since the overwhelming share of calories
  consumed by the malnourished populations is
  required for BMR and essential maintenance. the
  typical individual in the labour force had
  relatively small amounts of energy left for
  work.

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What does Malnutrition Cost the Nation

• Malnutrition negatively impacts the GDP as it
  reduces physical/ cognitive growth, reduces
  productivity and earnings of individuals, and
  results in economic loss to the nation.
• It lowers the resistance of the body to
  infections and capacity to recover from illness
  and adds to the health costs of the nation.
• Protein Calorie Intake, Micronutrient Intake,
  Infections and illness, Nature of Occupation
  determine working capacity and income generation
  capacity
• Based on the findings of NNMB repeat surveys in
  the years 1988-90 and 1996-97, that 30 of the
  households consume less than 70 of energy
  requirement, an attempt has been made to
  calculate loss of productivity in adults, and the
  resultant economic loss to the nation as a result
  of malnutrition. This equals approximately US
  29 Billion (4 of GDP).
• Other studies conducted by Administrative Staff
  College of India in the year 1996, CARE India and
  Linkages India 2003, confirm that 3 of GDP is
  lost on account of malnutrition and its various
  types of manifestations.

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GDP Loss due to Calorie Deficit

• Total no. of households in India 193,579,954
  (Census of India 2001)
• 30 of households 58,073986 consume less than
  70 of energy requirements (NNMB Repeat Surveys
  in 1988-90 and 1996-97)
• Norm level of calorie intake 2700Kcal
• Actual Calorie Intake 1890 Kcal (70 of
  2700Kcal)
• Energy required for Basal Metabolic Rate (BMR)
  1515 Kcal
• Calorie left for productive work 375 Kcal (1890
  Kcal- 1515 Kcal)
• Heavy work requires 219 Kcal per hour.
• Moderate work requires 122 Kcal per hour.
• Work hour lost per day per person due to
  inadequate calorie consumption 4 hours of
  moderate work and 7.5 hours of heavy work

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• GDP Loss due to Calorie Deficit
• Calculated on the formula
• Ea X Total No. of days in year (365)
• Er X Total No. of working days in year (250)
• Ea is the Energy available for work 375 Kcal
• Er is the energy required for a particular
  work 219 Kcal for heavy work and 122 Kcal for
  moderate.
• Assuming average household has 5 Consumer
  Units,(NSS in Nutritional Intake in India, 50th
  Round, July 1993 June 1994) then total no. of
  population consuming less than norm level for
  calorie intake 290,369,930
• 55 of Adults 159,703,461.
• Based on actual average wage of Rs. 60/- per man
  per day of 8 hours, per hour earning Rs.
  7.50/-
• Loss of total money due to low productivity due
  to inadequate calorie consumption Rs. 30/-
  approx. per day per person.
• Total money lost by entire adult population per
  day Rs. 4,791,103,830.

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• GDP Loss due to Calorie Deficit
• Assuming total of 250 working days, total money
  lost in a year Rs. 1,197,775,957,500 US
  29,944,398,937 approx. (1 US Rs. 40/-)
  Approx. US 29 Billion
• Total GDP for year 2006-07 Rs. 28481.57
  billion, or US 712 billion
• GDP loss 4 GDP
• In absence of reliable data this study does not
  take into account the productivity loss through
  protein and micronutrient deficit.

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What does Malnutrition Cost the Nation
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Estimated annual productivity losses due to
Nutritional deficiencies
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Productivity Losses due to malnutrition in India
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Other Studies

• GDP Loss- US 114 billion between 2003 and 2012
  owing to productivity losses due to PEM, IDD and
  IDA(CARE India and Linkages India,2003)
• GDP Loss- US 2.3 billion or Rs. 103 billion,
  associated with foregone wage employment
  resulting from child malnutrition (Bhandari and
  Zaidi 2004)
• GDP Loss-US 2.5 billion annually due to
  micronutrient deficiencies (Alderman 2005)
• Productivity loss from stunting, iodine
  deficiency and iron deficiency resulting in loss
  of productivity 3 of GDP (Horton 1999)

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International Comparisons

• Indias position in the Human Development Report
  for 2008 is 134 from (128 of previous year),
  (China ranks 91, Sri Lanka 102 and Bangladesh
  146).
• Despite our high growth rate, the improvement in
  the nutritional status of our population has been
  marginal compared to countries like China, Sri
  Lanka, Bangladesh.
• In certain indicators such as Children Under
  weight, and Stunted Children, the situation is
  worse than Sub Saharan countries such as
  Ethiopia, Angola, Sudan and Congo (DR)

Cont
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Inter-generational Cycle of Malnutrition and Ill
Health
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Causes and Consequences of Malnutrition-The Cause
Consequence Exchange

• Since the problem of malnutrition is
  inter-generational, the solution Must also be
  inter-generational.
• No single intervention can eradicate
  malnutrition.
• The package of interventions must be
• Inter-sectoral so as to address the majority of
  causes of malnutrition such as poverty, lack of
  access to health care, information, unsafe water
  and lack of sanitation, frequent infections
• Cover the entire life cycle of women and children
  to create an immediate impact within one
  generation on the nutritional status of the three
  critical links of malnutrition, viz., infants
  children, adolescent girls and pregnant and
  lactating women
• Simultaneous so that the benefit of one
  intervention is not lost on account of absence of
  another

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The Inter-generational Strategy Pilot Project
Mokhada Jawhar Blocks Thane District -
Maharashtra

• Unique Features
• Interventions to address the critical
  inter-generational linkages viz., Infancy and
  childhood, adolescence and motherhood
• Providing information to the community regarding
  improving the nutritional status by generating
  awareness regarding the Inter-generational cycle
  of malnutrition and ill health through a strong
  Health and Nutrition Education module for the
  care of infants, adolescent girls, pregnant and
  lactating mothers
• Training Womens Self Help Groups for Production
  of low cost indigenously prepared energy food
  supplements appropriate to the needs of the
  three critical links
• Consumption of Energy Food by the 3 groups
  (infant and child feeding under supervision)
• Demand creation/other critical interventions,
  such as, providing timely immunization,
  de-worming, information on safe handling of
  drinking water, chlorination of drinking water at
  domestic level, Sanitation, information on
  prevention and control of diarroeah, preparation
  of ORS, providing IFA tablets, health check ups
  and referral services for women and children

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Project Status

• The project is under implementation with the help
  of NGO MITTRA- BAIF since
• September 2006 in the tribal blocks of Jawhar and
  Mokhada, Thane District, Maharashtra
• with the following progress
• Baseline Survey
• Awareness Generation, (ongoing)
• Capacity Building of SHGs for the production and
  distribution of energy foods
• Setting up of 8 Production Units of in each
  tribal block
• Production of energy foods for all the three
  target groups
• Consumption of energy foods by infants and
  children commenced in August 2007 and for
  adolescent girls and pregnant and lactating
  mothers in September 2007
• Monthly Weight Monitoring of all the three target
  groups
• The Monthly Weight Monitoring results reveal that
  there has been a steady weight gain
• for all the three target groups viz., infants and
  children, adolescent girls, pregnant and
• lactating women. The response of the community
  indicates that they have a better sense
• of well being on all accounts

Cont
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Coverage of the Project- Aug.07- May 09

• 
  Jawhar
  Mokhada Total
• Total no. of Infants (0-6 mths) -
  73 78
  151
• Total no. of Children (6 mths - 6 yrs) -
  3579 2456
  6035
• Total no. of Adolescent Girls -
  297 407
  704
• Total no. of Pregnant Women -
  83-134 162-178 245-312
• Total no. of Lactating Women -
  238-251 147-226
  385-477
• Total Population
  31,210 27,512 58,722
• (50 villages in each block)-

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Success of Strategy Significant Reduction in
LBW babies

• Mokhada Block

• Jawhar Block

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Random Sample of 5 Pregnant Women
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Findings
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Infant Child Mortality

• Infant Mortality

• Child Mortality

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Significant Improvement in Nutritional Status -
Infants- 6-23 months - WHO norms

• Mokhada

• Jawhar

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Significant Improvement in Nutritional Status
Children 2-6 years - WHO norms

• Jawhar

• Mokhada

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Average Weight Hb count - Adolescent Girls

• Jawhar

• Mokhada

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Average Weight Gain Hb count among Pregnant
Lactating Women

• Pregnant Women

• Lactating Women

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Composition Portion of Energy Food for Infants
Children
Ragi (Millet) Malt Energy Food for Infants and
Young Children (6 months-6 years) Ingredients
Germinated Ragi (70 gms), Germinated Wheat (15
gms), Green Gram (15 gms), Milk/
Water Sugar. Process Germinated,
Roasted, Milled, Sieved, Mixed. Portion
Size for Infants 6 months 12 months - 50
gms Children 12 months- 100gms. Nutritive
Value of Ragi Malt - (100 gms).
No. Ingredient
Nutritive value 1. Protein(g)
10.48 2. Energy (kcal) 331.00
3. Calcium (mg) 250.00 4.
Phosphorous (mg) 300.00 5.
Iron(mg) 4.13 6. Beta carotene
(mg) 53.10 7. Thiamine (mg)
0.433 8. Riboflavin (mg)
0.200 9. Niacin (mg) 1.91 10.
Folic Acid (mg) 18.30
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Composition Portion of Energy Food for
Adolescent Girls, Pregnant Lactating women.
Energy Food for Adolescents, Pregnant and
Lactating Women Ingredients Germinated Ragi
(75 gms), Defatted Soya(20 gms), Peanuts
Jaggery. Process Germinated, Roasted, Milled,
Sieved, Mixed. Portion Size for Adolescent
Girls 100 gms, Pregnant and Lactating Women 150
gms. No. Ingredient
Nutritive value
1. Protein(g)
17.00
2. Energy (kcal)
330.00 3.
Calcium (mg)
410.50 4.
Phosphorous (mg) 235.40
5. Iron(mg)
6.00
6. Beta carotene (mg)
1161.00
7. Thiamine (mg) 0.472
8.
Riboflavin (mg) 0.511
9. Niacin (mg)
1.783
10. Folic Acid (mg)
46.700
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Improvement in Nutritional Status of Women and
Children
Name Piyanka Vilas Gavali Age 10 months
Before
After 5 months
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Improvement in Nutritional Status of Women and
Children
Name Shakuntala Eknath Sanekare
After Delivery
During Pregnancy
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Improvement in Nutritional Status of Child
Name Eshram Budhya Bhoye
Before
After
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Improvement in Nutritional Status of Child
After delivery (Gulab Vasant Bhondva -
Dongarpada, Jawhar with Healthy Child)
Lactating Women with healthy Savita Motiram
Bonge- Dongarpada
Kalpana Ravindra Bhoye- Dongarpada with Healthy
Baby
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SHG women working with Nutrition processing unit
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Packaging
NAGALI SAKAS AHAR
VRINDAVAN MIX
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Analysis of the current situation

• India has no comprehensive National Program for
  the eradication of Malnutrition. The ICDS
  programme in governmental and general perception
  is seen as a programme to address malnutrition.
  However, ICDS is not a programme for the
  eradication of malnutrition, but for Integrated
  Child Development.
• Other Nutrition and related programmes such as
  the Mid Day Meal Programme, Kishori Shakti
  Yojana, Vitamin A supplementation programme,
  National Nutritional Anaemia Control Programme,
  and the National Iodine Deficiency Disorder
  Control Progreamme address some of the causes of
  Malnutrition but not all of them.
• (iii) Malnutrition in India is deeply rooted in
  the inter-generational cycle. However, the
  current policies and programmes do not address
  the issue inter-generationally, as depicted in
  the diagram.

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• (iv) The population of India suffers from a high
  Protein Calorie deficit. Studies reveal that 30
  of the households in India consume less than 70
  of the energy requirement and calorie intake(NNMB
  repeat surveys 1988-1990 and 1996-97).
• (v) There is inadequate awareness and information
  regarding proper nutritional practices amongst
  the population.
• (vi) Crucial prescriptions of the National
  Nutrition Policy, 1993, were not translated into
  National Programmes, viz., popularization of low
  cost nutritious foods, reaching the adolescent
  girl, fortification of essential foods and
  control of micronutrient deficiencies.
• (vii) Most importantly, eradication of
  malnutrition should be articulated as high
  priority in the National Development Agenda.

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A National Strategy to Combat Malnutrition

• Underlying Principles Bridging the
  Calorie-Protein Gap
• Introduce nutrition and micro-nutrient
  interventions for the three critical links of
  malnutrition viz. children 6 months 6 years,
  adolescent girls, and pregnant and lactating
  women to be prepared by SHGs from low cost,
  locally available agricultural produce.
• Introduce nutrition and micro-nutrient
  interventions for the general population to
  bridge the protein-calorie gap by making
  available in the market, protein-energy dense
  foods.
• Make available low cost energy foods for the
  general population (Corporate Sector/PPP)
• Structure and monitor tightly integrated
  multi-sectoral interventions to address all or
  majority of the direct and indirect causes of
  malnutrition simultaneously.
• Initiate a sustained general public awareness
  campaign regarding proper nutritional practices
  within existing family budgets, and to create
  demand.
• .

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Essential Interventions to Combat Malnutrition

• Direct interventions
• Related to the consumption and absorption of
  adequate protein calorie/micro-nutrient rich
  foods essential to combat malnutrition, namely
• Weighment of child within 6 hours of birth and
  thereafter at monthly intervals.
• Timely initiation of breastfeeding within one
  hour of birth, and feeding of colostrum to the
  infant.
• Exclusive breastfeeding during the first six
  months of life.
• Timely introduction of complementary foods at six
  months and adequate intake of the same, in terms
  of quantity, quality and frequency for children
  between 6-24 months.
• Dietary supplements of all children between 6
  months 72 months through energy dense foods
  made by SHGs from locally available food material
  to bridge the protein calorie gap.
• Safe handling of complementary foods and hygienic
  complementary feeding practices.
• Complete immunization and Vit. A supplementation.
  
• De-worming of all family members bi-annually.

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• Frequent, appropriate, and active feeding for
  children during and after illness, including oral
  rehydration with Zinc supplementation during
  diarrhea.
• Timely and quality therapeutic feeding and care
  for all children with severe and acute
  malnutrition.
• Dietary supplements of iron rich, energy dense
  foods made from locally available food material
  prepared by women SHGs for adolescent girls and
  women, especially during growth periods and
  pregnancy to fill the protein calorie gap and
  ensure optimal weight gain during pregnancy.
• Anaemia screening for children, adolescent girls
  and women.
• Weight monitoring of all adolescent girls and
  pregnant women.
• Prevention and management of Micro-Nutrient
  deficiencies, especially through IFA
  supplementation to prevent anaemia in adolescent
  girls and women.
• Making available low cost energy foods for the
  general population.
• Fortification of common foods.

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• Indirect Interventions
• Related to issues of health, safe drinking
  water, hygienic sanitation and socio-cultural
  factors such as early marriage and pregnancy of
  girls, female literacy and poverty reduction, to
  eradicate malnutrition on a long term,
  sustainable basis.
•  
• Access to safe drinking water (treatment,
  storage, handling and transport), sanitation and
  hygiene.
• Increased female education and completion of
  secondary schooling for the girl child.
• Increased access to basic health services by
  women.
• Expanded and improved nutrition education and
  involvement at Panchayat and community level to
  create demand.
• Increased gender equity.
• Promotion of nutrition best practices especially
  for girls and women.

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Nutrition Monitoring and Surveillance

• A computerized Central and Block level monitoring
  systems should be devised with deliverable
  targets and time frames
• An effective concurrent monitoring system through
  an external agency can also be established for
  measuring outcomes, and for effecting changes and
  mid course corrections
• At the AW level, community based nutrition
  monitoring and surveillance through ICDS
  infrastructure could include growth monitoring of
  infants and children and weight monitoring of
  adolescent girls and women
• Creating a data base on the nutritional status of
  children, adolescents and women in each Anganwadi

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Concluding Observations

• Since at least 4 of Indias GDP (29 Billion)
  annually is lost on account of malnutrition, the
  cost of addressing malnutrition is far below the
  cost of not addressing it.
• It may be noted that the cost of construction of
  3 kilometres of rural road is in excess of the
  amount required to address the nutrition deficit
  of the key target groups in the Block.
• Investing in human resources development for the
  future in the shape of healthy children,
  adolescents and adults with higher cognitive and
  productive capacity, is an investment that will
  pay for itself several times over, will eradicate
  the curse of malnutrition in the shortest
  possible time, so that every Indian is able to
  reach his or her full physical and cognitive
  potential, enhance income generation capacity and
  contribute to the country's progress.

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• Thank you