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 Table of Contents  
ORIGINAL ARTICLE
Year : 2021  |  Volume : 11  |  Issue : 6  |  Page : 269-279

Trends of malnutrition from 1947-2021 among under-five children in India


1 Department of Home Science (Foods and Nutrition), University of Delhi, New Delhi, India
2 Department of Food Technology, Vivekananda College, University of Delhi, New Delhi, India
3 Department of Paediatrics, Lady Hardinge Medical College and Associated Kalawati Saran Children's Hospital, New Delhi, India

Date of Submission13-May-2021
Date of Decision15-Nov-2021
Date of Acceptance29-Nov-2021
Date of Web Publication31-Dec-2021

Correspondence Address:
Ms. Shivani Rohatgi
1/9380 West Rohtash Nagar Street No. 7 Shahdara, New Delhi - 110 032
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/cmrp.cmrp_43_21

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  Abstract 


Context: Malnutrition is a silent emergency and a leading cause of morbidity and mortality amongst children under 5 years of age. There are intra and inter-generational consequences of malnutrition.
Aim: To study the trends of prevalence of malnutrition among under-five children in India since its independence.
Subjects and Methods: The trends in malnutrition indicators from 1947 to 2021 in India through 40 studies out of 186 descriptive, cross-sectional and epidemiological studies, reports, etc., from the national and international electronic databases were reviewed and analysed.
Results: Indicators of malnutrition have changed over the years. There is the paucity of data on child malnutrition from 1947 to 1972. Until the 1980s, the data were represented in the proportion of under-five children falling below a specified percent of the median as per weight-for-age. From 1980 to 2021, the data on the nutrition status of children under five are available as prevalence based on weight-for-age, height-for-age and weight-for-height. Overall, not much progress can be observed towards achieving sustainable development goals (SDGs) targets for underweight, stunting and wasting since 2005.
Conclusions: The past seven decades have witnessed upward as well as downward trends during various periods of time in the prevalence of undernutrition. However, there has always been an upward trend in the prevalence of over-nutrition. To achieve SDG-2 by 2030, i.e., to reduce and maintain wasting by 5%, stunting by 40% and no further increase in childhood obesity, there is a need to strengthen the existing strategies and focus on the most vulnerable and critical age groups.

Keywords: Burden, COVID-19, malnutrition, morbidity, stunting, undernutrition, wasting


How to cite this article:
Rohatgi S, Suri S, Kumar P. Trends of malnutrition from 1947-2021 among under-five children in India. Curr Med Res Pract 2021;11:269-79

How to cite this URL:
Rohatgi S, Suri S, Kumar P. Trends of malnutrition from 1947-2021 among under-five children in India. Curr Med Res Pract [serial online] 2021 [cited 2022 May 19];11:269-79. Available from: http://www.cmrpjournal.org/text.asp?2021/11/6/269/334580




  Introduction Top


Malnutrition refers to the insufficiency of one or more nutrients required to function potentially.[1] While the concept of malnutrition has remained the same, the indicators of malnutrition have changed over the past seven decades.[2],[3] According to the available literature, protein energy malnutrition became a matter of concern and was recognised at an International platform sometime in 1954.[4],[5],[6],[7] Malnutrition is now recognised as a major contributor to childhood morbidity and mortality.[8] Various programmes have been implemented during different time periods to eradicate malnutrition.[9],[10],[11] In this paper the trends on prevalence of malnutrition in under five children (U5C) of India from 1947 to 2021 have been analysed. It provides a journey of different terminologies used for the classification of undernutrition, resulting in lacunae and shortcoming of this study.


  Subjects and Methods Top


Types of study subjects

Children under 5 years of age.

Types of outcome measures

Studies reporting public health perspective on trends of malnutrition, outcomes and assessment of nutrition status were considered and enrolled while reviewing data.

Types of study

Review articles, reports, policies, prospective and retrospectives studies.

Source of data

Reference books and databases, including published articles in indexed journals assessing the issues linked with undernutrition as well as the effects of socio-demographic variables on health and wellness as per sustainable development goals (SDGs), were included in this study.

Search methods

A thorough review of scientific literature was done using the keywords 'burden', 'kwashiorkor', 'marasmus', 'malnutrition', 'nutrition', ' national family health survey', 'National Nutrition Monitoring Bureau (NNMB)', 'prevalence', 'proportion', 'protein calorie malnutrition', 'stunting', 'undernutrition', 'underweight', 'under-five', 'wasting' etc., in PubMed, Google scholar and Inflibnet. The national and international reports on hunger, millennium development goals, SDGs, trends of malnutrition etc., policy documents and scientific literature of Global Nutrition Report, WHO, United Nation Children's Fund (UNICEF), United Nations Development Programme, World Bank, Ministry of Health and Family Welfare (MoHFW) and Ministry of Women and Child Development Health, India were reviewed thoroughly. The search was limited to literature published between 1945 and 2021.

Selection criteria and analysis

As per the inclusion and exclusion criteria, all titles and abstracts were screened to determine eligibility and full articles were independently assessed. For inclusion, scientific literature had to cover research or data on at least one topic.

This paper focuses on the:

  • Prevalence of malnutrition namely, wasting, stunting, underweight and overweight among under-five population in our country since independence
  • Trends in the prevalence of various forms of malnutrition over the past seven decades
  • Probable reasons for changing trends in the prevalence of malnutrition.


The paper concludes with discussion on policy and research recommendations pertaining to trends of undernutrition, methods of assessment and the road ahead.


  Results Top


Out of all the scientific literature that followed the search results; reviews, opinions, letters to the editor and articles not in English, from India's context were excluded. Out of the remaining studies, an enormous number of literature were excluded which correlated only the impact of nutrition to several secondary complications as well as studies conducted on animals. Salient programmes and their reports were identified in which data on nutrition indicators and nutrition-specific and/or nutrition sensitive interventions implemented in India were given. Finally, a total of one hundred and eighty-six articles/scientific papers/literature/websites were shortlisted. Data from these references/sources were identified and reviewed by the authors and forty were selected for this paper [Figure 1].
Figure 1: Algorithm of method followed for inclusion of studies chosen for full-text review

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Many studies and surveys have been conducted over the years to assess the nutrition status of U5C in India.[12],[13],[14],[15],[16],[17],[18],[19],[20],[21],[22],[23] These studies were initiated by Dr. Gopalan in the 1960s.[4] The results of one of such intensive studies carried out on approximately 2000 children aged under 5 indicated that kwashiorkor was prevalent in 1.3% of the population. Amongst the enrolled population 2%–3% showed severe emaciation and were considered as marasmus cases. In another longitudinal study conducted during the 1960s on 300 children from birth to 3 years of age indicated that about 1%–1.5% and 2%–3% of malnourished children suffered from kwashiorkor and frank marasmus respectively. At that time it was considered that marasmus and kwashiorkor were the end result of protein-calorie deficiency.[24] Before 1972, data on nutrition status of communities were collected by Nutrition Bureaus of certain states. In 1972 NNMB units were established in 10 states of the country viz, Andhra Pradesh, Karnataka, Kerala, Tamil Nadu, Maharashtra, Madhya Pradesh, Orissa, Uttar Pradesh, Gujarat, and West Bengal under the banner of National Institute of Nutrition, Indian Council of Medical Research. Data on diet as well as nutrient intake at individual and household levels, nutrition status of different populations in these states were collected so that analysis of the underlying causes of malnutrition could be assessed.[25]

These surveys provided data on indicators of nutrition and health necessary for policy and programme purposes, and identify important emerging health and family issues. Most of the surveys, however, lacked evidence-based methodology and well-designed surveillance system. They were held at variable intervals and with different sample sizes. There was a lack of coordination within and between various departments and states.

Large scale systematised community-based surveys NNMB started in India in mid-1970s. The data of the surveys held from 1975 to 1984 [Table 1] indicate that the situation of nutrition status (on basis of weight for age) remained nearly static during this period, though some improvement had been observed in the dietary intake and nutritional status of children under 5 years. It should be noted that these surveys were more concentrated in the southern and central states of India. According to the data, the percentage of underweight U5C (<−2standard deviation [SD] NCHS weight − for − age median), particularly those severely underweight, declined in all these states but to varying degrees. Overall for the country, the prevalence of underweight U5C was 78% (1975 − 77) and 69% (1987 − 89) respectively. Most of this reduction was in the more severe grades (<−3 SD median) which dropped from 38% (1975 − 77) to 27% (1987 − 89).[26]
Table 1: National nutrition monitoring bureau surveys pooled data of nutrition status (weight-for-age) of under five children from 1975-1984

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Till 1980s, data on anthropometric measurements of U5C were available as 'proportion of children falling below a specified per cent of the median' only for the indicator underweight (weight-for-age). Thereafter, the nutrition status (1980-90) of U5C was presented through the prevalence of stunting (50%), wasting (21%), and underweight (52%), respectively.[27] During the period 1984–1992, no data were generated from the surveys carried out exclusively under the banner of the national organisations. However, the data from the World Bank, UNICEF and WHO on the Indian population are available [Figure 2] and [Table 2].
Figure 2: Prevalence of malnutrition in under five population by World Health Organization (1974-2006)

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Table 2: Trends in prevalence of nutrition status of U5C (world bank and United Nation Children's Fund)

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With the help of WHO, data on stunting wasting and underweight between the years 1974 and 2006 was generated for U5C. The data were collected only from 8 states in 1974–79, 1988–89, 1991–92, 11 states in 2004–05 and 10 states in 2005–06 respectively. Additional parameters such as severe underweight, severe stunting and severe wasting were also estimated from 1992 to 93, 2004-05 and 2005-06. The prevalence of underweight reduced by 27% during 1974–2005 but increased again by 3.2% during the period 2005–06. The trends in the prevalence of stunting however indicate a continuous decline; the prevalence was 67.3% in 1974–79 which reduced to 44.6% in 2004–05. No definite trends in the prevalence of wasting were observed during 1974–2006; the percent decline was highest during 1996–97 year and lowest during 1988–90 year.

Regarding, World-Bank and UNICEF datasets, the first reported data on weight-for-age, height-for-age and weight-for-height were in 1989 and such data are available till 2017. The data were available for U5 children gender wise (boys and girls separately) and also combined for both genders.[28] The trends showed decline in the rate of stunting from 62.7% (1989) to 34.7% (2017). The prevalence rates of underweight children improved from 55.5% (1989) to 29.4% (2014), but the rates increased to 36.3% in 2015 and again declined to 33.4% in 2017. Wasting rates declined from 20.3% in 1989 to 17.1% in 1999 thereafter increasing to 20% in 2006 than 15% in 2014, 20.8% in 2015 and 17.3% in 2017, respectively.

During the period 1992–2021, data on malnutrition indicators were generated both by national and international organizations. This responsibility was taken up by MoHFW in the form of National Family Health Surveys (NFHS) which have been carried out since 1992–93. Till date, we have reports from five surveys; 1992–93, 1998–99, 2005–06, 2015–16 and 2019–2021, respectively. These surveys were large-scale, multi-round with representative sample of households throughout India from all states and provided data on indicators of malnutrition as well as factors affecting it. These surveys have been funded by various national and international organisations, namely, United States Agency for International Development Department for International Development, the Bill and Melinda Gates Foundation, UNICEF, United Nations Population Fund, and MOHFW, Government of India. The technical support was given by the International Institute for Population Sciences Mumbai.

NFHS-I (1992–93), 2 (1998–99), 3 (2005–06), 4 (2015–16) and 5 (2019–21) were carried out in 25, 25, 29, 36, 36 states and union territories (UTs) respectively [Figure 3]a. Electronic interactive data is available from NFHS-4 onwards. All the surveys provided information on indicators and factors associated with malnutrition.[29] The latest NFHS-5 is being carried out in phases due to the COVID-19 pandemic emergency. The first phase, carried out from 17 June 2019–30 January 2020, covered 22 states and UTs. The remaining states were covered from 2 January 2020-30 April 2021. The nutrition status data of all five surveys show a decline in different forms of undernutrition.
Figure 3: (a) Prevalence of malnutrition in U5C as per National Family Health Surveys-1, 2, 3, 4, 5. (b) Comparison of trends on nutrition status according to National Family Health Surveys, Annual Health Survey, Rapid Survey of Children and CNNS survey

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Amongst the BIMARU (1992–2020) states (Bihar, Madhya Pradesh, Rajasthan and Uttar Pradesh), Bihar reported the highest proportion of underweight, stunted and wasted children in NFHS-1 i.e., 62.6%, 60.9% and 21.8%, respectively. Since then, the underweight and stunting rates have improved to 41.0% and 42.9% but wasting rates increased to 22.9% (NFHS-5). Rajasthan had 41.6%, 43.1% and 19.5% of underweight, stunted and wasted children in NFHS-1. Consistent decline in underweight (32.1%), stunting (35.5%) and wasting (19.3%) rates but an incline in severe wasting (7.7%) has been reported in the NFHS-5 survey. Good performing states include Mizoram, Chandigarh and Puducherry which had the lowest cases of underweight (12.7%), wasted (2.3%) and stunted (20.0%) children during the NFHS-5 survey [Table 3].
Table 3: Trends of undernutrition from national family health surveys surveys conducted from 1992-2021

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The trends of the triple burden of malnutrition (overnutrition, undernutrition and micronutrient deficiencies) at national and state levels have been examined by some organizations. Various surveys have been compared in a study conducted by Tata Cornell Institute wherein data sets from Indian Human Development Survey 2005 and 2011; NFHS-1-5; the Annual Health Survey (2014); The Rapid Survey of Children (RSoC-2013–14), and District Level Health Survey (2002) have been analysed.[30],[31] Analysis highlights a strong association of malnutrition and other diseases.[32] Through [Figure 3]b, it can be concluded that trends of underweight prevalence declined in NFHS and RSOC survey but got hyped by 4% in CNNS survey. The trends on the prevalence of stunting have declined from the year 1992-2018 as per these surveys. However, the wasting trends were raised in NFHS-3 and 4. It can be seen that in 2013–14 the prevalence of wasting was 15.1% (RSoC), then 21% in 2014–15 (NFHS-4) and subsequently declined in 2016–18 (CNNS) to 17.3%.

The trends in the prevalence of nutrition status of U5C given by World Bank and UNICEF (1989–2017) as given in [Table 2] shows the status on stunting, severe stunting, wasting, severe wasting, underweight, and severe underweight for the country as a whole. However, NFHS surveys (1992–2020) provide the country status along with state and district wise trends but only for stunting, underweight, wasting and severe wasting. The prevalence rates of comparable indicators are nearly the same.

Data on indicators of malnutrition has been used for evidence-based programme planning, implementation and evaluation. Several health and nutrition initiatives taken by the government have aimed at reducing the prevalence of malnutrition. The salient ones are the: Integrated Child Development Services, National Health Mission, Janani Suraksha Yojana, Matritva Sahyog Yojana, Mid-Day Meal Scheme and National Food Security Mission, National Food Security Act. However, despite concentrated efforts, malnutrition continues to be a public health problem.


  Discussion Top


Through the review, it was found that there were too many inconsistencies in the nutrition indicators across various data sources. Ideally, the data should be consistent through time and geographical units. There was a period of the plateau from 1992 to 2005 (NFHS-1, 2, 3) with both upward and downward trends in stunting, wasting and underweight i.e., the decline was seen from NFHS-1 to NFHS-2 but incline was seen in NFHS-3. The data sets indicate downward trends in the prevalence of stunting among U5C from 2005 to 2016. There has been reduction in the proportion of U5C who are underweight (67.3% in 1974 and 33.4% in 2017).

Although the rate of decline in India's child undernutrition rates has accelerated since 2006, the progress is still well below the recommended speed needed to achieve the global nutrition targets adopted by the World Health Assembly to which India is a signatory. By 2030, the SDG-2 is aimed to reduce and maintain wasting by 5%, stunting by 40% and no further increase in childhood obesity to achieve the desired targets.

The evidence accumulated in the WHO Global Database on Child Growth and Malnutrition permits an accurate description of the magnitude and geographical distribution of childhood undernutrition and overnutrition worldwide. Analysis of such data sets confirms that child undernutrition remains a major public health problem in India. It continues to hamper the physical growth and mental development of several children and is still an important cause of mortality which influences the gross domestic product considerably.[33]


  Conclusions Top


During the past seven decades, India has made reasonable improvements in nutrition outcome indicators (stunting, wasting and underweight); though the rate of improvement has not been consistent and there have been periods of fall out. A more consistent but modest change has been observed in the past 15 years.

India has adopted a multi-sectoral approach on nutrition and effectively engaged its multiple stakeholders in the planning, coordination, implementation, review and surveillance of initiatives aimed at reducing the curse of malnutrition among children. However, these need to be further strengthened which would primarily require an understanding of how and to what extent different sectors contribute towards improvements in nutrition outcomes. There is a need for greater joint planning so that the government can identify ways of making different schemes, particularly core schemes, more nutrition sensitive. This should be based on scientific data.

Hence, there is a need to have more reviews on outcome-based analysis. Moreover, quantitative analysis rather than qualitative analysis is necessary and the outcomes and factors should be measurable. The effective implementation of health initiatives/programmes/schemes depends on the holistic development of parent departments to a great extent. Each department should therefore develop its own framework of action and standard operating procedures (SOPs) to micromanage the policy decisions and provide desirable results. Finally, it is imperative that all stakeholders including the beneficiaries should jointly review the situation with the government regularly to iron out and identify issues that different states/departments may have experienced during implementation, what the impacts of the programmes have been, and deliberate on what can be done better.

Actions to drive progress in combatting undernutrition

Despite limited resources and vast population, India has managed the COVID-19 pandemic fairly well so far. Yet, India is beginning to experience the after effects of disruptions to health service delivery, food supply chains, economies, etc., as a result of the COVID-19 pandemic. While the virus continues to spread in resource-poor populations; health, food, education and social protection systems are experiencing several challenges which may precipitate malnutrition, especially in the vulnerable segments in times to come. Contributions from all sectors of society are necessary to address the diverse challenges. While the political stakeholders are leading the response by providing strategic direction and ensuring coordinated and aligned programming, the following measures hold potential and may be considered to curb the pandemic of malnutrition as an outcome of COVID-19 pandemic:[34],[35],[36]

  1. Emphasising on continuing all critical community-based nutrition services such as promotion of breastfeeding, micronutrient supplementation, etc.
  2. Promoting diet diversity in resource-stricken communities by strengthening partnerships with the agriculture community. This can be facilitated by the following measures: (a) national policies to dissuade trade bans on food supplies, especially for staple foods; (b) strengthening local supply chains for vegetables, fruit and other perishable foods that are subject to waste through the Ministry of Food processing industries.
  3. Strengthen the safety net programs (including school meals and employment generation initiatives) to reach the lesser reached segments of the society.
  4. Scaling up of cash transfers, as done during the lockdown period should be continued and the vulnerable segments such as parents of U5C, lactating mothers, pregnant women should be given preference.
  5. Fortification of foods needs a push and availability of fortified foods amongst the vulnerable segments needs to be ensured. This can be done through close coordination of the ministry of food processing industries with the food safety and standards authority of India.
  6. Communication campaigns on COVID-19 need to be given impetus[37],[38]
  7. The COVID-19 vaccines have been introduced in the country on 16th January after regulatory bodies have cleared its efficacy and safety. 'Early adopters' in the community should be bought to the forefront to ensure the acceptability of vaccine.
  8. Need to revisit the planning and implementation of interventions targeted at the U5 population in view of COVID-19 as increase in cases of malnutrition are expected.
  9. Extensive studies/survey to screen how COVID-19 may enhance the malnutrition, especially children, the future of a nation need to be carried out at national level.
  10. Regular reframing of taxation and marketing regulations on unhealthy foods such as sugar sweetened beverages and junk foods that promote obesity. This would not only prevent over-nutrition but will also help provide fiscal space in developing countries at a time when budgets are severely constrained.
  11. Mobilizing private or corporate sector leadership and partnerships such as with government agencies, public sector and the civil society in public policy dialogues, advocacy and institution building. This can be done for:


    1. Widening the scope of agriculture growth corridors and industrial agriculture projects
    2. Opening up and strengthening existing channels which link producers with export-oriented value chains by supporting local, regional and global food and health systems
    3. Promoting delivery of technology-enabled health and nutrition services
    4. Marketing of health promotive foods/practices/messages.
    5. Philanthropic contributions and crowdfunding for vulnerable populations


  12. Encouraging institutional innovations such as of product, process and services especially those which can benefit the vulnerable community is necessary. Academia-industry partnerships can help in taking innovations from the laboratory to the field. Curriculum offered by schools and higher education institutions should have teaching-learning transactions between students and the corporate sector, Nongovernmental Organisation, etc.


In Budget 2020, focus is on strengthening three areas: Preventive, Curative and Wellbeing. Also to strengthen nutrition content, delivery, outreach and outcome, Supplementary Nutrition Programme will be merged with the Poshan Abhiyan and there will be the launch of Mission-Poshan 2.0. It prioritises 112 aspirational districts to develop practices that will nurture health, wellness and immunity of children and pregnant women which will help in eradicating malnutrition from its roots.[39],[40] One plan fits all' may not provide the desired results, therefore there should be scope to modify or alter the plan of action so that the interventions become need-based and suits regional/demographic/cultural demands, etc.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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    Figures

  [Figure 1], [Figure 2], [Figure 3]
 
 
    Tables

  [Table 1], [Table 2], [Table 3]



 

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Abstract
Introduction
Subjects and Methods
Results
Discussion
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