Prema Ramachandran

1. ASSESSMENT OF NUTRITIONAL STATUS IN CHILDREN Prema Ramachandran Director, Nutrition Foundation of India

2. Nutrition transition and assessment nutritional status in children Developing countries are currently undergoing economic, social, demographic, health and nutrition transitions. The term dual nutrition burden was coined in the nineties to denote the phase of ongoing nutrition transition in low and middle income countries, characterized by persistent undernutrition mainly among poorer segments of population and emerging problem of overnutrition seen mostly among the urban affluent segments.

3. Dimensions of dual nutrition burden • During last two decades, Indian scientists have been in the forefront of global efforts exploring epidemiological, clinical and biochemical dimensions and health implications of dual nutrition burden. These studies have • Defined the magnitude of dual nutrition burden • Shown that undernutrition & overnutrition can be seen in • same family • same individual at different periods of time • same individual at the same time • Documented trans-generational impact and • Explored the challenges and opportunities India faces in in combating dual nutrition

4. Why focus on nutritional status in early childhood? • Under-nutrition in early childhood will • adversely affect their growth, development and health status during childhood and adolescence • influence their nutrition and health status through out their life span • may render them more susceptible to over-nutrition and non communicable disease risk in adult life

5. METHODS USED FOR ASSESSMENT OF NUTRITIONAL STATUS IN CHILDREN In the last century the focus was on undenutrition. Tools used for assessment of nutritional status in children were Dietary intake Clinical signs of nutritional deficiency Height and weight measurements In the current century, severe clinical forms deficiencies are rare; focus is therefore on under and overnutritionDietary intake and physical activity measurement, Ht, wt and BMI for age, measurement of body fat and its distribution are now used for assessment of nutritional status in children

6. Dual nutrition burden begins in utero

7. Dual nutrition burden begins in utero Low birth weight (<2.5kg ) rate in India about 30 %; about 2 % of Indian infants have high birthweight Low maternal height, low prepregnancy weight , low maternal weight gain and anaemia in pregnancy are major factors associated with low birthweight in India - trans-generational impact of maternal undernutrition Gestational diabetes with maternal overnutrition predisposes to large for date babies – trans-generational impact of maternal overnutrition Pregnancy induced hypertension with or without diabetes is emerging as an important obstetric factor predisposing to LBW Effective antenatal care including treatment for anaemia , PIH & food supplements when needed can reduce LBW by about 5 %

8. Low birth weight – consequences

9. Over the last three decades there is no increase in mean birth weight or reduction in LBW. • Majority of LBW babies are mature. • Prevalence of preterm births is about 12%.

10. Year 1967 - Dr Shanti Ghosh’s research findings: • Low birth weight can be due to Intrauterine growth retardation (IUGR) or preterm birth. • Majority of LBW babies in India are term IUGR. Their survival chances are much better than the pre-term babies with similar birth weight. • With warmth, breast feeding and prevention infection most term IUGR babies will survive. • Only preterm babies & those weighing below 2kg require intensive care in nurseries.

11. Do Indian children begin life with a disadvantage ? Birthweight is the critical determinant of trajectory of growth during infancy and child hood Birth weight is a major determinant of growth trajectory during infancy and child hood.

12. Birth-weight is a critical determinant of growth Birth-weight is a major determinant of growth during infancy childhood, adolescence and adult life. Focus on antenatal care will bring about a modest reduction low birth-weight especially preterm births and bring about some improvement in nutritional status

13. South Asian enigma: is it due to IUGR ? Prevalence of underweight in preschool children India is higher than the prevalence of under weight in sub-Saharan Africa but infant and under five mortality rates in India are low: so called South Asian enigma. Low birthweight rates in India is 30%; in sub-Saharan Africa is 15 %. Most of the Indian LBW neonates are mature and can survive with minimal essential care; they have a low growth trajectory. Most of the sub-Saharan LBW neonates are preterm and require special care; in the absence of adequate pediatric care neonatal and infant mortality rates are high. The high U5 MR and under-nutrition in the predominantly normal birth weight survivors in sub-Saharan Africa might be due to low dietary intake and poor access to health care.

14. The thin -fat neonate Indian neonates are short and wasted; they have low muscle mass but fat mass is spared. Over the last two decades there has been no change in birthweight but there has been an increase in fat fold thickness of neonates - in boys and girls, in all gestational age and birth weight categories Indian’s proneness for adiposity begins in utero

15. Infant and young child feeding and nutritional status

16. Infant feeding practices Semisolid complementary feeds Household food Breast milk +other milk Exclusive breast feeding Not breast fed Not breast fed Breast feeding was nearly universal; however less than 50 % of infants were exclusively breast fed upto six months Very few received semisolid complementary feeds at six months. Majority of children received household food along with breast feeding by 9-11 months

17. IYCF - Key for reduction in undernutrition • Most women exclusively breast feed in the first three months and this ensures that there is no further increase in underweight rates during this period • After 3 months underweight rate rises – due to early introduction of milk supplements and higher morbidity rates due to infections, • Between 6 and 11 months underweight rate further rises to 45% - partly due to inadequate complementary feeding and partly due to increase in morbidity due to infections. Nutrition education on appropriate infant feeding is critical to prevent rise in undernutrition rates between 3-11 months

18. How do we improve intra family distribution of food ? The gap between RDA and the actual energy intake is greatest in preschool children and lowest in adults. Poor intrafamilial distribution rather than poverty appears to be the major factor responsible for low energy intake in children. Nutrition education on appropriate intra-family distribution of food holds the key for combating childhood under-nutrition

19. Over years there has been a increase in the number of households where adults are getting adequate food but children are not; poor child feeding and caring practice rather (not poverty) are major factors responsible for undernutrition in preschool child

20. Intra-family dual nutrition burden ( NFHS -3) Child undernutrition rates are higher in families in which mother is undernourished. But even if mother is normal, over 40 % of children are underweight. Poor IYCF, intrafamily distribution of food and poor health care rather than poverty is increasingly responsible for undernutrition in preschool children. Nutrition & health education on balanced adequate food , and physical activity hold the keyfor optimal health and nutrition for all age groups in the family

21. Morbidity due to infections

22. Prevalence of morbidity due to infections in relation to age Prevalence of morbidity is low in the first three months when infants are mostly solely breast fed and are relatively not exposed to poor environmental hygiene Diarrhea is the most common infection; prevalence of diarrhea and fever increase between between 6 and 23 months perhaps due to introduction of food other than breast milk and greater exposure to bacterial contamination and poor environmental hygiene After the first two years there is some reduction in morbidity due to infection.

23. Children who had morbidity during the last fortnight weighed less than those did not have morbidity during that period This could either because undernutrition predisposed to infection or infections had an adverse effect on body weight

24. Nutritional Status of children by Income Source: NFHS 1998-99 Under-nutrition rates among poor in Kerala are similar to under-nutrition rates among the rich in UP. Appropriate feeding and health care are critical for reduction in under-nutrition rates.

25. Prevention of under-nutrition in 0-59 months • Nutrition education is the critical intervention • Exclusive breast feeding for first six months, • Appropriate adequate complementary feeding 3-5 times a day from six months of age, • Continued breast feeding and feeding family food 4-5 times a day upto 24 months, • Feeding 2-5 year old children 4-6 times a day from family food consisting of cereals, pulses and vegetables. • Advise regarding timely immunisation, measures to prevent infections, and care during illness and convalescence.

26. WEIGHING INFANTS AND YOUNG CHILDREN Weighing infants and young children

27. ZERO ERROR CORRECTED ZERO ERROR CORRECTION SCREW

28. CHECKING ACCURACY OF THE BALANCE USING STANDARD WEIGHT OF ONE KILO GRAM

29. WEIGHING THE BABY

30. DETECTION OF UNDERNUTRITION USING WHO 2006 WEIGHT FOR AGECHARTS

31. Assessment of nutritional status of children by plotting weight for age AWW has marked weight for age on the WHO 2006 standard chart. There are 3 children with severe , 8 children with moderate under-nutrition. Ten children are normally nourished .

32. GROWTH MONITORING

33. Advantages of serial weight measurement

34. Normal growth trajectory in children with different birth weight 3 4 1 2 Birth weight is a major determinant of growth in infancy. If serial measurements are not taken child 3 and 4 will be classified as under-nourished; but serial measurements show that they are growing normally according to their trajectory.

35. Growth faltering detected through serial measurements of weight for age Serial measurements enable early detection of deviation from growth trajectory; correction at this early stage is easy.

36. Excessive weight gain detected through growth monitoring Serial measurement enable early detection of overnutrition, as soon as the growth deviates from the normal trajectory . Correction at this time is easy .

37. Are we using the right index for assessing nutritional status in the dual nutrition burden era ?

38. Data from NNMB surveys indicate that there has been a steady decline in stunting and underweight. As the decline in these indices have been happening at similar rates, there has not been much change in reduction in wasting rates. The lack of decline in wasting rate has not been viewed with concern.

39. Are we using right indicators to assess under-nutrition • Between NFHS 1 and 2 there was substantial reduction in stunting and underweight and some reduction wasting. These were interpreted as improvement in nutritional status of children. • In the last five years there had been no decline in underweight rates (NFHS2-NFHS3), stunting rates had shown substantial decline and wasting rates have shown an increase. • If the three indices of under-nutrition move in different directions how do we interpret results?

40. Prevalence of under-nutrition in relation to age Between three and twenty four months, there is a progressive increase in stunting and underweight rates. Wasting and low BMI rates are highest in the first three months; this is because stunting rates in the first six months are lower than underweight rates. With the progressive and relatively steeper increase in stunting rates as compared to underweight rates between six and 24 months, the wasting and low BMI rates decline. This decline should not be interpreted as improvement in nutritional status

41. There is a socio-economic gradient in prevalence of under-nutrition; however even in the highest income groups (families who had not known food insecurity or lacked access to health care for some generations) about 1/4th are stunted,1/5th underweight but only 10% are wasted .

42. Normal height, weight & BMI Normal height low Wt &low BMI Stunted, low wt & normal BMI Stunted , low wt & low BMI

43. Chronic Energy Deficiency (CED )in children initially leads to wasting. Slow growth is an adaptation to continued CED and child becomes stunted; stunted children have normal BMI. If energy intake is too low even to meet the requirements of stunted children, wasting occurs and the cycle continues…..

44. Normal height, weight & BMI Normal height low Wt &low BMI Stunted, low wt & normal BMI Stunted , low wt & low BMI NFHS 1-2 NFHS 2-3

45. Between NHFS 1 and 2 there was reduction in stunting and wasting . So there was a reduction in stunting , underweight and wasting Between NFHS 2 and 3 there was reduction in wasted children becoming stunted . So there is a reduction in stunting , not much change in underweight and increase in wasting This the natural process of improvement in nutritional status and should not cause any alarm

46. Use of BMI for detection of under and over nutrition In India stunting rates in preschool children are very high. Reversal of stunting after the first two years is rare. Many short children with high BMI are classified as underweight. India has entered the dual nutrition burden era. Shifting over to BMI-for-age will enable early detection of both under- and over-nutrition so that appropriate interventions can be initiated.

47. Nearly half the preschoolchildren are stunted and underweight . However only 1/6th have low BMI for age Among preschool children about 2% have high BMI for age; dual nutrition burden begins right in early childhood

48. Nutritional status of school age children

49. Is there a nutritional rationale for MDM School age children have relatively very low morbidity and morality rates. Growth rates of Indian school age children are comparable to the growth rates of school age children in developed countries. It is assumed that school age children have overcome their earlier nutrition and health problems. Are these assumptions backed by facts?

50. Dual nutrition burden increases during school age In preschool children prevalence of undernutrition is 17% and overnutrition is 2 %. In adults prevalence of under-nutrition is about 30% and over-nutrition is about 10% . There has been a rise in prevalence of both under and over-nutrition between preschool age and adult years. This rise could be prevented/minimised by MDM and physical activity in school age children.