Dr. Banarsi Lal
Poverty was rampant in India at the time of independence. At that time 3/4th of the Indians were poor, they spent 3/4th of their income on food and 3/4th of the children were under weight. The country was not self-sufficient in food production and regional food shortages were common. Child mortality rates were very high. The importance of the children health and nutritional status was recognized in national building and steps to improve the health services with special efforts to poor and marginalised sections of population were initiated. Since 1970 India has been self-sufficient in food production and public distribution system has improved for the poor people. The infrastructure and human resources for improving the health and nutritional services have been built up and almost the entire country was covered but still there are loopholes in terms of coverage, content and quality of all these services and sometimes it is observed that the most needy have the least access to services.
It is important to mention that India has the largest food supplementation programmes in the world. Integrated Child Development Services (ICDS) and Mid Day Meal school programme cover all the children across the country up to 14 years of age. Despite the rapid economic growth and ready access to affordable food and food supplementation programmes for children across the country nearly half of the children under five are under weight. It has been observed that there has been a progressive increase in over nutrition and obesity especially in the urban affluent children. Health experts warn that unless effective health interventions are implemented there will be a huge increase in obesity, diabetes and cardio vascular diseases when these children become adults. Now it is a question that how child malnutrition can be combated? Weight, height and Body Mass Index (BMI) are three anthropometric parameters used for the assessment of nutritional status in children. The World Health Organisation (WHO) has provided the standards for weight, height and BMI in pre-school children and school-age children. The WHO has advocated the use of Body Mass Index (BMI) for early detection and effective management of both under-nutrition and over nutrition in children. The use of Body Mass Index (BMI) for assessment of current nutritional status in the Indian children is essential in all settings where height measurements are possible because early detection of current energy inadequacy (low BMI) and its correction can prevent stunting. Focus on early detection of low BMI for age and its expeditious correction with increase in food intake and treatment of infections can be achieved through convergence of health services. ICDS can substantially accelerate the pace of reduction in stunting and under-nutrition rates among the children. Small studies have analysed that under-nutrition is a problem in school age children from poorer sections of the population and limits the adolescent growth spurt and adversely affects the adult height. Alarming increase in over-nutrition had been reported in urban affluent children. It is essential to assess nutritional status of all children by measuring height, weight and computing BMI. Based on their BMI, children who are undernourished and those who are over-nourished can be identified. Providing undernourished children food supplements and treating infections if any detected through the school health system can reduce under nutrition rates. Increased physical activity both in school and at home can be useful in combating over-nutrition among the children.
The three major determinants of growth during infancy and early childhood are: birth weight, feeding practices and infections. Indian infants had a low growth trajectory. Breast milk provides all the nutrients that infant needs and protects them from infections. Infants grow normally if they are exclusively breast fed for the first six months. In India breast feeding is nearly universal and the majority of mothers exclusively breast feed their infants during the first three months. During this period, there is no further increase in underweight and stunting rates in infants. Introduction of animal milk between 3-5 months and rise in morbidity rates results in increase in underweight and stunting rates during this period. Between 6-11 months infants have to be fed semisolid household food 3-5 times a day to meet their growing energy needs. Late introduction, inadequate quantity and low calorie density of semisolid food is responsible to increase in underweight and stunting rates between 6-11 months. Between 12-23 months most children are shifted to the general family diet. Adult food is bulky and not calorie dense. Children have small stomach capacities and cannot get enough calories if they are fed only 3-4 times a day. The observed increase in the underweight and stunting rates between 12-23 months is the result of inadequate energy intake when children are shifted to the general household diet. Infections under nutrition, especially under nutrition as indicated by low BMI for age are consistently associated with infection in pre-school children. Under-nutrition could be the cause of increased susceptibility to infections or effect of increased nutrient requirement and greater nutrient loss. Early detection and effective management of infections can play a crucial role in reducing the under nutrition rates in pre-school children. Dietary intake of children malnutrition is due to imbalance between energy intake and expenditure. It is therefore essential to find out how much food children eat and what is the gap between requirement and actual food intake. In the last two decades, advance technologies which allow computing human nutrient requirements especially energy requirements with greater precision under free living conditions over a relatively long period have become available. There have been major changes in lifestyles and physical activity patterns in the present era. Taking all these into account Indian Council of Medical Research (ICMR) has revised the nutrient requirements and recommended dietary intake of the Indians.
Child malnutrition is due to the difference between energy intake and energy expenditure. When the food intake is equal to the requirement the child is normally nourished. When food intake is less than the requirement the child become undernourished; when the food intake is higher than required the child becomes overweight and obese. Depending on the severity and duration, energy deficiency can result in underweight and stunting among the children. All over nourished children irrespective of their current height should be advised to increase physical activity by playing at least for one hour every day and avoid eating too much of calorie dense food such as fried, sweets and ice creams etc. India is one of the fastest growing economies of the world during the last two decades and there has been sustained large investment in nutrition services for children. However even at present time about half of the pre-school children are underweight and stunted. The persistent high stunting and underweight rates have been a matter of concern. Nutrition and health professional are worrying about the future health status of these adults when they will reach at middle age and become elderly.
In India under nutrition is still the major problem especially for the children. At present coverage under Integrated Child Development Scheme (ICDS) and Mid Day Meal Programme is universal; they provide one meal for all children who come to anganwadi or school. But neither of these programmes screen children and provide double rations for those who are undernourished. Convergence with health system can ensure that all children are screened for undernutirtion and infections. Those who suffer with infections can be treated and undernourished children can be given double rations; these interventions can be achieved with the existing infrastructure and investments and lead to accelerated reduction in stunting. Over nourished children often grow into over nourished adults and incur increased risk of noncommunicable diseases which require lifelong expensive interventions. Only 2 per cent of Indian preschool children and about 5-10 per cent of school age children are over nourished. Screening of all the children will lead to early detection of over nutrition in pre-school and school age children; with appropriate counseling, parents can intervene over nutrition by altering food habits and increasing physical activity of children. Combating overnutrition burden has globally been viewed as a major challenge especially in countries with high burden of overnutrition. Under nutrition is a problem but can be readily addressed through convergence and focused attention through existing programmes.
(The writer is: Dr.Banarsi Lal, Asstt. Prof./Scientist, KVK Reasi (Sher-e-Kashmir University of Agricultural Sciences and Technology-Jammu).