Schoolchildren have a mid-day meal, distributed by a government-run primary school at Brahimpur village, Chapra, Bihar July 2013. Photo: Reuters/Adnan Abidi
There are several concerns about the state of nutrition in the country, and the recently released fifth National Family Health Survey (NFHS) (2019-2021) phase 2 compendium, covering 14 States and Union territories, offers an opportunity to look specifically at nutrition related indicators.
Stunting and underweight
According to NFHS 5, the number of children under 5 years who are stunted (less height-for-age) in India has come down from 38.4% to 35.5% and the number of children who are underweight (less weight-for-age) has come down from 35.8% to 32.1%.
The cycle of undernutrition in children can start in utero and contribute to low weight and stunting, which are themselves independently associated with higher mortality and morbidity, as the children may not be able to produce essential antibodies and immune responses crucial to fight infectious organisms they are commonly exposed to. So what would have been an asymptomatic or mild infection in an otherwise healthy child can become fatal in a malnourished child.
Additionally, these children could also have reduced muscle mass, reduced cough reflex, electrolyte disturbances, and other coexisting illness and disease. On the other hand, a child who develops an infection can lose appetite and may not be able to absorb nutrients adequately, thus deteriorating into (more) malnutrition.
In the same age group, the number of overweight (more weight-for-height) children has increased from 2.1 to 3.4%. There is a need to assess the dietary patterns of the children and their families. The most common nutritional cause of overweight or obese children are diets that are predominantly cereal- or millet-heavy without other nutrient-dense foods, plus excessive sugar, junk and processed foods consumption and seed oils and trans fats.
Women with a body mass index (BMI) below 18.5 kg/m2 has reduced from 22.9% to 18.7%, but continues to be a grave concern. While the BMI for women and men in Arunachal Pradesh is 5.7% and 4.9% respectively, in Chattisgarh it is 23.1% and 17.4%. The BMI for men is 16.2 in this round, compared to 20.2 in NFHS 4. A low BMI can increase one’s susceptibility to fractures and risk of acquiring infections because of lowered immunity.
Vaccine preventable diseases and nutrition
It is well known that there is a close association between vaccine-preventable diseases and nutrition. The Universal Immunisation Program (UIP) in India protects against many infections that contribute to mortality in children under 5 years of age.
The NFHS 5 data shows that 76.4% children aged 12–23 months are fully vaccinated – ranging from 64.9% in Arunachal Pradesh to 82% in Puducherry. Immunisation coverage has been severely affected by the prolonged COVID-19 pandemic and unplanned lockdown, particularly in hilly, remote and tribal areas.
Vitamin A deficiency is still a leading cause of preventable childhood blindness in India, and leads to reduced immune function and increased risk of mortality from infections, which can in turn lead to even more vitamin A deficiency. Severe forms of this deficiency, such as keratomalacia, have to be prevented as they lead to irreversible visual loss and cannot be addressed in retrospect.
Dietary sources of vitamin A can either be preformed or provitamin A and beta carotene – with the former being superior. Preformed vitamin A is found in animal fats, eggs, liver, milk and dairy, and oily fish. Beta carotene and provitamin A are found in green leafy and yellow vegetables (mango, papaya), carrots and bright-coloured vegetables (capsicum), especially if eaten with some fat/oil, as Vitamin A is a fat soluble vitamin.
As with other nutrition-related interventions, the vitamin A programme in India came to a halt during the extended lockdown, and has shown no sign of picking up again. The NFHS 5 II phase data shows low coverage with vitamin A in NCT of Delhi (52.9%) and in Uttarakhand (53.7%).
According to established standards, babies should be exclusively breastfed for six months (with no additional food or drink, including water). Breastfed children are likely to have better immunity against ear infections, diarrhoea and respiratory infections, among other ailments, and also a lower risk of allergies, asthma, diabetes and obesity. Breastfeeding helps the uterus to contract and also confers a reduced risk of breast, uterine and ovarian cancers in the mother.
In NFHS 5, children under age 6 months who were exclusively breastfed has gone up from 54.%9 to 63.7% (more in rural areas, at 65.1%). It is high at 80.3% in Chhattisgarh. This indicator would have been affected post-pandemic and post-lockdown, with more women having to seek employment. Maternity benefits scheme for the informal sector has to be implemented properly to allow women to be able to breastfeed their babies.
The percentage of children under age 3 years of age who were breastfed within one hour of birth remains around 41.8% in India. The growing number of Caesarean sections could also contribute to delay in breastfeeding. Caesarean sections have gone up from 17.2% to 21.5%. While this has gone up from 40.9% to 47.4% in private sector facilities, it has gone up from 11.9% to 14.3% in public sector facilities.
Since the ideal rate of Caesarean sections is usually around 10-15%, there is a need to constantly monitor and regulate the private sector to prevent unnecessary Caesarean sections.
From six months onwards, semi-solid foods can be introduced into an infant’s diet. Giving the child sugary drinks, high carbohydrate foods and junk or processed foods like biscuits will affect the child’s nutrition status and can also create a lifelong culture of poor eating and its subsequent complications.
Shockingly, according to NFHS 5, the percentage of total children aged 6-23 months receiving an adequate diet is just 11.3%. This is dismal and calls for concerted and serious nutritional interventions, with a break-up of the indicators based on the socio-demographic profile of the population. The mid-day meal is a legally mandated right of children upto the age of 14 years under the National Food Security Act 2013, and this should be implemented with care.
The fraction of children aged 6-59 months who are anaemic has gone up from 58.6% to 67.1% in NFHS 5. The percentage of all women aged 15-19 years who are anaemic has gone up from 54.1% to 59.1%. Anemia can lead to adverse clinical outcomes such as low birth weight, neonatal mortality and premature births. Intra and postpartum bleeding is the biggest preventable cause of maternal deaths.
In India, however, rather than challenge the high levels of anemia, there has been at least one attempt – by Dr Harshpal Sachdeva, a paediatric specialist in New Delhi, and his colleagues – to minimise the concerns by challenging the anaemia cutoffs using data from the Comprehensive National Nutrition Survey (CNNS).
Ideally, cutoffs have to be calculated based on a sample population that is likely to have the best outcomes in terms of the given indicator, and selected through a thorough process of screening, examinations, exclusions and inclusions. Importantly, it has to be correlated with clinical outcomes, not just by juggling data on a computer. By that criterion, the CNNS data is unsuitable for the calculation of cutoffs.
On the other hand, a relatively better designed study by better designed study by H. Khusun, from the University of Indonesia, and others found that there was no need to develop different cutoff points for anemia and that the WHO hemoglobin cutoffs were valid for an Indonesian population.
It is important that the India government looks at some of this data on nutrition and design food and nutrition security for the country in a more evidence-based manner.
Dr Sylvia Karpagam is a public health doctor and researcher, part of the Right to Food and Right to Health campaigns.