Transcript Document

CHILD NUTRITION
CHALLENGES AND OPPORTUNITIES
Prema Ramachandran
Director, Nutrition Foundation of India
Major nutrition-related public health
problems
Chronic energy deficiency and
undernutrition
Micro-nutrient deficiencies
•Anaemia due to iron and folate
deficiency
•Vitamin A deficiency
•Iodine Deficiency Disorders
•Chronic energy excess and obesity
Low birth weight – why is it remaining unchanged
Why are we unable to ensure
Exclusive breast feeding for the first six months
Timely appropriate & adequate complementary
feed
What is responsible for low dietary intake and
high under-nutrition rates in preschool child
What can we do to reduce anaemia in children
Massive dose Vit A -Where do we go now ?
Can we achieve universal access to iodised salt
by 2010
What should we do to tackle over- nutrition
What are the priority areas for R&D
Low birth weight
Why is it remaining unchanged
What is its impact on IMR
What happens to growth and development are our children short , thin but fat ?
What are the long term implications of low
birth-weight and low growth trajectory
Trends in Low Birth Weight
Mean Gest
Preterm
Mean Wt
?
74g
0.8W
20-15%
52g
0.7W
21-16%
78g
0.3W
14-10%
126g
0
?
1988
60
50
40
30
20
10
0
1962
1969
1969-73
1986
1989-93
Rourkela
(OR)
1994
North
North
Arcot (TN) Arcot (TN)
Current
Vellore
Previous
1995
Mumbai
Multicentric Data
• National Neonatology Forum (1995/ 2002)
Institutional Data on 37082 / 66512 Births
LBW - 33% / 31.6%
VLBW - 3.3% / 3.3%
Preterm - 12.3% / 14.7%
• ? Overestimates: Underprivileged and
High Risk Population
120
Source: RGI 2002
2000
68
66
64
2002
70
2001
72
71
1999
72
1998
74
1997
80
1996
94
1988
1985
1982
1979
105 97
1993
129
1991
140
120
100
80
60
40
20
0
1976
Rate/1000
Time trends in IMR
Over the last three decades there is no significant
change in mean birth weight or incidence of LBW
However there has been a steep decline in IMR
If IUGR is major cause of LBW improvement in BW is
not essential prerequisite for reduction in IMR
Birth weight and health
In India about one third of all infants
weigh less than 2.5 kg at birth.
Low birth weight is associated with
Low growth trajectory
?Increased risk of obesity, diabetes and
coronary heart disease in later life
Child nutrition begins with
maternal nutrition
Birth weights in relation to maternal
BMI
3100
3000
2900
2800
2700
2600
2500
2400
2300
2200
60
50
40
30
20
10
0
< 16
16-17
17-18.5
18.5-20
20-25
> 25
BMI (Kg/m2)
Mean Birth Weight (g)
Source: Tenth Five Year Plan 2002
Prevalence of LBW (%)
Improving maternal nutrition
During the Tenth Plan efforts will be made to
weigh all women as early in pregnancy as
possible and to monitor their weight gain
This is not being done at the national level
Under the ICDS programme, food supplements
are being provided to pregnant and lactating
women who come to anganwadis.
Coverage is between 15 and 20%
Women who receive supplements are not
being chosen on the basis of their nutritional
status
Tenth Plan strategy
Operationalising universal antenatal care for all
pregnant women
ANC coverage is low ; content suboptimal
Majority do not get weighed ; very few get Hb
estimation done (NFHS -DLHS data).
Operationalisation of nutrition interventions for
the management of under-nutrition through:
targeted food supplementation and health care
for those with under-nutrition
Appropriate management of anaemia non
existent
Tenth Plan -Improving maternal nutrition
Women who weigh < 40 kg should be identified and
given food supplements consistently throughout
pregnancy;
given adequate antenatal care;
monitored for weight gain during pregnancy and, if
weight gain is sub-optimal, identify the causes and
attempt remedial measures; and
given
appropriate
antenatal,
intrapartum
and
postpartum care.
Under NPAG in 51 poor districts
 all pregnant women were weighed
 those weighing <40 kg given 6 kg of food grains/month
Reported coverage high –cost low
Programme is getting evaluated
Low birth weight –10 Plan strategy
anganwadi workers to report all births in village,
weigh all neonates delivered at home soon after
birth and
refer those weighing less than 2.2 kg to a
hospital with a pediatrician.
Current status
Feasibility demonstrated in small studies
Anganwadis should have a 10kg tubular Salter
scale for reasonably accurate weighing of
neonate
Need to have information about nearest hospital
with a pediatrician
Unfinished agenda - action will help in NNMR
Time trends in subscapular fat fold thickness (mm)
Subscapular (mm)
5.5
5
4.5
4
3.5
3
2.5
2001-2500
2501-3000
3001-3500
3501-4000
Birth w eight (g)
boys sachdev
boys puri
girls sachdev
girls puri
Over two decades there has been an increase in
fat fold thickness of neonates in boys and girls in
all birth weight categories
Tim e trends in Triceps fat fold thickness in neonates
triceps (mm)
4.5
3.5
2.5
1.5
36
37
boys sachdev
girls sachdev
38
39
Gestation (w ks)
40
41
boys puri
girls puri
Over two decades there has been an increase in
fat fold thickness of neonates in boys and girls in
all gestational age categories
Birth weight, plasma glucose and
insulin concentrations in 4-year old
urban children
Birth weight
(kg)
Number of
children
Plasma glucose Plasma insulin
(mmol/l) at 30 (pmol/l) at 30
min
min
=< 2.4
36
8.1
321
-2.6
36
8.3
337
-2.8
44
7.8
309
-3.0
42
7.9
298
=>3.0
43
7.5
289
All
201
7.9
310
36
0.01
0.04
P for trend
Source: Yagnik et al, 1998
Time Trends in nutritional
status of Delhi cohort
Male
Female
Age
No.
Weight(Kg)
No.
Weight (Kg)
At birth
803
2.89±0.44
561
2.79±0.38
2 yrs
834
10.3±1.3
609
9.8±1.2
12 yrs
867
30.9±5.9
625
32.2±6.7
30 yrs
886
71.8±14.0
640
59.2±13.4
Source: Bhargava et al, 2004
Current Status of Delhi cohort
Characteristics
Male
No.
Female
Value
No.
Value
Weight (Kg.)
886
71.8±14.
0
640
59.2±13.4
Height (m)
886
1.70±0.0
6
638
1.55±0.06
BMI
886
24.9±4.3
638
24.6±5.1
Waist:Hip ratio
886
0.92±0.0
6
639
0.82±0.07
BMI>_25
886
47.4
638
45.5
BMI>_23
886
66.0
638
61.8
Central Obesity (%) 886
65.5
639
31
Impaired GTT
16
539
14
849
Source: Bhargava et al, 2004
Breast feeding – protection from under
and over nutrition
How far have we succeeded in protection
and promotion of breast feeding
Emerging challenges
Improving Infant Feeding
Parameter
Excl BF<4mo
%
Excl BF
Median
Solid food 6 mo
Solid food
12mo
NFHS1 (92-93) NFHS2 (98-99)
51
55
1.4 mo
1.9 mo
17
24
68
71
Infant feeding practices -NFHS -2
Source: NFHS 1998-99
100
90
80
70
percent
60
50
40
30
20
INDIA
W.Bengal
Uttar Pr.
Tamil Nadu
Sikkim
Rajasthan
Punjab
Orissa
Nagaland
Meghalaya
Manipur
Maharashtra
Madhya Pr.
Infants(0-3 months) exclusively brest fed
Kerala
Karnataka
J&K
Him. Pr.
Haryana
Gujarat
Goa
Delhi
Bihar
Assam
Ar. Pr.
Andhra Pr.
0
Mizoram
10
Timely complementary feeding of infants 6-9 mths
Breast feeding is universal in India but exclusive breast
feeding upto six months and introduction of
complementary feeds at six months is not common
Prevalence of undernutrition (Weight
for age % below -2 SD)
60
50
Source: NFHS 1998-99
40
30
20
10
0
<6
6-11
12-23
Age-groups
24-35
%-2SD
%-3SD
As a result there is steep increase in under nutrition
between 6-23 months of age
Tenth Plan- major focus
on Prevention of
undernutrition in infancy through
promotion of exclusive breast feeding in the
first six months;
nutrition education for the introduction of
appropriate low-cost, energy dense (home
available) complementary food at 6 months ;
focus on nutrition education by AWW/ ANM
during each contact. Yet to be operationalised
under ICDS /NRHM
Needed clear crisp messages; AWW to district
doctor should all say the same things repeatedly
to bring about behavioral change
Use of mass media as in NRHM - will it help in
bring uniformity in messages of health and ICDS
workers ?
The goals for the Tenth Plan are to
enhance early initiation of breast-feeding
(colostrum feeding) from the current level of 15.8
per cent (as per NFHS 2) to 50 per cent;
enhance the exclusive breast-feeding rate for
children up to the age of six months from the
current rate of 55.2 per cent (as per NFHS 2) to
80 per cent;
enhance the complementary feeding rate at six
months from the current level of 33.5 percent (as
per NFHS 2) to 75 per cent.
Available data from DLHS and BPNI surveys
indicate that these goals will not be achieved
Operationalisation of this component should
get major attention during 11th Plan
Under nutrition in Preschool children
Role of poverty and poor caring practices
Screening , early detection and effective
management can change the scenario
Time Trends in Energy intake and
undernutrition in children (1-3 years)
Source: NNMB reports
40
900
35
800
30
700
25
600
20
%
Kcal
1000
1979-80 1989-90 1994-95 1996-97 2001-02
Energy intake
Severe Underw eight(<3 S.D)
Even though there is no increase in energy intake over
time there has been a decline in severe undernutrition
perhaps because of better access to health care
35
Nutritional Status of children by
Income Source: NFHS 1998-99
30
25
20
15
10
5
Low
Medium
Gujarat
Uttar
Pradesh
Orissa
Punjab
Tamil
Nadu
Kerala
0
High
Undernutrition rates among poor in Kerala are
similar to undernutrition rates among the rich
in UP. Appropriate IYCF and caring can lead to
steep fall in undernutrition rates in preschoolers
Mean Energy Consumption- NNMB 2000
Age groups
Males
Females
Kcals RDA
Kcals
Pre-school
889
%
RDA
1357 65.5
RDA
897
%
RDA
1351 66.4
School Age
1464 1929 75.9
1409
1876 75.1
Adolescents
2065 2441 84.6
1670
1823 91.6
Adults
2226 2425 91.8
1923
1874 102.6
The gap between RDA and the actual energy
intake is greatest in preschool children and
lowest in adults
Poor caring practices rather than poverty appear
to be the major factor for low energy intake in
children
Dietary
Intake
+++
++ - - -
Adult
Male
Adequate
Adequate
Inadequate
Adult
Female
Adequate
Adequate
Inadequate
Preschool
Children
Adequate
Inadequate
Inadequate
Over years there has been a increase in the number of
households where adults are getting adequate food but
children are not; this confirms that poor child feeding
and caring practices rather than poverty is becoming the
common cause of of undernutrition in preschool child
Over years there has been a decline in severe under
nutrition ( weight for age and height for age) but not in
wasting ( weight for height).
Health implications of wasting are not well documented
Does low wasting rate explain the South Asian paradox ?
Energy Intake (INP) & Undernutrition
among children (NFHS II)
2760
2700
2614
2431
2426
Kilocalories
24.3
2000
2340
20.7
16.5
1000
2375
16.3
2211
2140
2115
20.8
17.6
16.2
2115
2055
21.9
10.3
8.8
30
25.5
1871
10.6
20
10
4.7
Kilo Calories
% Children (0-3 years) severely under weight as per NFHS-II
Higher dietary intake will not lead to better child
nutrition unless infections are controlled
Tamil Nadu*
Bihar#
Uttar
Pradesh*
Rajasthan#
Kerala*
Maharashtra*
Andhra
Pradesh*
Gujarat*
West Bengal*
Karnataka*
Madhya
Pradesh*
Orissa*
0
Punjab#
0
% children
3000
Source: NFHS 1998-99
Under-5 mortality rate
Maharashtra
Madhya
Pradesh
Orissa
Uttar
Pradesh
Bihar
Karnataka
Rajasthan
Assam
Tripura
West Bengal
<4 yrs severely under weight
Gujarat
Delhi
Himachal
Pradesh
Tamil Nadu
Jammu
Kashmir
Punjab
Arunachal
Pradesh
Andhra
Pradesh
Meghalaya
Haryana
Goa
Nagaland
Manipur
Kerala
Mizoram
% of severe underweight(<4yrs) and
under-5 mortality rate
35
145
30
125
25
105
20
85
15
65
10
45
5
25
35
Nutritional Status of children by
Income
30
25
20
15
10
5
Low
Source: NFHS 1998-99
Medium
Gujarat
Uttar
Pradesh
Orissa
Punjab
Tamil
Nadu
Kerala
0
High
Tenth Plan Goals
Reduce prevalence of
severe undernutrition in children in 0-6 age
group by 50%
Mild and moderate under-nutrition from
current level of 47% to 40%
Tenth Plan recommended strategies for reduction
of undernutrition have not been operationalised
Available data from DLHS show that there is no
major reduction in undernutrition since 1998-99.
BUT
Projects in Orissa, WB ,MP has demonstrated
that if the suggested strategies are followed
these goals are achievable with in the existing
constraints
Capacity building in ICDS: Tenth Plan
enhancing the quality and impact of ICDS
substantially through training, supervision of the
ICDS personnel
and improved community
ownership of the programme;
concentrating on the improvement of the quality of
care
and
inter-sectoral
coordination
and
strengthening nutrition action by the health sector;
creating nutrition awareness through IEC at all
levels (community, women’s group, village-level
workers, PRIs, programme managers and policy
makers at the state and central levels); and
establishing a reliable monitoring and evaluation
mechanism
Yet to be operationalised; should receive priority
Convergence of services
AWW can
weigh neonates in home deliveries and
refer those requiring care
advise regarding exclusive breast
feeding and complementary feeding
identify undernourished pre-school
children by weighing them at least once
every three months and give food on
priority to them;
act as depot holder for ORS.
assist in emergency referral
Convergence of services
ANM will
 Immunize all infants, pregnant women and
children as per schedule.
 Screen children – especially the under
nourished ones for health problems and
manage/ refer those with problems.
AWW will
 Assist ANM in organizing immunization
health check ups in anganwadi;
 Assist ANM in administering massive dose
Vitamin A
Micronutrient deficiencies
All effort for combating anaemia
Review Vitamin A supplementation
Universal access to iodised salt
Prevalence of Anaem ia (%){DLHS 2003}
Percentage
100%
80%
60%
40%
20%
0%
preschool
children
adolescent girls
pregnant w omen
Group
severe
moderate
mild
no anaemia
Anaemia is a major problem right from
childhood; it worsen during adolescence in girls
Advent of pregnancy further aggravates anaemia
Combating anaemia
Promote breastfeeding, improve
complementary feeding
Dietary diversification
Double fortified salt
Screen all children where ever possible –
school health, hospitals OPDs
Detect and treat anaemia vigorously
Vitamin A Deficiency
• Clinical Deficiency Marked Reduction
• Blindness: 2% (1974) to 0.04% (1985)
• Bitot Spots: ICMR (1969) – 4.2%
DWCD (1996) – 0.21%
NNMB: 2% (1996), 0.7% (1990 & 1997)
• Isolated Areas – Bihar, UP (DNP-ICMR 01’)
• Night Blindness (<4 yr) MICS 2000: 0.6%
Coverage Under Massive dose of Vitamin A
Coverage can be improved -Orissa, UP
But overall coverage remains low
Prevalence (%) of Bitot Spots
among 1-<5 yrs. children
0.8
0.5
0.7
0.8
Percent
0.7
0.2
-0.1
NNNB-MND
ICMR-MND
NNNB-2001
WHO cut - off level (0.5%) of Pub lic
Health significance
Prevalence of Bitot spot has declined
Is this the right time to review the massive
dose vitamin A programme ?
Progress of iodised salt production in India
16
Million Tonnes
12
8
4
Source:Salt Department
Production
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
0
Capacity
Huge installed capacity for producing iodised salt
This is under utilised. We supply iodised salt to
other countries who attain high rates of iodised
salt use
Many coastal , salt manufacturing states with good
health indices have low iodised salt use. Prevalence of
goitre in these non endemic states is relatively high
% Household consumption of iodised salt source
Source: DLHS 2002-03
RCH2 (2002)
Pu
nj
ac
ab
ha
lP
ra
de
sh
Hi
m
Ke
ra
la
G
M
uja
ad
ra
hy
t
a
Pr
ad
es
M
h
ah
ar
as
ht
ra
Ha
ry
an
W
a
es
tB
en
ga
l
a
ri s
s
O
Pr
ad
es
h
Bi
ha
r
An
dh
ra
Ut
ta
rp
ra
de
sh
Ta
m
il N
ad
u
Ka
rn
at
ak
a
Ra
ja
sth
an
100
90
80
70
60
50
40
30
20
10
0
NFHS2 (1998-99)
There was a decline in household access to
iodised salt after the ban on sale of noniodised salt was lifted
Reimposition of ban is under way
Tenth Plan strategy
Promotion of appropriate dietary intake and
lifestyles for the prevention and management of
obesity and diet-related chronic diseases
Nutrition monitoring and surveillance to enable
the country to track changes in the nutritional and
health status of the population to ensure that:
 existing opportunities for improving nutritional
status are fully utilized; and
emerging problems are identified early and
corrected expeditiously.
Tenth Plan strategy
Research efforts to be directed towards:
review of the recommended dietary intake of
Indians;
building up of epidemiological data on:
•relationship between birth weight, survival,
growth and development in childhood and
adolescence;
•body mass index norms of Indians and health
consequences of deviation from these norms.
NORMAL
CHILD
WASTED
CHILD
SHORT
CHILD
SHORT
AND
WASTED
CHILD
A NORMAL
CHILD
B TALL & SLIM CHILD
A & B have same
bodyweight.
B should get
more food to
reach
appropriate
weight for his
height
and
continue
linear
growth
A NORMAL
CHILD
B SHORT FAT CHILD
A & B have
same
weight. B is
short
and
requires
more
exercise to
get
to
appropriate
weight for
his height .
BMI is the most widely used parameter for
assessment of nutritional status in adults but is
not used as an index to assess nutritional status
in childhood and adolescence.
This is perhaps because computation of BMI for
age in growing children appears complicated
Nutritional status of public school children using
BMI-for-age and weight-for-age (NFI, 2000)
120
Percentage
100
80
60
40
20
0
BMI-for-age
<(-3)SD
<(-2)SD
Weight-for-age
normal
>(+2)SD
>(+3)SD
Weight for age and BMI for age
BMI which takes into account the current
height while assessing the nutritional status
is a sensitive index for detection of under
and over nutrition in children.
It worth while to put in the additional effort to
compute BMI for age to assess nutritional
status in children & adolescents because it
will enable early detection of both under and
over nutrition and appropriate management
so that these children grow into healthy
adults.
Indices to be monitored
Rationale for monitoring–assess progress, identify
problems and take mid course correction
Process indicators are to be monitored as per
the NRHM/ICDS formats. In addition
100% Civil registration- reconciled at village level
Births- check with No of pregnant women
Deaths- assess MMR, neonatal, infant and child
mortality rates
Monitor- infant and child feeding practices
Under-nutrition rates in children – reconcile with the
DLHS data after converting data to IAP classification