How to tackle malnutrition effectively

 

Government programmes to fortify staples should be supplemented with initiatives on balanced diets

As a haematologist, I regularly examine patients with anaemia. One of the many causes of anaemia or low haemoglobin is iron deficiency. It primarily impacts children and women. It’s common knowledge that good nutrition is critical for overall health, but what’s not as well-known is the two-way relationship between nutritional deficiencies and certain disorders. Consistent intake of food lacking in essential micronutrients can lead to iron deficiency anaemia and Vitamin A, and zinc deficiency, and impair immunity. Conversely, conditions such as celiac disease and infections like h. pylori or worm infestations can disturb the digestive system, leading to nutrient deficiencies. Malnutrition caused by micronutrient deficiency has inter-generational impacts — anaemic mothers are known to give birth to anaemic babies.

Government programmes like Anaemia Mukt Bharat (AMB) are among the biggest targeted measures to tackle the disorder. It involves administering iron and folic acid (IFA) tablets and other prophylactic measures. The Mid-day Meal Scheme for school children is another such intervention. However, challenges of effective implementation persist.

The burden of malnutrition is complex and needs to be addressed through multiple interventions. Diet plays a significant role. In pre-industrial times, a diverse and balanced diet was the norm. The traditional thaali comprises a balanced quantity of cereals, pulses, and vegetables seasoned with spices and herbs. Consuming fruits, seeds, nuts and dairy options has historically been regarded as an effective means of maintaining a balanced diet. Today, dietary patterns have shifted from seasonal and varied foods to processed and sugar-laden alternatives, which are calorically dense but nutritionally deficient. The onus seems to be on people to recognise that reducing consumption of processed foods is a crucial step towards ensuring better health outcomes.

The bigger challenge is that about 46 per cent of South Asia’s population lacks access to an affordable balanced diet, as per FAO data. According to The State of Food Security and Nutrition in the World, 2023, around 74 per cent of India’s population could not afford a healthy diet, and 39 per cent fell short of a nutrient-adequate one. Recent government interventions such as Large-Scale Food Fortification (LSFF) are timely. These could augment the ongoing efforts at individual and community levels. LSFF, when aligned with micronutrient supplementation programmes, diet diversity promotion and measures to induce behavioural change has immense potential to improve the efficacy of existing initiatives. Food fortification may not be the ideal remedy. However, it is a vital first step. Many countries adopted universal food fortification several years ago. India lags behind here.

At the same, fortification in India is not a completely novel strategy. The adoption of iodised salt under the National Iodine Deficiency Disorders Control Programme in 1992 significantly reduced goitre rates. The country’s food fortification programme now includes adding micronutrients to staples such as wheat flour, rice, edible oils, and salt.

Awareness is critical to the acceptance of fortified foods among the targeted beneficiaries. The appearance and texture of such foods — fortified rice kernels, for instance — often create misgiving. Addressing such concerns requires an intensive information, education and communication (IEC) campaign. An important step in this direction is to inform the beneficiaries about the stringent standards of fortification. Research also shows no danger of iron toxicity from such food — the quantity of iron in fortified foods is similar to that of the naturally occurring nutrient. In any case, the body’s homeostasis in people with normal health prevents excess iron absorption.

Multiple awareness strategies can be adopted to foster greater awareness. This includes utilising communication channels such as community radio, videos and door-to-door outreach. Messages in vernacular languages ensure that the information is easily understood and also helps dispel misconceptions and build trust. The way forward involves not just adoption of healthier dietary practices at the individual and community levels but also strategies by the state such as LSFF.

Written Tulika Seth

Source: Indian Express, 29/01/24

Recrafting India’s nutrition initiative

 

Amarjeet Sinha writes: Nutrition as a subject does not lend itself to narrow departmentalism. It calls for a whole-of-government and whole-of-society approach. Technology can at best be a means. Monitoring, too, has to become local.

The Registrar General of India has confirmed that India’s maternal mortality rate was 97 during 2018-2020. During 2001-03, it was 301. The infant mortality rate was 58 in 2005. In 2021 it was 27. While we have reasons to be less unhappy, we still have a long way to go. The pace of decline, however, has gained momentum post-2005.

The National Rural Health Mission (NRHM) was launched in 2005 to provide accessible and affordable healthcare through a public system of primary healthcare. And to provide secondary and tertiary care services in public systems alongside the private capacity to ensure good quality services at effective rates. Unfortunately, allocations for NRHM did not keep pace. But, it seems to have had a positive impact on many indicators. Health facilities started looking better with untied funds, doctors, drugs and diagnostics became a reality, institutional deliveries jumped, vacancies of ANMs (Auxiliary Nurse Midwife) and nurses started getting filled up, and the community’s ASHA worker started putting pressure on public systems to perform by getting patients there.

First, NRHM had a clear thrust on crafting credible public systems in primary health. Community connect, human resource capacity mattered and flexible financial resources were available at all levels. Second, the central, state and local government partnership with civil society, with the full involvement of frontline workers was a thrust. Planning had to begin from below. Community monitoring was civil society led. Third, the approach was pragmatic and provided for diversity of state-specific interventions. The decentralised planning process, where the states came up with their annual plans on the basis of district health action plans, became the norm.

Fourth, institution building was facilitated in work with panchayats and facility-specific Rogi Kalyan Samitis or hospital management committees. Civil society was engaged in community action through the Population Foundation of India. Professionals were brought in to improve processes. Over 60 per cent of funds were to be spent at the district level and untied grants were made available to every level of the health institution.

Unfortunately, nutrition has not seen this kind of initiative. The fifth National Family Health Survey 2019-21 reports 35.5 per cent of children under 5 are stunted, 19.3 per cent are wasted, and 32.1 per cent are underweight. These are unacceptable levels. The Poshan Abhiyan, though innovative, is still not addressing the institutional decentralised public action challenge yet.

Unfortunately, in our initiatives for nutrition, we have remained compartmentalised and fragmented. The ICDS is seen as a nutrition initiative, but the institutional role of local panchayats and communities with untied financial resources is still lagging. Nutrition does not lend itself to narrow departmentalism and such non-institutional wider partnerships are destined to fail.

The multi-dimensionality of under-nutrition makes it imperative that ICDS is revamped to converge with health, education, water, sanitation, and food security at all levels, under the local government umbrella. Given the diverse conditions, it is important to allow for context-specific and need-based prioritisation at every Anganwadi centre by allowing flexibility through decentralised local action, made possible by accountable decentralised financing.

The 12 reorganisation principles for nutrition success, should be the following: (i) Let the gram panchayat, gram sabha, women’s collectives of livelihood mission and other community organisations be responsible for education, health, nutrition, skills and diversified livelihoods; (ii) panchayat-led committees of the concerned wider departments are needed at the block and district zila parishad levels as well; (iii) operationalise village-specific planning process with decentralised financial resources; (iv) allow simultaneous interventions for all wider determinants of nutrition; (v) assess for additional care givers with capacity development to ensure household visits and intensity of monitoring needed for outcomes in nutrition; (vi) encourage diversity of local food including millets, served hot; (vii) ensure availability of basic drugs and equipment for healthcare and growth monitoring in each village; (viii) intensify behavior change communication; (ix) institutionalise monthly health days at every Anganwadi centre with community connect and parental involvement; (x) create a platform for adolescent girls in every village for empowerment and for diversified livelihoods through skills; (xi) decentralised district plans based on village plans should be the basis for interventions to ensure anganwadis face no deficits like no buildings or no untied resources; and (xii) move to a “leaving no one behind”, rights-based approach to ensure universal coverage of the under six, adolescent girls and pregnant women for all needs.

The challenge of undernutrition can be tackled effectively over a short period if the thrust is correct. The recently released NFHS-V brings out the unfinished agenda and the slow rate of decline in undernutrition. Nutrition as a subject does not lend itself to narrow departmentalism. It calls for a whole-of-government and whole-of-society approach. Technology can at best be a means and monitoring too has to become local. Panchayats and community organisations are the best way forward. But the nutrition challenge is also a women’s empowerment challenge. It requires a behaviour change in favour of exclusive breastfeeding, natural foods instead of junk food, and clean water and sanitation.

We should never give up efforts at crafting a credible public healthcare system. Let us begin re-crafting our nutrition initiative, learning from the hits and misses.

Source: The Indian Express, 5/12/22

Worrying trends in nutrition indicators in NFHS-5 data

 

Veena S Rao writes: India’s nutrition programmes must undergo a periodic review addressing gaps such as institutional delivery and adolescent anaemia

The NFHS-5 factsheets for India and all states and Union territories are now out. At first glance, it appears to be a mixed bag — much to cheer about, but concern areas remain.

The good news is that there seems to be a change in our demographic trends, particularly in the sex ratio. For the first time since the NFHS 1992-93 survey, the sex ratio is slightly higher among the adult population. It is also for the first time in 15 years that the sex ratio at birth has reached 929 (it was 919 for 1,000 males in 2015-16).

The total fertility rate has also dropped from 2.2 per cent to a replacement rate of 2 per cent, albeit with not much change in the huge fertility divide between the high and low fertility states. It appears that states which were already experiencing a decline in fertility rates have continued to do so, without much change in the trends in the higher fertility states. This fertility divide can have several socio-economic and political repercussions in any society. One assumes that adequate attention will be given to this challenge at the policymaking and social levels after the detailed report is out. But, clearly, policies and programmes for the girl child and women’s empowerment have produced positive results, and a direct correlation between higher female literacy, the improvement in the sex ratio, and the decrease in the total fertility rate can easily be drawn.

There has been an appreciable improvement in general literacy levels and in the percentage of women and men who have completed 10 years or more of schooling, which has reached 41 per cent and 50.2 per cent respectively. Of course, much remains to be done, especially because these figures imply that around half of our workforce still does not have the qualifications and skills to achieve upward mobility and escape the poverty trap.

The health sector deserves credit for achieving a significant improvement in the percentage of institutional births, antenatal care, and children’s immunisation rates. There has also been a consistent drop in neonatal, infant and child mortality rates — a decrease of around 1 per cent per year for neonatal and infant mortality and a 1.6 per cent decrease per year for under five mortality rate.

Now turning to the areas of concern — nutrition or nutrition-related indicators. To begin with, India has become a country with more anaemic people since NFHS-4 (2015-16), with anaemia rates rising significantly across age groups, ranging from children below six years, adolescent girls and boys, pregnant women, and women between 15 to 49 years. Almost half our human capital lacks iron power.

The insidious, adverse effects of anaemia affect all age groups — lower physical and cognitive growth and alertness among children and adolescents, and lesser capacity to learn and play, directly impacting their future potential as productive citizens. Lower capacity to work and quick fatigue for adolescents and adults, translates into lower work output and lesser earnings. Further, anaemia among adolescent girls (59.1 per cent) advances to maternal anaemia and is a major cause of maternal and infant mortality and general morbidity and ill health in a community.

Though there has been some improvement, an area of concern is the poor consumption of IFA tablets by pregnant women. Perhaps the detailed report will explain why a dedicated programme like Anaemia Mukt Bharat which focused on IFA consumption failed to gain impetus.

Equally worrying is the exceedingly slow pace of improvement in nutritional indicators across all age groups. Between NFHS 4 and NFHS 5, the percentage of children below five years who are moderately underweight has reduced from 35.8 per cent to 32.1 per cent, moderately stunted children have fallen from 38.4 per cent to 35.5 per cent, moderately wasted from 21 per cent to 19.3 per cent and severely wasted have increased slightly from 7.5 per cent to 7.7 per cent. Details regarding severely stunted and underweight children will be published in the detailed report.

The root cause for this is that the percentage of children below two years receiving an adequate diet is a mere 11.3 per cent, increasing marginally from 9.6 per cent in NFHS-4. This foundational nutritional deficit which ought to be considered an indicator of great concern, is generally ignored by policy makers and experts. Unless this is addressed, rapid improvement in nutritional indicators cannot happen.

India’s nutrition programmes must undergo a periodic review, just as our health programmes did right from the Reproductive and Child Health (RCH) programme in 1997 to the present National Health Mission (NHM), addressing gaps such as institutional delivery, ambulance services, adolescent anaemia, and additional health volunteers. The Integrated Child Development Services (ICDS), which is perceived as the guardian of the nation’s nutritional well-being must reassess itself and address critical intervention gaps, both conceptually and programmatically, and produce rapid outcomes. Ad hoc add-ons are just not enough, and smartphones, tweets and webinars cannot substitute hard action on the ground.

Written by Veena S Rao

Source: Indian Express, 7/01/22

Why community matters in tackling malnutrition

 Malnutrition is one of the leading causes of death and diseases in children under-five years of age globally. It adversely affects cognitive development and learning capacities among children, thereby resulting in decreased productivity in the booming years. According to a study by Lancet, 68 per cent of the under-5 deaths in India can be attributed to malnutrition. Besides, India is home to nearly half of the world’s “wasted or acute malnourished” (low weight for height ratio) children in the world.

Wasting is a critical health condition where a child is nine times more likely to die as compared to a healthy child. According to National Family Health Survey (NFHS)-4 conducted in 2015-16, 21 per cent of children in India under-5 suffered from Moderate Acute Malnourishment (MAM) and 7.5 per cent suffered from Severe Acute Malnourishment (SAM).

Despite various targeted outreach and service delivery programmes run by the government such as POSHAN Abhiyaan, Supplementary Nutrition and Anaemia Mukt Bharat, to name a few, 16 out of the 22 states and Union territories have still shown an increase in SAM, as per NFHS-5 conducted in 2019-20.

While the deteriorating facets of malnutrition continue to remain a matter of grave concern, the emergence of COVID-19 has only worsened it. The partial closure of Anganwadi Centres (AWCs) along with disruptions in supply chains due to subsequent lockdowns has resulted in halting of mid-day meals scheme, reduced access to take home ration (a nutritional measure to supplement some portion of a child’s calorie needs) and restricted mobility to health care services.

According to a study published in journal Global Health Science 2020, the challenges induced by COVID-19 are expected to push another four million children into acute malnutrition. This is also evident from India poor ranking, an abysmal 94th out of 107 countries on the Global Hunger Index 2020.

Acute malnutrition is a complex socio-cultural problem that lies at the interplay of inequitable access to nutritious foods and health services, sub-optimal infant, and young child-feeding practices (IYCF) including breastfeeding, low maternal education, low capacities of field functionaries in detection malnutrition, poor access to clean water and sanitation, poor hygiene practices, food insecurity and unpreparedness for emergencies. And COVID-19 has significantly unravelled all these inefficiencies, therefore, bringing to the fore, the need to adopt sustainable solutions aimed at integrated management of acute malnutrition in tandem with mitigating the impact of COVID-19.

The first step to reduce this burgeoning burden acute malnutrition is to ensure early identification and treatment of SAM children to stop them from further slipping into the vicious cycle of malnutrition. Currently, in India, SAM children with complications are usually referred to the Nutrition Rehabilitation Centres (NRCs), mostly established in district hospitals with a low ratio of hospital beds per population.

While access to health infrastructure is a major thorn in the flesh, it is also a proven fact that 70-80 per cent of the children face no medical complication and need not required to be hospitalised. Therefore, in such a scenario, it is feasible to adopt an approach that treats the uncomplicated SAM children more efficiently and “Community Management of Acute Malnutrition (CMAM)” works wonders in this regard.CMAM is recommended by both WHO and UNICEF and has shown positive results across many countries and some of the states and district in India where it has been implemented as a pilot project. One such state that has fared well in CMAM is Maharashtra.

Taking cognisance of growing SAM children, in 2007, the Maharashtra government went on to implement CMAM at four different levels in the Nandurbar district. The first step involved community level screening, identification, and active case finding of SAM children by Anganwadi/ASHA workers.

The second step initiated treatment of SAM children without any complications at community level through Village Child Development Centre (VCDC) by using different centrally and locally produced therapeutic food. These energy-dense formulations are often at the core of nourishing the children since they are fortified with critical macro- and micro-nutrients. It ensures that the target population gains weight within a short span of six to eight weeks.

The third step included treatment of children with complications at the NRCs. And the fourth step involved following-up of children discharged from the CMAM programme to avoid a relapse, along with promotion of good IYCF practices, child stimulation for development, hygiene and other practices and services to prevent the further occurrence of SAM.

As a result, the district witnessed a decline in SAM children — from 15.1 per cent in 2015-16 (NFHS-4) to 13.5 per cent in 2019-20 (NFHS-5). Nandurbar is a difficult terrain and if CMAM approach could achieve such favourable results in such a place, it has the potential to be scaled up anywhere in India.

Given the renewed political interest in nutrition through Poshan 2.0, CMAM must be given a serious thought if India plans to come anywhere close to meeting the stunting and wasting targets by 2025.

Written by M A Phadke

The writer is former Vice Chancellor Maharashtra University of Health Sciences

Source: Indian Express, 18/04/21

Solving the child malnutrition puzzle

 The recently released National Family Health Survey (NFHS) 5 data raise serious concerns about India’s growth story. Behind the glitter of the stock market touching new heights, lies the gloomy reality of India’s ballooning childhood malnutrition. In India, 37.8 per cent of children under 5 years of age are stunted. This is 16 per cent higher than the average for Asia (22 per cent). The situation of wasting is no better, with 20.8 per cent of children under 5 years of age affected, which is higher than average for Asia (9 per cent). The Global Nutrition Report, 2020, highlights that 68 per cent of under-5 mortality in India is due to malnutrition. As per the latest NFHS 5 report, over 35 per cent of children under 5 are stunted and over 20 per cent are wasted in 18 out of the 22 states for which data is released. That amounts to 47 million children, the largest in any part of the world. Out of the two, stunting, also known as growth retardation, has serious long-term health and economic consequences.

As countries move up the income ladder, the rates of stunting and wasting declines, a phenomenon observed globally. However, India is an outlier and breaks this causality. States with relatively high per capita incomes have stunting rates comparable to the poorest African countries. In many Indian states, the situation is worse than that of poor sub-Saharan African countries. For instance, Bihar, Manipur and West Bengal have similar per capita income ($) as sub-Saharan African countries — Liberia, Tanzania and Zimbabwe — but, the average stunting rates in Bihar (43 per cent), Assam (35 per cent) and West Bengal (34 per cent) are 10-12 per cent higher than that of Liberia (33 per cent), Tanzania (32 per cent) and Zimbabwe (3 per cent) respectively. The situation is worse when it comes to middle-income states like Goa, Maharashtra, Gujarat, Andhra Pradesh, Telangana and Karnataka with similar per capita income ($) as Peru, Egypt and Morocco. The average stunting rates in Goa (26 per cent) Maharashtra (35 per cent), Gujarat (39 per cent), Telangana (33 per cent) and Karnataka (35 per cent) are almost 10-15 per cent higher than that of Peru (12 per cent), Egypt (22 per cent) and Morocco (15 per cent). Understanding this paradox among Indian states, which has an unusually high level of stunting relative to their economic development, merits investigation.

Despite this high prevalence, India has rarely undertaken a comprehensive study to understand the pathogenesis of stunting. Therefore, what we have is a lopsided understanding of the problem. As per WHO, stunting can be attributable to medical and socio-economic factors. The medical factors include genetics (parents’ height), access to nutrition and mother’s health (anaemia, BMI). Besides, there are economic factors — income, poverty, access to healthcare, mother’s education and labour force participation — and social factors — caste, race, women status and place of residence etc. Of these, which ones are proximate and which one the distant factors, we simply don’t know.

Based on this conceptualisation, economic factors like average per capita income and prevalence of multi-dimensional poverty are loosely correlated with the prevalence of high stunting in states of AP, Telangana, Gujarat, Maharashtra & Karnataka. Similarly, maternity care characteristics (ante-natal care during pregnancy, post-natal care and consumption of folic acid during pregnancy), although extremely important, but, are weakly associated with high stunting rates in these states. Despite relatively modest economic growth and favourable maternity characteristics, high prevalence of stunting in these states defies logic. After all, these states have been the flagbearers of India’s growth story since 1991.

In popular parlance, poverty is synonymous with stunting. Poor households and poor states are expected to have stunted children. But what could explain significantly higher stunting rates in middle-income states?

First, women’s educational status, especially secondary and above, along with female labour force participation partly resonates with high stunting rates. Maternal literacy is an important determinant of a child’s nutritional status. Literate mothers are expected to be aware of their health, nutrition and breastfeeding practices. This finding, however, reflects the tragic reality of women bearing the undue burden of childcare. Second, the mother’s health, the prevalence of anaemia in women of reproductive age. India is one of the most anaemia-prone countries in the world. Children under age 5 and women of productive age are particularly vulnerable. Several studies have explored the strong association between stunting and the presence of anaemia in women of childbearing age. For instance, women of low BMI had greater odds of developing anaemia and the children of anaemic mothers are at greater risk of being stunted. The implication, a vicious circle of anaemia and stunting — stunted children of anaemic mothers are at greater risk of developing anaemia. The NFHS 5 data corroborate this finding — all women in reproductive age who are anaemic stands at 59 per cent in Andhra Pradesh, 40 per cent in Goa, 63 per cent in Gujarat, 48 per cent in Karnataka, 55 per cent in Maharashtra and 58 per cent in Third, urban slums and lack of sanitation is a potential contributor to stunting. Despite claims, India still lags behind sub-Saharan African countries in terms of safely managed sanitation services. States like Maharashtra, Andhra Pradesh, Telangana, Karnataka have a significant population living in urban slums who do not have access to improved sanitation facilities. The difference in sanitation practices between Indian states and their African counterparts explains the difference in stunting rates.

The other, atypical factor that has an impact on the prevalence of stunting is genetics (mother’s height). As per WHO, the golden rule of measuring stunting in children is the height for age Z score (HAZ). A child is considered stunted if the HAZ score is two standard deviations below the median of WHO child growth standard. The height of children is closely associated with the height of mothers. For instance, the average female height in South Asia, including India, is approx. 150-156 cm, whereas, the average female height in Europe and Africa is 164-168 cm and 160-165 cm respectively. Genetic differences can explain the differences in the stock of stunted children in two regions, but it can’t be the dominant factor in explaining the flow of stunted children. The analysis, then, boils down to the real culprits — anaemia and low BMI among women, social and gender inequalities, which together manifest in the problem of malnutrition among children.

(The writer is an economist with Swaniti Initiative, previously worked with Prime Minister Economic Advisory Council, Government of India & FAO of United Nations. Views are personal).

Source: Indian Express, 20/01/21

Community action, with a focus on women’s well-being, can fight malnutrition

 

Anganwadi workers, ASHAs, ANMs and anganwadi supervisors can work together with panchayat members to ensure that all children and mothers are covered with immunisation, antenatal care, maternity benefits and nutrition services

On an MGNREGA worksite in Kolar, Karnataka, a male worker came up to me and said that men ought to be paid more than women. I asked him why. “Adhu yaavaagalu hange,” he replied: That was how it always was. Not so in MGNREGA, I told him.

With equal wages for women and men, and direct payments to workers’ bank accounts, MGNREGA helps to increase women’s incomes. Another major programme which can improve women’s livelihood, their social empowerment and their lives is the National Rural Livelihood Mission (NRLM). Increased incomes give women more voice in family decisions, and the ability to care better for their families and themselves.

Data from the fifth round of the National Family Health Survey (NFHS-5) shows gains in some important areas. In most of the 22 states and Union territories surveyed, infant mortality rates and under-five mortality rates have fallen; and institutional births and child immunisation rates have increaOn child malnutrition, the NFHS’s findings are worrying. Beyond behaviour change communication and regular monitoring, direct nutrition interventions are key, especially during pregnancy, breastfeeding and in the early years of a child’s life. Pregnant women, lactating mothers and young children need hot cooked meals with adequate protein, milk, and green leafy vegetables. States like Karnataka, Andhra Pradesh and Telangana have replaced take-home rations for mothers with daily hot cooked meals.sed. Access to improved drinking water and sanitation has increased in almost all areas surveyed.

While providing hot cooked meals frontline health workers also have the opportunity to give pregnant women iron, folic acid and calcium tablets. They are also engaged in early childhood stimulation activities and parenting sessions. Instead of frontline workers going to each woman’s house, women coming to the anganwadi makes it easier to provide all women with appropriate services and counselling. Mothers’ lunch groups at the anganwadi can also function as informal social networks. A study by the Public Health Foundation of India (PHFI) of Karnataka’s Mathrupoorna programme for pregnant women and breastfeeding mothers found a reduction in anaemia, improved gestational weight gain, improved birth weight, and reduced depression among women participants.

Beyond the “first thousand days”, the intergenerational cycle of malnutrition and its social determinants call for a life cycle approach. Such an approach should address the complex social ill of child marriage. One of the best ways to prevent child marriage is by supporting girls to stay in high school. Grass roots social empowerment programmes should focus on increasing girls’ enrolment, access and retention in secondary education. The nutritional status of adolescent girls could be improved by extending the mid-day meal programme to secondary educational institutions, as some states have done.

Malnutrition should also be understood in the context of women’s work. Childcare enables women to earn a livelihood. Longer working hours for the anganwadi, such as in Karnataka where it runs from 9.30 am to 4 pm, will help women go out to do paid work, including on MGNREGA worksites. Mobile creches for younger children at these worksites and construction sites will help women to work without anxiety about their children’s safety and well-being.

The anganwadi system needs strengthening. Anganwadi supervisors can be supported with interest-free loans and fuel allowance for two-wheelers, enabling them to provide regular guidance to their cluster. Their skills should be upgraded with certificate courses on nutrition and early childhood stimulation. Online training at scale has been the discovery of the pandemic year. Anganwadi workers and supervisors can be supported for professional development through live online sessions on nutrition, growth monitoring and early childhood education.

Anganwadi infrastructure needs attention: Sturdy buildings, kitchens, stores, toilets, play areas and fenced compounds, functional water connections and arrangements for handwashing are urgent imperatives. To cater to multiple meal requirements, anganwadi kitchens need double-burner stoves, gas cylinders, pressure cookers and sufficient steel cooking vessels. Kitchen gardens should be planted with drought-resistant and highly nutritive plants like moringa.

The most effective platform for community action on the ground is the gram panchayat. We often talk of the “last mile” for communication services. The panchayat should be the first mile for social welfare services. There are around 2,50,000 gram panchayats in India, and nearly 14 lakh anganwadis, the majority in rural areas. The anganwadi committee, chaired by a stakeholder mother and including other parents, grandparents and the panchayat ward member, should be a subcommittee of the gram panchayat. It should meet every month on a fixed day, and its discussions should be presented to the gram panchayat for action.

Exclusion and convergence are two major challenges in social welfare programmes. Local governments are the best placed to address the problem of exclusion. They can ensure coverage of the poorest women and children, especially nomadic and semi-nomadic communities, and seasonal migrants such as brick workers and sugarcane harvesters. Panchayats are also the best forum to prevent child marriage and ensure that all girls stay in school.

Convergent action on the ground is one of the strengths of gram panchayats. Anganwadi workers, ASHAs, ANMs and anganwadi supervisors can work together with panchayat members to ensure that all children and mothers are covered with immunisation, antenatal care, maternity benefits and nutrition services. Gram panchayats can use their funds, converged with MGNREGA, to strengthen anganwadis. They can engage women’s collectives under NRLM for anganwadi and school needs, and provide panchayat services such as end-to-end solid waste management, water pump operations, surveys, bill collections and management of fair price shops. Such steps will increase women’s individual and group incomes in sustainable ways. They will also lead to greater social and economic empowerment of women, their participation in local governance, and, eventually, better nutrition for all.

Written by Uma Mahadevan Dasgupta

Source: Indian Express, 5/01/21

Malnutrition, the silent pandemic

 

COVID-19 has pushed back our efforts on ending malnutrition, which plagues India's children. Urgent efforts need to be made to address the shortfalls

India is home to about 30 per cent of the world’s stunted children and nearly 50 per cent of severely wasted children under the age of five. Malnutrition remains the predominant risk factor for child deaths, accounting for 68 per cent of total under-five deaths and 17 per cent of the total disability-adjusted life years. Nutrition is not a peripheral concern. It is central to our existence. Increased food and nutrition insecurity severely weakens our immune systems and contributes to poor growth, intellectual impairment, and lowers human capital and development prospects.

COVID-19 has posed serious threats to children and their health and nutritional rights. According to recent estimates, even in the best possible scenario and accounting for changes in the provision of essential health and nutrition services due to COVID-19, India could have around additional 60,000 child deaths (around 3,00,000 in the worst-case scenario) in the next six months. Based on evidence from the field, there is a need to explore possible solutions and putting forward key policy and programme proposals for the integrated management of acute malnutrition and mitigating the impact of COVID-19.

Inadequate dietary intake and disease are directly responsible for undernutrition, but multiple indirect determinants exacerbate these causes. These include food insecurity, inadequate childcare practices, low maternal education, poor access to health services, lack of access to clean water and sanitation, and poor hygiene practices.

The lockdown disrupted access to essential services, including mid-day meals, which are not only a nutritional measure to supplement some portion of a child’s calorie needs but is also a tool to access education. Through a concurrent rapid needs assessment in its programme areas, carried out in June 2020 across 14 states and 2 union territories, and covering 7235 respondents, Save the Children found that around 40 per cent of eligible children have not received mid-day meal during the lockdown.

There is a steady and silent revolution taking place in the field of nutrition, with an ever-increasing political will on the issue. This should be sustained throughout the year and in the coming years. Since the pandemic has pushed back our efforts on ending malnutrition by a few years, here are some immediate steps that need to be taken to address the issues.

First, core indicators across the lifecycle should be prioritised and reviewed at all levels (national, state, district, and block). Second, for easy and sustained access to nutritious food, we need to bring the spotlight back on locally-available, low-cost nutritious food. We also need to maximise maternal, infant and young child nutrition actions.

Third, we need to strengthen take-home ration and mid-day meal service delivery strategies to ensure the continuation of services and coverage of the most vulnerable communities, especially in urban areas. Fourth, child-sensitive social protection schemes, like PMMVY, need to be implemented in a way so that they reach the last child.

Fifth, strict measures are needed to ensure that the PDS is accessible to all, especially the vulnerable population. Sixth, efforts to ascertain allocation and distribution of additional food supply to the most vulnerable population and to ensure food security under the Pradhan Mantri Garib Kalyan Anna Yojna (PMGKAY) for next five months, need to be undertaken urgently. Finally, the use of newer technologies in service delivery, data management, evidence generation and real-time monitoring will help this process.

Given the range of drivers of nutrition — spanning multiple sectors of agriculture, social protection, health, WASH, and education — tackling undernutrition demands a multi-sectorial response. Political, cultural, social, and economic factors also play a role. Nutrition interventions are not sufficient to tackle the problem of undernutrition: Even at 90 per cent coverage, the core set of proven nutrition-specific interventions would only decrease stunting by 20 per cent. Reducing under-nutrition requires effective implementation of both nutrition-specific and complementary nutrition-sensitive interventions, addressing the underlying and basic causes of undernutrition.

Antaryami Dash

The writer is head of nutrition at Save the Children.

Source: Indian Express, 25/09/20

To fight malnutrition in India, engage all stakeholders | Analysis

One of the major advantages of a multisectorial approach is resource optimisation. Also, it aims to ensure a strong focus on management through institutional and programmatic convergence, by integrating it in the planning, implementation and supervision processes

Zero hunger and good nutrition have the power to transform and empower the present and future generations. India’s greatest national treasure is our people but one-fourth of our children are born with low birth weight, 35.7% of children under five are underweight, 38.4% are stunted and 21% are wasted. Severe acute malnutrition (SAM), estimated, as severe wasting is 7.5%. Although India has shown progress in improving child nutrition, malnutrition remains high.

Poor nutrition in the first 1,000 days of children’s lives can have irreversible consequences. For millions of children, it means they are stunted, which in turn makes them more susceptible to sickness. The consequences of child hunger and undernutrition can be extreme, both for families and cumulatively for the communities and nations.

Community management of acute malnutrition (CMAM) is a proven approach to manage SAM and MAM moderate acute malnutrition (MAM) in children under five. It involves timely detection of SAM children in the community and the provision of treatment for those without medical complications with nutrient-dense foods at home. The Integrated Child Development Services programme provides supplementary nutrition in the form of take-home ration to cater to the malnourished children. Currently, there is a lack of policies and common national guidelines to address both, the treatment and the prevention of SAM children. The guidelines of Poshan Abhiyaan states that the community-based traditional events must be organised once in a month at Anganwadi centres to promote and support social behaviour change to improve maternal and child nutrition through the information, education and communication approach along with interpersonal commination. In the absence of clear guidelines, however, community management faces challenges such as poor follow-up of cases, the lack of convergence among ministries and line departments, poor networking among government functionaries due to a lack of clarity, as highlighted in the position paper on India’s CMAM review.

United Nations Children’s Fund’s (Unicef, 1990) conceptual framework on the determinants of child malnutrition illustrates the multidimensional nature of the problem and requires a multisectoral approach to address it. Multisectoral approach is one of the key steps to tackle malnutrition and micronutrient deficiencies to help control infections, morbidity, disability and mortality.

Poshan Abhiyan recognises that chronic malnutrition is a major nutrition problem in the country. This approach considers the factors that limit the capacity of government institutions to implement it. The Poshan Abhiyaan already ensures convergence with various line departments aimed at initiating convergent action plans at every level of care, to achieve synergy and the desired results. Taking a sector-wide approach by engaging multiple stakeholders can leverage knowledge, expertise, reach, and resources, benefiting from their combined and varied strengths to produce better health outcomes.

One of the major advantages of a multisectorial approach is resource optimisation. Also, it aims to ensure a strong focus on management through institutional and programmatic convergence, by integrating it in the planning, implementation and supervision processes. This approach will lead to better policies, institutions and programmes to improve nutrition outcomes.

However, there is still a massive challenge in making a functional multisector action plan. This hurdle can be overcome with national guidelines, and its implementation through leadership at every level — a strong catalyst to initiate and strengthen the convergence and collaboration.

Rajasthan and Gujarat have been successful in implementing a community-based model for treating children. It’s time to make efforts in the rest of the country as well.

There are no medical complications for the majority of children with SAM and they can be managed at their homes with standard protocols. There is an urgent need to streamline CMAM guidelines as a routine part of the government system. Together, this may prove to be the most robust investment we can make to fulfil the promise of the 2030 agenda.

Sujeet Ranjan is executive director, The Coalition for Food and Nutrition Security

Source: Hindustan Times, 23/09/2019

Two out of three child deaths due to malnutrition: report

Analysis of health data finds that Assam, Bihar, Rajasthan and U.P. are the most affected States

Two-thirds of the 1.04 million deaths in children under five years in India are still attributable to malnutrition, according to the first comprehensive estimate of disease burden due to child and maternal malnutrition and the trends of its indicators in every State from 1990.

The report states that the disability-adjusted life year (DALY) rate attributable to malnutrition in children varies 7-fold among the States and is highest in Rajasthan, Uttar Pradesh, Bihar and Assam, followed by Madhya Pradesh, Chhattisgarh, Odisha, Nagaland and Tripura.

The report was published on Wednesday in The Lancet Child & Adolescent Health by the India State-Level Disease Burden Initiative. The report says the overall under-five death rate and the death rate due to malnutrition has decreased substantially from 1990 to 2017, but malnutrition is still the leading risk factor for death in children under five years, and is also the leading risk factor for disease burden for all ages considered together in most States.

The malnutrition trends over about three decades reported in this paper utilised all available data sources from India, which enable more robust estimates than the estimates based on single sources that may have more biases.

The India State-Level Disease Burden Initiative is a joint initiative of the Indian Council of Medical Research (ICMR), Public Health Foundation of India, and Institute for Health Metrics and Evaluation in collaboration with the Ministry of Health and Family Welfare along with experts and stakeholders associated with over 100 Indian institutions, involving many leading health scientists and policy makers from India.

Vinod K. Paul, member, NITI Aayog, said that the government is now intensifying its efforts to address the issue of malnutrition across the country. “State governments are being encouraged to intensify efforts to reduce malnutrition and undertake robust monitoring to track the progress,” he said.

Balram Bhargava, Director General, ICMR said: “The National Institute of Nutrition, an ICMR institute, and other partners are setting in place mechanisms to ensure that there is more data available on malnutrition in the various States which will help monitor progress. The findings reported in the paper published today highlight that there are wide variations in the malnutrition status between the States. It is important therefore to plan the reduction in malnutrition in a manner that is suitable for the trends and context of each State.”

Low birth weight

Senior author of the paper Lalit Dandona, also director of the India State-Level Disease Burden Initiative, explained that the study reports that malnutrition has reduced in India, but continues to be the predominant risk factor for child deaths, underscoring it importance in addressing child mortality. “It reveals that while it is important to address the gaps in all malnutrition indicators, low birth weight needs particular policy attention in India as it is the biggest contributor to child death among all malnutrition indications and its rate of decline is among the lowest. Another important revelation is that overweight among a subset of children is becoming a significant public health problem as it is increasing rapidly across all States,” he said.

Soumya Swaminathan, chief scientist at the World Health Organisation and first author on this paper, noted that the study findings have highlighted where efforts need to be intensified.

“For substantial improvements across the malnutrition indicators, States will need to implement an integrated nutrition policy to effectively address the broader determinants of under-nutrition across the life cycle. Focus will be needed on major determinants like provision of clean drinking water, reducing rates of open defecation, improving women’s educational status, and food and nutrition security for the most vulnerable families,” she explained.

Source: The Hindu, 19/09/2019

Bindu Shajan Perappadan

Malnutrition still a factor in 68% of child deaths: Study

‘U5 Deaths Due To It Fell By 2/3rd From 1990 To 2017

Malnutrition continues to be the leading risk factor for death in children under five years of age across India causing 68% of mortality in the category, even as the death rate due to malnutrition has dropped by two-third during 1990-2017, according to estimates released by Indian Council of Medical Research on Wednesday. Data shows malnutrition is also the leading risk factor for health loss in persons of all ages, accounting for 17% of the total DALYs (disability adjusted life years). The DALY rate attributable to malnutrition in children varies sevenfold between states and is highest in Rajasthan, UP, Bihar and Assam, followed by MP, Chhattisgarh, Odisha, Nagaland and Tripura. Among malnutrition indicators, low birth weight is the biggest contributor to child deaths in India, followed by child growth failure which includes stunting, underweight and wasting. The prevalence of low birth weight was 21% in India in 2017, ranging from 9% in Mizoram to 24% in UP. The findings also highlight rapidly increasing prevalence of child overweight. This annual rate of increase in child overweight between 1990 and 2017 was pegged at 5% in India, which varied from 7.2% in MP to 2.5% in Mizoram. In 2017, the prevalence of such children was 12%. The estimates, part of the Global Burden of Disease Study 1990–2017, were also published in the Lancet Child & Adolescent Health on Wednesday. The study was conducted by the India State-Level Disease Burden Initiative — a joint initiative of the ICMR, Public Health Foundation of India, and Institute for Health Metrics and Evaluation in collaboration with health ministry.

Source: Times of India, 19/09/2019

Why India’s health system fails to spot malnourished children

The fundamental problem is structural. The anganwadi worker reports into the Integrated Child Development Services (ICDS) system of the women and child development (WCD) ministry, the ANM into the health ministry, and the ASHA to health (with a dotted line to WCD). With two ministries controlling three women workers, there is inadequate data sharing and weak accountability.

In a tiny village somewhere in northern India, three-year-old Leela is malnourished, but no one knows. Her parents, poor labourers barely making ends meet, don’t notice. The government health system hasn’t spotted the child. Across hundreds of villages, mothers and children who need attention are routinely being missed out. That is a key reason why almost 36% of children under the age of five are underweight and over 50% of pregnant women are anaemic, according to national health statistics.

In every village, government health and nutrition services are delivered through three women health workers. The Accredited Social Health Activist (ASHA) mobilises the community through home visits, and the anganwadi worker is responsible for nutrition needs of women and children, and early childhood education. The ASHA and the anganwadi worker independently share their information with the Auxiliary Nurse Midwife (ANM), who delivers services such as immunisation, and antenatal care, basic diagnosis, treatment and referral. These three women who have complementary health related responsibilities comprise an enlightened system on paper. Where they team up, they are a powerful force.

The fundamental problem is structural. The anganwadi worker reports to the Integrated Child Development Services (ICDS) system of the women and child development (WCD) ministry; the ANM into the health ministry; and the ASHA to health (with a dotted line to WCD). With two ministries controlling three women workers, there is inadequate data sharing and weak accountability.

There are problems with data collection, recording and sharing, with practices varying across states. In Rajasthan, the anganwadi worker and the ASHA do separate baseline surveys of the village population — one looks at every household, and the other only at dwellings with eligible couples in the age group of 15-49. They even use different house numbers in their records. Each of the AAA keeps voluminous registers, and their records are often unreliable. There can be different ways of collecting data. In most states, the anganwadi worker assesses malnutrition by weighing the child. In Rajasthan, the ASHA does it measuring mid upper arm circumference (MUAC). Common baseline, data collection and recording are essential if the AAA workers are to zero in on cases like Leela.

Accountability for case identification fundamentally requires role clarity. ASHA’s and anganwadi worker’s responsibilities overlap. The latter maintains information on anaemia, blood pressure and other indicators, which she could easily obtain from her health department counterparts. This would allow her to discharge her primary functions of nutrition and early childhood education provision more effectively. With overlapping functions, it is difficult to hold workers accountable. The accountability issue extends upward through the system, since the AAA workers have different supervisory systems, reporting into different ministries.

The first solution is better coordination, and best practices are to be found in a few states like Tamil Nadu and Kerala. Certain states, and the central government, are taking good steps. In every village in Rajasthan, through the Rajsangam programme, ASHAs, ANMs and AWWs are being trained to use a common ‘AAA platform’. They together map their villages, work off a common database, and routinely share data. Poshan Abhiyan, a visionary central government programme requires that several ministries (beyond health and woman and child) take up joint activities for better nutrition.

Convergence activities are good, but ultimately, there must be a more incisive structural solution — bring ICDS within the purview of the health ministry and create a single chain of command for health and nutrition workers and supervisors. Nutrition is ultimately a health issue. Mother and child should receive a continuum of care from conception till the child turns six. This system would also spur innovation. For instance, the Common Application Software (CAS) has been introduced by the ICDS department. It is a wonderful product, and its obvious evolution is into a ‘CAS2’— an integrated product that would link all three workers in real time. We have created such an integrated app and field tested it and seen that it makes a huge difference to workers morale as well as efficiency. The question is whether, with two ministries involved, CAS2 will happen any time soon.

Today there is talk about convergence in activities, but little debate about structural change. Merger of ICDS with health could be painstaking, but the best solution. All stakeholders — media, influentials, communities must raise the issue. The well being of thousands of Leelas is at stake.

Ashok Alexander is founder-director of the Antara Foundation

Source: Hindustan Times, 24/01/2019

1/3 of world’s stunted kids are from India, says report

Also Home To Huge Number Of Wasted & Overweight Kids

India is among the countries accounting for the highest burden of stunted, wasted and overweight children, the new Global Nutrition Report, 2018 reflecting the growing concern around child nutrition in the country. With 46.6 million stunted children, India accounted for nearly one-third of the world’s 150.8 million children who are stunted, the report shows. India is followed by Nigeria (13.9 million) and Pakistan (10.7 million). The three countries together are home to almost half of all stunted children in the world. This is despite the improvement made by India in reducing stunting since 2005-06. According to the latest National Family Health Survey-4 data, India recorded a 10 percentage point decline in stunting from 48% during 2005-06 to 38.4% in 2015-16. Stunting, or low height for age, is caused by long-term insufficient nutrient-intake and frequent infections. Underlining the variation in stunting within the country, the report said India is so diverse from state to state, it is important to understand how and why stunting prevalence differs. “The mapping showed that stunting varies greatly from district to district (12.4% to 65.1%), with 239 of 604 districts having stunting levels above 40%,” it said. India also accounts for the largest number of wasted children with low weight for height. India recorded 25.5 million children who are wasted. This is more significant because percentage of wasted children has increased in India. According to NFHS-4, percentage of wasted children under five years increased from 19.8% in 2005-06 t0 21% in 2015-16. Wasting, usually caused by food shortage or disease, is a strong predictor of mortality among children under five years of age. India figures among the set of countries that have more than a million overweight children. “The figures call for immediate action. Malnutrition is responsible for more illhealth than any other cause,” Corinna Hawkes, co-chair of the report and director of the Centre for Food Policy said.

Source: Times of India, 30/11/2018 

Empowered women farmers can help fight malnutrition

Rural women’s close interdependence with agriculture points to solutions which co-opt cultivation practices in addressing malnutrition

Nutrition has been a focal point of the human development efforts in India for the right reasons. However, for women, it attains special importance because of the intergenerational carry over of the impacts through children. The nutritional status of women can make or mar entire generations, thereby carving a deep furrow on the nation’s human resources pool over time. Since we celebrated the national nutrition month in September, it may be worth looking at the link between rural women, agriculture and nutrition.

Agriculture in India is significantly dependent on women. Women make up about 33% of cultivators and about 47% of agricultural labourers in rural India. Overall, the percentage of rural women who depend on agriculture for their livelihood is as high as 84%. But systemic barriers to finance, inputs, extension services and land rights have limited their potential and recognition as the mainstay of our agrarian ecosystem. Juxtapose this with the findings of the National Family Health Survey 2015-16 which state that 26.7% of rural women are underweight and 54.2% anaemic. Clearly a majority of our women agricultural producers and workers are themselves victims of malnutrition.

However, these women can be co-opted in to the solution itself. One such evidence comes from the Pathways programme implemented by CARE India. Given financial support and choice in crop selection, women farmers preferred crops that would contribute to household dietary diversity while promoting food and nutrition security. Male farmers, on the other hand, were found to be more inclined to use the farmland for cash crops. They also preferred mono-cropping instead of cultivating a diverse set of crops.

Making agriculture sensitive to nutritional needs isn’t a new concept. It had interested MS Swaminathan, the father of the Green Revolution. What is needed, however, is a realistic approach to achieving that goal. That is where the focus should be on enabling women. Making women participants in the financial aspects of the farm and family is both a cause and result of achieving success in this regard. Financial support specifically ensuring availability of institutional credit to women farmers is the key. The complementary necessity is skill and knowledge transfer in sustainable agriculture techniques, crop varieties and farm management. These efforts need to be strengthened by engaging with existing village level collectives of women for social mobilisation, accessing formal financial services and collective market action. Naturally, these steps have broader connections to providing women with greater autonomy, participation and influence in household decision-making and the ability to exercise their choices which lead to better food security and nutrition outcomes.

This isn’t to say that empowered agricultural women is a panacea to the malnutrition problem. To plug the lack of nutrition in pregnant women and infants the government should keep running schemes like the Integrated Child Development Scheme. The shared theme that needs to be applied there too is strengthening the choice of the women about what should go into their and their children’s food intake. This again is possible through providing them financial support to exercise their choice and necessary knowledge about nutritive resources.

Overall, rural women’s close interdependence with agriculture points to solutions which co-opt cultivation practices in addressing malnutrition. Already multiple models of nutrition-layered agriculture are being experimented with under the leadership of women land holders and their collectives. One hopes that these will provide an evidence-driven pathway to policy reforms that promote availability and affordability of a more nutritious food system; and build capacity and leadership to institutionalise nutrition sensitive agriculture in India.

Shashank Bibhu is a technical specialist with the economic development unit of CARE India.

Source: Hindustan Times, 5/10/12