India and Acute Malnutrition in

Children

Veena Shatrugna

National Institute of Nutrition

Hyderabad
India
-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)
10 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 52.2 56.6 68.9

(509-3870)
-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 M F M F M
01+ 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+ 99.6 100.5 100.4 102.1 102.5 103.2 102.4 102.6 108.4 109.9
(229-747)
10+ 125.7 125.1 126.8 127.9 128.5 128.7 128.9 129.0 138.3 137.5
(304-734)
20-24 151.2 163.4 151.5 164.0 151.1 163.3 152.0 164.2 163.7 176.8

(509-3870)
>=70 147.9 162.3 147.9 161.0 146.8 160.0 145.5 159.9 -
(339-728)
-3-
 % DISTRIBUTION OF ADULTS ACCORDING TO BMI
CLASSIFICATION 20 YEAR TREND
 
BMI 1974‑79* 1988‑90* 1996-97** 1993‑94*** 2002*
CLASSES (RURAL) (RURAL) (RURAL) (URBAN) (RURAL)
 
<18.5
(CED) F 51.8 49.3 47.7 36.7 38.9

M 55.6 49.0 45.5 42.8 36.6

(NORMAL) F 44.8 46.6 46.3 51.7 52.4

18.5‑25.0
M 42.1 48.3 50.4 51.8 57.2

(OBESE) F 3.4 4.1 6.3 11.6 8.7

>=25
M 2.3 2.7 4.1 5.5 6.2
* NNMB, 1991, quoted by N,Nadamuni Naidu et al, 1994.
* Rural, 2002
 -4a-

% 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
<16.0 8.6 5.7 11.8 8.0
16.0-17.0 11.0 7.9 12.8 9.0
17.0-18.5 25.9 19.6 23.2 19.0
18.5-20.0 25.3 21.7 20.0 18.7
20.5-25.0 25.2 37.3 26.4 34.4
>25 4.1 7.0 6.0 9.1
Source: NNMB, 1996 & 2006(Rural)
-5- Thinness as a public health problem

Low prevalence (warning sign,

monitoring required): 5-9% of population with BMI <18.5

Medium prevalence
(poor situation): 10-19% of population with BMI <18.5

High prevalence
(serious situation): 20-39% of population with BMI <18.5

Very high prevalence

(critical situation):  40% of population with BMI <18.5
-6-
Mean Birth Weights in different parts of the world

Region Mean Birth Weight

(kg)

North America, Western Europe 3.5-3.6

and 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 (<2500g) Birth weight
(Kg)

India 4307 33.0 2.63

Nepal
Rural 2529 14.3 2.78
Urban 3629 22.3 2.76
Sri Lanka 1851 18.4 2.84
Myanmar 3582 17.8 2.85
Indonesia 1647 10.5 2.94
Thailand 4124 9.6 3.00
USA
Afro-American 4614 10.6 3.14
Whites 16481 6.0 3.36
*Source: WHO, 1993.
-8- MATERNAL PARAMETERS (MEANS) ACCORDING TO BMI STATUS

BMI CLASSES N MOTHER'S (Wt, Kg.) BIRTH (Wt, Kg.) LBW (<2500 g)%

<16.0 81 35.4 2510 53.1

CED III

16.0-16.9 133 38.1 2573 41.4

CED II

17.0-18.4 460 40.9 2653 35.9

CED I

18.5-19.9 553 44.1 2771 27.7

(NORMAL)

20.0-24.9 717 49.6 2812 26.4

(NORMAL)

25.0-29.9 68 60.6 2972 14.7

(OBESE)

> 30 5 75.5 2972 20.0

(OBESE)

TOTAL 2017 45.2 2742 30.5

Source : NNMB Repeat Surveys (1991) , Quoted by Nadamuni Naidu et al, 1994.
- 9-
Birth Weight and Socio-Economic Status
Poor Middle High
income income income

Height (cms) 151.5 154.2 156.3

Weight (kg) 45.7 49.9 56.2
Hb(g/dl) 10.9 11.1 12.2
Birth weight (kg) 2.70 2.90 3.13
-10-
BIRTH WEIGHTS IN POOR AND WELL TO DO GROUPS IN
MADRAS AND COONOR

N B.WT PREMATURE
Lbs Kg (%)

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

1954
SPEL.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 group

1. Iron
2. Folic acid
3. Iron and Folic acid
4. Zinc
5. Vitamin A
6. 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 classification

Nutrition Grades* Boys Girls Pooled

(n=2011) (n=1957) (n=3968)
Normal 13.1 12.1 12.6
Mild 45.5 45.5 45.5
Moderate 37.4 37.8 37.6
Severe 4.0 4.6 4.3

* NCHS standards
Source: NNMB 2005.
-14 a-
Distribution (%) of 1-5 years according to Weight for age – standard
deviation (SD) classification by gender

Weight for age* Boys Girls Pooled

(n=2011) (n=1957) (n=3968)

 Median 3.5 3.6 3.6

-1SD to Median 11.4 10.1 10.8
-2SD to -1SD 31.4 31.1 31.2
-3SD to -2SD 38.2 37.7 37.9
<Median - 3SD 15.5 17.5 16.5

* NCHS standards
- 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
<Median -3SD 6.1 20.2 14.9

* NCHS standards
Source: NNMB 2005.
- 15 a -
Distribution (%) of 1-5 years children according to Height for age
standard deviation (SD) classification by gender

Height for age* Boys Girls Pooled

(n=2011) (n=1957) (n=3968)

 Median 8.0 6.6 7.3

-1SD to Median 15.5 13.4 14.5
-2SD to -1SD 26.4 25.5 26.0
-3SD to -2SD 26.6 27.9 27.2
<Median - 3SD 23.5 26.6 25.0

* NCHS standards
Source: NNMB 2005.
- 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
<Median -3SD 5.7 26.5 23.5

* NCHS standards
Source: NNMB 2005.
-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 to Median 31.5 31.1 31.3
-2SD to -1SD 41.8 41.6 41.7
-3SD to -2SD 13.3 11.8 12.6
<Median - 3SD 2.5 2.3 2.4

* NCHS standards
Source: NNMB 2005-06.
-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
<Median -3SD 4.4 2.6 2.2

* NCHS standards
Source: NNMB 2005.
 -17 -

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 - - -
- 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 56 8 5 11

Male 58 29 15 39 56 8 3 11
10-12
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 45 50 54 24 9 9
10-12
Female 57 41 51 22 11 9

Male 55 40 65 32 10 11
13-15
Female 70 39 58 25 15 9

Male 70 40 60 32 12 9
16-17
Female 70 43 62 35 14 10

Male 80 77 85 70 29 11
>18
Female 89 78 77 61 15 11
- 20 –
Other nutritional problems
Apart from stunting and under weight –

1. Anaemia - 60-90%
2. Iodine Deficiency - endemic most parts of the country
3. Goitre - endemic in North East, sub Himalayan
range, many tribal belts in central India
4. Fluorosis - endemic many parts of the country
-21 –

According to Recommended Dietary Guidelines

60-65% Calories from Carbohydrates
25-30% from Fat
10-12% from Protein
Each of these calories, proteins and fats must be derived from as
many foods as possible
In 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 available…this 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 units
Minimum Wages
Poverty Line
Green 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-Units
Adult male (sedentary worker) 1.0
Adult male (moderate worker) 1.2
Adult male (heavy worker) 1.6
Adult female (sedentary worker) 0.8
Adult female (moderate worker) 0.9
Adult female (heavy worker) 1.2
Adolescents 12 – 21 years 1.0
Children 9 to 12 years 0.8
Children 7 to 9 years 0.7
Children 5 to 7 years 0.6
Children 3 to 5 years 0.5
Children 1 to 3 years 0.4
*Source: Gopalan et al (1991)
- 26 -
Minimum Wages - Criteria

1. 3 consumption units * for one wage earner

2. 2700 cals per average Indian adult
3. ? Clothing - 72 yards per annum per family
4. ? House rent
5. ? Fuel, Lighting etc… - 20% of wages
6. ? Education, Medical and other expenses
- 27 - Since Minimum wages are based on calories
Cheapest source of 2000 calories
(Gm) Cost (Rs.)
Sugar 520 8.00
Rice 571.4 11.0
Oil 225 ml 18.0
Dals 500.0 22.0
Potato 2000 20.0
Sapota, banana 1740 25
Milk 3250ml 60
Chicken 2000 120
Dry fruits 400 200
- 28 - Micironutrients essential for man
Vitamins Trace minerals
A. Micronutrients known to be essential for man and animals
Vitamin A Thiamin Iron Selenium
Vitamin D Riboflavin Iodine Manganese
Vitamin K Nicotinic acid Zinc Chromium
Vitamin E Pyridoxine Copper Cobalt
Essential fatty acid Folic acid
(-6 and  -3)
Biotin (?) Vitamin B12
Pantothenic acid (?) Ascorbic acid

B. Micronutrients essential for animals and not yet established as essential for man
Choline Silicon Molybdenum
p-Aminobenzoic acid Fluorine Arsenic
Nickel
Source: Narasinga Rao BS.
- 29 - Phytonutrients for Health Promotion
Phytonutrient class

Carotenoids
Glucosinolates,
Isothiocyanates,
Indoles
Inositol phosphates
Phenolics, cyclic compounds
Phytoestrogens
Phytosterols
Polyphenols
Protease inhibitor
Saponins
Sulfides 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
Riboflavin
Sulfur amino acids Anthocyanins
Cysteine and methionine Isoflavones
Selenium Phenolic compounds (catechin) Indoles
- 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 status
Age (yrs) % with adequate % with adequate
calories Vitamins Minerals

1-3 31.8 8.0 15.0

4-6 28.2 10.0 20.0
7-9 28.1 7.5 20.0
10-12 26.0 (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 energy Iron
Mean ±SD (n)

< 70 9.6 ± 7.50 (1081)

(9.2 – 10.0)
Women
70 – 100 13.2 ±8.07 (2567)
12.9 - 13.5)

 100 17.0 ±9.64 (2034)

16.3 – 17.1)

Pooled 13.8 ±8.94 (5682)

-34 –
Mean intake of one nutrient iron (mg) by levels of
percentage RDA of energy
Details % RDA of energy Iron
Mean ±SD (n)

< 70 5.9 ±4.57 (2898)

Children (5.7 – 6.1)
1-6 yrs
70 – 100 9.7 ± 6.46 (856)
(9.3 – 10.2)

 100 14.0 ± 9.19 (234)

(12.9 – 15.2)

Pooled 7.2 ± 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
1. Oxidative damage, diarrhea, in undernourished populations
2. Infections, like Malaria, TB, HIV,
3. Even deaths

What is required is sources of foods which make the iron available

such as
1. Vitamin C rich foods
2. Small amounts of meat which provides haem iron
3. Fill the calorie gap with foods other than cereals
These 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 times
Ferrous sulfate - without EDTA low bioavailability
alters taste – with EDTA – iron amount have to be
decreased net iron intake the same
Elemental 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.John’s 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 humans

Need to re-look at strategy

Studies done in the following countries did not show
improvements in haemoglobin after the distribution
of iron fortified wheat flour.
Srilanka
Bangladesh
Thailand
Morocco
Ivory coast
India
- 41 –
The National Anemia Prophylaxis Programme
Iron 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.Aykroyd’s Recommended Diet (1957)
gr.
Cereals- 14 oz - 420
Pulses 03oz - 90
Vegetables 10 oz - 300
Milk 10 oz - 300
Sugar/ 02oz - 60
Oil / ghee 02oz - 60
Fruits 02 oz - 60
Fish / meat 03 oz - 90
Eggs 01 oz - 30
- 43 - Average Intake of Nutrients (per day) (Boys and Girls)

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

Approximate cost of a 1000 Kcal diet – Rs 15 /-
- 45 -
Rehabilitation diet for undernourished children
Diet - as close to the home diet as possible

Routine Diet at Nutrition ward for children

6 AM Milk
8.30 am Khichri
11 AM Bread and Milk / egg
1.30pm Lunch Rice, Dal,etc
4pm Milk / Egg
7pm Dinner Rice Dal etc
10pm Milk

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.
1. Problems of processed food which is not produced
locally.
2. Half the children of this country will require this
3. Assured supply for years is hard to imagine
4. Local populations will learn to trust only packaged
food
5. Women will forget how to feed their children
6. Local employments of millions of women will be
affected
- 47 -
Iron content (mg) of common foods in 100g of edible portion

Cereal Iron (mg)

Bajra 8.0
Jowar 4.1
Ragi 3.9
Rice, raw, hand pounded 3.2
Rice, bran 35.0
Rice, flakes 20.0
Rice, puffed 6.6
Wheat, bulgar (parboiled) 4.9
Wheat, whole 5.3
Wheat flour (whole) 4.9
Wheat flour (refined) 2.7
Wheat germ 6.0
Wheat bread (brown) 2.2
- 48 -
Contd/- Pulses Iron (mg)
Bengal gram dhal 5.3
Bengal gram roasted 9.5
Cow pea 8.6
Horse gram whole 6.77
Lentil 7.58
Moth beans 9.5
Rajmah 5.1
Soya bean 10.4
Leafy Vegetables
Amaranth polygonoides 27.3
Cauliflower greens 40.0
Manathakkali leaves 20.5
Mint 15.6
Mustard leaves 16.3
Parsley 17.9
Radish leaves table 18.0
- 49
-Contd/- Other vegetables Iron (mg)
Karonda dry 39.1
Lotus stem dry 60.6
Plantain green 6.27
Sundakai dry 22.2
Nuts and oilseeds
Almond 5.09
Cashewnut 5.81
Walnut 2.64
Condiments and spices
Asafoetida 39.4
Mango powder 45.2
Omum 12.5
Pepper dry (black) 12.4
Poppy seeds 15.9
Tamarind pulp 17.0
Turmeric 67.8
- 50
-Contd/- Fruits Iron (mg)
Ambada 3.9
Apricot dry 4.6
Raisins 7.7
Seethaphal 4.31
Fishes and other sea foods
Bombay duck dried 19.1
Chingri goda, dried 49.6
Crab muscle 21.2
Meat and poultry
Beef meat 18.8
Liver sheep 6.3
Mutton muscle 2.5

Pork muscle 2.2