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India and Acute Malnutrition in Children Veena Shatrugna National Institute of Nutrition Hyderabad

India and Acute Malnutrition in Children Veena Shatrugna National Institute of Nutrition Hyderabad India. -1- Absolute Weights – A 30 year trend (Mean in Kg)

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India and Acute Malnutrition in Children Veena Shatrugna National Institute of Nutrition Hyderabad

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  1. India and Acute Malnutrition in Children Veena Shatrugna National Institute of Nutrition Hyderabad India

  2. -1- Absolute Weights – A 30 year trend (Mean in Kg) • Rural Rural Rural Rural NCHS Median 1977 1996 2003 2006 Values • Age F M F M F M F M F M • 01+ 7.5 8.1 8.1 8.7 8.1 8.6 8.3 8.9 9.5 10.2 • (219-920) • 03 10.6 10.4 11.3 11.7 11.4 11.9 11.8 12.1 14.1 14.6 • (218-916) • 05 13.7 14.1 13.6 14.4 14.1 14.6 14.5 14.7 17.7 18.7 • (229-747) • 22.0 21.6 22.4 22.6 23.1 23.1 23.9 23.9 32.5 31.4 • (304-734) • 20-24 42.9 48.1 43.5 50.3 43.8 50.9 45.0 52.2 56.6 68.9 • (509-3870) • >70** - - 39.1 47.3 41.5 49.2 40.6 49.0 - - • (161-178) • Source:** NNMB 1977, 1996, 2003, 2006

  3. -2- Absolute Heights – A 30 year trend (Mean in cm) Rural Rural Rural Rural NCHS Median 1977 1996 2003 2006 Values Age F M F M F M F M F M 01+ 71.9 73.1 72.8 75.0 73.8 75.3 74.0 75.7 74.3 76.1 (219-920) 3+ 85.8 86.4 88.4 90.1 89.8 91.1 89.9 91.1 93.9 94.9 (218-916) 05+ 99.6 100.5 100.4 102.1 102.5 103.2 102.4 102.6 108.4 109.9 (229-747) 10+ 125.7 125.1 126.8 127.9 128.5 128.7 128.9 129.0 138.3 137.5 (304-734) 20-24 151.2 163.4 151.5 164.0 151.1 163.3 152.0 164.2 163.7 176.8 (509-3870) >=70 147.9 162.3 147.9 161.0 146.8 160.0 145.5 159.9 - (339-728) Source: NNMB Reports, 1977, 1996, 2002, 2006

  4. -3- % DISTRIBUTION OF ADULTS ACCORDING TO BMI CLASSIFICATION 20 YEAR TREND BMI 1974‑79* 1988‑90* 1996-97** 1993‑94*** 2002* CLASSES (RURAL) (RURAL) (RURAL) (URBAN) (RURAL) <18.5 (CED) F 51.8 49.3 47.7 36.7 38.9 M 55.6 49.0 45.5 42.8 36.6 (NORMAL) F 44.8 46.6 46.3 51.7 52.4 18.5‑25.0 M 42.1 48.3 50.4 51.8 57.2 (OBESE) F 3.4 4.1 6.3 11.6 8.7 >=25 M 2.3 2.7 4.1 5.5 6.2 * NNMB, 1991, quoted by N,Nadamuni Naidu et al, 1994. * Rural, 2002 ** NNMB, Rural surveys, 1996; *** NNMB Urban Surveys, 1994

  5. - 4 a - % DISTRIBUTION OF ADULTS ACCORDING TO BMI CLASSIFICATION - NNMB 2006 < 16 16-17 17-18.5 18.5-20 20-25 > 25 (CED III) (CED II) (CED I) (Low Wt. (Normal) (Over wt.) Normal) Men 5.7 7.9 19.6 21.7 37.3 7.0 Women 8.0 9.0 19.0 18.7 34.4 9.1

  6. - 4b - Distribution (%) of Adults According to BMI Classification 10 year trend BMI Males Males Females Females 1996 2006 1996 2006 <16.0 8.6 5.7 11.8 8.0 16.0-17.0 11.0 7.9 12.8 9.0 17.0-18.5 25.9 19.6 23.2 19.0 18.5-20.0 25.3 21.7 20.0 18.7 20.5-25.0 25.2 37.3 26.4 34.4 >25 4.1 7.0 6.0 9.1 Source: NNMB, 1996 & 2006(Rural)

  7. - 5 - Thinness as a public health problem Low prevalence (warning sign, monitoring required): 5-9% of population with BMI <18.5 Medium prevalence (poor situation): 10-19% of population with BMI <18.5 High prevalence (serious situation): 20-39% of population with BMI <18.5 Very high prevalence (critical situation):  40%of population with BMI <18.5

  8. - 6 - • Mean Birth Weights in different parts of the world • Region Mean Birth Weight • (kg) • North America, Western Europe 3.5-3.6 • and Australia • Eastern Europe 3.1-3.3 • Africa and East Asia 2.9-3.1 • South Asia 2.7

  9. - 7 - Mean Birth Weights and LBW in SEAR LBW Country N (<2500g) Birth weight (Kg) India 4307 33.0 2.63 Nepal Rural 2529 14.3 2.78 Urban 3629 22.3 2.76 Sri Lanka 1851 18.4 2.84 Myanmar 3582 17.8 2.85 Indonesia 1647 10.5 2.94 Thailand 4124 9.6 3.00 USA Afro-American 4614 10.6 3.14 Whites 16481 6.0 3.36 *Source: WHO, 1993.

  10. - 8 -MATERNAL PARAMETERS (MEANS) ACCORDING TO BMI STATUS BMI CLASSES N MOTHER'S (Wt, Kg.) BIRTH (Wt, Kg.) LBW (<2500 g)% <16.0 81 35.4 2510 53.1 CED III 16.0-16.9 133 38.1 2573 41.4 CED II 17.0-18.4 460 40.9 2653 35.9 CED I 18.5-19.9 553 44.1 2771 27.7 (NORMAL) 20.0-24.9 717 49.6 2812 26.4 (NORMAL) 25.0-29.9 68 60.6 2972 14.7 (OBESE) > 30 5 75.5 2972 20.0 (OBESE) TOTAL 2017 45.2 2742 30.5 Source : NNMB Repeat Surveys (1991) , Quoted by Nadamuni Naidu et al, 1994.

  11. - 9- Birth Weight and Socio-Economic Status Poor Middle High income income income Height (cms) 151.5 154.2 156.3 Weight (kg) 45.7 49.9 56.2 Hb(g/dl) 10.9 11.1 12.2 Birth weight (kg) 2.70 2.90 3.13

  12. -10- BIRTH WEIGHTS IN POOR AND WELL TO DO GROUPS IN MADRAS AND COONOR NB.WT PREMATURE Lbs Kg (%) 1949 SPEL.WARD 1269 7.12 3.2 - GEN.WARD 1179 6.3 2.8 - 1954 SPEL.WARD 200 6.85 3.08 12.3 GEN.WARD 500 6.01 2.7 8.4 SOURCE : Varkki C, et al, 1955.

  13. -11- • Birth weights (kg) in poor after supplementation • 1971 1972 • No No • Supplementation Supplementation Supplementation Supplementation • Food Folic acid Iron Iron+ Folic acid • 2.704 3.028 2.920 2.570 2.650 2.899 • Source : L.Iyengar, 1972.

  14. -12 - Attempts made to increase birth weights in poor socio-economic group 1. Iron 2. Folic acid 3. Iron and Folic acid 4. Zinc 5. Vitamin A 6. N3 fats, fish oils 7. Micro nutrients 8. Reduction of activities

  15. - 13 - Distribution (%) of 1-5 years children according to nutritional status (Weight for age) by sex-Gomez classification Nutrition Grades* Boys Girls Pooled (n=2011) (n=1957) (n=3968) Normal13.1 12.1 12.6 Mild 45.5 45.5 45.5 Moderate 37.4 37.8 37.6 Severe 4.0 4.6 4.3 * NCHS standards Source: NNMB 2005.

  16. -14 a- Distribution (%) of 1-5 years according to Weight for age – standard deviation (SD) classification by gender Weight for age* Boys Girls Pooled (n=2011) (n=1957) (n=3968)  Median 3.5 3.6 3.6 -1SD to Median 11.4 10.1 10.8 -2SD to -1SD 31.4 31.1 31.2 -3SD to -2SD 38.2 37.7 37.9 <Median - 3SD 15.5 17.5 16.5 * NCHS standards Source: NNMB 2005.

  17. - 14b - Distribution (%) of 1-5 years according to Weight for age – standard deviation (SD) classification by Age groups Weight for age* < 1 1-3 3-5  Median 23.1 4.5 2.7 -1SD to Median 26.7 11.5 10.9 -2SD to -1SD 27.9 28.8 31.7 -3SD to-2SD 16.2 35.0 39.9 <Median -3SD 6.1 20.2 14.9 * NCHS standards Source: NNMB 2005.

  18. - 15 a - Distribution (%) of 1-5 years children according to Height for age standard deviation (SD) classification by gender Height for age* Boys Girls Pooled (n=2011) (n=1957) (n=3968)  Median 8.0 6.6 7.3 -1SD to Median 15.5 13.4 14.5 -2SD to -1SD 26.4 25.5 26.0 -3SD to -2SD 26.6 27.9 27.2 <Median - 3SD 23.5 26.6 25.0 * NCHS standards Source: NNMB 2005.

  19. - 15 b - Distribution (%) of 1-5 years according to Height for age – standard deviation (SD) classification by Age groups Height for age* < 1 1-3 3-5  Median 28.3 9.4 6.2 -1SD to Median 27.6 16.3 14.0 -2SD to -1SD 25.5 23.0 28.2 -3SD to-2SD 12.8 24.8 28.2 <Median -3SD 5.7 26.5 23.5 * NCHS standards Source: NNMB 2005.

  20. -16 a - Distribution (%) of 1-5 years children according Weight for Height standard deviation (SD) classification by gender Weight forHeight * Boys Girls Pooled (n=2457) (n=2399) (n=4856)  Median 10.8 13.2 12.0 -1SD to Median 31.5 31.1 31.3 -2SD to -1SD 41.8 41.6 41.7 -3SD to -2SD 13.3 11.8 12.6 <Median - 3SD 2.5 2.3 2.4 * NCHS standards Source: NNMB 2005-06.

  21. -16 b - Distribution (%) of 1-5 years according to Weight for Height– standard deviation (SD) classification by Age groups Weight for Height * < 1 1-3 3-5  Median 23.5 11.7 12.2 -1SD to Median 39.4 30.2 32.4 -2SD to -1SD 24.1 43.6 39.9 -3SD to-2SD 8.6 11.8 13.3 <Median -3SD 4.4 2.6 2.2 * NCHS standards Source: NNMB 2005.

  22. -17 - ICMR Balanced diet for adults (1 Cu) Cereals Pulses Veg Roots Flesh Milk Fats Sugar Nuts Fruits Condi- foods ments 460 40 40 60 - 150 25 30 - - -

  23. - 18 - Intake by age (> 70% of RDA) Age Cereals Pulse L.V. Others R& T Milk Fat Sugar (yrs) 1-3 54 15 8 35 55 10 10 14 4 - 6 62 29 10 42 56 8 5 11 Male 58 29 15 39 56 8 3 11 10-12 Female 67 30 15 37 55 7 3 12 Male 81 51 15 47 60 33 10 31 > 18 Female 77 39 10 50 56 37 27 50

  24. - 19 -Nutrient intakes ( >70% of RDA) by Age Age (yrs) Energy Protein Fat Calcium Iron Vitamin A 1-3 30 62 23 19 15 8 4 -6 31 73 30 28 15 10 7- 9 38 61 36 37 13 7.5 Male 45 50 54 24 9 9 10-12 Female 57 41 51 22 11 9 Male 55 40 65 32 10 11 13-15 Female 70 39 58 25 15 9 Male 70 40 60 32 12 9 16-17 Female 70 43 62 35 14 10 Male 80 77 85 70 29 11 >18 Female 89 78 77 61 15 11

  25. 20 – • Other nutritional problems • Apart from stunting and under weight – • Anaemia - 60-90% • Iodine Deficiency - endemic most parts of the country • Goitre - endemic in North East, sub Himalayan range, many tribal belts in central India • Fluorosis - endemic many parts of the country

  26. 21 – • According to Recommended Dietary Guidelines • 60-65% Calories from Carbohydrates • 25-30% from Fat • 10-12% from Protein • Each of these calories, proteins and fats must be derived from as many foods as possible • In the rural area of India 80% of Calories are derived from from Cereals • Those with adequate calories from cereals have high iron intakes, but because almost All the calories come from cereals, the iron is not available…this population must derive its calories from other sources such as pulse, meat, vegetable, milk egg to use this iron.

  27. - 22 - • Children Only 30% have calorie adequacy (from cereals). They are deficient in all the other nutrient rich foods recommended for children. • The WHO Recommendation • Calories -30-40% must come from fats (low volumes and energy densities) • Vitamin A, calcium, iron - from milk, eggs, flesh foods, vegetables, fruit etc. (will also contribute additional calories), • Cereals, pulse to be used to bridge the calorie gap. • In India – it is reversed, cereal load has resulted in simple minded diagnosis of micronutrient deficiencies.

  28. - 23 - How did we reach this Cereal – Calorie Trap ? RDA, Consumption units Minimum Wages Poverty Line Green Revolution---PDS The consumption unit story

  29. - 24- RDA ICMR Balanced diet for adults (1 Cu) Cereals Pulses Veg Roots Flesh Milk Fats Sugar Nuts Fruits Condi- foods ments 460 40 40 60 - 150 25 30 - - -

  30. - 25 - Coefficient for computing calorie requirement of different groups* Group Cu-Units Adult male (sedentary worker) 1.0 Adult male (moderate worker) 1.2 Adult male (heavy worker) 1.6 Adult female (sedentary worker) 0.8 Adult female (moderate worker) 0.9 Adult female (heavy worker) 1.2 Adolescents 12 – 21 years 1.0 Children 9 to 12 years 0.8 Children 7 to 9 years 0.7 Children 5 to 7 years 0.6 Children 3 to 5 years 0.5 Children 1 to 3 years 0.4 *Source: Gopalan et al (1991)

  31. - 26 - Minimum Wages - Criteria 1. 3 consumption units * for one wage earner 2. 2700 cals per average Indian adult 3. ? Clothing - 72 yards per annum per family 4. ? House rent 5. ? Fuel, Lighting etc… - 20% of wages 6. ? Education, Medical and other expenses

  32. - 27 - Since Minimum wages are based on calories Cheapest source of 2000 calories (Gm) Cost (Rs.) Sugar 520 8.00 Rice 571.4 11.0 Oil 225 ml 18.0 Dals 500.0 22.0 Potato 2000 20.0 Sapota, banana 1740 25 Milk 3250ml 60 Chicken 2000 120 Dry fruits 400 200

  33. - 28 - Micironutrients essential for man • Vitamins Trace minerals • Micronutrients known to be essential for man and animals • Vitamin A Thiamin Iron Selenium • Vitamin D Riboflavin Iodine Manganese • Vitamin K Nicotinic acid Zinc Chromium • Vitamin E Pyridoxine Copper Cobalt • Essential fatty acid Folic acid • (-6 and  -3) • Biotin (?) Vitamin B12 • Pantothenic acid (?) Ascorbic acid • B. Micronutrients essential for animals and not yet established as essential for man • Choline Silicon Molybdenum • p-Aminobenzoic acid Fluorine Arsenic • Nickel • Source: Narasinga Rao BS.

  34. - 29 - Phytonutrients for Health Promotion Phytonutrient class Carotenoids Glucosinolates, Isothiocyanates, Indoles Inositol phosphates Phenolics, cyclic compounds Phytoestrogens Phytosterols Polyphenols Protease inhibitor Saponins Sulfides and thiols Source: Beecher

  35. - 30 - Dietary antioxidants Nutrients Non-nutrients -Carotene-provitamin A Carotenoids (lycopene,xanthophyls) Ascorbic acid-vitamin C Lutein, -and -carotenes (cryptoxanthine, zeaxanthine) Tocopherols Flavonoids (quercetin, myricetin, quercetagatin, gossypetin) Tocotrienols Riboflavin Sulfur amino acids Anthocyanins Cysteine and methionine Isoflavones Selenium Phenolic compounds (catechin) Indoles Source: Narasinga Rao, BS.

  36. - 31 - • Phytonutrients act synergistically with micronutrients – as part of an orchestra. • Example - -carotene, vitamin C, vitamin E and selenium act as Antioxidants with flavonoids, carotenoids and phenolic compounds. • An orchestra cannot be converted to a solo. • -carotene supplementation to prevent lung cancer did not lower rates of lung cancer – it increased it among high risk groups. • Single agents can be counter productive.

  37. - 32 - Distribution (%) of children by protein –calorie adequacy status Age (yrs) % with adequate % with adequate calories Vitamins Minerals 1-3 31.8 8.0 15.0 4-6 28.2 10.0 20.0 7-9 28.1 7.5 20.0 10-12 26.0 (B) 9.0 15.0 32.9 (G) Source: NNMB Reports, 2002

  38. 33 – • Mean intake of one Nutrient iron (mg) by levels of percentage RDA of energy

  39. 34 – • Mean intake of one nutrient iron (mg) by levels of percentage RDA of energy

  40. - 35 - Supplying additional iron would reduce anemia only if iron is very deficient and only up to the point where another factor becomes rate limiting. In the case of poor societies, other factors- both nutritional and environmental- are as important. Therefore, management of nutritional anemia requires Health and food (providing many nutrients, not just iron). Instead of putting all nutrients into one food (cereal) Cereal should be eaten with nutrient rich foods.

  41. - 36 - • Further addition of iron in these diets or iron supplements may cause iron overload known to have the following impacts on • Oxidative damage, diarrhea, in undernourished populations • Infections, like Malaria, TB, HIV, • Even deaths • What is required is sources of foods which make the iron available such as • Vitamin C rich foods • Small amounts of meat which provides haem iron • Fill the calorie gap with foods other than cereals • These increase the iron availability by 10 times.

  42. 37 - • Wheat flour fortification • To increase intakes of iron – using whole wheat flour (cereal) - iron availability is only – 1-2% • Other option - chemical addition to whole wheat flour • NaEDTA – to increase iron availability by 2-3 times • However, it increases viscosity of the flour • ? Toxicity – and binding with other metal ions • Costly – four times • Ferrous sulfate - without EDTA low bioavailability • alters taste – with EDTA – iron amount have to be decreased net iron intake the same • Elemental iron – Low bioavailability • Fortification of flour in the West is carried out using MAIDA (refined flour)

  43. - 38 - Options – whole country to switch to Refined flour (MAIDA) or Tolerate Toxicity of EDTA Safe levels to be calculated in undernourished populations Intake should not be more than 2.5 mg / kg body weight At this level of EDTA it does not provide adequate iron for children No studies on the use of fortified flour in children

  44. - 39 - St.John’s study (Kurpad) Role of school lunch programme on anemia status of school children Government school children – given the usual vitamin A and anti-helmenthic Had the regular school lunch programme (cooked rice, dal, some vegetables) No iron tablets were distributed Anemia reduced from 60% to 20% Important role of providing food on Anemia

  45. - 40 - Millions of tons of cereals will be processed so that a few mg quantities of a nutrient is added– and only 1-5% is available to humans Need to re-look at strategy Studies done in the following countries did not show improvements in haemoglobin after the distribution of iron fortified wheat flour. Srilanka Bangladesh Thailand Morocco Ivory coast India

  46. 41 – • The National Anemia Prophylaxis Programme • Iron tablets – distributed undermedical supervision. • Health care may be accessed (differences between Pemba and Nepal study) • Iron Fortified Wheat Flour – may leave Governments and people complacent. • Research on the relative safety of iron supplements as tablets or elixirs and fortified foods in areas endemic for malaria and other intracellular infections are not known.

  47. - 42 - 15th ILC - Dr.Aykroyd’s Recommended Diet (1957) gr. Cereals- 14 oz - 420 Pulses 03oz - 90 Vegetables 10 oz - 300 Milk 10 oz - 300 Sugar/ 02oz - 60 Oil / ghee 02oz - 60 Fruits 02 oz - 60 Fish / meat 03 oz - 90 Eggs 01 oz - 30

  48. - 43 - Average Intake of Nutrients (per day) (Boys and Girls) Age (yrs) 1 – 3 4 - 6 Mean RDA Mean RDA Protein (g) 20.2 22.0 28.7 30.0 Total fat (g) 10.7 25.0 12.7 25.0 Energy (Kcal) 719 1240 1020 1690 Calcium (mg) 245 400 272 400 Iron (mg) 5.7 12 8.6 18 Vit.A (µg) 129 400 166 400 Thiamin (mg) 0.5 0.6 0.7 0.9 Riboflavin (mg) 0.3 0.7 0.4 1.0 Niacin (mg) 5.2 8.0 7.9 11.0 Vit.C (mg) 17 30 25 40 Free folic acid (µg) 20.3 30 28.8 40

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