Staying Focused on the Undernourished Child—India

Manifestation of Undernutrition 

Prevalence rates of undernutrition among children in India (47.5%) are far greater than that of Sub-Saharan Africa (30%) (8, 9). Almost three quarters of Indian children are underweight due to undernutrition. Undernutrition here is not just related to access to food, but is also due to poor access to health care, poor sanitation, early weaning, and poor maternal nutritional status during pregnancy (10). Undernutrition in India is observed primarily in the form of protein energy malnutrition and micronutrient deficiencies (11). More than 57% of preschool children have vitamin A deficiency (12). The overall prevalence of iron-deficiency anemia among children ages 6 to 35 months is 74% (13). Iodine deficiency still exists in many parts of the country. In a study of 3,088 children in Orissa conducted during 1996-1999, it was documented that 18% of the school children had goiter (14). Undernutrition has also been associated with diarrhea and acute respiratory infections. The highest odds ratio (OR) for diarrhea was for those children who were wasted, stunted, and underweight (OR=1.72, 95% confidence interval [CI]: 1.52 to 1.95) (15). This group also had the highest odds for acute respiratory infection (OR=1.39, 95% CI: 1.28 to 1.58). Twenty-two percent of the burden of disease among children is attributed to undernutrition (12).

Factors to Determine Undernutrition 

Undernutrition in young children is usually determined by measurements of height, weight, and skinfold thickness (16). The most commonly used measures of undernutrition are: low height-for-age, low weight-for-height, and low weight-for-age. One of the most comprehensive surveys that collected anthropometric measurements on children ages 1 to 3 years in India (1998-1999) is the National Family Health Survey II (NFHS II). Some researchers have used data from NHFS II to construct a composite index of anthropometric failure, which includes seven classifications: no failure; wasting only; wasting and underweight; wasting, stunting, and underweight; stunting and underweight; stunting only; and underweight only (17). Using the composite index of anthropometric failure, the prevalence of undernutrtion for the children in the NFHS II is 60%, with the subgroup of children who were stunted and underweight as the largest group (28%) (15).

Causes of Undernutrition 

The causes of undernutrition in India are multifactorial. Some of the factors are: poor maternal nutritional status (80% of women are iron-deficient); low birth weight (30% of children are born underweight); social and economic status that limits the ability to access resources for health and nutrition; and poor hygiene and sanitation leading to infections and compromised health status (18). Among the undernourished, more than 50% live in rural areas, 49% are girls, and 53% are from the lower socioeconomic status. There are also geographic clusters of undernourished children, with 10% of villages and districts having undernourished prevalence rates of 28% (12). Although iron-deficiency anemia can be present in the absence of undernutrition, the relationship between undernutrition and standard of living scores have consistently shown an inverse association. In India, the composite index of anthropometric failure classification for those who have wasting, stunting, and underweight was inversely associated with the poorest households (15).

Estimating Mortality due to Undernutrition 

Childhood mortality rates due to undernutrition are also underestimated. These rates are underestimated because mortality as a result of factors related to undernutrition is not even listed as an underlying cause of death. For example, a child who has vitamin A deficiency is at risk for death from diarrhea. However, the vitamin A deficiency as the underlying cause of death is not usually documented, therefore not allowing a true estimate of the conditions related to undernutrition (19). Understanding the determinants of child mortality due to undernutrition will assist in developing appropriate interventions.

Steps to Reducing Undernutrition 

Jones and colleagues report that nutrition interventions alone can save about 2.4 million children each year (22). Clearly, health education and prevention of undernutrition with a focus on mothers and children is the first step. Also needed is community involvement in promoting programs such as breastfeeding, oral rehydration therapy, and providing micronutrient supplement (21).

One of the United Nations Millennium Development Goals set in 2000 was to reduce by half the proportion of people who suffer from hunger, which is defined as a lack of food that is needed to meet the daily requirements (23). Unless major changes are made, India will only meet the Millennium Development Goals by 2024. Just reducing the prevalence of underweight by five percentage points can reduce child mortality by 30% (24). The Food and Agriculture Organization in a recent report outlined some measures that can assist in reducing hunger. Recommendations to achieve a Millennium Development Goal of 27% for underweight in children in India include better medical care at birth, increased government spending for nutrition programs specifically related to children, real income growth, expanding medical access to sanitation, expanding electric supplies, expanding female education, and improving access to rural roads (25).

Conclusion 

The physical toll of undernutrition is bad for those who experience it and also for the economies that require human contributions. Even with nutrition transitions in shifting economies, long-term sustainability requires a population that can function and have a positive impact on the economy. Until a large segment of the population is able to participate in the growth and development of a nation, progress cannot be made. There is clearly an urgent need to stop persistent undernutrition and subsequent mortality among the children.

We are guilty of many errors and many faults, but our worst crime is abandoning the children, neglecting the foundation of life. Many of the things we need can wait. The child cannot. Right now is the time his bones are being formed, his blood is being made and his senses are being developed. To him we cannot answer “Tomorrow”. His name is “Today”.—Gabriela Mistral, 1948