Young Child Undernutrition: Crucial to Prioritize Nutrition Interventions in the First 1000 Days of Life.

The implications of young childhood undernutrition on health, development and productivity are grave. In the last two decades, global and Indian studies on undernutrition in under five years have concluded that stunting and underweight rate increases steadily between 0-24 mo, and then stabilises. The available evidence highlights the significance of concentrating interventions to tackle child undernutrition in the first 1000 d of life, which should aim at universal coverage of essential nutrition interventions (ENIs) and maternal-child health care package comprising maternal nutrition care, adoption of appropriate infant and young child feeding practices (IYCF), iron-folic acid supplementation, immunization, deworming, appropriate management of childhood illness etc. Additionally, it is critical to address context specific nutrition sensitive measures such as socio-economic empowerment of women, preventing domestic violence, adolescent conception, appropriate water -sanitation-hygiene and family planning services etc. Mapping of the 'at risk' households having a member falling in the 1000 d window needs special attention and is central to the ongoing efforts in India through the National Nutrition Mission/ POSHAN Abhiyaan. However, for effective implementation, there is an urgent need to consider to shift the lead responsibility of ENIs in the first 1000 d of life to the health care system in India and strategize to integrate maternal nutrition care interventions and establishing of IYCF practices by ensuring optimum use of contacts with antenatal care and routine child immunization services.

Establishment of cross-cradle hold technique combined with intensive breastfeeding counselling positively impacts the weight gain rate in early infancy.

A quasiexperimental field study was undertaken in 576 exclusively breastfed (EBF) infants from 0 to 14 weeks in Gujarat, India to assess the effect of the use of appropriate breastfeeding techniques on daily weight gain rate and on reducing the underweight rate in early infancy. The interventions were delivered through the existing health system and focused primarily on counselling pregnant women during antenatal and post-natal sessions for ensuring 'effective breastfeeding' by adoption of the technique of 'cross cradle hold', appropriate breast attachment, emptying of one breast before shifting to the other along with conducting regular monitoring of infant's weight. The intervention care group (ICG) of 300 EBF infants were compared with 276 EBF infants in the control standard care group (SCG). The findings revealed that median weight gain per day between 0 and 14 weeks was significantly higher (p = 0.000) in ICG (32.7 g) as compared with SCG (28.05 g). The median weight-for-age Z at 14 weeks of age was also significantly higher in ICG compared with SCG (p = 0.000). Underweight prevalence was three times lower in ICG (5.3%) compared with SCG (16.7%) at 14 weeks of age. Infants in the ICG were noted to be 2.65-fold more likely to achieve a weight gain of 30 g or more per day compared with infants in SCG. Nutrition interventions, therefore, must aim not only on mere promotion of EBF for up to 6 months but stress on ensuring EBF is 'effective' for optimum transfer of breastmilk through adoption of appropriate techniques, including cross-cradle hold, by mothers.

Anaemia in Indians aged 10-19 years: Prevalence, burden and associated factors at national and regional levels.

Anaemia control programmes in India are hampered by a lack of representative evidence on anaemia prevalence, burden and associated factors for adolescents. The aim of this study was to: (1) describe the national and subnational prevalence, severity and burden of anaemia among Indian adolescents; (2) examine factors associated with anaemia at national and regional levels. Data (n = 14,673 individuals aged 10-19 years) were from India's Comprehensive National Nutrition Survey (CNNS, 2016-2018). CNNS used a multistage, stratified, probability proportion to size cluster sampling design. Prevalence was estimated using globally comparable age- and sex-specific cutoffs, using survey weights for biomarker sample collection. Burden analysis used prevalence estimates and projected population from 2011 Census data. Multivariable logistic regression models were used to analyse factors (diet, micronutrient deficiencies, haemoglobinopathies, sociodemographic factors, environment) associated with anaemia. Anaemia was present in 40% of girls and 18% of boys, equivalent to 72 million adolescents in 2018, and varied by region (girls 29%-46%; boys 11%-28%) and state (girls 7%-62%; boys 4%-32%). Iron deficiency (ferritin < 15 µg/L) was the strongest predictor of anaemia (odds ratio [OR]: 4.68, 95% confidence interval [CI]: [3.21,6.83]), followed by haemoglobinopathies (HbA2 > 3.5% or any HbS) (OR: 2.81, 95% CI: [1.66,4.74]), vitamin A deficiency (serum retinol <20 ng/ml) (OR: 1.86, 95% CI: [1.23,2.80]) and zinc deficiency (serum zinc < 70 µg/L) (OR: 1.32, 95% CI: [1.02,1.72]). Regional models show heterogeneity in the strength of association between factors and anaemia by region. Adolescent anaemia control programmes in India should continue to address iron deficiency, strengthen strategies to identify haemoglobinopathies and other micronutrient deficiencies, and further explore geographic variation in associated factors.

Improving women's nutrition imperative for rapid reduction of childhood stunting in South Asia: coupling of nutrition specific interventions with nutrition sensitive measures essential.

The implications of direct nutrition interventions on women's nutrition, birth outcome and stunting rates in children in South Asia are indisputable and well documented. In the last decade, a number of studies present evidence of the role of non-nutritional factors impacting on women's nutrition, birth outcome, caring practices and nutritional status of children. The implications of various dimensions of women's empowerment and gender inequality on child stunting is being increasingly recognised. Evidence reveals the crucial role of early age of marriage and conception, poor secondary education, domestic violence, inadequate decision-making power, poor control over resources, strenuous agriculture activities, and increasing employment of women and of interventions such as cash transfer scheme and microfinance programme on undernutrition in children. Analysis of the nutrition situation of women and children in South Asia and programme findings emphasise the significance of reaching women during adolescence, pre-conception and pregnancy stage. Ensuring women enter pregnancy with adequate height and weight and free from being anemic is crucial. Combining nutrition-specific interventions with measures for empowerment of women is essential. Improvement in dietary intake and health services of women, prevention of early age marriage and conception, completion of secondary education, enhancement in purchasing power of women, reduction of work drudgery and elimination of domestic violence deserve special attention. A range of programme platforms dealing with health, education and empowerment of women could be strategically used for effectively reaching women prior to and during pregnancy to accelerate reduction in stunting rates in children in South Asia.

Impact of community-based mitanin programme on undernutrition in rural Chhattisgarh State, India.

BACKGROUND: Community health workers known as mitanins undertook family-level counseling and mobilized the community to improve coverage of maternal and child health services in the state of Chhattisgarh, India. The Nutrition Security Innovation (NSI) project was launched in selected blocks with additional inputs for promoting appropriate complementary feeding practices and disseminating information on Public Distribution System (PDS) entitlement. Within 3 years of project implementation, all NSI inputs in the project group (PG) were scaled up in the entire state. OBJECTIVE: To study the impact of interventions on nutritional status in PG and non-NSI comparison group (CG) blocks. METHODS: Quasi-experimental mixed methods were used. The sample consisted of 3,626 households with children under 3 years of age and 268 mitanins. RESULTS: A ratio of 1 mitanin per 250 to 500 population was effective. The coverage of exclusive breastfeeding, timely introduction of complementary feeding, DPT immunization, and antenatal care services was more than 70%. The PDS reached almost 90% of beneficiaries. In both the PG and the CG, one-third of children were undernourished, with one-quarter of children undernourished by 6 months of age. The prevalence of low birthweight was over 40%, and half of all women were undernourished. The estimated annual average reduction rate (AARR) for the entire state was estimated to be 4.22% for underweight and 5.64% for stunting. CONCLUSIONS: The strategy of Mitanin Programme in the Indian state of Chhattisgarh was unique with the implementation of direct nutrition actions being spearheaded by the health sector and community health volunteers in coordination with the Integrated Child Development Services (ICDS) and the Public Distribution System (PDS). The highest priority was given to interventions in the first 92 weeks of life. This implied ensuring frequent counseling and delivery of services through the entire pregnancy period and continued follow up till the children were at least one year of age. An accelerated decrease in the annual rate of reduction of underweight and stunting was observed. The emerging findings point to the significant contributions that can be made by the National Rural Health Mission (NRHM) in India by involvement of community health volunteers known as Accredited Social Health Activists (ASHAs) towards reducing the persistent problem of undernutrition in the country.

Community based maternal and child health nutrition project, uttar pradesh: an innovative strategy focusing on "at risk" families.

RESEARCH QUESTION: Use of community based volunteers, frequently reaching and counseling a selected group of prioritized families, can make a substantial difference in improving maternal and child care practices and in reducing child undernutrition. SETTING: Program Rural Uttar Pradesh, India. STUDY DESIGN: A comparison of baseline and endline surveys following 4 years of community based project intervention. PARTICIPANTS: "At risk" undernutrition families comprising mothers of under twos, newlyweds, and severely undernourished children below 6 years. INTERVENTION: Mapping and counseling of "at risk" families. Measuring impact on maternal-child care practices, underweight status. RESULTS: Trained community mobilizers identified and counseled selected "at risk" families. Following 4 years of implementation in 907 villages of 8 blocks of four districts, significant improvement was noted in practices of early initiation of breastfeeding, feeding colostrum, timely introduction of complementary feeding, and washing the hands after defecation. Percentage of mothers exclusively breastfeeding at 6 months was only 2.1% with 78% receiving prelacteal feeds. A small increase in normal and mild malnutrition and a significant reduction of 43% in severe malnutrition was noted. CONCLUSION: Frequently counseling by accredited social health activists by focusing on selected defined "at risk" families of under twos and those with severe malnourished children could result in increasing acceptability of correct child health, feeding, and care practices and in contributing to improving nutritional status scenario.

Weekly iron and folic acid supplementation with counseling reduces anemia in adolescent girls: a large-scale effectiveness study in Uttar Pradesh, India.

BACKGROUND: Weekly iron-folic acid supplementation in small-scale research trials and as administered in institutions has been demonstrated to be effective in reducing anemia in adolescent girls. OBJECTIVE: To assess the effectiveness of weekly iron-folic acid supplementation in a large-scale project in reducing the prevalence of anemia in adolescent girls. METHODS: The project provided weekly iron-folic acid tablets, family life education, and deworming tablets every 6 months to 150,700 adolescent school girls and non-schoolgirls of a total district population of 3,647,834. Consumption of the iron-folic acid tablets was supervised for schoolgirls but not for non-schoolgirls. Hemoglobin levels were assessed in a random sample of non-schoolgirls at 6 and 12 months and schoolgirls at 6 months. The effect of supplementation on the prevalence of anemia and the compliance rate were assessed over a 4-year period. RESULTS: In 4 years, the overall prevalence of anemia was reduced from 73.3% to 25.4%. Hemoglobin levels and anemia prevalence were influenced significantly at 6 months. No difference in the impact on hemoglobin or anemia prevalence was observed between supervised and unsupervised girls. Counseling on the positive effects of regular weekly iron-folic acid intake contributed to a high compliance rate of over 85%. The cost of implementation was US$0.36 per beneficiary per year. CONCLUSIONS: Weekly iron-folic acid supplementation combined with monthly education sessions and deworming every 6 months is cost-effective in reducing the prevalence of anemia in adolescent girls. Appropriate counseling, irrespective of supervision, is critical for achieving positive outcomes.

Reaching the goal of Universal Salt Iodization (USI): experience of Uttar Pradesh, India.

BACKGROUND: In 2002, the percentage of households consuming iodized salt in the state of Uttar Pradesh (UP) in India dropped to as low as 6%. This implied that 3.5 million newborns in this non-salt producing state, with 180 million population, were at risk of brain damage unless universal accessibility and consumption of iodized salt was ensured and sustained. OBJECTIVES: Urgent measures were introduced in 3 phases in the statefor accelerating procurement, distribution and consumption of iodized salt. METHODS: In the first phase, a study on mapping of salt wholesalers and understanding the salt trading system--including understanding the knowledge, attitudes, and practices of salt traders was undertaken to accelerate efforts to influence availability, marketing, and accessibility of iodized salt. The study revealed that a total of only 344 primary wholesalers supplied salt to the entire state. Of these, 126 wholesalers marketed 80% of salt and were located in only 15 of the total 70 districts of the state. This finding became a very strong basis for the program in phase II, which focused on the critical group of wholesalers and set up a system to frequently interact with them. The salt wholesalers were equipped with Salt Testing Kits (STKs) to ensure adequate iodine content in the salt procured by them and adherence to the legal ban on the sale of non-iodized salt for human consumption. Simultaneously, a "child-to-community" approach was launched through involvement of middle and high school children to create demand and monitor consumption of iodized salt at the household level. Over 217,000 salt samples (about 26,000 samples per quarter) were brought in by school children and tested for iodine content. RESULTS: The school activities resulted not only in influencing consumption of iodized salt, but also galvanized the entire chain linking consumers, retailers, and wholesalers. In less than 2 years, salt procured with nil iodine decreased from 38% to 15.3%, and salt marketed with adequate iodine level increased from 28.6% to 64.9%. School data revealed an increase in consumption of iodized salt from 6% to 46.7%. In phase 3, additional standardized activities at the school level were included and the program was taken to scale in the state. CONCLUSION: The findings revealed that identification and inclusion of salt wholesalers-not only the salt manufacturers-was important for achieving a rapid positive shift in iodized salt marketing and consumption practices.

Current status of iodine deficiency disorders (IDD) and strategy for its control in India.

Iodine Deficiency Disorders (IDD) reflects the broad manifestations of iodine deficiency including the implications on reproductive functions and lowering of IQ levels in school aged children. Today, IDD is a public health problem in 130 countries and affects 13% of world's population. In India, no state is free from iodine deficiency and 200 million people are 'at risk' of IDD. Daily consumption of salt fortified with iodine is a proven effective strategy and is the measure stressed by the Government of India. The paper describes the major five phases of the IDD Control Programme in India. The paper describes the major five phases of the IDD Control Programme in India since 1962 and synthesizes the spectrum of activities that significantly attributed to the Universal salt Iodisation (USI) efforts launched in 1992. The sustainability of the USI programme is critical since IDD prevalence will rise if programme of salt iodisation weakens. A two pronged strategy needs to be institutionalized for ensuring continued demand for iodised salt, linked to ongoing health, nutrition and education programmes as well as for ensuring supply of quality iodised salt.