Is India under Serious Threats of Triple Burden of Malnutrition?

According to the World’s Children Report of 2019 published by the UNICEF, the unhealthy eating habits and diets with modern processed food have led to various non-communicable diseases caused by lack of nutrition. This has become a significant threat to public health in general. The National Family Health Survey since 1992 has shown the trends of mortality, morbidity, immunization, nutritional status and maternal health status through its various rounds survey.

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Is India under Serious Threats of Triple Burden of Malnutrition_the policy times

Malnutrition is considered more than the lack of food, can be defined in three tiers: undernutrition, overnutrition and nutrition deficiency. Globally, 12% of deaths among under-five are due to breastfeeding, and 45% from undernutrition. Good nutrition is considered the bedrock of child survival, health and development and lays the foundation for healthy, thieving and productive communities and nations.  Malnutrition in children is a significant public health challenge in developing, and under-developed countries and half of the under-five children in India attributed to malnutrition. In other words, one among three children in India is malnourished. India has 46.6 million stunted children, i.e. one-third of the world as per the Global Nutrition Report 2018. Among 474 million children in India (Census 2011), 97million are anaemic, and among under-five children, 40% are stunted, and 42.4% are underweight.

According to the World’s Children Report of 2019 published by the UNICEF, the unhealthy eating habits and diets with modern processed food have led to various non-communicable diseases caused by lack of nutrition. This has become a significant threat to public health in general. The National Family Health Survey since 1992 has shown the trends of mortality, morbidity, immunization, nutritional status and maternal health status through its various rounds survey.

UNDER NUTRITION

An individual is undernourished if they lack calories or one/more essential nutrients. It develops when an individual’s consumption does not meet the body’s need for calories. When a person does not consume enough calories at first, the body initially breaks down fat but after exhaustion leads to breaking down of muscles and tissues of internal organs. The indicators used here to study the prevalence of undernutrition among under-five children are stunting, wasting and underweight.

Stunting: The impaired growth and development among children due to poor nutrition, repeated infection, and inadequate psychosocial stimulation causes low height-for-age or stunting. The consequences of stunting are poor cognition and education performance, low adult wages and low productivity. According to the estimates of 2012, 90% of the stunted children belong to the continents of Asia and Africa.  Open defecation due to lack of sanitation facilities is a fundamental cause of stunting in India.

Wasting: Low weight-for-height or wasting is one of the strong predictors of mortality among children below five.  It results due to acute significant food shortage/disease. According to the United Nations’ latest estimates, wasting causes a person or a part of the body to become more emaciated and progressively weaker. About 52 million under-five children were wasted in 2011.  Episodes of wasting, also referred to as acute malnutrition are shorter in duration compared to stunting.

Underweight: Among the undernutrition factors, low weight-for-age or underweight is one of the most contributing. It too results from insufficient supply of nutrients to the body. Underweight people have protruding bones, dry and inelastic skin, dry hair with lots of hair fall, etc.

Related Article: Did time win over malnourishment in India or vice versa?

OVER NUTRITION

Overnutrition is a type of malnutrition which takes place due to excessive intake of nutrients.  It leads to the accumulation of body fat, causing overweight or obesity.  Overnutrition leads to chronic non-communicable diseases and have a massive impact on cardiometabolic conditions since the amount of nutrients getting inside the body is far more than the amount required for normal growth development and metabolism. According to WHO, in the developing countries, the significant risk factors behind chronic diseases are spreading even though infectious diseases and undernutrition dominate their current disease burden. The people living in developing countries and low-income groups in more prosperous countries show the prevalence of overweight and obesity.

Overweight is the abnormal or excessive fat accumulation that may impair health. For children below five years of age, overweight is the weight-for-height of more than 2 standard deviations above the WHO child growth typical median. Overweight is mainly caused due to increased intake of energy-dense foods having a high amount of fat and sugar. Changes in society and environment are primarily responsible for the differences in diet and physical activity.

NUTRITIONAL DEFICIENCY

A human body needs various vitamins and minerals for it to develop and prevent diseases. These micronutrients are not produced naturally in the body they have to be taken in through diet. A nutritional deficiency occurs when the body does not absorb or get the necessary nutrients from the food. It causes various health problems like digestion problems, skin disorders, stunted or defective bone growth and even dementia. The most common widespread nutritional deficiency throughout the world is iron deficiency leading to anaemia. Anaemia is a blood disorder causing dizziness, fatigue, body tension, weakness, loss of appetite, low body weight, paleness etc. According to the WHO, about 30% of the total population suffers from anaemia. Anaemia is the only type of nutritional deficiency affecting both developing and developed nations. Anaemia is a killer disease in India, affecting children of both sexes. Childhood anaemia is a condition in which a child does not have haemoglobin in sufficient quantities to provide adequate oxygen to the body tissues.

Western States: The level of malnutrition among under-five children depends on many factors, including sanitation, the quality of good drinking water, and their mothers’ literacy status. Furthermore, socioeconomic factors are exclusive breastfeeding until 6 months after birth, getting an adequate diet, receiving vitamin A supplements, getting vaccinated etc.

India’s western part is chosen as the study area as most of the under-five children here do not receive an adequate diet. The practise of exclusive breastfeeding till 6 months is less in these states primarily in the state of Gujarat. Daman& Diu and Dadra and Nagar Haveli have a low level of sanitation. Recently, there has been a fall in the proportion of children receiving vaccination and vitamin A supplements in Maharashtra.Triple Burden of Malnutrition_The Policy Times1

Chart URL: https://www.datawrapper.de/_/kiQky/

Thus our study aims to see whether this impacts malnutrition among under-five children living in the Western States. Goa, among the western states, shows the least prevalence of stunting, wasting, underweight and anaemia among the under-five children. At the same time, for overweight, it is the union territories of Daman & Diu and Dadra and Nagar Haveli. The proportion of under-five children suffering from anaemia is the highest, among the malnourished children, especially in the western states. Stunted under-five children are mainly found in Daman & Diu and Dadra & Nagar Haveli. Of all the under-five children living in Western India, those living in Maharashtra mainly suffer from wasting and obesity while those living in Gujarat from underweight and anaemic. This may be because of the low quality of water used for farming in Maharashtra.  In terms of overall nutrition, Gujarat tops the list while Goa comes at the bottom. Thus, we can say that the general level of nourishment among under-five children is low and demands better efficiency in implementing government policies.

Methodology

Local Moran’s I am a local spatial autocorrelation statistic based on the Moran’s I statistic. The LISA for each observation indicates the extent of significant spatial clustering of similar values around the observation. The sum of LISAs for all observations is proportional to a global indicator of spatial association.

The significance maps show the locations with a significant local statistic with the degree of significance reflected in increasingly darker green shades. The map starts with non-significant states followed by p<0.05 and shows all the categories of relevance that are meaningful for 999 permutations. The smallest pseudo-p-value is 0.001.

The cluster map augments the significant locations with an indication of the type of spatial association, based on the value’s site and its spatial lag in the Moran scatter plot. The red colour shows tracts where high rate cluster with high rates and blue shows where low rates cluster with low rates. There is even a  mix of high-low in pink colour and low-high in light blue colour. From the LISA scatter plot we can ascertain the statistically significant clustering at the calculated Moran’s I at p=0.001, 0.01 and 0.05.

Stunting: The significance map (Figure 1(a)) shows significant stunting in under 5 aged children in Maharashtra at pseudo p = 0.001 with a high-low type of clustering with Moran’s I = 0.143365 shown in LISA scatter plot (Figure 1(b))

Figure 1(a). Stunting Significance Map
Figure 1(b). Stunting Moran’s I Scatter Plot

Wasting: Maharashtra, Goa and Dadra & Nagar Haveli & Daman & Diu show statistically significant wasting among under 5 aged children at pseudo p = 0.001 (Figure 2(a)). Moran’s I = -0.611554 (Figure 2(b)) with the type of clustering being low-high in Goa and Dadra & Nagar Haveli & Daman & Diu while it is high-low in Maharashtra and Gujarat.

Figure 2(a). Wasting Significance Map
Figure 2(b). Wasting Moran’s I Scatter Plot

Underweight: Maharashtra shows the underweight statistically significant presence under 5 aged children at pseudo p = 0.001 (Figure 3(a). While Gujarat and Dadra & Nagar Haveli & Daman & Diu show high-high clustering, Maharashtra shows high-low and Goa offers a low-high clustering type Moran’s I = 0.0700746 (Figure 3(b)).

Figure 3(a). Underweight Significance Map
Figure 3(b). Underweight Moran’s I Scatter Plot

Overweight: Statistically significant overweight under 5 aged children are found in Goa, Maharashtra and Dadra & Nagar Haveli & Daman & Diu at pseudo p = 0.001 (Figure 4(a)). High-low clustering is located in Gujarat and Maharashtra, and low-high clustering is found in Goa and Dadra & Nagar Haveli & Daman & Diu with Moran’s I = -0.575324 (Figure 4(b)).

Figure 4(a). Overweight Significance Map
Figure 4(b). Overweight Moran’s I Scatter Plot

Anaemia: Anemia is statistically not significant in either of the states for p values at 0.05, 0.01 and 0.001 (Figure 5(a)). Furthermore, about clustering Gujarat and Dadra & Nagar Haveli & Daman & Diu are found to have high-high, Goa low-low and Maharashtra low-high type of clustering with Moran’s I = 0.170258 (Figure 5(b)).

Figure 5(a). Anaemia Significance Map
Figure 5(b). Anaemia Moran’s I Scatter Plot

References

  1. Meenakshi, J.V. (2016), Trends and patterns in the triple burden of malnutrition in India. Agricultural Economics, 47: 115-134. https://doi.org/10.1111/agec.12304
  2. Jain, A., Agnihotri, S.B. Assessing inequalities and regional disparities in child nutrition outcomes in India using MANUSH – a more sensitive yardstick. Int J Equity Health19, 138 (2020). https://doi.org/10.1186/s12939-020-01249-6
  3. https://www.orfonline.org/expert-speak/changing-face-of-malnutritiontrends-in-the-indian-context-57738/
  4. https://www.unicef.org/nutrition/index_faces-of-malnutrition.html
  5. Ramachandran P. Combating Triple Burden of Malnutrition in Children. Indian Pediatr. 2019 Oct 15;56(10):821-822. PMID: 31724538.
  6. Sunuwar, D.R., Singh, D.R. & Pradhan, P.M.S. Prevalence and factors associated with double and triple burden of malnutrition among mothers and children in Nepal: evidence from 2016 Nepal demographic and health survey. BMC Public Health20, 405 (2020). https://doi.org/10.1186/s12889-020-8356-y
  7. http://www.fao.org/news/story/en/item/1199760/icode/
  8. https://www.insightsonindia.com/2019/10/17/state-of-the-worlds-children-report/
  9. Combating malnutrition requires granular approach (NITI Aayog)
  10. NFHS-5 & NFHS-4 FACTSHEET
  11. HMIS

By,
Subham Kumar Mohanta

M.Phil. in Biostatistics and Demography, International Institute for Population Sciences, Mumbai

Gaurav Suresh Gunnal
M.Sc. in Biostatistics and Demography, International Institute for Population Sciences, Mumbai

Shristi Guha
M.Sc. in Population Studies, International Institute for Population Sciences, Mumbai

Akhil P M
M.Sc. in Biostatistics and Demography, International Institute for Population Sciences, Mumbai

Summary
Article Name
Is India under Serious Threats of Triple Burden of Malnutrition?
Description
According to the World’s Children Report of 2019 published by the UNICEF, the unhealthy eating habits and diets with modern processed food have led to various non-communicable diseases caused by lack of nutrition. This has become a significant threat to public health in general. The National Family Health Survey since 1992 has shown the trends of mortality, morbidity, immunization, nutritional status and maternal health status through its various rounds survey.