7 PM | Turning the policy focus to child undernutrition | 20th November, 2019

Context: Malnutrition and the findings of Comprehensive National Nutrition Survey (CNNS) report.

More in news:

• Government recently released Comprehensive National Nutrition Survey (CNNS) report which assumes importance as India ranks 102 out of 117 countries in the Global Hunger Index (GHI), 2019.

Comprehensive National Nutrition Survey (CNNS):

• The survey was conducted between 2016 and 2018 by the Ministry of Health And Family Welfare, with the United Nations Children’s Fund (UNICEF) and the Population Council of India.
• The CNNS is the first survey to give detailed nutrition information of children between 5 and 14 years, and to study over nutrition and markers of Non Communicable Diseases (NCDs) in children.
• The specific objectives of the CNNS were:  

• to assess the extent and severity of micronutrient deficiencies among children andν adolescents  
• to assess risk factors for non-communicable diseases among school-age childrenν and adolescents  
• to estimate the prevalence of dual burden of malnutrition in children and adolescentsν using a comprehensive set of established anthropometric measures

Unique about the survey:

There are two unique things about the survey:

1. It creates link between the nutritional status of children and the nutritional and educational status of the mother; 
2. It links the nutritional status of children with household wealth.

Data Collection:

• The Comprehensive National Nutrition Survey (CNNS) India 2016–18 is the largest micronutrient survey ever conducted.
• The CNNS was conducted in all 30 states of India using a multi-stage survey design covering rural and urban households. The survey collected data from three target population groups: pre-schoolers (0–4 years), school-age children (5–9 years) and adolescents (10–19 years).
• In each state, the rural sample was selected in two stages. The first stage was the selection of PSUs using probability proportional to size (PPS) sampling and the second stage was a systematic random selection of households within each PSU.
• To ensure representation of different socioeconomic groups in the sample, a stratified sampling procedure was adopted at the first sampling stage in rural areas, following methods employed in the NFHS-3 survey.
• Survey data collection was implemented by four survey agencies, one field-based quality assurance team, one field and lab-based quality assurance team (CDSA), one main laboratory, two quality control laboratories (AIIMS and National Institute of Nutrition) and the lead management agency Population Council.

Findings of the CNNS report:

• Between 2005-06 and 2015-16, child stunting and the condition of being underweight declined by 10% and 7% points, respectively. In wasting, the decline was a paltry 1% point.
• Stunting: Stunting, or low height-for-age, is a sign of chronic undernutrition that reflects failure to receive adequate nutrition over a long period and is also affected by recurrent and chronic illness. 

• In the CNNS, 35% of Indian children aged 0–4 years were stunted
• A higher prevalence of stunting in under-fives was found in rural areas (37%) compared to urban areas (27%).
• Wasted: Wasting, or low weight-for-height, is a measure of acute undernutrition and represents the failure to receive adequate nutrition leading to rapid weight loss or failure to gain weight normally. Wasting may result from inadequate food intake or from a recent episode of illness causing weight loss.

• Overall, 17% of Indian children age 0–4 years was wasted.
• A higher proportion of children under fi ve years of age in the poorest wealth quintile were wasted (21%) compared to those in the highest wealth quintile (13%).
• Underweight: Underweight, or low weight-forage, is a composite index that takes into account both acute and chronic undernutrition.

• 33% of Indian children aged 0–4 years were underweight.
• Rural areas had higher prevalence of underweight in children under five (36%) compared to urban areas (26%). 
• Scheduled tribes had the highest prevalence of underweight (42%) as compared to scheduled castes (36%), other backward classes (33%), and other groups (27%).

• Malnutrition refers to deficiencies, excesses or imbalances in a person’s intake of energy and/or nutrients. The condition encompasses both undernutrition and overweight and obesity.
• Overweight and obesity, or high weight-for-height, refl ect body weight that is higher than what is considered a healthy weight for a given height.
• About 5% of children and adolescents, 5-19 years, were overweight, the survey found.

• According to the CNNS, the prevalence of vitamin A deficiency was 16% among adolescents, vitamin D deficiency was 24%, zinc deficiency was prevalent in 32% of adolescents, and 31% and 37% of adolescents had vitamin B12 and folate deficiency, respectively.

Anaemia:

• Anaemia is a condition marked by low haemoglobin (Hb) concentration and is an important risk factor for the poor health and development of children and adolescents. 
• It adversely affects brain development, causes weakness, fatigue and poor productivity; and predisposes individuals to infections. Low haemoglobin is caused by inadequate bioavailability of micronutrients (iron, folate, vitamin B12).
• Overall, 41% of pre-schoolers aged 1–4 years, 24% of school-age children aged 5–9 years and 28% of adolescents aged 10–19 years had some degree of anaemia
• The prevalence of anaemia varied by the schooling status of children and adolescents. Compared to those currently in school, anaemia prevalence was higher among out-ofschool children aged 5 to 9 years (32% vs. 23%) and adolescents aged 10–19 years (36% vs. 26%).
• The prevalence of anaemia decreased with a higher level of mother’s schooling among both school-age children and adolescents

Education of women: The survey reveals a worrying statistic relating to education of women: 53 per cent of the mothers surveyed had no education at all. Only 20 per cent of mothers of preschool children, 12 per cent of mothers of school going children and 7 per cent of mothers of adolescents had completed 12 years of schooling.

Challenges in handling child undernutrition:

• Vicious cycle of undernutrition, disease/infections and mortality: Maternal and Child Undernutrition is the attributable cause of more than one third of the mortality of children under five years, many of which are preventable through effective nutrition interventions operating at scale. Around two thirds of undernutrition related deaths are related to inappropriate caring and Infant and Young Child Feeding practices, and occur in the first year of life.
• Maternal and Child Undernutrition: Every third woman in India is undernourished (35.6 % with low Body Mass Index) and every second woman is anaemic (55.3%). This intergenerational cycle of undernutrition is perpetuated, with high incidence of babies born with low birth weight (22 %), more susceptible to infections, more likely to experience growth failure, reflected in high levels of child undernutrition and anaemia.
• Infant and Young Child Feeding practices remain sub optimal- early initiation of breastfeeding within 1 hour is 25 % (NFHS 3).
• Lack of focus on the girl child: The girl child goes on to become an undernourished and anaemic adolescent girl, often deprived of adequate health care and nutritional support, educational opportunities, denied her right to be a child- married too early, with early child bearing, inadequate inter pregnancy recoupment. This perpetuates a vicious cycle of undernutrition and morbidity that erodes human capital through irreversible and intergenerational effects on cognitive and physical development.
• Wide disparities in nutrition status exist across and within states, districts and different community groups. The proportion of children aged 6 to 23 months who received a minimum diverse diet or more was highest in Meghalaya (62%) and lowest in Jharkhand (12%) and Rajasthan (12%).
• Lack of dietary diversity: To assess dietary diversity for children aged 2 to 4 years, the consumption of seven food groups during the previous day was assessed; grains, roots and tubers; legumes and nuts; dairy products; flesh foods; eggs; vitamin A-rich fruits and vegetables; and other fruits and vegetables. India lacks in providing dietary diversity due to various factors ranging from religious believes to family income status.

What can be done?

• Women’s Education: Women’s secondary education might be capturing the cumulative effects of household wealth, women’s empowerment and knowledge and health-seeking behaviour. The findings of survey shows that stunting among children under four years came down when maternal education went up from illiteracy/no schooling to 12 years of schooling completed. 
• Ending open defecation and enhancing access to safe water and sanitation are indeed appropriate policy goals, which need to be sustained.
• Dietary diversity: It is important to move away from the present focus on rice and wheat, which studies denounce as ‘staple grain fundamentalism,’ of Public Distribution System (PDS), to a more diversified food basket, with an emphasis on coarse grains. It would be worth including millets in the PDS on a pilot basis, in States where stunting levels are high. 
• Behavioral Change: Maintaining clean and hygienic environment along with active care seeking behaviour for common childhood diseases helps to ensure rapid healthy growth in early childhood.
• Implementing National Nutrition Mission in true spirit: The prevalence of undernutrition-related diseases during 2016-18, when this survey was conducted, was lower than it was during the National Family Health Survey of 2015-16, which found that 38.3% of children were stunted, 35.8% were underweight, and 21% were wasted. If the Poshan Abhiyaan is implemented in letter and spirit, it will help in achieving its aim of a 25% fall in the prevalence of child stunting and a three-percentage-point annual decline in the prevalence of anemia among women and children under the age of five years of age by 2022.

Source: https://www.thehindu.com/opinion/op-ed/turning-the-policy-focus-to-child-undernutrition/article30019889.ece