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India and Acute Malnutrition in
Children
Veena Shatrugna
National Institute of Nutrition
Hyderabad
India
Absolute Weights – A 30 year trend (Mean in Kg)
-1-
Rural
1977
Age
01+
Rural
1996
Rural
2003
Rural
2006
NCHS Median
Values
F
7.5
M
8.1
F
8.1
M
8.7
F
8.1
M
8.6
F
8.3
M
8.9
F
9.5
M
10.2
10.6
10.4
11.3
11.7
11.4
11.9
11.8
12.1
14.1
14.6
14.1
13.6
14.4
14.1
14.6
14.5
14.7
17.7
18.7
22.0
21.6
22.4
22.6
23.1
23.1
23.9 23.9
32.5
31.4
42.9
48.1
43.5
50.3
43.8
50.9
45.0
52.2 56.6
68.9
-
39.1
47.3
41.5
49.2
40.6
49.0
(219-920)
03
(218-916)
05
13.7
(229-747)
10
(304-734)
20-24
(509-3870)
>70**
-
(161-178)
Source:** NNMB 1977, 1996, 2003, 2006
-
-
-2Absolute Heights – A 30 year trend (Mean in cm)
Rural
1977
Age
F
01+
71.9
(219-920)
3+
85.8
Rural
1996
Rural
2003
Rural
2006
NCHS Median
Values
M
73.1
F
72.8
M
75.0
F
73.8
M
75.3
F
74.0
M
75.7
F
M
74.3 76.1
86.4
88.4
90.1
89.8
91.1
89.9
91.1
93.9
100.5
100.4
102.1
102.5 103.2
102.4
102.6 108.4 109.9
125.1
126.8
127.9 128.5 128.7
128.9
129.0 138.3 137.5
163.4
151.5
164.0
151.1 163.3
152.0
164.2 163.7 176.8
162.3
147.9
161.0
146.8 160.0
145.5
159.9
94.9
(218-916)
05+
99.6
(229-747)
10+
125.7
(304-734)
20-24
151.2
(509-3870)
>=70
147.9
(339-728)
Source: NNMB Reports, 1977, 1996, 2002, 2006
-
-3% DISTRIBUTION OF ADULTS ACCORDING TO BMI
CLASSIFICATION 20 YEAR TREND
1974-79*
(RURAL)
BMI
CLASSES
<18.5
(CED)
(NORMAL)
1988-90*
(RURAL)
1996-97**
(RURAL)
1993-94***
(URBAN)
2002*
(RURAL)
F
51.8
49.3
47.7
36.7
38.9
M
55.6
49.0
45.5
42.8
36.6
F
44.8
46.6
46.3
51.7
52.4
M
42.1
48.3
50.4
51.8
57.2
F
3.4
4.1
6.3
11.6
8.7
M
2.3
2.7
4.1
5.5
6.2
18.5-25.0
(OBESE)
>=25
* NNMB, 1991, quoted by N,Nadamuni Naidu et al, 1994.
* Rural, 2002
** NNMB, Rural surveys, 1996; *** NNMB Urban Surveys, 1994
-4a-
% DISTRIBUTION OF ADULTS ACCORDING TO BMI
CLASSIFICATION - NNMB 2006
< 16
16-17
(CED III) (CED II)
17-18.5
18.5-20
(CED I)
(Low Wt.
20-25
> 25
(Normal) (Over wt.)
Normal)
Men
5.7
Women 8.0
7.9
9.0
19.6
21.7
37.3
7.0
19.0
18.7
34.4
9.1
- 4b -
Distribution (%) of Adults According to BMI
Classification 10 year trend
BMI
Males
Males
Females
1996
2006
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
<16.0
Source: NNMB, 1996 & 2006(Rural)
1996
Females
2006
-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
-6Mean Birth Weights in different parts of the world
Region
Mean Birth Weight
(kg)
North America, Western Europe
and Australia
3.5-3.6
Eastern Europe
3.1-3.3
Africa and East Asia
2.9-3.1
South Asia
2.7
-7-
Mean Birth Weights and LBW in SEAR
Country
N
India
4307
Nepal
Rural
2529
Urban
3629
Sri Lanka
1851
Myanmar
3582
Indonesia
1647
Thailand
4124
USA
Afro-American
4614
Whites
16481
*Source: WHO, 1993.
LBW
(<2500g)
Birth weight
(Kg)
33.0
2.63
14.3
22.3
18.4
17.8
10.5
9.6
2.78
2.76
2.84
2.85
2.94
3.00
10.6
6.0
3.14
3.36
-8-
MATERNAL PARAMETERS (MEANS) ACCORDING TO BMI STATUS
BMI CLASSES
N
<16.0
CED III
81
35.4
2510
53.1
16.0-16.9
CED II
133
38.1
2573
41.4
17.0-18.4
CED I
460
40.9
2653
35.9
18.5-19.9
(NORMAL)
553
44.1
2771
27.7
20.0-24.9
(NORMAL)
717
49.6
2812
26.4
25.0-29.9
(OBESE)
68
60.6
2972
14.7
> 30
(OBESE)
5
75.5
2972
20.0
2742
30.5
TOTAL
2017
MOTHER'S (Wt, Kg.)
45.2
BIRTH (Wt, Kg.)
LBW (<2500 g)%
Source : NNMB Repeat Surveys (1991) , Quoted by Nadamuni Naidu et al, 1994.
- 9Birth Weight and Socio-Economic Status
Poor
income
Middle
income
High
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
-10BIRTH WEIGHTS IN POOR AND WELL TO DO GROUPS IN
MADRAS AND COONOR
N
B.WT
Lbs
Kg
1949
SPEL.WARD
GEN.WARD
1269
1179
7.12
6.3
3.2
2.8
1954
SPEL.WARD
GEN.WARD
200
500
6.85
6.01
3.08
2.7
SOURCE : Varkki C, et al, 1955.
PREMATURE
(%)
-
12.3
8.4
-11Birth weights (kg) in poor after supplementation
1971
1972
No
Supplementation
No
Supplementation
Supplementation
Food Folic acid
2.704
3.028
Source : L.Iyengar, 1972.
2.920
Supplementation
Iron Iron+ Folic acid
2.570
2.650
2.899
-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
- 13 Distribution (%) of 1-5 years children according to nutritional
status (Weight for age) by sex-Gomez classification
Nutrition Grades*
Boys
(n=2011)
Girls
(n=1957)
Pooled
(n=3968)
Normal
13.1
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.
-14 aDistribution (%) of 1-5 years according to Weight for age – standard
deviation (SD) classification by gender
Girls
(n=1957)
Pooled
(n=3968)
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
Weight for age*
 Median
* NCHS standards
Source: NNMB 2005.
Boys
(n=2011)
- 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
-1SD to Median
23.1
26.7
4.5
11.5
2.7
10.9
-2SD to -1SD
-3SD to-2SD
<Median -3SD
27.9
16.2
6.1
28.8
35.0
20.2
31.7
39.9
14.9
* NCHS standards
Source: NNMB 2005.
- 15 a Distribution (%) of 1-5 years children according to Height for age
standard deviation (SD) classification by gender
Height for age*
 Median
Boys
(n=2011)
Girls
(n=1957)
Pooled
(n=3968)
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.
- 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
-1SD to Median
28.3
27.6
9.4
16.3
6.2
14.0
-2SD to -1SD
-3SD to-2SD
<Median -3SD
25.5
12.8
5.7
23.0
24.8
26.5
28.2
28.2
23.5
* NCHS standards
Source: NNMB 2005.
-16 a Distribution (%) of 1-5 years children according Weight for Height
standard deviation (SD) classification by gender
Weight for Height *
 Median
Boys
(n=2457)
Girls
Pooled
(n=2399) (n=4856)
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.
-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
-1SD to Median
-2SD to -1SD
23.5
39.4
24.1
11.7
30.2
43.6
12.2
32.4
39.9
-3SD to-2SD
<Median -3SD
8.6
4.4
11.8 13.3
2.6
2.2
* NCHS standards
Source: NNMB 2005.
-17 -
ICMR Balanced diet for adults (1 Cu)
Cereals
460
Pulses
40
Veg
Roots Flesh Milk Fats Sugar Nuts Fruits Condifoods
ments
40
60
-
150 25
30
-
-
-
- 18 -
Intake by age (> 70% of RDA)
Age Cereals Pulse
(yrs)
L.V.
Others R& T Milk Fat Sugar
1-3
54
15
8
35
55
10
10
14
4-6
62
29
10
42
56
8
5
11
Male 58
10-12
Female 67
29
15
39
56
8
3
11
30
15
37
55
7
3
12
Male 81
> 18
Female 77
51
15
47
60
33
10
31
39
10
50
56
37
27
50
- 19 -
Nutrient intakes ( >70% of RDA) by Age
Age (yrs)
Energy
1-3
4 -6
7- 9
Male
10-12
Female
Male
13-15
Female
Male
16-17
Female
Male
Protein Fat
Calcium Iron Vitamin A
30
31
38
45
62
73
61
50
23
30
36
54
19
28
37
24
15
15
13
9
8
10
7.5
9
57
41
51
22
11
9
55
40
65
32
10
11
70
39
58
25
15
9
70
40
60
32
12
9
70
43
62
35
14
10
80
77
85
70
29
11
89
78
77
61
15
11
>18
Female
- 20 –
Other nutritional problems
Apart from stunting and under weight –
1. Anaemia - 60-90%
2. Iodine Deficiency - endemic most parts of the country
3. Goitre - endemic in North East, sub Himalayan
range, many tribal belts in central India
4. Fluorosis - endemic many parts of the country
-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.
- 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.
- 23 -
How did we reach this Cereal – Calorie Trap ?
RDA,
Consumption units
Minimum Wages
Poverty Line
Green Revolution---PDS
story
The consumption unit
- 24RDA
ICMR Balanced diet for adults (1 Cu)
Cereals
Pulses
Veg
460
40
40
Roots Flesh Milk Fats Sugar Nuts Fruits Condifoods
ments
60
-
150
25
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)
- 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
- 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
- 28 -
Micironutrients essential for man
Vitamins
Trace minerals
A. 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
Essential fatty acid
(-6 and  -3)
Pyridoxine
Folic acid
Copper
Cobalt
Biotin (?)
Vitamin B12
Pantothenic acid (?)
Ascorbic acid
B. Micronutrients essential for animals and not yet established as essential for man
Choline
p-Aminobenzoic acid
Source: Narasinga Rao BS.
Silicon
Molybdenum
Fluorine
Arsenic
Nickel
- 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
- 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.
- 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.
Distribution (%) of children by protein –calorie
adequacy status
Age (yrs)
% with adequate
% with adequate
calories
Vitamins
Minerals
- 32 -
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
-33 –
Mean intake of one Nutrient iron (mg) by levels of
percentage RDA of energy
Details
% RDA of energy
Mean ±SD
Iron
(n)
< 70
9.6 ± 7.50
(9.2 – 10.0)
(1081)
70 – 100
13.2 ±8.07
12.9 - 13.5)
(2567)
 100
17.0 ±9.64
16.3 – 17.1)
(2034)
13.8 ±8.94
(5682)
Women
Pooled
-34 –
Mean intake of one nutrient iron (mg) by levels of
percentage RDA of energy
Details
% RDA of energy
Mean ±SD
(n)
< 70
5.9 ±4.57
(5.7 – 6.1)
(2898)
70 – 100
9.7 ± 6.46
(9.3 – 10.2)
(856)
Children
1-6 yrs
 100
Pooled
Iron
14.0 ± 9.19
(234)
(12.9 – 15.2)
7.2 ± 5.87
(3988)
- 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.
- 36 Further addition of iron in these diets or iron supplements may
cause iron overload known to have the following impacts on
1. Oxidative damage, diarrhea, in undernourished populations
2. Infections, like Malaria, TB, HIV,
3. Even deaths
What is required is sources of foods which make the iron available
such as
1. Vitamin C rich foods
2. Small amounts of meat which provides haem iron
3. Fill the calorie gap with foods other than cereals
These increase the iron availability by 10 times.
-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)
- 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
- 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 antihelmenthic
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
- 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
- 41 –
The National Anemia Prophylaxis Programme
Iron tablets – distributed under medical 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.
- 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
- 43 -
Average Intake of Nutrients (per day) (Boys and Girls)
Age (yrs)
1–3
Mean
RDA
4-6
Mean
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
RDA
40
- 44 Nutrition Rehabilitation Centre (National Institute of
Nutrition)
Average intake in hospital of a 7 kg child
Bread
Rice
Milk
Oil
Dal
sugar
Banana
Eggs
40 gms
50 gms
500 ml
20 ml
25 gms
10 gms
1
1
1100 cal, 35 gms protein
Approximate cost of a 1000 Kcal diet – Rs 15 /-
- 45 Rehabilitation diet for undernourished children
Diet - as close to the home diet as possible
Routine Diet at Nutrition ward for children
6 AM
8.30 am
11 AM
1.30pm
4pm
7pm
10pm
Milk
Khichri
Bread and Milk / egg
Lunch Rice, Dal,etc
Milk / Egg
Dinner Rice Dal etc
Milk
Extra milk given during night if required
- 46 The need to provide regular food, familiar as close to
home food as possible vs high density packaged food.
1. Problems of processed food which is not produced
locally.
2. Half the children of this country will require this
3. Assured supply for years is hard to imagine
4. Local populations will learn to trust only packaged
food
5. Women will forget how to feed their children
6.
Local employments of millions of women will be
affected
- 47 Iron content (mg) of common foods in 100g of edible portion
Cereal
Iron (mg)
Bajra
8.0
Jowar
4.1
Ragi
3.9
Rice, raw, hand pounded
3.2
Rice, bran
35.0
Rice, flakes
20.0
Rice, puffed
6.6
Wheat, bulgar (parboiled)
4.9
Wheat, whole
5.3
Wheat flour (whole)
4.9
Wheat flour (refined)
2.7
Wheat germ
6.0
Wheat bread (brown)
2.2
- 48 Contd/-
Pulses
Iron (mg)
Bengal gram dhal
5.3
Bengal gram roasted
9.5
Cow pea
8.6
Horse gram whole
6.77
Lentil
7.58
Moth beans
9.5
Rajmah
5.1
Soya bean
10.4
Leafy Vegetables
Amaranth polygonoides
27.3
Cauliflower greens
40.0
Manathakkali leaves
20.5
Mint
15.6
Mustard leaves
16.3
Parsley
17.9
Radish leaves table
18.0
- 49 Contd/-
Other vegetables
Iron (mg)
Karonda dry
39.1
Lotus stem dry
60.6
Plantain green
6.27
Sundakai dry
22.2
Nuts and oilseeds
Almond
5.09
Cashewnut
5.81
Walnut
2.64
Condiments and spices
Asafoetida
39.4
Mango powder
45.2
Omum
12.5
Pepper dry (black)
12.4
Poppy seeds
15.9
Tamarind pulp
17.0
Turmeric
67.8
- 50 Contd/-
Fruits
Iron (mg)
Ambada
3.9
Apricot dry
4.6
Raisins
7.7
Seethaphal
4.31
Fishes and other sea foods
Bombay duck dried
19.1
Chingri goda, dried
49.6
Crab muscle
21.2
Meat and poultry
Beef meat
18.8
Liver sheep
6.3
Mutton muscle
2.5
Pork muscle
2.2