Alleviation: An International Journal of Nutrition, Gender & Social Development, ISSN 2348-9340 Volume 7, Number 7 (2020): 1-11
© Arya PG College (College with Potential for Excellence Status by UGC) & Business Press India Publication, Delhi http://apcjournals.com, www.aryapgcollege.com

Understanding Indicators and Challenges of Malnutrition: An Appraisal in Children

Anjali Dewan
Associate Professor and Head (Retd.), Department of Home Science
St. Bede’s College, Shimla
(Himachal Pradesh), India
Email: dewananjali2014@gmail.com

Abstract

Malnutrition is the state of being poorly nourished. It is not merely a result of too little food, but of a combination of factors like insufficient protein, energy and micronutrients, frequent infections or disease, poor care and feeding practices, inadequate health services and unsafe water and sanitation. Although one of the major causes for malnutrition is inadequate food intake, it is influenced by other factors too. The availability of health services and access to these, the availability of care for the child and the pregnant woman, the quality of that care, whether acceptable hygiene practices are followed or not, are important contributing factors. Due to their lower social status, girls are far more at risk of malnutrition than boys of their age. Partly as a result of this cultural bias, up to one third of all adult women in India are underweight. Inadequate care of these women already underdeveloped, especially during pregnancy, leads them in turn to deliver underweight babies who are vulnerable to further malnutrition and disease. Key tools in the effort to defeat malnutrition include an adequate diet, which includes immediate and exclusive breastfeeding for the first six months and continued breastfeeding with age-appropriate complementary foods, micronutrients, prevention and treatment of disease and proper care and feeding practices. Governments have the legal responsibility to protect that rights and it is in the best interest of all that they fulfill this obligation. Children’s nutrition and well-being are the foundation of a healthy and productive society.

Keywords: Children, Deficiencies, Health, Indicators, Malnutrition.

Introduction

The nutritional status of a nation has close relationship with other indicators like the extent of economic growth, food adequacy and its effective distribution, levels of poverty, status of women, rate of population growth and access to health. Education, safe drinking water, environmental sanitation and hygiene play an important role in its determination. Every individual requires an adequate supply of nutrients in suitable proportions for normal growth and development. Malnutrition means disordered nutrition, which may be due to excessive nutrition (overnutrition), or deficient nutrition (undernutrition). Despite major improvements in the last 30 years in the health system, lives continued to be lost due to early childhood illnesses, poor or inadequate newborn care and childbirth-related causes. Sixty-three infants per every 1,000 of those born alive die before the age of one. The odds against a child surviving just being born are high, 63 infants per every 1,000 of those born alive die before the age of one. The reason for this high rate of infant mortality is closely tied up with the equally high rate of maternal deaths as few women have access to skilled birth attendants, fewer still to quality and emergency obstetric care. For those infants who do survive, the prevalence of early childhood illnesses poses a serious threat to their growth and development. More than two million children are known to die every year from preventable infections including measles and tetanus. In addition is the problem of malnutrition, which severely affects a child’s capacity to learn and grow. One in every three of the world’s malnourished children lives here and about 50 per cent of all childhood deaths in India are attributable to malnutrition.
Although one of the major causes for malnutrition is inadequate food intake, it is influenced by other factors too. The availability of health services and access to them, the availability of care for the child and the pregnant women, the quality of that care, whether acceptable hygiene practices are followed or not are important contributing factors. Due to their lower social status, girls are far more at risk of malnutrition than boys of their age. Partly as a result of this cultural bias, up to one third of all adult women in India are underweight. Inadequate care of these women especially during pregnancy, leads them in turn to deliver underweight babies who are vulnerable to further malnutrition and disease. In addition is the widespread prevalence of anaemia amongst children under three and of vitamin A and iodine deficiencies.
India having 2.5 per cent of the global land mass and 16 per cent of the global population recognized the importance of human resources as the engines powering national development and gave high priority to improvement of the health and nutritional status of the population. Article 47 of the Constitution of India states that, ‘the State shall regard raising the level of nutrition and standard of living of its people and improvement in public health among its primary duties’. As a result of various interventions, famines and severe food insecurity are no longer a threat but even today seasonal food insufficiency is seen in different pockets of the country. The UN Secretary-General’s Zero Hunger Challenge launched at Rio+20 called on governments, civil society, faith communities, the private sector and research institutions to unite to end hunger and eliminate the worst forms of malnutrition. The Zero Hunger Challenge has since garnered widespread support from many member States and other entities. It calls for:
• Zero stunted children under the age of two.
• Hundred per cent access to adequate food all year round.
• All food systems are sustainable.
• Hundred per cent increase in small holder productivity and income.
• Zero loss or waste of food.
The Sustainable Development Goal (SDG-2) to ‘End hunger, achieve food security and improved nutrition and promote sustainable agriculture’ recognizes the inter linkages among food and nutritional security in India. Beyond adequate calories intake, proper nutrition has other dimensions that deserve attention, including micronutrient availability and healthy diets. Inadequate micronutrient intake of mothers and infants can have long-term developmental impacts. Unhealthy diets and lifestyles are closely linked to the growing incidence of non-communicable diseases in both developed and developing countries. Adequate nutrition during the critical 1,000 days from beginning of pregnancy through a child’s second birthday merits a particular focus

Hazards of Malnutrition
Malnutrition can be hazardous to the physical, physiological, behavioural, mental and emotional well-being of the individual. A malnourished person will be below normal in height and weight as compared to the normal person. He will have low resistance to and high susceptibility for infectious diseases. Normal tissue functions will not be improved especially of the intestinal tract. The liver may suffer from damage due to low protein diet, becoming more susceptible to injury by toxic agents.
Undernourished persons are more susceptible to cold and may have a subnormal body temperature. They may have a tendency towards low blood pressure and oedema. Malnutrition’s most devastating impact is in the womb – when the foetus fails to develop properly and during the first years of a child’s life, when it can hamper her or his physical and mental development. They are also more prone to contracting diseases like dysentery, chicken pox and respiratory infections. Children of poorly nourished mothers who have been breastfed may grow satisfactorily for the first few months but growth becomes impaired and slows down afterwards. Malnourished children have delayed milestones and impaired cognitive development and are likely to be handicapped for life if an innovative approach is not adopted. Thus, malnutrition impairs intelligence, strength, energy and productivity.

Indicators of Malnutrition
The symptoms of malnutrition are generally manifested in the form of physical cellular activity. Normal composition of the body fluids is often altered as in the case of oedema. Several clinical symptoms which can be noticed in the body are as follows:
Hair
Lack of lustre, easy pluckability, dry hair, easy falling of the hair while combing.
Face
Becomes dry, develops rashes, dermatitis, nasolabial seborrhoea and cracking of the lips.
Eyes
The eyes are very sensitive to nutritional disorders. In the case of severe deficiency, the epithelium of the conjunctiva becomes keratinized, followed by excessive dryness due to insufficient secretion. The cornea in front of the eye gets usually bright and the moist lustre of the eye is lost. There is corneal vascularization, photophobia and bitot spots.
Lips
Cheilosis and angular stomatitis characterized by cracking, crusting and swollen lips.
Tongue
Glossitis, oedema accompanied by pain, loss of taste, magenta coloured tongue which has cracks.
Teeth
Teeth become decayed, fall off quickly, are mottled, chalky white or brownish discolouration of enamel.
Gums
Becomes spongy, swollen with bleeding.
Skin Xerosis (abnormal dryness of the skin and eyes) and excessive follicular hyperkeratosis resulting in dermatitis and rash. The skin becomes loose, pale, cold, rough, pigmented in patches especially around the hair follicles resulting in phyrnoderma or toad’s skin.
Glands
Enlargement of the parotid and thyroid glands occurs due to malnutrition.
Skeleton and Muscles
Skeletal abnormalities are manifested in the form of enlarged wrists, bending of ribs, bending of bones as in the case of rickets and osteomalacia. Muscle wasting occurs in underfed persons. Muscular dystrophy also occurs.
Nervous and Cardiac Disorders
Nervous symptoms are in the form of motor weakness, mental confusion and loss of sensations. Undernutrition may also lead to cardiac enlargement in certain cases.
Causes of Undernutrition
There are a number of causes of undernutrition which are as follows: Ignorance
Lack of knowledge about the kinds and amounts of food needed for good nutrition is one of the main causes of inadequate food intake and consequent undernutrition. The specific requirements of children, increased nutritional needs of women during pregnancy and lactation are examples where such knowledge is required. Wrong ways of weaning the child often lead to infant malnutrition. Ignorance about health and nutrition and frequent episodes of infections due to nutrition related deficiencies have been recognized as associated as well as aggravating factors.
Poverty
Malnutrition has been perceived mainly as a problem of poverty due to which a large number of poor cannot afford a balanced diet. Poor economic conditions, which reduce the purchasing power of an individual, constitute one of the major reasons for the inadequate food intake among the poorer sections of the society. Poverty together with ignorance precipitates a condition of undernutrition among individuals. Infants of mothers from low economic strata suffer in two ways. Firstly, they are weaned off without suitable alternative foods. Secondly, other milk given in dilute forms under poor hygienic conditions may substitute the breast milk.
Individual Factors
Individuals may be undernourished due to their socio-cultural and religious values that force them to stick to old beliefs about food habits. Personal food fads and the desire to look slim may also deprive an individual of adequate nourishment.
Maternal Health
Various studies have shown that nearly one third of infants are of low birth weight (less than 2.5 Kg), largely attributable to poor maternal health and nutritional status. Nutritional anaemia, due to iron deficiency, continues to be a major public health problem among women in the reproductive age, especially during pregnancy and adolescence. Nearly 88 per cent of pregnant women are estimated to be anaemic. This is a cause for concern since the status of maternal nutrition determines the course of intra-uterine growth and development of the foetus, the birth weight of the infant, the lactation performance of the mother, the growth and development of the infants.
Accidents and Ill-health
Prolonged and acute illness like anaemia, diarrhoea, , trauma from burns, fractures, profuse bleeding due to accidents and operations and resultant malnutrition may also lead to undernutrition.
Alcoholism and Drug-Addiction
Excessive intake of alcohol and drugs during pregnancy interferes with normal food consumption and digestion. Psychological factors lead to lack of appetite. Inability to eat foods or allergy may also contribute to undernutrition in the mother as well as her children.
Environmental Factors
The home environment is an important factor in developing proper nutritional habits. Faulty meal timings, over-fatigue before taking food, overemphasis on table manners among children often interferes with satisfactory food intake. These factors affect the feeding habits of the children leading to malnutrition. Natural calamities like famine, floods and droughts cause acute shortage and non-availability of food resulting in starvation.
Increasing Urbanization
A number of families go from villages to cities hoping to find better means of livelihood. Often, living conditions for such families are even worse than what they had in villages. Overcrowding, insanitary environmental conditions, poor hygiene, contaminated water supplies cause recurrent attacks of diarrhoea and other diseases. This intensifies the problem because whatever little food is consumed is not absorbed but lost.
Both the Parents Have to Work
In poor communities, often an elder child who is a few years older than the infant is left to take care of the young ones. Without the supervision by adults, the children are not fed properly and may start to show the symptoms of undernutrition.
Wrong Cooking Practices
Like draining off the rice water at the end of cooking, prolonged boiling in open pans, peeling of vegetables, cutting of too small or too big pieces of food all influence the nutritive value of foods.
Challenge- How to Rectify the Problem of Malnutrition
Government of India Action on Nutrition
The key tools in the effort to defeat malnutrition include: an adequate diet, which includes immediate and exclusive breastfeeding for the first six months and continued breastfeeding with age-appropriate complementary foods, micronutrients, prevention and treatment of disease and proper care and feeding practices. It is also important to protect the rights of women and girls. Wherever women are discriminated against, there is greater malnutrition. Children born to mothers with no education are twice as likely to die in infancy as those born to mothers with even four years of schooling. Reproductive health, including birth spacing for at least three years, also reduces stunting and death. A child’s nutritional future begins with the mother’s nutritional status in adolescence and in pregnancy. Low birth weight occurs because of poor maternal health and nutrition and poor foetal growth.
A mother needs an extra share of the best foods available to the family, just as she did in pregnancy. She needs these foods right through two years of breastfeeding, not just in the first months. If a mother is moderately malnourished, she will continue to make milk of good quality, better than infant formula. If she is severely malnourished, the quantity of breast milk produced for each feeding may be diminished. In both cases, for the health of the mother and the child, it is safer and better to feed the mother adequately while helping her to continue breastfeeding.
A multi-sectorial approach is, therefore, required to tackle the problem of malnutrition and other associated disorders. Vulnerability of children, pregnant women and nursing mothers has been recognized. The range of direct interventions expanded over the years to cover supplementary feeding of children and mothers needs to be recognized. The future strategy needs to emphasize the value of diversification and improvement of the diets. Increased production of cereals and pulses, green leafy vegetables, fruits, eggs, fish, milk and their availability at an affordable price are important. Strict implementation of the Prevention of Food Adulteration Act will also be necessary, so that the nutritive value of foods is not affected. Diet nutrition intervention programmes will need to focus on children below six years of age, adolescent girls, pregnant and nursing mothers belonging to low income groups. Scheduled castes, scheduled tribes and people living in drought prone areas, backward and hill areas and urban slums need special care. Attention should be given to tackle the nutritional problems of anaemia, vitamin A deficiency, goitre, lathyrism and fluorosis.
Dietary Guidelines for the Poor
The Indian Council for Medical Research (ICMR) makes periodic recommendations on desirable diets for Indian populations. Considering the fact that at least one-third of the households in India are not able to afford even the minimum nutritional requirements (these households spend 80% of their income on food), the ICMR felt that it’s Recommended Diet Intake (RDI) should also have practical suggestions as to how the recommended nutrient allowance could be procured from low-cost diets.
In recommending diets for poor Indian Groups, the ICMR has been guided by the following considerations:
• Diets recommended should be least expensive and confirm to traditional and cultural practices as closely as possible.
• Energy derived from cereals need not exceed 75 per cent of the total energy requirement.
• Pulse (legume) intake should be such that the ratio of cereal protein to pulse protein does not exceed 5:1. This would imply that pulse intake should be at least around 9 per cent to 10 per cent of the cereal intake. The diet should provide for a minimal milk intake of 150 ml. These recommendations regarding intake of pulses and milk were designed to improve the protein quality of the predominantly cereal-based diet, usually devoid of animal protein to minimal acceptable levels.
• About 150g of vegetables (leafy and other vegetables) should be provided. These were considered as levels which will not unduly increase the bulk of the cooked food-a major consideration in all diets that are heavily cereal-based.
• Energy derived from fat and oil need not exceed 15 per cent of total calories. This takes into consideration the fact that cereal diets already provide invisible fats at levels of about 10 per cent of total energy.
• Energy derived from refined carbohydrates (sugar or jaggery) need not exceed 5 per cent of total calories.
Agriculture Production
Agriculture systems worldwide must become more productive and less wasteful. Sustainable agricultural practices and food systems, including both production and consumption, must be pursued from a holistic and integrated perspective. Land, healthy soil, water and plant genetic resources are key inputs into food production and their growing scarcity in many parts of the world makes it imperative to use and manage them sustainably. Boosting yields on existing agricultural lands, including restoration of degraded lands, through sustainable agricultural practices would also relieve pressure to clear forests for agricultural production. Wise management of scarce water through improved irrigation and storage technologies, combined with development of new drought-resistant crop varieties, can contribute to sustaining dry land productivity. Halting and reversing land degradation will also be critical to meeting future food needs. There are many elements of traditional farmer knowledge enriched by the latest scientific knowledge, can support productive food systems through sound and sustainable soil, land, water, nutrient and pest management and the more extensive use of organic fertilizers. An increase in integrated decision-making processes at national and regional levels are needed to achieve synergies and adequately address trade-offs among agriculture, water, energy, land and climate change. Building resilience of local food systems will be critical to averting large-scale future shortages and to ensuring food security and good nutrition for all.
Efforts of UNICEF to Deal with the Problem of Malnutrition
UNICEF supports the national reproductive and child health programme in its aim to reduce maternal, neonatal and child mortality. In partnership with the government, it aims to improve overall immunization coverage, to raise awareness of the indispensable role played by routine immunization in protecting a community’s health and to promote an integrated management of early childhood illnesses. UNICEF also helps the government in its strategies to reduce and prevent malnutrition. It assists the government in expanding and enhancing its integrated child development service programme by helping to improve the training of childcare workers and developing community-based, early childcare interventions that address issues surrounding inadequate nutrition and mineral and vitamin deficiencies.
When an emergency strikes, UNICEF’s foremost priority is to prevent death and malnutrition in the affected population, particularly in the most vulnerable groups: infants, children, pregnant women and breastfeeding mothers. UNICEF assesses the nutritional and health needs of affected populations, protects and supports breastfeeding, especially exclusive breastfeeding by providing safe havens for pregnant and lactating women, provides essential micronutrients, supports therapeutic feeding centres for severely malnourished children and provides food for orphans. Through its strong supply capability and global on-the-ground presence, UNICEF is able to ensure rapid delivery of emergency supplies, including food. UNICEF and the World Food Programme (WFP) work together to strengthen and sustain the ability of households to meet their basic needs for food, care of children and women, health services and water and sanitation. The acute forms of malnutrition must be treated in 24-hour care facilities, either in hospitals, health centres or in therapeutic feeding centres. After recovery from severe malnutrition, these children require special support in the community to ensure they continue to grow normally.
The Path Forward
There has been a substantial reduction in severe grades of under nutrition and micronutrient deficiencies and some improvement in the nutritional status of all the segments of population. As the population continues to grow, much more effort and innovation will be urgently needed in order to sustainably increase agricultural production, improve the global supply chain, decrease food losses and waste and ensure that all who are suffering from hunger and malnutrition have access to nutritious food. Availability and use of safe drinking water is a must for prevention of water-borne diseases. Education of the community on the consumption of safe water and keeping the environment clean would be necessary to improve the health and hygiene. Nutrition education would focus on nutrition management, nutritional rehabilitation of malnourished children, food safety, environmental sanitation and hygiene, safe drinking water. Mass and folk media, non-formal channels of communication should be used to project messages which take into account dietary habits, local availability of food and beliefs associated with avoidance and intake of foods.
The socio-cultural bias in the intra-family distribution of food in a manner, which adversely affects the girl children and women, should be tackled through nutrition education. Modernization has tended to erode traditional breast feeding and weaning practices. The consumption of commercial baby foods is increasing. Breast-feeding and home made nutritious inexpensive weaning food recipes should be promoted. Health and nutrition education needs to be taken up on a large scale through the infrastructure of academic institutions, training organizations, industrial establishments and the mass media.
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