MALNUTRITION IN INDIA

Afsha Chevelwalla Ainesh Jishnu Nandita C Sonia Jaiswal

Ther e are two maj or type s of mal nutri tion: Pro teinener gy mal nutri tion resu lting from defic ienci es in any or all nutri ents Mic ronu trien t defic ienc y dise ases resu lting from a defic ienc y of spec ific micr onut rient s Prot einener gy mal nutr itio n Ther e are thre e type s of prot einener gy mal nutri tion in child ren:

There are two major types of deficiency malnutrition: Protein-energy malnutrition - resulting from deficiencies in any or all nutrients Micronutrient deficiency diseases - resulting from a deficiency of specific micronutrients. Example- Vitamin Deficiency Disorders.
Typ e Appearance Cause Acut Wasting or e thinness mal nutri tion Acute inadequate nutrition leading to rapid weight loss or failure to gain weight normally Chr Stunting or onic shortness mal nutri tion Inadequate nutrition over long period of time leading to failure of linear growth Acut Underweight e and chro nic mal nutri tion A combination measure, therefore, it could occur as a result of wasting, stunting, or both

 What Is Malnutrition?
Malnutrition is the condition that results from taking an unbalanced diet in which certain nutrients are lacking or are in excess or in the wrong proportions. People who are Malnourished may: Not consume adequate calories and protein for growth and maintenance, such as undernutrition or proteinenergy ( calories) malnutrition (PEM).

Consume too many calories (overnutrition). Have abnormal nutrient loss (due to diarrhoea or chronic illness) or increased energy expenditure (secondary malnutrition).

 KWASHIORKAR
Kwashiorkor (displaced child) is mainly caused by inadequate protein intake resulting in a low concentration of amino acids. Kwashiorkor is identified by swelling of the extremities and belly, which is deceiving of actual nutritional status. The main symptoms are : Edema. Wasting. Liver enlargement. Hypoalbuminaemia. Depigmentation of skin and hair.

 MARASMUS
Marasmus (to waste away) is caused by an inadequate intake of both protein and energy. The main symptoms are : severe muscle wasting, little or no oedema. minimal subcutaneous fat. non-normal serum albumin levels. the metabolism adapts to prolong survival. it is traditionally seen in famine, food restriction, or anorexia

 Vitamin A Deficiency
Symptoms: Xerophthalmia. Night Blindness. Corneal Kiratomalacia. Bitots Spots. Pregnant woman should be advised to take food rich in Carotene. Green leafy vegetables Yellow Fruits. Liver. Fish oils. Milk, cheese,butter.

 Vitamin D Deficiency
Rickets. Skeletal deformity
Toddlers: Bowed legs (Genu Varum) Older children: Knock-knees (Genu Vulgam). Cranial, pelvic, and spinal deformities (such as lumbar lordosis). Osteomalacia in Adults. Softening of bones. Sources: Mainly manufactured in skin under sunlight. Dietary sources : Egg yolk, oily fish, butter &milk.

 Vitamin B-1 Deficiency

Vit B1- Thiamin Condition : Beri- Beri Causes : Chronic alcoholism. Polished rice as staple diet. Mother to infant. Symptoms : Peripheral Neuropathy. Wrist/foot drop. Korsakoffs Psychosis. Generalised oedema due to heart failure

 Vitamin B-3 Deficiency

Vit B3- Niacin Condition : Pellagra Causes: Maize as staple diet Symptoms : 3Ds. Diarrhea Dementia Dermatitis Erythema on exposed parts, ulcerations etc.

 Vitamin C Deficiency
Vit C Ascorbic Acid Condition Scurvy

Causes : insufficient intake of vitamin C This may be due to ignorance, famine, anorexia, restrictive diets, Lack of fresh fruits and vegetables. Symptoms : Swollen gums which bleed easily Bleeding in the eye Petechial Hemorrhages Poor wound healing Anaemia

Site Face

signs Moon face (kwashiorkor, simian facies (marasmus)

Eye
Mouth Teeth Hair

Dry eyes, pale conjunctiva, Bitot's spots (vitamin A), periorbital edema
Angular stomatitis, glossitis, spongy bleedng gums (vitamin C), parotid enlargement Enamel mottling, delayed eruption Dull, sparse, brittle hair, hypopigmentation, flag sign (alternating bands of light and normal color), broomstick eyelashes, alopecia Loose and wrinkled (marasmus), shiny and edematous (kwashiorkor), dry, patchy hyper/hypopigmentation, erosions, poor wound healing Koilonychia, thin and soft nail plates, fissures or ridges Muscles wasting, particularly in the buttocks and thighs Deformities usually a result of calcium, vit D, or vit C deficiencies Distended - hepatomegaly with fatty liver, ascites may be present Bradycardia, hypotension, reduced cardiac output. development delay, loss of knee and ankle reflexes, impaired memory Pallor, petechiae, bleeding diathesis Lethargic, apathetic

Skin Nail Musculature Skeletal Abdomen Cardiovascular Neurologic Hematological Behavior

 Essential Inorganic Nutrients.

Sodium Potassium Iron Zinc Copper Iodine Fluoride Selenium etc.

 The Number One Factor That Causes Malnutrition

POVERTY!

 Other Causes :
Dirty Environment. Lack of sound sleep and rest Lack of educational awareness

Negligence in children and adults.

Bodily diseases. Heavy work. Lack of games and exercises.

 Classification of Malnutrition :
Gomez Classification: The child's weight is compared to that of a normal child (50th percentile) of the same age. It is useful for population screening and public health evaluations. Percent of reference weight for age = ((patient weight) / (weight of normal child of same age)) * 100 Interpretation: 90 - 110% :normal 75 - 89% Grade I : mild malnutrition 60 - 74% Grade II : moderate malnutrition < 60% Grade III : severe malnutrition

 Waterlow Classification
John Conrad Waterlow established a new classification for malnutrition. Percent weight for height = ((weight of patient) / (weight of a normal child of the same height)) * 100 Percent height for age = ((height of patient) / (height of a normal child of the same age)) * 100
Degree of PEM Normal: Grade 0 Mild: Grade I Moderate: Grade II Stunting (%) Height for age >95% 87.5-95% 80-87.5% Wasting (%) Weight for height >90% 80-90% 70-80%

Severe: Grade III

<80%

<70%

 Why Concentrate on Malnutrition?

 Why Concentrate on Malnutrition?

 Effect and Prevalence

Malnutrition amongst Women is one of the prime causes of Low Birth-weight babies and poor growth.

Low birth weight is a significant contributor to Infant Mortality.

Under-nutrition is the underlying cause for about 50% of the 2.1 million Under-5 deaths in India each year. The prevalence of under nutrition is the highest in Madhya Pradesh (55%) Bihar (54%) Orissa (54%) Uttar Pradesh (52%) and Rajasthan (51%) While Kerala (37%) and Tamil Nadu (27%) have lower rates.

 PREVALENCE

 Latest Country prevalence estimates for Underweight among children under 5 years of age

 Latest country prevalence estimates for wasting among children under 5 years of age

 Programs for Malnutrition in

India

 Mid-Day Meal Scheme

It is the worlds largest school feeding programme reaching out to about 12 crore children in over 12.65 lakh schools/EGS centres across the country. It involves provision of lunch free of working days. It has been adopted by most Indian states after a landmark direction by the Supreme Court of India on November 28, 2001. The success of this scheme is illustrated by the tremendous increase in the school participation and completion rates in Tamil Nadu..

 The Akshaya Patra Foundation runs the world's largest NGO-run midday meal programme serving freshly cooked meals to over 1.3 million hungry school children in government and governmentaided schools in India. This programme is conducted with part subsidies from the Government and partly with donations from individuals and corporate. The meals served by Akshaya Patra complies with the nutritional norms given by the government of India and aims to eradicate malnutrition among children in India.

 ICDS Program
The Government of India has started a program called Integrated Child Development Services (ICDS) in the year 1975. ICDS has been instrumental in improving the health of mothers and children under age 6 by providing health and nutrition education, health services, supplementary food, and pre-school education. The ICDS national development program is one of the largest in the world. It reaches more than 34 million children aged 06 years and 7 million pregnant and lactating mothers.

 Marathwada Initiative,Maharasthra
Focused on sharpening and making the existing Integrated Child Development Scheme (ICDS) more effective. By 2005, the Initiative had succeeded in bringing down the rate of severe malnutrition in Maharashtra by 90%. Under the Initiative, children are given regular check-ups and mothers are given nutrition lessons and supplements at child treatment centers (CTCs). Mothers who lose wages to bring their children to the CTC are compensated monetarily as an incentive. It has also inspired similar efforts in states like Bihar and Karnataka.

 National Childrens Fund

The National Children's Fund was created during the International Year of the Child in 1979 under the Charitable Endowment Fund Act, 1890 This Fund Provides support to the voluntary organisations that help the welfare of children.

 National Plan of Action for Children

India is a signatory to the 27 survival and development goals laid down by the World Summit on children 1990. In order to implement these goals, the Department of Women & Child Development has formulated a National Plan of Action on Children. Each concerned Central Ministries/Departments, State Governments/U.Ts. and Voluntary Organisations dealing with women and children have been asked to take up appropriate measures to implement the Action Plan. These goals have been integrated into National Development Plans.

 United Nations Childrens Fund

India is associated with UNICEF since 1949 and is now in the fifth decade of cooperation for assisting most disadvantaged children and their mothers. Traditionally, UNICEF has been supporting India in a number of sectors like:o child development o women's development o urban basic services o support for community based convergent services o health, education, nutrition, water & sanitation o childhood disability o children in especially difficult circumstances

 Nutrition Society Of India

The Nutrition Society of India (NSI), established in 1967, is an organization dedicated to keep abreast of the latest developments in the basic and applied aspects of science of Nutrition
It continues to analyse issues related to the diverse aspects of nutrition Its activities involve scientists, programmers and policy makers throughout the country and abroad who are working in the field. Through its annual conference, the society provides a forum for new ideas, encourages innovations, recognizes important research findings, increases awareness of the latest survey data and promotes action programmes.

 Nehru Yuva Kendra Sangthan(NYKS)

It is in partnership with UNICEF

It is a body that runs various health related initiatives created by the government and NGOs through youth volunteers under the Ministry of Sports and Youth Affairs Working on the Universal Salt Iodization Program. Through this program, over 200 young people are working in 6 districts of Rajasthan to create awareness about the nutritional benefits of iodized salt amongst the community, including with salt producers and traders.

 Malnutrition Eradication Programme,M.P.

RMFs Malnutrition Eradication Program in Madhya Pradesh boasts the Largest field presence of any NGO working in malnutrition in the region Result of strong partnerships with government, NGOs, business, and most importantly, local communities. Primary Goal -to reduce the prevalence of underweight children aged less than 5 -to prevent malnutrition-related deaths among children RMF had an initial program in 5 of the worst-hit districts in MP where local women were trained to act as Community Nutrition Educators. After its success is created a pilot project which will educate anganwadi workers (members of the ICDS) to provide high quality health and nutrition education to the community and mobilize them to recognize the signs of malnutrition.

 National Rural Health Mission

NRHM was created for the years 2005-2012

Its goals-to improve the availability and accessibility to quality healthcare by people especially those residing in the Rural areas, the poor, women and children. One of its aim is to reduce IMR and MMR and to provide Universal access to Public Health Services

 Why Not the Necessary Impact?

Indias primary policy response to child malnutrition, the Integrated Child Development Services (ICDS) program, is well-conceived and well-placed to address the major causes of child Undernutrition in India.

More attention has been given to increasing coverage than to improving the quality of service delivery.
Distributing food rather than changing family-based feeding and caring behavior.

 Older children (between 3-6 years) participate much more than younger ones and children from wealthier households participate much more than poorer ones. The program fails to preferentially target girls, lower castes or poorest villages (all of whom are at higher risk of Undernutrition) Inadequate worker skills, shortage of equipment, poor supervision

 Improvements Can Be Made

Resolve the current ambiguity about the priority of different program objectives and interventions. Activities need to be refocused on the most important determinants of malnutrition. Policy makers and program implementers need to clearly understand many linkages between Education and Health, Sanitation and Hygiene, Drinking water and Nutrition.

 A Bigger & Wider Picture

A grass-roots level approach that works with communities with a coordinated program that brings to mainstream identified problems. Need for evolving strategies separately for urban and rural areas