Nutrition morbidity interactions in pre-school children

Background & objectives: Research studies in the 1970s reported that in pre-school children, undernutrition increased the risk of infections and infections aggravated undernutrition. Over decades, there has been a reduction in prevalence of undernutrition and improvement in access to healthcare for treatment of infections. A mixed longitudinal study was undertaken to assess whether over time there were any changes from the earlier reported effect of undernutrition prior to infection on the risk of morbidity and effect of morbidity on nutritional status in pre-school children. Methods: Pre-school (0-59 months of age) children from urban low- and middle-income families whose parents were willing to allow their participation in the study were enrolled. Information on sociodemographic profile of the families was collected at enrolment. Weight of all children and length in infants were recorded every month; length/height in children 12-59 months of age was recorded once in three months. Morbidity information was collected through fortnightly visits. Results: 3888 pre-school children were followed up in 74636 home visits. Among these children, underweight and wasting were associated with a small increase in risk of infections. The odds ratio for risk of infection for underweight children was 1.09 (95% CI: 1.02 to 1.16) and for wasting was 1.18 (95% CI: 1.08 to 1.29). The deterioration in Z scores for weight-for-age and body mass index-for-age in children during illness and convalescence was small but significant (P<0.001). Interpretation & conclusions: The increased risk of infections in undernourished children living in overcrowded tenements in areas with poor environmental hygiene was not significant, perhaps because the risk of infection in normally nourished children was also high. The deterioration in nutritional status following infection was small because of the ready access to and utilization of health and nutrition care.

INTRA-FAMILY DIFFERENCES IN NUTRITIONAL STATUS BETWEEN PRE-SCHOOL AND SCHOOL AGE CHILDREN

Currently under- and over-nutrition are public health problems in Indian children. A community-based study in 3249 children was undertaken to assess the magnitude of intra-family differences in nutritional status between pre-school and school age children from urban low middle income families. Length/height and weight were measured; nutritional status was computed using WHO Anthro and Anthro Plus software. One-fourth of children were stunted, 1/5th underweight, 1/10th wasted and less than 5% were overweight. Prevalence of stunting, underweight and wasting was higher in children whose elder siblings were stunted, underweight or wasted. However, majority of the younger siblings of under-nourished elder siblings were normally nourished; majority of the elder siblings of undernourished younger sibling were normally nourished. In view of this, it is essential to screen all children, identify those who are under- or overnourished using BMI-for-age and provide appropriate interventions.

Time Trends in Prevalence of Anemia in Preschool Children in India

Introduction Anemia is a major public health problem in Indian children. India introduced iron-folic acid supplementation for preschool children in the 1970s. In 1990, the component of detection and treatment of anemia was added. It is important to assess the impact of these programs on the prevalence of anemia in preschool children. Materials and Methods Prevalence of anemia in preschool children at the national and state level was tabulated from National Family Health Survey (NFHS) 2, 3, and 4 national and state reports. Raw data from NFHS 2, 3, 4; District Level Household Survey (DLHS) 2 and 4; and Annual Health Survey and its Clinical Anthropometric and Biochemical component (AHS CAB) were analyzed to find out the changes in mean Hb, prevalence of anemia, and frequency distribution of Hb. Results Compared with NFHS 2, there was a 5% increase in prevalence of anemia, 0.3 g/dL fall in mean Hb levels, and a small shift to the left in frequency distribution of Hb levels in NFHS 3. There was a 10% reduction in prevalence of anemia in NFHS 4 as compared with NFHS 3. Comparison between DLHS 2, DLHS 4, and AHS CAB showed that there was a 15 to 20% reduction in prevalence of anemia, approximately 1 g/dL increase in mean Hb and a shift to the right in distribution of Hb levels. Conclusion There has been some improvement in Hb levels in preschool children in the last decade, but prevalence of anemia continues to be very high. Effective implementation of the comprehensive package of interventions recommended in National Iron Plus Initiative (NIPI) guidelines is urgently needed to achieve rapid and sustained reduction in anemia.

Time Trends in Prevalence of Anaemia in Adolescent Girls

Introduction: Anaemia in adolescent girls has been recognised as a major public health problem. The Mid-day meal programme guidelines envisage inclusion of 75 g/day of vegetables and use of iron fortified iodised salt for hot cooked meal. The National Iron Plus Initiative envisages weekly iron-folic acid (IFA) supplementation for adolescent girls; however, coverage and compliance have been reported to be low. Data from national surveys carried out in the last two decades were analysed to assess changes, if any, in Hb levels and prevalence of anaemia in adolescent girls. Material and Methods: Raw data from National Family Health Surveys (NFHS) -2, -3, and -4, District Level Household Surveys (DLHS) 2 and 4, and Annual Health Survey-related to Clinical, Anthropometric and Biochemical Components (AHS-CAB) were analysed to assess mean Hb, prevalence of anaemia and frequency distribution of Hb in adolescent girls. Comparison in these parameters was made between non-pregnant girls 10-14 years and 15-19 years of age in DLHS-2, -4 and AHS-CAB; in the 15-19 year age group comparisons were made between pregnant and nonpregnant girls in NFHS series and DLHS AHS series. Results: There were no clear and consistent changes in mean Hb, prevalence of anaemia and frequency distribution of Hb in pregnant and non-pregnant adolescent girls between NFHS-2, -3 and -4 either at national or at State level. However, there was a 0.7 and 1.3 g/dL increase in mean Hb levels in nonpregnant girls (10-19 yrs) between DLHS-2 and AHS-CAB and DLHS-4 States, respectively. The increase in mean Hb of pregnant girls (15-19 yrs) was 1.1 g/dLand 1.4g/dLin AHS-CAB and DLHS 4 States, respectively. There was significant reduction in prevalence of anaemia in both pregnant and non-pregnant girls between DLHS 2 and DLHS 4 and AHS-CAB at the aggregate level for each survey and in all States except Uttarakhand. Conclusion: There has been some improvement in Hb levels in adolescent girls in the last two decades. Improving dietary intake of vegetables and promoting use of iron fortified iodised salt in all households in the country have to be taken up so that iron intake across all age groups improves. This when combined with daily IFA supplementation for three months in a year in adolescent girls, might lead to sustained improvement in Hb.

Food & nutrition security: Challenges in the new millennium.

The World Food Summit in 1996 provided a comprehensive definition for food security which brings into focus the linkage between food, nutrition and health. India has been self sufficient in food production since seventies and low household hunger rates. India compares well with developing countries with similar health profile in terms of infant mortality rate (IMR) and under five mortality rate (U5 MR). India fares poorly when underweight in under five children is used as an indicator for food insecurity with rates comparable to that of Subsaharan Africa. If wasting [low body mass index (BMI) for age in children and low BMI in adults] which is closely related to adequacy of current food intake is used as an indictor for the assessment of household food security, India fares better. The nineties witnessed the emergence of dual nutrition burden with persistent inadequate dietary intake and undernutrition on one side and low physical activity / food intake above requirements and overnutrition on the other side. Body size and physical activity levels are two major determinants of human nutrient requirements. The revised recommended dietary allowances (RDA) for Indians takes cognisance of the current body weight and physical activity while computing the energy and nutrient requirements. As both under- and overnutrition are associated with health hazards, perhaps time has come for use of normal BMI as an indicator for food security.

ICMR’s tryst with HIV epidemic in India: 1986-1991.

The Indian Council of Medical Research (ICMR) undertook screening of asymptomatic persons from high risk group with the ELISA test for HIV infection in 1986 and found that HIV infection has reached India. ICMR in collaboration with the central and State health services initiated the national sero- surveillance programme for HIV infection in 43 surveillance and five reference centres to determine the major modes of transmission and magnitude of infection. Data from the sero-surveillance showed that HIV infection was present in all the known high risk groups and in the general population in all the States both in urban and rural areas. HIV was getting transmitted through all the known modes of transmission. In most States heterosexual transmission was predominant but in Manipur intravenous (iv) drug use was the most common mode of transmission. Prevalence of HIV infection in high risk groups was not high and that in low risk groups was quite low. ICMR initiated hospital based sentinel surveillance in high risk groups and general population to obtain time trends in seroprevalence. Between 1986 and 1991, National AIDS Programme was carried out as a collaborative effort of ICMR, and central and State health services. As the dimensions of the epidemic unfolded, rational evidence based interventions which could be implemented within the existing health system, were initiated. National AIDS Control Programme (NACP) continued and upscaled all these interventions. Effective implementation of a multi-pronged, rational strategy for HIV infection containment and control right from the initial stages, and dedicated work done by committed professionals belonging to government and voluntary sectors, cultural ethos of the country, responsible behaviour of the population and relatively low iv drug use have resulted in rapid decline in new infection and in prevalence of infection within a quarter of a century after the initial detection of HIV.

Assessment of nutritional status in Indian preschool children using WHO 2006 Growth Standards.

Background & objectives: This study attempts to compare the pattern of growth of Indian children as assessed by weight for age, height for age and BMI for age with the WHO standards for growth (2006) and to explore the implications of differences in undernutrition rates in the 0-59 months of age group as assessed by these three indices. Methods: From the National Family Health Survey -3 database, growth curves for height, weight and BMI for age in Indian preschool children were computed using LMS software and compared with the WHO (2006) standards. Using the WHO (2006) standards, trends in prevalence of undernutrition as assessed by height, weight and BMI for age in the 0-59 month age group were computed. Results: During the first three months there was no increase in underweight and stunting rates. There was progressive increase in underweight and stunting rates between 3-23 months of age. Low BMI for age and wasting rates were highest at birth. Interpretation & conclusions: Poor growth is an adaptation to chronic low energy intake and stunting is a measure of cumulative impact of chronic energy deficiency on linear growth. It is important to prevent stunting because it is not readily reversible. Low BMI is an indictor of current energy deficit. Early detection of energy deficit using BMI for age and expeditious interventions to correct the deficit might be effective in prevention of stunting.

Nutrition and child survival in India.

India recognized the importance of improving the health and nutritional status of children, and initiated steps to improve access to nutrition and health services soon after independence. Over the years, the infrastructure and human resources for manning the health and nutrition services have been built up and currently cover the entire country. However these are inadequacies in terms of content and quality of services and undernutrition rates and under five morality rates continue to be high. Undernutrition begins in utero, and with low birthweight, effective antenatal care can help in reducing low birth weight. The poor infant and young child feeding (IYCF) practices, repeated morbidity due to infections and poor utilization of health and nutrition services are other causes of undernutrition in children in India. The key intervention to prevent undernutrition is nutritional and health education through all modes of communication, to bring about is a behavioral change towards appropriate IYCF and utilization of health care. Appropriate convergence and synergy between health and nutrition functionaries can play a major role in early detection and effective management of both undernutrition and infections, accelerate the pace of reduction in both undernutrition and under five mortality and enable India to reach Millennium Development Goals.

Poverty nutrition linkages.

At the time of independence majority of Indians were poor. In spite of spending over 80 per cent of their income on food, they could not get adequate food. Living in areas of poor environmental sanitation they had high morbidity due to infections; nutrition toll due to infections was high because of poor access to health care. As a result, majority of Indians especially children were undernourished. The country initiated programmes to improve economic growth, reduce poverty, improve household food security and nutritional status of its citizens, especially women and children. India defined poverty on the basis of calorie requirement and focused its attention on providing subsidized food and essential services to people below poverty line. After a period of slow but steady economic growth, the last decade witnessed acceleration of economic growth. India is now one of the fastest growing economies in the world with gross domestic product (GDP) growth over 8 per cent. There has been a steady but slow decline in poverty; but last decade's rapid economic growth did not translate in to rapid decline in poverty. In 1970s, country became self sufficient in food production; adequate buffer stocks have been built up. Poor had access to subsidized food through the public distribution system. As a result, famines have been eliminated, though pockets of food scarcity still existed. Over the years there has been a decline in household expenditure on food due to availability of food grains at low cost but energy intake has declined except among for the poor. In spite of unaltered/declining energy intake there has been some reduction in undernutrition and increase in overnutrition in adults. This is most probably due to reduction in physical activity. Under the Integrated Child Development Services (ICDS) programme food supplements are being provided to children, pregnant and lactating women in the entire country. In spite of these, low birth weight rates are still over 30 per cent and about half the children are undernourished. While poverty and mortality rates came down by 50 per cent, fertility rate by 40 per cent, the reduction in undernutrition in children is only 20 per cent. National surveys indicate that a third of the children from high income group who have not experienced any deprivations are undernourished. The high undernutrition rates among children appears to be mainly due to high low birthweight rates, poor infant and young child feeding and caring practices. At the other end of the spectrum, surveys in school children from high income groups indicate that between 10-20 per cent are overnourished; the major factor responsible appears to be reduction in physical activity. Some aspects of the rapidly changing, complex relationship between economic status, poverty, dietary intake, nutritional and health status are explored in this review.