the dual burden of malnutrition in

India

Zubiya ShaikhRoll no. 50

Department of Composite Home Science S.V.T College of Home Science

Year 2015-2016

the dual burden of

malnutrition in India

What is nutrition ? It is the science that interprets the interaction

of nutrients and other substances in food in relation to maintenance, growth, reproduction, health and disease of an organism. It includes food intake, absorption,

 assimilation, biosynthesis, catabolism and excretion.

Getting to know malnutrition..• A term used to refer to any condition in which the body does not receive

enough nutrients for proper function. Malnutrition may range from mild to severe and life-threatening.

• People are malnourished if their diet does not provide adequate calories and protein for growth and maintenance or they are unable to fully utilize the food they eat .

• At times malnutrition can be so severe that the damage it does to the body is permanent even though you survive.

Forms of Malnutrition• Malnutrition is a broad term commonly used as an alternative

to undernutrition but technically it also refers to overnutrition.

Under nutrition –

• Being below the optimum nutrient level for a healthy growth, development and living is called undernourishment.

Under-nutrition results in: Stunting• Stunted growth, also known as stunting and nutritional stunting, is a

reduced growth rate inhuman development.• Stunted children may never regain the height lost as a result of stunting,

and most children will never gain the corresponding body weight.• Measured by height for age.

Wasting• Wasting, also known as wasting syndrome, refers to the

process which causes muscle and fat tissue to "waste" away.• Measured by Weight-for-height (WFH).

Low Birth Weight• Low birth weight (LBW) is defined as a birth weight of a liveborn

infant of less than 2,500 g (5 pounds 8 ounces) regardless of gestational age.

• Their chance of survival is poor; they have less ability to resist diseases, therefore, suffer from frequent infection, inability to cope up thus they are Severely Malnourished.

• Reduced ability to perform normal tasks / physical performance – for example, not being able to walk as far or as fast as usual .

• Altered mood – malnutrition can be associated with lethargy and depression.

• Recurring illness : Recurrent or chronic infections

• Weak immune system

• Low immune function 

• Weight loss  • Tiredness, loss of energy

• Poor concentration

The Two forms of Under nutrition

• Protein-Energy Malnutrition (PEM)

• Protein Energy Malnutrition (PEM) is a malnutrition resulting from the deficiency of protein and/or energy in diet.

PEM iceberg

Kwashiorkor

• It is found in children who have a diet that is usually insufficient in energy and protein and often in other nutrients.

• Kwashiorkor is often associated with, or even precipitated by, infectious diseases

Signs of kwashiorkar • Oedema

• Stunting

• Wasting

• Fatty infiltration • of the liver.

• Mental changes

• Hair changes.

• Skin changes.

• Anaemia.

• Diarrhoea.

• Moonface. 

Nutritional marasmus

• In marasmus the main deficiency is one of food in general, and therefore also of energy.

• Nutritional marasmus is in fact a form of starvation, and the possible underlying causes are numerous. For whatever reason, the child does not get adequate supplies of breastmilk or of any alternative food.

Signs of marasmus

Nutritional Deficiency Diseases• It is caused by relative / absolute lack of individual nutrient.

• Nutrient deficiencies alter bodily functions and processes at the most basic cellular level.

• These processes include water balance, enzyme function, nerve signaling, digestion, and metabolism.

• Nutrient deficiencies can also lead to other diseases

THE HINDU MAY 2015

Over nutrition

• Overnutrition is a form of malnutrition in which the intake of nutrients is oversupplied. The amount of nutrients exceeds the amount required for normal growth, development, and metabolism.

• Overnutrition can develop into obesity, which increases the risk of serious health conditions, including cardiovascular disease, hypertension, cancer, and type-2 diabetes.

• By 2020, an estimated two-thirds of the global burden of disease will be caused by chronic non-communicable diseases, most of which are associated with diet.

The prevalence of wasting in South Asia is so severe, at just under 15 per cent, that it is approaching the level of a critical public health problem

Indicating out of every five children in India one is wasted

Undernutrition contributes to nearly half of all deaths in children under 5 and is widespread in Asia and Africa;

Percentage of children under 5 who are stunted, 2008-2015*Data are the most recent available estimate between 2008 and 2015

GLOBAL UNDER-FIVE MORTALITY RATE , UNICEF Oct 2015

Malnutrition is India's silent emergency

Nearly half of India's children- approximately 60 million - are underweight, 48% have stunted growth (too short for their age), 20% are wasted (too thin for their height, indicating acute malnutrition), 75% are anaemic, and 57% are deficient in Vitamin A.Describing malnutrition as India's silent emergency, the World Bank report says that the rate of malnutrition cases among children in India is almost five times more than in China, and twice than in Sub-Saharan Africa.

• THE TIMES OF INDIA MARCH 2014

• 75% of Indians suffer vitamin deficiency: THE TIMES OF INDIA OCTOBER 2015

Food security and Hunger

• Food security is often defined as access by all people at all times to sufficient food required for a healthy and active life

• India is a food surplus nation but according to The 2015 Global Hunger Index (GHI) Report ranked India 20th amongst leading countries with a serious hunger situation. It has more than 190 million food-insecure people, the most in the world

sanitation• In India ,more than 122 million households have no toilets, and 33% lack access to

latrines, over 50% of the population (638 million) defecate in the open.• Although 211 million people gained access to improved sanitation from 1990–

2008, only 31% use the facilities provided.• Only 11% of Indian rural families dispose of stools safely whereas 80% of the

population leave their stools in the open or throw them in the garbage. Open air defecation leads to the spread of disease and malnutrition through parasitic and bacterial infections.

Poverty• It suggests economic causes of malnutrition

• Breastfeeding • Social and cultural factors • Natural calamities & the landless.

Treatment for Malnutrition – Under Nutrition Hospitalization Diet Rehydration. Treatment of hypothermia Recover

Case study : NRC at nandurbar

• The district has six blocks all of which are tribal viz. Dhadgaon, Akkalkuwa, Taloda, Shahada, Navapur and Nandurbar. There are a total of 931 villages and four towns. Of the total villages, 492 have a population of less than 500, out of these 131 are difficult to access. Pucca roads connect about 32% of the villages

Nandurbar at a glance……Total Population (Census 2011) 1,602,902

Non Tribal Population 36 %

Tribal Population 64 %

Below Poverty Line (BPL) Population (%) 75.43 %SC / ST Population (%) 68.69 %

Blocks 6

Gram Panchayat 501

Villages 939

Padas (Hamlets) 1465No. Of PHCs 58

No. of RH / Cottage / SDH 15

Sub centres 290

• Till 23.12.2011…….. NO special treatment Facility for Children with Malnutrition (SAM) in District Hospital Nandurbar

Nutritional Rehabilitation Center , NandurbarDistrict Hospital

Challenges at Beginning• Administrative support – Financial / Manpower shortage

(SN/Dietician) / Logistics (Equipments and Supplies)• Very Low Patient flow.. (BOR) – No linkages• Stay of mothers in NRC – 2-3 days• High rates of Defaulter.• Language barrier.• Low attendance for follow up camp

Admissions procedure• Triage the patients in waiting area• Give all severely malnourished ~10% sugar-water to drink

(assistant)• Do anthropometry (assistant)• Do appetite test (assistant)• Check IMCI signs (nurse)• Decide with the mother Out- or In- patient care (nurse)• Register the patient• Fill out the multi-chart • Explain to the caretaker the procedures of the program/ centre

(nurse)• Take only essential history and examination in order to start of

treatment (surveillance data - nurse)• Start routine treatment (nurse)

ANTHROPOMETRIC MEASUREMENTS

45

Body weight Poor Moderate Good

kg Gram of SF( Special Feed)

3 – 3.9 < 15 15 – 20 >20

4 – 5.9 < 20 20 – 25 >25

6 – 6.9 < 20 20 – 30 >30

7 – 7.9 < 25 25 – 35 >35

8 – 8.9 < 30 30 – 40 >40

9 – 9.9 < 30 30 – 45 >45

10 – 11.9 < 35 35 – 50 >50

12 – 14.9 < 40 40 – 60 >60

APPETITE TEST -To pass the appetite test the intake of a test meal has to be at least in the moderate range.

Preparation of Special Food (SF)Sr. No.

Ingredients Amount

1 Groundnut 1 kg2 Whole Milk Powder 1200 g3 Sugar 1120 g4 Coconut Oil 600 g

Method :•Roast the groundnuts and take off the peel •Finely grind the groundnuts and sugar together to a powder like consistency•Sieve the powder to remove any lumps •Add milk powder and oil to it and mix well

1 Spoon (15 ml) = 12 gm of TF

During the Stay at NRC : Medical Check up by Paediatrician (Daily)

Proper Cleanliness in NRCs

Cleanliness of mother & child Cleanliness of Staff

Cleanliness of Kitchen Cleanliness of Ward

Cook preparing glasses for feed….

Mothers taught Hand washing before feeding the child….

Feeding in NRC

Mother feeding the child

Mother feeding the child

Wheat & Green Gram Sprouted Dried Roasted Floured

In 3:1 Proportion55

What is amylase flour????

Sr. No

Ingredient Amount (gms)

Calories (Kcal)

Proteins (gms)

1. Milk 25 33.3 1.82. Sugar 5 20.0 003. Amylase flour (Wheat) 20 68 2.564. Amylase flour (Green gram) 10 34.8 2.45

5. Groundnut 10 56.8 2.526. Oil 20 180 007. Gingelly Seed (Til) 5 28.15 0.928. Spices and condiments for

tasteTotal 95 421.05 10.25

56

Recipe of Upma

Cost of recipe is Rs. 4.25

Amylase flour based recipes prepared by Mother at home

Health Education Counselling session to Mothers

Play Therapy for Emotional and Sensory stimulation to children

Stimulation and play therapy

Event celebration: (Anniversary / Makar sankranti / Birthday etc)

Counseling of Parents in Local language by UNICEF resource person…

Bathing of children in Phase II with Hot water

On Admission 4 Weeks Later

ON ADMISSION - 4 WEEKS LATER

Counseling with breastfeeding support

Adm date 12.05.12Adm wt 1.825kg

II- 3.7.12- wt 3.375

INNOVATIONS

ACTIVITIES TO MAINTAIN FOLLOW UP- Follow up camps at Taluka place (Rural Hospital)

Activities to increase referral- Training Session on Introduction to NRC for ASHA Workers

Gift to children who visit NRC timely for follow up

Follow up camp:

Sensitization of ASHA Workers about NRC

Sensitization of ASHA Workers about NRC

Visited by Collector Nandurbar

Other Visits…Dr Pandge (Dy Director RJHN Mission)

Dr Karnataki (State Maternal Health Consultant)

Conclusion• NUTRITION AS AN UNALIENABLE RIGHT • We cannot, we must not, accept the present condition of the great

majority of the world’s population as something to be dealt with band-aids• The major reason for formulating this document is to realize that

international justice demands that we recognize the rights and needs of all people of this world we inhabit- and that we work jointly, towards a common goal of betterment of human condition

References• By Stuart R. Gillespi ,2003,The Double Burden of Malnutrition in Asia: Causes,

Consequences, and Solutions

• The double burden of malnutrition Case studies from six developing countries. FAO FOOD AND NUTRITION PAPER. 84

• Indian Dietetic Association National Conference: Severe Acute Malnutrition 2011

• Monika Blössner Mercedes de Onis (2005) Malnutrition quantifying the health impact at national and local levels. (WHO)

• Umezawa M, Kogishi K, Tojo H, (February 1999). "High-linoleate and high-alpha-linolenate diets affect learning ability and natural behavior in SAMR1 mice". J. Nutr. 129

• UNICEF-WHO-World Bank Group : Joint child malnutrition estimates . Key findings of the 2015 edition

• www.who.int/

• en.wikipedia.org

• www.wfp.org/countries/india World food Programme

• www.nlm.nih.gov

• Michael C. Latham . Rome, 1997, Human nutrition in the developing world , Food and agricultural organization of United States Document.

• Spears, D. (2013). How much international variation in child height can sanitation explain? - Policy research working paper. The World Bank, Sustainable Development Network, Water and Sanitation Program

 • Intensive Care Nursery House Staff Manual

• Chopra M, Galbraith S, Darnton-Hill I: A global response to a global problem: the epidemic of overnutrition.  Bulletin of the World Health Organization 2002, 80:952-958.

• “Nutrition In Global Health.” Global Health Education Consortium, 29 June 2011. Web. 15 May 2012.1

•  Parks, Naomi. "What Is Overnutrition and Undernutrition?" Livestrong.

• Subramanian SV, Kawachi I, Smith GD. Income inequality and the double burden of under- and overnutrition in India. J Epidemiol Community Health 2007;61:802–9.

• World Health Organization. World Health Assembly. Global Strategy on Diet, Physical Activity and Health. 2004.

•  "2015 Global Hunger Index Report" (PDF). International Food Policy Research Institute (IFPRI).

•  "Putting the smallest first". The Economist. 23 September 2010. Retrieved 13 • February 2012.

• The Wall Street Journal India , December 2015

• "Water, Environment and Sanitation". Source: UNICEF India. Retrieved 2011-09-20.

THANK YOU…

Awaiting a better future…