India and Acute Malnutrition in Children

Veena Shatrugna

National Institute of NutritionHyderabadIndia

-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 52.256.6 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

-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 MF M F M01+ 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+ 99.6 100.5 100.4102.1 102.5 103.2 102.4 102.6 108.4109.9(229-747)10+ 125.7 125.1 126.8 127.9 128.5 128.7 128.9 129.0 138.3137.5(304-734)20-24 151.2 163.4 151.5164.0 151.1 163.3 152.0 164.2 163.7176.8 (509-3870)>=70 147.9 162.3 147.9161.0 146.8 160.0 145.5 159.9 -(339-728)Source: NNMB Reports, 1977, 1996, 2002, 2006

-3- % DISTRIBUTION OF ADULTS ACCORDING TO BMI CLASSIFICATION 20 YEAR TREND BMI 197479* 198890* 1996-97** 199394*** 2002* CLASSES (RURAL) (RURAL) (RURAL) (URBAN) (RURAL)=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

- 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

- 4b -Distribution (%) of Adults According to BMI Classification 10 year trend BMI Males Males Females Females 1996 2006 1996 2006 25 4.17.0 6.0 9.1Source: NNMB, 1996 & 2006(Rural)

- 5 - Thinness as a public health problem

Low prevalence (warning sign,monitoring required): 5-9% of population with BMI

- 6 -Mean Birth Weights in different parts of the world

Region Mean Birth Weight (kg)

North America, Western Europe 3.5-3.6and Australia

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 LBW Country N (

- 8 - MATERNAL PARAMETERS (MEANS) ACCORDING TO BMI STATUS

BMI CLASSES N MOTHER'S (Wt, Kg.) BIRTH (Wt, Kg.) LBW (

- 9-Birth Weight and Socio-Economic StatusPoorMiddleHighincomeincomeincomeHeight (cms)151.5154.2156.3Weight (kg)45.749.956.2Hb(g/dl)10.911.112.2Birth weight (kg)2.702.903.13

-10-BIRTH WEIGHTS IN POOR AND WELL TO DO GROUPS INMADRAS AND COONOR N B.WT PREMATURELbs Kg (%)

1949SPEL.WARD 1269 7.12 3.2 -GEN.WARD 1179 6.3 2.8 -

1954SPEL.WARD 200 6.85 3.08 12.3 GEN.WARD 500 6.01 2.7 8.4

SOURCE : Varkki C, et al, 1955.

-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.

-12 - Attempts made to increase birth weights in poor socio-economic group1. Iron2. Folic acid3. Iron and Folic acid 4. Zinc5. Vitamin A6. 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 classificationNutrition Grades* Boys GirlsPooled (n=2011) (n=1957) (n=3968)Normal 13.1 12.112.6 Mild 45.5 45.545.5Moderate 37.4 37.837.6Severe 4.0 4.6 4.3

* NCHS standardsSource: NNMB 2005.

-14 a-Distribution (%) of 1-5 years according to Weight for age standard deviation (SD) classification by gender

Weight for age* Boys GirlsPooled (n=2011) (n=1957) (n=3968) Median 3.5 3.6 3.6-1SD toMedian 11.4 10.1 10.8-2SD to -1SD 31.4 31.1 31.2-3SD to -2SD 38.2 37.7 37.9

- 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

- 15 a -Distribution (%) of 1-5 years children according to Height for age standard deviation (SD) classification by gender

Height for age* Boys GirlsPooled (n=2011) (n=1957) (n=3968) Median 8.0 6.6 7.3-1SD toMedian 15.5 13.4 14.5-2SD to -1SD 26.4 25.5 26.0-3SD to -2SD 26.6 27.9 27.2

- 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

-16 a -Distribution (%) of 1-5 years children according Weight for Height standard deviation (SD) classification by gender

Weight for Height * Boys Girls Pooled (n=2457) (n=2399) (n=4856) Median 10.8 13.2 12.0-1SD toMedian 31.5 31.1 31.3-2SD to -1SD 41.8 41.6 41.7-3SD to -2SD 13.3 11.8 12.6

-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

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 - - --17 -

- 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 42 568 5 11

Male 58 29 15 39 56 8 3 1110-12 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

- 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 4550 54 24 9 9 10-12 Female 57 41 51 22 11 9

Male 5540 65 32 10 1113-15 Female 7039 58 25 15 9

Male 7040 60 32 12 916-17 Female 7043 62 35 14 10 Male 8077 85 70 29 11 >18 Female 89 78 77 61 15 11

20 Other nutritional problemsApart from stunting and under weight

Anaemia - 60-90% Iodine Deficiency - endemic most parts of the countryGoitre - endemic in North East, sub Himalayan range, many tribal belts in central IndiaFluorosis - endemic many parts of the country

21 According to Recommended Dietary Guidelines 60-65% Calories from Carbohydrates 25-30% from Fat10-12% from ProteinEach of these calories, proteins and fats must be derived from as many foods as possibleIn 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 availablethis 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 unitsMinimum WagesPoverty LineGreen Revolution---PDS The consumption unit story

- 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 - - -

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

- 26 -Minimum Wages - Criteria

1.3 consumption units * for one wage earner2.2700 cals per average Indian adult3.? Clothing - 72 yards per annum per family4.? House rent5.? Fuel, Lighting etc - 20% of wages6.? Education, Medical and other expenses

- 27 - Since Minimum wages are based on calories Cheapest source of 2000 calories (Gm)Cost (Rs.)Sugar5208.00Rice571.411.0 Oil225 ml18.0Dals500.022.0Potato200020.0Sapota, banana 174025Milk3250ml60Chicken2000120 Dry fruits400200

- 28 - Micironutrients essential for manVitamins Trace mineralsMicronutrients known to be essential for man and animalsVitamin A ThiaminIronSeleniumVitamin D Riboflavin IodineManganeseVitamin K Nicotinic acidZincChromiumVitamin E PyridoxineCopperCobaltEssential fatty acid Folic acid(-6 and -3)Biotin (?) Vitamin B12Pantothenic acid (?) Ascorbic acid

B. Micronutrients essential for animals and not yet established as essential for man Choline SiliconMolybdenum p-Aminobenzoic acid FluorineArsenicNickelSource: Narasinga Rao BS.

- 29 - Phytonutrients for Health Promotion Phytonutrient classCarotenoidsGlucosinolates,Isothiocyanates, IndolesInositol phosphatesPhenolics, cyclic compoundsPhytoestrogensPhytosterolsPolyphenolsProtease inhibitorSaponinsSulfides 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 RiboflavinSulfur amino acids AnthocyaninsCysteine and methionine IsoflavonesSelenium 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.

- 32 - Distribution (%) of children by protein calorie adequacy statusAge (yrs)% with adequate % with adequate calories Vitamins Minerals

1-3 31.8 8.0 15.04-628.2 10.0 20.0 7-928.1 7.5 20.010-1226.0 (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 energyIronMean SD (n)

Women< 709.6 7.50 (1081)(9.2 10.0)70 10013.2 8.07 (2567)12.9 - 13.5) 10017.0 9.64 (2034)16.3 17.1)Pooled13.8 8.94 (5682)

34 Mean intake of one nutrient iron (mg) by levels of percentage RDA of energy

Details% RDA of energyIronMean SD (n)Children 1-6 yrs< 705.9 4.57 (2898)(5.7 6.1)70 1009.7 6.46 (856)(9.3 10.2) 10014.0 9.19 (234)(12.9 15.2)Pooled7.2 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 Oxidative damage, diarrhea, in undernourished populationsInfections, like Malaria, TB, HIV, Even deaths

What is required is sources of foods which make the iron available such as Vitamin C rich foodsSmall amounts of meat which provides haem iron Fill the calorie gap with foods other than cerealsThese 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 timesFerrous sulfate - without EDTA low bioavailability alters taste with EDTA iron amount have to be decreased net iron intake the sameElemental 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.Johns 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

- 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 humansNeed to re-look at strategyStudies done in the following countries did not show improvements in haemoglobin after the distribution of iron fortified wheat flour.SrilankaBangladeshThailandMoroccoIvory coastIndia

41 The National Anemia Prophylaxis ProgrammeIron 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.Aykroyds Recommended Diet (1957) gr.Cereals-14 oz-420Pulses03oz- 90Vegetables10 oz-300Milk10 oz-300Sugar/02oz- 60Oil / ghee02oz- 60Fruits02 oz- 60Fish / meat03 oz- 90Eggs01 oz- 30

- 43 - Average Intake of Nutrients (per day) (Boys and Girls)

Age (yrs) 1 3 4 - 6Mean RDA Mean RDAProtein (g) 20.2 22.0 28.7 30.0Total fat (g) 10.7 25.0 12.7 25.0 Energy (Kcal) 719 1240 1020 1690Calcium (mg) 245 400 272 400Iron (mg) 5.7 12 8.6 18 Vit.A (g) 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 40Free folic acid (g) 20.3 30 28.8 40

- 44 - Nutrition Rehabilitation Centre (National Institute of Nutrition) Average intake in hospital of a 7 kg child Bread 40 gms Rice 50 gms Milk 500 ml Oil 20 ml Dal 25 gms sugar 10 gms Banana 1 Eggs 1 1100 cal, 35 gms proteinApproximate cost of a 1000 Kcal diet Rs 15 /-

- 45 -Rehabilitation diet for undernourished childrenDiet - as close to the home diet as possible Routine Diet at Nutrition ward for children 6 AMMilk 8.30 amKhichri 11 AMBread and Milk / egg 1.30pmLunch Rice, Dal,etc 4pmMilk / Egg 7pmDinner Rice Dal etc 10pmMilk 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.Problems of processed food which is not produced locally.Half the children of this country will require this Assured supply for years is hard to imagine4. Local populations will learn to trust only packaged food5. Women will forget how to feed their children6. Local employments of millions of women will be affected

47 - Iron content (mg) of common foods in 100g of edible portion

CerealIron (mg)Bajra8.0Jowar4.1Ragi3.9Rice, raw, hand pounded3.2Rice, bran35.0Rice, flakes20.0Rice, puffed6.6Wheat, bulgar (parboiled)4.9Wheat, whole5.3Wheat flour (whole)4.9Wheat flour (refined)2.7Wheat germ6.0Wheat bread (brown)2.2

- 48 - Contd/-

PulsesIron (mg)Bengal gram dhal5.3Bengal gram roasted9.5Cow pea8.6Horse gram whole6.77Lentil7.58Moth beans9.5Rajmah5.1Soya bean10.4Leafy VegetablesAmaranth polygonoides27.3Cauliflower greens40.0Manathakkali leaves20.5Mint15.6Mustard leaves16.3Parsley17.9Radish leaves table18.0

- 49 -Contd/-

Other vegetablesIron (mg)Karonda dry39.1Lotus stem dry60.6Plantain green6.27Sundakai dry22.2Nuts and oilseedsAlmond5.09Cashewnut5.81Walnut2.64Condiments and spicesAsafoetida39.4Mango powder45.2Omum12.5Pepper dry (black)12.4Poppy seeds15.9Tamarind pulp17.0Turmeric67.8

- 50 -Contd/-

FruitsIron (mg)Ambada3.9Apricot dry4.6Raisins7.7Seethaphal4.31Fishes and other sea foodsBombay duck dried19.1Chingri goda, dried49.6Crab muscle21.2Meat and poultryBeef meat18.8Liver sheep6.3Mutton muscle2.5Pork muscle2.2