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Nutritional Status of Children in India

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The "Nutritional Status of Children in India" blog seeks to give the learner a fundamental understanding of the state of children's nutrition in India today. The learner also gains insight into the different surveys carried out across India to assess children's nutritional status and the government-formulated programs designed to address the issue of malnutrition in India.

Content

  1. Introduction
  2. Statistical Data on Current Nutritional Status of Children in India and Nutritional Deficiencies.
  3. Causes of Malnutrition in India and Surveys Made to Assess Them.
  4. Governmental Efforts to Curb Malnutrition in India. 
  5. The Way Forward.
  6. Conclusion

Introduction 

Children today will be the adults of tomorrow, thus it is crucial to provide them with access to excellent health care facilities and a nutritious diet. Investment in the development of human resources is now widely recognised as a prerequisite for any country. Early childhood, or the first six years of life, is the most important time since it is during this time that the foundations for cognitive, social, and emotional development, language acquisition, physical and motor growth, and cumulative lifelong learning are laid (Hurlock, 1978). The young kid is particularly susceptible to the vicious cycles of undernourishment, illness or infection, and the ensuing handicap, all of which have an impact on both the macro and micro levels of a nation's future human resource development. Malnutrition is a significant underlying cause of child mortality in many countries, including India, where it is a serious problem for children.

Relevant Definitions

Below are definitions pertinent to the subject of "The Nutritional Status of Children in India." This will make it possible to comprehend how children are now doing in terms of their dietary consumption, the methods used to assess their nutritional status, and the general occurrence of malnutrition. According to Children in India (GOI, 2012), the following definitions apply:

  • Biological Definition: Childhood is the span of life from birth to adolescence. 
  • United Nation’s Convention on the Rights of the Child(UNCRC): According to Article 1 of UNCRC “A child means every human being below the age of 18 years unless, under the law applicable to the child, majority is attained earlier.” 
  • Legal Definition of Child in India is taken from relevant statutes: 
    • The Census of India considers children to be any person below the age of 14, as do most government programmes. 
    • Article 21 (a) of the Indian Constitution states that all children between the ages of six to fourteen should be provided with free and compulsory education. 
    • Under the Indian Majority Act, 1875 a person has not attainted majority until he or she is of eighteen years of age.

Nutrition: 

According to World Health Organization (WHO, 2013) nutrition is the intake of food, considered in relation to the body’s dietary needs. Nutrition can be either good or poor.
  • Good nutrition-an adequate, well balanced diet combined with regular physical activity-is a cornerstone of good health. 
  • Poor nutrition - can lead to reduced immunity, increased susceptibility to disease, impaired physical and mental development, and reduced productivity.

Malnutrition

he United Nations International Children’s Fund (UNICEF, 2006) has defined malnutrition as follows: Malnutrition is a broad term commonly used as an alternative to under-nutrition but technically it also refers to over-nutrition. People are malnourished if their diet does not provide adequate calories and protein for growth and maintenance or they are unable to fully utilize the food they eat due to illness (under-nutrition). They are also malnourished if they consume too many calories (over-nutrition).

Nutritional Deficiencies and Resultant Diseases

When a person's nutrient intake continuously falls below the advised amount, nutritional deficiencies happen. According to the World Health Organization, severe nutritional deficits affect children between the ages of 10 and 19 worldwide. The following is a list of some of the diseases that dietary deficiencies can lead to, according to The American Heritage Dictionary from 2000:
  • Beriberi: it is a clinical manifestation of thiamin (Vitamin B1) deficiency. Symptoms include nervous system abnormalities (e.g., leg cramps, muscle weakness), limb swelling, elevated pulse, and heart failure. 
  • Pellagra: it is a disease caused by a dietary deficiency of, or a failure to absorb, niacin(vitamin B3) or the amino acid tryptophan, a precursor of niacin. Pellagra means "rough skin." Primary symptoms include the "3 Ds": dementia (mental symptoms), dermatitis (scaly skin sores), and diarrhea. 
  • Osteoporosis: caused mainly due to mineral deficiency of Calcium and Vitamin D. This deficiency is characterized by a decrease in the mass of otherwise normal bone and is the most common metabolic bone disease. 
  • Rickets: Rickets is caused by a deficiency in vitamin D. During growth, human bone is made and maintained by the interaction of calcium, phosphorus, and vitamin D. Calcium is deposited in immature bone (osteoid) in a process called calcification, which transforms immature bone into its mature and familiar form. However, in order to absorb and use the calcium available in food, the body needs vitamin D. In rickets, the lack of this important vitamin leads to low calcium, poor calcification, and deformed bones. 
  • Anemia: Aneamia caused basically due to nutritional deficiencies is also a cause of major concern in India. Anaemia is characterized by the lack of an adequate amount of haemoglobin in the blood. A low level of haemoglobin interferes with the ability of the blood to carry oxygen from the lungs to other organs and tissues. Anaemia in young children results in increased morbidity from infectious diseases, and it can result in impairments in coordination, cognitive performance, behavioural development and language development. 
  • Kwashiorkar: A severe malnutrition of infants and young children, primarily in tropical and subtropical regions, caused by deficiency in the quality and quantity of protein in the diet and characterized by anemia, edema, potbelly, depigmentation of the skin, loss or change in hair color, hypoalbuminemia, and bulky stools containing undigested food. 
  • Marasmus: A form of protein-energy malnutrition predominantly due to prolonged severe caloric deficit, chiefly occurring in the first year of life, with growth retardation and wasting of subcutaneous fat and muscle.

Methods Used to Assess Nutrition in India.

The following anthropometric indices are used to evaluate children's physical development, per a statistical evaluation carried out by the Ministry of Statistics and Programme Implementation (GOI, 2012; WHO, 2013):
  • Height-for-age: Inadequate height-for-age indicates stunting. 
  • Weight-for-height: Inadequate weight-for-height indicates wasting. 
  • Weight-for-age : Inadequate weight-for-age indicates underweight.
Height-for-age (stunting): Children who are stunted and chronically undernourished are those whose height-for-age is less than minus two standard deviations (-2 SD) below the reference population's median. Children are deemed to be severely stunted if their height is below minus three standard deviations (-3 SD) from the reference population's median. Inadequate nutrition over a long length of time is shown in stunting. Therefore, height-for-age is a measure of the long-term impacts of malnutrition in a community and is independent of current food intake.
Weight-for-height (wasting): The weight-for-height index calculates body mass as a percentage of height and provides information on dietary intake. Children who are acutely malnourished and below -2SD from the reference population's median are deemed to be thin (wasted) for their height. Wasting, which is defined as inadequate nutrition in the period just before the survey, might be the result of insufficient food intake or a recent sickness that led to weight loss and the beginning of malnutrition. Severely wasted children are those whose weight-for-height is less than -3 SD from the reference population's median.
Weight-for-height (wasting) :Height-for-age and weight-for-height are both components of the weight-for-age (underweight) index. It considers both recent and long-term malnutrition. Underweight children are those whose weight-for-age is less than minus 2 SD from the reference population's median. Children are deemed to be very underweight if their weight-for-age is less than minus 3 SD from the reference population's median.

Statistical Data on Current Nutritional Status of Children in India and Nutritional Deficiencies.

In order for a child to receive the necessary nourishment, the parent or guardian must have the financial means to do so and, in the lack of such resources, must have access to government programs that are adequate in their place. Malnourishment has grown to be a significant issue due to the widespread lack of these basic needs in India. The results gathered from numerous surveys carried out across India are evidence of the country's growing malnutrition problem among children.

Statistical Data as Provided by the National Family Health Survey of India-3 on Malnutrition amongst Children. 

The percentage of children under the age of five who were classed as malnourished using the three anthropometric indices used by the NFHS 3 (2005–06) is suggestive of the considerable malnourishment among Indian children, according to a study on nutrition by the Government of India (2009). Half of the country's children are chronically malnourished, as evidenced by the fact that 48 percent of children under the age of five are stunted (too short for their age). A youngster who is acutely malnourished, as shown by wasting, is too thin for his or her height. One in five children in India are wasted, according to the 19.8% of children under the age of five that live in the nation. Children under the age of five are underweight on average by 43 percent. A composite indicator of both chronic and acute malnutrition is underweight status.

Statistical Data from the National Family Health Survey of India-3 on Anaemia amongst Children.

Iron and other crucial minerals and vitamins, as well as illnesses like malaria and sickle cell disease, can all contribute to anaemia in the diet. The frequency of anaemia among children under the age of three was discovered to be incredibly common at the time of NFHS-2, and it actually rose between NFHS-2 and NFHS-3. According to the Government of India's 2009 report on nutrition,
  • The percentage of children with any anaemia increased from 74 percent in NFHS-2 to 79 percent in NFHS-3. 
  • Seven out of every 10 children aged 6-59 months in India are anaemic. 
  • Three percent of children aged 6-59 months are severely anaemic, 40 percent are moderately anaemic, and 26 percent are mildly anaemic.

Causes of Malnutrition in India and Surveys Made to Assess Them

It is impossible to pinpoint a single cause of child malnutrition. A child's malnutrition is the result of a number of variables coming together. Several of these factors can be gleaned from the literature in this field, including:
  • Lack of purchasing power of the parent/guardian due to existence of wide spread poverty caused by stunted economic growth resulting in inability to provide their children with nutritious meals. The percentage of underweight children in the lowest wealth index category (56.6%) is nearly 3 times higher than that in the highest wealth index category (19.7%). 
  • Though there are several government schemes which have been framed in order to deal with the problem of malnourishment amongst children in India these schemes lack proper planning and implementation by the government.
  • Inadequate health care services provided to the poor, especially to those below the poverty line, making it difficult to provide medical and nutritional facility to severe cases of malnutrition. 
  •  Illiteracy amongst parent/guardian as to what is nutritious is also a major cause of malnourishment. High malnutrition of all types prevails in the group of illiterate mothers and mother’s with less than 5 year’s education, according to NFHS-3. 
  • Absence of health education in school curriculum. 
  • Relevance and importance of breastfeeding practices not understood by all. For instance, span of time for which breast feeding to be given to the child, importance of first milk and when to be given etc. are not known to a lot of people. 
  • Nutritional status of pregnant and lactating mothers also has a direct effect on the nutritional status of the child eg. anaemic mothers give birth to children who are undernourished from birth itself. India has a large population of anaemic mothers, thus increasing the number of malnourished children. It has been mentioned in a statistical appraisal conducted by the Ministry of Statistics and Programme Implementation that malnutrition among children is highest for underweight mothers (GOI, 2012).

Surveys Conducted to Analyze Nutritional Status in India. 

In order to track the continuing nutrition transition and launch effective interventions, surveys to evaluate the population's dietary intake and nutritional status are crucial. The routine reporting of nutritional status by the social welfare and health officials in India is not up to par. India has consequently made significant investments in frequent surveys to collect information on nutrition transition. It is crucial that at least state level data are provided given its vastness and variety. There are currently initiatives on to gather and report district specific data whenever possible because of the known inter-district variances within the same state and the current emphasis on decentralized district based planning, implementation, and monitoring of intervention programmes. The following are the most significant surveys, as listed by the Government of India in 1993:
  1. National Nutrition Monitoring Bureau (NNMB) : Recognizing the need for good quality data for monitoring nutritional status, Indian Council of Medical Research (ICMR) in 1972 established the National Nutrition Monitoring Bureau (NNMB) in the National Institute of Nutrition (NIN), Hyderabad. Since 1973, surveys carried out by the NNMB have been a major source of data on diet and nutritional status of the Indian population. 
  2. India Nutrition Profile (INP) Survey : Food & Nutrition Bureau in the Department of Women & Child Development of the Ministry of Human Resource Development of the Government of India organized a survey in 1995-96 to obtain a reliable nutrition profile of all districts (India Nutrition Profile INP) in 18 States and Union Territories (UTs) in which NNMB was not conducting nutrition surveys. The INP survey used sampling design and survey methodologies similar to NNMB. Overall 187 districts were covered in 18 states and UTs. INP provides mid nineties data, on dietary intake and nutritional status of all age groups, in all states of the country, in urban and rural areas. 
  3. National Family Health Survey (NFHS): Three National Family Health Surveys have been conducted so far. NFHS-1 conducted in 1992–93, NFHS-2 conducted in 1998–99 and NFHS-3 conducted in 2004-05 provide national and state-level information on fertility, family planning, infant and child mortality, reproductive health, child health, nutrition of women and children, and the quality of health and family welfare services. The NFHS-2 sample covers more than 99 percent of India’s population living in all 26 states. It does not cover the union territories. NFHS2 is a household survey with an overall target sample size of approximately 90,000 ever-married women in the age group 15–49. Data on nutritional status of women and children from NHFS 1, 2 and 3 provide information on time trends in prevalence of under nutrition in the last 15 years. In addition, NFHS-2 provides information on dietary diversity among the women surveyed.
  4. District Level Household Survey (DLHS): This survey is conducted by the Department of Family Welfare to assess performance under the Reproductive and Child Health programme. The first round was conducted in 1998-99 and the second round of the survey was conducted between 2002 and 2004. The survey used a systematic multi-stage stratified sampling; stages of selection are districts, primary sampling units (PSUs) and households; 1000 representative households were identified for the survey using appropriate sampling procedure from each district 
  5. Micronutrients Surveys: NNMB and ICMR have conducted micronutrient surveys at subnational level during the last few years. In addition, NFHS and DLHS provide information on the household availability of iodized salt and coverage under massive dose vitamin A programme.

Governmental Efforts to Curb Malnutrition in India.

The nutritional status of children in India has been improved via the implementation of numerous programs. Even before India gained its independence, efforts were made, with the British Administration launching a midday meal program for underprivileged kids in the Madras Municipal Corporation in 1925. The government is currently making a number of measures in partnership with international organizations like the Food and Agriculture Organization (FAO), WHO, and UNICEF. However, the following are the primary programs that have significantly reduced child malnutrition in India:

The Integrated Child Development Services (ICDS) Scheme: The programme adopts a multi-sectoral approach incorporating both health and education interventions. The Ministry of Women and Child Development (MoWCD) is responsible for coordinating ICDS and working with state governments to monitor and evaluate the scheme’s performance. In many states, panchayats have also been actively involved in the implementation and monitoring of ICDS since the 73rd Amendment Act was passed in 1992. The Integrated Child Development Services (ICDS) scheme integrates several aspects of early childhood development and provides supplementary nutrition, immunization, health check-ups, and referral services to children below six years of age as well as expectant and nursing mothers (WCD, 2013). 
ICDS Scheme Objectives: 
  1. To improve the nutritional and health status of children below the age of six. 
  2. To lay the foundation for the proper psychological, physical and social development of the child. 
  3. To reduce the incidence of mortality, morbidity, malnutrition and school dropouts. 
  4. To achieve effective coordination of policy and implementation among various departments to promote child development. 
  5. To enhance the capability of the mother to look after the normal health, nutritional and developmental needs of the child through proper community education.
Performance of the ICDS Scheme: 
The prevalence of stunted and underweight children under the age of 5 has somewhat decreased, by 6 and 3 percentage points, respectively, according to statistics from the NFHS 3 (2005-06). However, the number of wasted children increased by 3%. Children with severe anemia increased by 25% during the same time period. The data shows that more than one in 18 children die within the first year of life and one in 13 children die before the age of five, with the Scheduled Castes and Scheduled Tribes experiencing higher mortality rates. This is true despite a modest decline in infant mortality rates over the three national survey periods.

Instead of the inputs technique normally used to monitor other government programs, the Ministry of Woman and Child Development has adopted an outcomes strategy for the implementation and monitoring of the program during the Eleventh Plan period. With reorganization, improved design, and implementation, it is anticipated that the program will produce better results and provide states with a framework to measure results and monitor progress.

The Mid Day Meal Scheme: According to the Ministry of Human Resource Development, Government of India (2013), the Mid Day Meal Scheme is the largest school feeding program in the world, serving more than 12 crore students across more than 12.65 lakh schools and Education Guarantee Scheme (EGS) centers. In India, midday meals in schools have a lengthy tradition. A Mid Day Meal Program for underprivileged kids was launched in Madras Municipal Corporation in 1925. By the middle of the 1980s, a prepared mid-day meal program for primary-aged students had been universalized in three States—Gujarat, Kerala, Tamil Nadu, and the UT of Pondicherry. By 1990–1991 there were twelve states that were using their own funds to establish the universal or extensive midday meal program. The National Programme of Nutritional Support to Primary Education (NP-NSPE) was introduced as a Centrally Sponsored Scheme on August 15, 1995, initially in 2408 blocks across the nation, with the goal of increasing enrollment, retention, and attendance while also improving nutritional status among children.
Objectives of the Mid-Day Meal Scheme: 
  • Improving the nutritional status of children in classes I-V in Government, Local Body and Government aided schools, and EGS and Alternative and Innovative Education (AIE) centres. 
  •  Encouraging poor children, belonging to disadvantaged sections, to attend school more regularly and help them concentrate on classroom activities. 
  • Providing nutritional support to children of primary stage in drought affected areas during summer vacation
Progress made by the Mid-Day Meal Scheme: In order to meet the problems of a developing society, the Human Resource Development Ministry has continuously adjusted the midday meal program. In order to improve the scheme's implementation, adjustments were made in 2009. The amount of pulses has been increased from 25 to 30 grams, the amount of vegetables has been increased from 65 to 75 grams, and the amount of oil and fat has been decreased from 10 grams to 7.5 grams in order to provide children in the upper primary group with a balanced and healthy diet. Thus, in order to ensure proper implementation, the system is regularly altered as needed, and numerous committees have been established for its monitoring and review. The Human Resource Development Department has established the following committees for monitoring and evaluation:
  • National Steering-Cum-Monitoring Committee. 
  • State Steering–Cum-Monitoring Committee. 
  • Quarterly Progress Reports. 
  • State wise monitoring mechanisms
Nodal Department of UNICEF: The nodal department for Unicef is the Department of Women and Child Development. Since 1949, India has had a relationship with Unicef, and the two organizations have worked together to help the most vulnerable children and their mothers. Unicef has historically assisted India in a number of areas, including planning and program support, information and communication, planning and support for urban basic services, support for community-based convergence services, health, education, nutrition, water & sanitation, childhood disability, children in particularly difficult circumstances, and information and communication. India now belongs to the Unicef.

National Nutrition Policy, 1993:  A national nutrition policy was established in 1993 to address the issue of undernutrition. By using both direct (short-term) and indirect (long-term) interventions in the fields of food production and distribution, health and family welfare, education, rural and urban development, woman and child development, etc., it seeks to address this issue.

National Plan of Action for Children: The National Plan of Action for Children, 2005 is by far the most comprehensive planning document concerning children. Its value is that it clearly outlines goals, objectives, and strategies to achieve the objectives outlined and recognizes the needs of all children up to the age of eighteen. It is divided into four basic child right categories as per the United Nations Convention on the Rights of a Child: Child survival, Child development, Child protection and Child participation (WCD, 2005).

The Way Forward. 

It is crucial that some changes be made to the programs in order to address this issue, as well as a shift in the roles played by local authorities, particularly those that are present in rural regions. So that the various plans are implemented properly, monitoring and evaluating the efforts made by them should be given a special emphasis.

Recommendations for Dealing with Malnutrition in India. 

Some steps which can be taken in order to efficiently deal with malnutrition in India are: 
  1. There is need for advocacy, awareness building and counselling regarding nutrition at various levels. 
  2. Empower panchayats with the necessary human and financial resources, in addition to adequate administrative authority, with regard to all programmes concerning or related to nutrition. Since the panchayat is transparent in it’s functioning, it can be made more accountable.
  3.  Install/Identify a catalytic institution at the block level for capacity building, monitoring, data collection, and programme management. This could be an agency such as an NGO, or another organisation that can enhance and work alongside the panchayat. 
  4. ICDS needs to be in mission mode, with separate and adequate resources and authority. There is a great need for convergence at all levels. Funds should be given at the district level, and monitoring and accountability should come into play at the same level, as well as at other levels. 
  5. Prioritise monitoring and surveillance in order to better assess problems as well as monitor the areas of improvement regarding nutrition. There is a need for national criteria on what information should be collected and how this should be done to ensure consistency in the data across the nation. 
  6. It is well recognized that the first 24 months are the opportunity window for preventing malnutrition in children. Data from NFHS 3 shows that during the first 2 years, less than a third received any services and the proportion receiving food and supplements were negligible. It is essential that the various schemes existing in India on nutrition for children give sufficient emphasis on proper dietary intake by this category of children that is children who are less than 2 years of age.

Role of Trained Social Workers. 

Social workers are crucial in filling up the gaps where the government fails to reach out to the undernourished. Among the actions they must perform are the following:
  • To be well aware of the schemes present with regards to nutrition and make this knowledge available to underprivileged families especially in rural areas. 
  • To co-operate with the government and it’s various departments which are carrying out schemes so that there is better implementation. 
  • To create uniform modules on a regional level for social workers to follow while dealing with the problems of malnutrition amongst children
  • To create awareness among new mothers and pregnant women of the primary importance of breast feeding as well as dietary intake as it has a direct effect on the nutritional status of the new born and children in the age group of 0-2yrs. 
  • Encourage education of girls as a minimum of 5 years of schooling is a protective factor in preventing malnutrition of children.

Conclusion

Failure to address child malnutrition decreases potential macroeconomic growth because of the severe effects it has on child morbidity and mortality as well as the detrimental effects it has on productivity. Micronutrient deficits and protein energy deficiency both negatively impact children's physical and cognitive development and make them more susceptible to infections and illnesses. It is clear that attention must be paid urgently to the nutritional requirements and general developmental needs of children. Although the government is making attempts to address this issue, it is crucial that more programs specifically designed to reduce childhood malnutrition in India be established shortly along with strengthening the implementation of the existing ones.

References:

  1. American Heritage Dictionary. (2003). (4th Ed.). Houghton Mifflin Company. http://medical/dictionary.the free dictionary.com 
  2. GOI. (1993). National Nutrition Policy, Department of Women and Child Development, New Delhi. http://www.wcd.nic.in/research/nti1947/7.1%20pr%203.2.pdf 
  3. GOI (2009). Nutrition in India. IIPS, Mumbai. http://www.measuredhs.com/pubs/pdf/OD56/OD56.pdf GOI. (2012) Children in India 2012-A statistical appraisal. Ministry of statistics and Programme Implementation, New Delhi. http://mospi.nic.in/mospi_new/upload/Children_in_India_2012.pdf 
  4. GOI (2013) Ministry of Human Resource Development’s official website. http://mdm.nic.in/ 
  5. Hurlock, E.B.(1978). Child Development (6th ed). New York: McGraw Hill.
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