Resource centre on India's rural distress
 
 

Malnutrition

 

 

KEY TRENDS 
 
• Average dietary energy intake per person per day was 2233 Kcal for rural India and 2206 Kcal for urban India during 2011-12 (based on Schedule Type 2) *$

• At the all-India level protein intake per person per day was 60.7gm in the rural sector and 60.3gm in the urban sector during 2011-12 (based on Schedule Type 2) *$
 
• Prevalence of stunting among children below 5 years age has reduced from 47.9% in 2005-06 (National Family Health Survey, NFHS-3) to 38.8% in 2013-14 (Rapid Survey on Children, RSOC). As a result, the population of under-five children affected by stunting has gone down from 5.82 crore in 2005-06 to 4.38 crore in 2013-14 **

• Prevalence of wasting among children below 5 years age has reduced from 20.0% in 2005-06 (National Family Health Survey, NFHS-3) to 15.0% in 2013-14 (Rapid Survey on Children, RSOC). As a result, the population of under-five children affected by wasting has gone down from 2.43 crore in 2005-06 to 1.69 crore in 2013-14 **
 
• In the Maharashtra state of India, the percentage of stunted children dropped from 39 per cent in 2005 to 23 per cent in 2012 largely because of support to frontline workers who focus on improving child nutrition *

• Total number of malnourished children (Grade I, II, III and IV) exceeded the 40 percent mark in 10 states/ UTs (Andhra Pradesh: 49 percent, Bihar: 82 percent, Haryana: 43 percent, Jharkhand: 40 percent, Odisha: 50 percent, Rajasthan: 43 percent, UP: 41 percent, Delhi: 50 percent, Daman and Diu: 50 percent and Lakshadweep: 40 percent), as on 31 March, 2011 σ

• Poor hygiene and sanitation were noticed in the AWCs due to the absence of toilets in 52 percent of the test checked AWCs and non-availability of drinking water facility for 32 percent of the test checked AWCs σ

• India's 2012 GHI score is 22.9 (rank: 65) as compared to China's GHI score of 5.1 (rank: 2), Bangladesh's score of 24.0 (rank: 68), Pakistan's score of 19.7 (rank: 57), Nepal's score of 20.3 (rank: 60) and Sri Lanka's score of 14.4 (rank: 37) €

• Children in the poorest households are more than twice as likely to be stunted as those in the richest households in India α

• 48% of children in India are stunted. 450 million children will be affected by stunting in the next 15 years, if current trends continue $

• Malnutrition is an underlying cause of the death of 2.6 million children each year–one-third of the global total of children’s deaths $

• The HUNGaMA study (2011) shows that in the 100 Focus Districts, 42 percent of children under five are underweight and 59 percent are stunted. Of the children suffering from stunting, about half are severely stunted $$

• The HUNGaMA study (2011) conducted in the 100 Focus Districts shows that 66 per cent mothers did not attend school; rates of child underweight and stunting are significantly higher among mothers with low levels of education; the prevalence of child underweight among mothers who cannot read is 45 percent while that among mothers with 10 or more years of education is 27 per cent $$
 
*$ NSS 68th Round Report entitled Nutritional Intake in India, 2011-12 (published in October 2014) (Please click here to access)
 
** Global Nutrition Report 2014: Actions and Accountability to Accelerate the World's Progress on Nutrition, IFPRI (Please click here to download)
 
* UNICEF report titled: Improving Child Nutrition: The achievable imperative for global progress (April, 2013),
http://www.unicef.org/publications/files/Nutrition_Report_final_lo_res_8_April.pdf

σ Report of the Comptroller and Auditor General of India on Performance Audit of Integrated Child Development Services (ICDS) Scheme, CAG Report no. 22 of 2012-13-Union Government (Ministry of Women and Child Development),
http://saiindia.gov.in/english/home/Our_Products/Audit_Report/Government_Wise/union_audit/recent_reports/union_performance/2012_2013/Civil/Report_22/Report_22.html

€ 2012 Global Hunger Index-The Challenge of Hunger: Ensuring Sustainable Food Security under Land, Water, and Energy Stresses, produced by IFPRI, Concern Worldwide and Welthungerhilfe,

α The Nutrition Barometer: Gauging national responses to undernutrition (2012) by Save the Children and World Vision,
http://www.savethechildren.in/images/resources_documents/nutrition_barometer_asia.pdf
 

$ A Life Free from Hunger: Tackling child malnutrition (2012), Save the Children 

http://www.savethechildren.org.uk/sites/default/files/docs/A%20Life%20Free%20From%20Hunger%20UK%20low%20res.pdf 

 

$$ HUNGaMA: Fighting Hunger & Malnutrition (2011), Naandi Foundation, http://hungamaforchange.org/HungamaBKDec11LR.pdf 

 

OVERVIEW 

 

India’s story of attaining self sufficiency in food grain production is the stuff of the legend. But a proud India was soon to learn that self sufficiency did not mean food for every citizen, leave alone adequate nutrition. However, one must not undermine the value of self reliance, knowing well enough the sinister link between hunger and a country’s dependence on food imports. One must also remember that many developed countries where nutrition is not a problem happen to be big importers of food. Obviously, nutrition security depends on a large number of factors, many of which have nothing to do with food.   

The issue of nutritional security is extremely complex. Many countries with similar per capita food consumption have vastly different rates of life expectancies and child mortality. Clearly, oversimplified statistical correlations and juxtapositions don’t work here. Jean Dreze and Amartya Sen have argued in their seminal work, Hunger and Public Action (OUP 1989), that we need to broaden our attention: a) from food-sufficiency to food-adequacy, b) from food adequacy to food entitlements, and c) from food entitlements to nutritional and related capabilities. The authors capture the big picture of nutritional security through many non-food factors like “medical attention, health services, basic education, sanitary arrangements, provision of clean water, eradication of infectious epidemics, and so on.”

If we want to know why one third of world’s underweight children (which comes to roughly 57 million) live in India, we only have to look at a child’s environment here.  According to NFHS, two third babies are born anemic and about one third have stunted growth. Those who survive the lack of healthcare, immunization, sanitation or safe drinking water grow up as victims of human trafficking, child abuse or forced child labour. It is obvious that improving the nutritional security of its children is much more complex than achieving self-sufficiency in food production. True, the country is committed to achieving this through the UN Convention on the Rights of the Child and the Millennium Development Goals (MDGs) but its progress is agonizingly slow.
 

 

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The NSS 68th Round Report entitled Nutritional Intake in India, 2011-12 (published in October 2014) is based on information collected during 2011-12 from 7469 villages and 5268 urban blocks spread over the entire country. Two different schedules were used to collect information on consumption, the first being canvassed in 101662 households and the second in 101651 households.


The key findings of the NSS 68th Round Report entitled [inside]Nutritional Intake in India, 2011-12 (published in October 2014)[/inside], Report No. 560(68/1.0/3) are as follows (please click here to access):


Intake of  Dietary Energy (based on Schedule Type 2*)

•    Average dietary energy intake per person per day was 2233 Kcal for rural India and 2206 Kcal for urban India. All the major States had per capita rural/urban levels of calorie intake within 11% (plus or minus) of the all-India rural/urban average.

•    In each sector average calorie intake increased steadily with monthly per capita expenditure (MPCE) class. The difference between the lowest fractile class (poorest 5% of population ranked by MPCE level) and the next fractile class (the next 5%) in per capita calorie intake was as high as 183 Kcal per day in rural India.

•    About 59.5% of the all-India rural population had energy intake in the range 80-120% of 2700 Kcal/consumer unit/day (a level used in NSS tabulation for comparisons), that is, 2160-3240 Kcal/consumer unit/day.

•    The all-India urban calorie intake distribution was similar to the rural, with slightly higher numbers of households in the top and bottom intake classes. Inter-State differences in energy intake distributions, especially at the lower end, were much less prominent in the urban sector of India than in the rural.

•    Among the bottom 5% of rural population ranked by MPCE, 57% of households had calorie intake below 2160 Kcal/consumer unit/day, the proportion falling to 39% for the next 5%, and continuing to fall until it dropped to only about 2% for the top 5% of population.

•    Similarly, the proportion of urban households with calorie intake below 2160 Kcal/consumer unit/day was 59% for the bottom 5% of population, falling to 47% for the next 5%, and reaching 1.6% for the top 5% of population.

•    The share of energy intake contributed by cereals was about 57% for rural India and 48% for urban India. The contribution of cereals varied across the major States from 42% (Punjab) to 70% (Odisha) in the rural sector and from 39% (Haryana) to 60% (Odisha and Bihar) in the urban sector.

•    The contribution of cereals to calorie intake was seen to fall progressively with rise in MPCE level, from 70% for the bottom 5% of population to 42% for the top 5% ranked by MPCE in rural India, and from about 66% to about 29% in urban India.

•    Non-cereal food contributed about 43% of calorie intake in rural India. The percentage break-up of this part of calorie intake (the part coming from non-cereal food) was: oils and fats: 22%; miscellaneous food, food products and beverages: 21%; milk and milk

•    Non-cereal food contributed about 52% of calorie intake in urban India. On the whole, the pattern of calorie intake from non-cereal food was similar in rural and urban areas, though the share of roots and tubers was, at 7%, somewhat lower.

•    The share of “milk and milk products” in calorie intake contributed by non-cereals, which was between 8% and 27% in the urban sector of all the major States, ranged from 3% to 36% in the rural sector, being 7% or less in 4 major States.

•    “Sugar and honey” usually had a higher contribution to calorie intake from non-cereal food in States with higher average levels of living.

Intake pf Protein and Fat (based on Schedule Type 2*)

•    At the all-India level protein intake per person per day was 60.7gm in the rural sector and 60.3gm in the urban sector

•    The range of inter-State variation for major States was appreciably wider in the rural sector, where per capita intake per day varied from about 52gm (Chhattisgarh) to about 73gm (Haryana), than in the urban, where it varied from 55gm (Assam) to about 69gm (Haryana).

•    In some of the poorer States, protein intake was markedly lower in the rural sector than in the urban; examples are Jharkhand (rural: 54.7gm, urban: 60.3gm) and Chhattisgarh (rural: 51.7gm, urban: 55.8gm). On the other hand, in the States with the highest levels of protein intake, viz., Haryana, Rajasthan and Punjab, it was the rural population and not the urban that had higher protein intake (about 4-5gm higher).

•    Average protein intake per capita per day was seen to rise steadily with MPCE level in rural India from 43gm for the bottom 5% of population ranked by MPCE to 91gm for the top 5%, and in urban India from 44gm for the bottom 5% to about 87gm for the top 5%.

•    The share of cereals in protein intake was 58% for rural and 49% for urban India.

•    The share of milk and milk products in protein intake was 10% in rural India and 12% in urban India. It was highest in Haryana (rural: 27%; urban: 22%) and Punjab (rural and urban: 23%), and between 14% and 18% in Rajasthan and Gujarat. Among the 17 major States, these 4 States and Uttar Pradesh (rural: 11%; urban: 13%) were the only 5 States where the contribution of milk and milk products to protein intake was higher than the national average.

•    The share of meat, fish and egg in protein intake was only 7% in rural India and 9% in urban India. The share was 26% in both rural and urban Kerala, and was 10% or more in only 5 other major States: West Bengal, Assam, Andhra Pradesh, Tamil Nadu, and Karnataka.

•    The contribution of cereals to protein intake is seen to fall steadily with rise in MPCE from 72% for the bottom 5% of population to 42% for the top 5% in rural India and from 68% to 31% in urban India. On the other hand, the contribution of milk and milk products to protein intake is seen to rise from 3% for the bottom fractile class of population in the rural sector to 16% in the highest, and from 4% to 17% in the urban sector. The contribution of egg, fish and meat to protein intake, too, climbs quite noticeably across MPCE classes from 2% to 12% in rural India and from 4% to 11% in urban India.

•    Average fat intake for the country as a whole was about 46gm per person per day in the rural sector and 58gm in the urban sector. Considerable inter-State variation, however, existed, especially in rural India. In both sectors, per capita intake was lowest in Odisha and Assam. The States with highest fat intake were Haryana (rural: 69gm; urban: 75gm), Gujarat (rural: 62gm; urban: 73gm) and Punjab (rural: 70gm; urban: 69gm).

•    Urban fat intake per person per day exceeded rural intake by 9gm or more in nine of the major States and by more than 13gm in West Bengal and Jharkhand. Rural intake exceeded urban in only one major State – Punjab.

•    Per capita fat intake was about 100g in the top fractile class of the urban sector and about 27gm in the lowest fractile class. In the rural sector the intake of the top fractile class was 92gm while that of the bottom class was 21gm.

•    At all-India level, in contrast to the remarkable closeness of average protein intake across the rural-urban divide, average urban fat intake was noticeably higher than rural intake in all the fractile classes.

Trends in Nutritional Intake (based on Schedule Type 1*)

•    Comparison of estimates for India and the major States from NSS surveys between 1983 and 2011-12 shows calorie intake declining in both sectors after 1999-2000, the decline being sharper in the urban sector, but recovering again to regain a level of about 2100 Kcal per person per day in the rural sector and about 2060 Kcal in the urban in 2011-12. At the level of individual States, a rise in average calorie intake level between 2004-05 and 2011-12 is noted in rural areas of most of the major States.

•    The proportion of households with calorie intake under 2160 Kcal per consumer unit per day, which in both sectors increased over the period 1993-94 to 2004-05, is seen to have subsequently declined appreciably to reach about 20% in the rural sector and 23% in the urban. On the whole, the distribution of dietary energy intake appears to have experienced a reduction in dispersion since the 1990s.

•    Over the 18-year period from 1993-94 to 2011-12, the share of cereals in total calorie intake has declined by nearly 10 percentage points in the rural sector and nearly 7 percentage points in the urban. On the other hand, the share of oils and fats has risen by about 3½ percentage points in both sectors.

•    In rural India as a whole, protein intake per person per day has definitely declined since 1993-94. However, the decline at the all-India level shows signs of flattening out, being only 0.5gm less in 2011-12 compared to 2004-05. The decline in rural protein intake since 1993-94 has been prominent in Rajasthan (a fall of 11gm), Haryana (about 10gm), and Punjab (8gm). In the urban sector the decline between 1993-94 and 2011-12 is less marked than in the rural. In both sectors, all the southern States except Karnataka show slight increases in protein intake per person during this period.

•    An unmistakable rising trend in per capita fat intake is visible not only at all-India level but in every major State. For rural India the rise has been from 31.4gm per day in 1993-94 to 41.6gm in 2011-12 and for urban India, from 42.0gm to 52.5gm– a rise of over 10gm in both sectors over the 18-year period. In both sectors, all the major States show a rise ranging from 5-6gm to 17-18gm during this period.

•    Over the 18 years preceding 2011-12, the contribution of cereals to protein intake has fallen by about 7 percentage points in rural India and nearly 6 percentage points in urban India while the shares of the other major food groups have all risen slightly.

* Note: The schedules of enquiry used were of two types. The two types had the same item break-up but differed in reference periods used for collection of consumption data. Schedule Type 1, as far as reference periods were concerned, was a repeat of the schedule used in most quinquennial rounds. For certain categories of relatively infrequently purchased items, including clothing and consumer durables, it collected information on consumption during the last 30 days and the last 365 days. For other categories, including all food and fuel and consumer services, it used a 30-days reference period. Schedule Type 2 used "last 365 days" (only) for the infrequently purchased categories, "last 7 days" for some categories of food items, as well as pan, tobacco and intoxicants, and "last 30 days" for other food items, fuel, and the rest. This was in line with the recommendations of an Expert Group that had been formed for the purpose of suggesting the most suitable reference period for each item of consumption.

 

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According to the [inside]Global Nutrition Report 2014[/inside]: Actions and Accountability to Accelerate the World's Progress on Nutrition, prepared by IFPRI (Please click here to download):

• Prevalence of stunting among children below 5 years age has reduced from 47.9% in 2005-06 (National Family Health Survey, NFHS-3) to 38.8% in 2013-14 (Rapid Survey on Children, RSOC). As a result, the population of under-five children affected by stunting has gone down from 5.82 crore in 2005-06 to 4.38 crore in 2013-14.

• Prevalence of wasting among children below 5 years age has reduced from 20.0% in 2005-06 (National Family Health Survey, NFHS-3) to 15.0% in 2013-14 (Rapid Survey on Children, RSOC). As a result, the population of under-five children affected by wasting has gone down from 2.43 crore in 2005-06 to 1.69 crore in 2013-14.

• The Government of India is yet to release all the findings of the 2013–2014 Rapid Survey on Children (RSOC). This new national survey, covering all 29 states in India, relies on data collected by the Ministry of Women and Child Development in partnership with UNICEF India. The Government has made preliminary estimates available for use in this Global Nutrition Report. Only data for children under age five are reported here.

• The average annual rate of reduction in stunting (47.9 percent to 38.8 percent in eight years) is 2.6 percent—below India’s target rate of 3.7 percent but well above the rate of 1.7 percent estimated on the basis of previous surveys. Because India has such a large population and a high stunting prevalence, this rate of change affects the global numbers significantly. Comparisons between the two surveys (i.e 2005–2006 NFHS and 2013–2014 Rapid Survey on Children-RSOC) also show declines in wasting.

• The rise in exclusive breastfeeding rates from 46.4 percent to 71.6 percent in eight years represents an average annual rate of increase of 5.5 percent—far above the rate required to meet India’s World Health Assembly (WHA) target by 2025 (1.5 percent). In fact, if the preliminary numbers hold, by 2025 India will have far surpassed its WHA exclusive breastfeeding target of 57 percent.

• For India—the second-most populous country in the world—new and preliminary national data suggest it is experiencing a much faster improvement in World Health Assembly (WHA) indicators than currently assumed. For example, if the new preliminary estimates undergo no further significant adjustments, then the numbers of stunted children under the age of five in India has already declined by more than 10 million.

• The Government of India has produced a new national survey on children. WHO and UNICEF have not yet reviewed the survey’s data and methodologies, and the survey results thus do not yet appear in the WHO’s Global Database on Child Growth and Malnutrition, but if the finalized rates of undernutrition are close to the preliminary reported rates, they should make us more optimistic about India's ability to meet the global World Health Assembly (WHA) goals.

• Experiences from the Indian state of Maharashtra suggest that significant change in nutrition status can happen over the medium term as a result of determined action sustained over a period of 6–12 years.

• There is a new statewide survey from Maharashtra in India (Haddad et al 2014). In the Maharashtra case study, it took only seven years to reduce child stunting by one-third, from 36.5 to 24.0 percent, for an annual average rate of reduction of 5.8 percent. Stunting declines resulted from a combination of nutrition-specific interventions, improved access to food and education, and reductions in poverty and fertility.

• The benefit to cost ratio of scaling up nutrition-specific interventions for stunting reduction in India is 34.

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Please click here to access the [inside]Executive Summary of the Lancet series on Maternal and Child Nutrition[/inside], published on 6 June, 2013


According to the [inside]2013 UNICEF report: Improving Child Nutrition[/inside]: The achievable imperative for global progress,
http://www.unicef.org/publications/files/Nutrition_Report_final_lo_res_8_April.pdf:

•    By 2011, the number of stunted children in India was 6,17,23,000 (i.e. 6.17 crore approximately) and its share in the world total of stunted children was 37.9 percent.

•    In South Asia, an estimated 28 per cent of infants are born with low birthweight. In South Asia, 39 percent of children are stunted. According to the NFHS-3 done in 2005-06, 48 percent of Indian children under the age 5 are stunted.

•    In Maharashtra, the wealthiest state in India, 39 per cent of children under age 2 were stunted in 2005–2006. But by 2012, according to a statewide nutrition survey, the prevalence of stunting had dropped to 23 percent.

•    In 2012, the Government of Maharashtra commissioned the first-ever statewide nutrition survey to assess progress and identify areas for future action. Results of this Comprehensive Nutrition Survey in Maharashtra indicated that prevalence of stunting in children under 2 years of age was 23 per cent in 2012 – a decrease of 16 percentage points over a seven-year period.

•    From 2005–2006 to 2012, the percentage of children 6 to 23 months old who were fed a required minimum number of times per day increased from 34 to 77 and the proportion of mothers who benefited from at least three antenatal visits during pregnancy increased from 75 to 90 per cent.

•    The provisional results of the Maharashtra survey showed that in spite of more frequent meals, only 7 per cent of children 6–23 months old received a minimal acceptable diet in 2012.

•    The proportion of stunted children under 5 in the poorest households compared with the proportion in the richest households ranges from nearly twice as high in sub-Saharan Africa (48 percent versus 25 per cent) to more than twice as high in South Asia (59 percent versus 25 per cent).

•    Recent longitudinal studies among cohorts of children from Brazil, Guatemala, India, the Philippines and South Africa confirmed the association between stunting and a reduction in schooling, and also found that stunting was a predictor of grade failure. Reduced school attendance and educational outcomes result in diminished income-earning capacity in adulthood. A 2007 study estimated an average 22 per cent loss of yearly income in adulthood.

•    Poor nutrition in the first 1,000 days of children’s lives can have irreversible consequences. More and more countries are scaling up their nutrition programmes to reach children during the critical period from pregnancy to the age of 2. From a life-cycle perspective, the most crucial time to meet a child’s nutritional requirements is in the 1,000 days including the period of pregnancy and ending with the child’s second birthday.

•    The World Health Assembly has adopted a new target of reducing the number of stunted children under the age of 5 by 40 per cent by 2025. A stunted child enters adulthood with a greater propensity for developing obesity and chronic diseases.

•    Globally, about one in four children under 5 years old are stunted (26 per cent in 2011). An estimated 80 per cent of the world’s 165 million stunted children live in just 14 countries.

•    Undernourished girls have a greater likelihood of becoming undernourished mothers who in turn have a greater chance of giving birth to low birthweight babies, perpetuating an intergenerational cycle.

•    More than 30 countries in Africa, Asia and Latin America have joined Scaling Up Nutrition (SUN). The present report highlights successes in scaling up nutrition and improving policies in 11 countries: Ethiopia, Haiti, India, Nepal, Peru, Rwanda, the Democratic Republic of the Congo, Sri Lanka, Kyrgyzstan, the United Republic of Tanzania and Viet Nam.

•    In Peru, stunting fell by a third between 2006 and 2011 following an initiative that lobbied political candidates to sign a commitment to reduce stunting in children under five by five per cent over the span of five years and to lessen inequities between urban and rural areas.

•    Ethiopia cut stunting from 57 per cent to 44 per cent between 2000 and 2011 by implementing a national nutrition programme, providing a safety net in the poorest areas and boosting nutrition assistance through communities.

 

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According to [inside]Report of the Comptroller and Auditor General of India on Performance Audit of Integrated Child Development Services (ICDS) Scheme[/inside], CAG Report no. 22 of 2012-13-Union Government (Ministry of Women and Child Development), http://saiindia.gov.in/english/home/Our_Products/Audit_Report/Government_Wise/union_audit/recent_reports/union_performance/2012_2013/Civil/Report_22/Report_22.html:


Status of Nutrition:

•    Total number of ICDS Supplementary Nutrition beneficiaries had been 7.06 crore in 2006-07, 8.43 crore in 2007-08, 8.73 crore in 2008-09, 8.84 crore in 2009-10, 9.59 crore in 2010-11 and 9.72 crore in 2011-12.

•    Total number of ICDS Pre-school education beneficiaries had been 3.01 crore in 2006-07, 3.39 crore in 2007-08, 3.41 crore in 2008-09, 3.55 crore in 2009-10, 3.66 crore in 2010-11 and 3.58 crore in 2011-12.

•    Total number of malnourished children (Grade I, II, III and IV) exceeded the 40 percent mark in 10 states/ UTs (Andhra Pradesh: 49 percent, Bihar: 82 percent, Haryana: 43 percent, Jharkhand: 40 percent, Odisha: 50 percent, Rajasthan: 43 percent, UP: 41 percent, Delhi: 50 percent, Daman and Diu: 50 percent and Lakshadweep: 40 percent), as on 31 March, 2011.    

•    The number of severely malnourished children (Grade III and IV) exceeded 1 percent of total weighed children in 8 states (Bihar: 26 percent, Chhattisgarh: 2 percent, Gujarat: 5 percent, Karnataka: 3 percent, Madhya Pradesh: 2 percent, Maharashtra: 3 percent, Uttarakhand: 1 percent and West Bengal: 4 percent) as on 31 March, 2011.

•    There was substantial decrease in the malnourished children in 6 states between 31 March 2007 and 31 March 2011 (Gujarat: from 71 percent to 39 percent, Karnataka: from 53 to 40 percent, Maharashtra: from 45 to 23 percent, UP: from 53 to 41 percent, Uttarakhand: 46 to 25 percent and West Bengal: 53 to 37 percent.

•    North-eastern states fared better in respect of the nutritional status of children, where percentage of normal children was satisfactory vis-a-vis the total weighed children as on 31 March 2011 (Arunachal Pradesh: 98 percent, Assam: 69 percent, Manipur: 86 percent, Meghalaya: 71 percent, Mizoran: 77 percent, Nagaland: 92 percent, Sikkim: 89 percent and Tripura: 63 percent).

•    In 5 other states/ UTs the percentage of normal children exceeded 70 percent as of 31 March 2011, viz. MP: 72 percent, Maharashtra: 77 percent, Uttarakhand: 75 percent, A & N Islands: 82 percent and Dadra & Nagar Haveli: 75 percent.   
 
Key findings:

•    The CAG chose to audit the ICDS since India's status on key child development and health indicators did not compare well with its own targets as well as with the neighbouring and other regions. The Infant Mortality Rate (IMR) was 48 per 1000 live birth and the Child Mortality Rate (CMR) 63 per 1000 live birth in 2010 as against the targets of 30 and 31 respectively. These indicators (IMR and CMR) for the neighbouring countries were: China (IMR: 16, CMR: 18) and Sri Lanka (IMR: 14, CMR: 17). In industrialized countries, the IMR and CMR were as low as 5 and 6 respectively.

•    The performance audit covered 2730 of the test checked Anganwadi Centres (AWCs) from 273 project offices of 67 districts from 13 states (Andhra Pradesh, Bihar, Chhattisgarh, Gujarat, Haryana, Jharkhand, Karnataka, Madhya Pradesh, Meghalaya, Odisha, Rajasthan, Uttar Pradesh and West Bengal) for the period 2006-07 to 2010-11 on 3 services viz. supplementary nutrition, pre-school education and nutrition and health education under scheme. The selection of the states was made on the basis of population, funding and nutrition indicators as per the NFHS-3, 2005.

•    To universalize the ICDS, Hon'ble Supreme Court had directed the Central and state Governments to operationalize 14 lakh AWCs by December, 2008. The Ministry sanctioned 13.71 lakh AWCs and could operationalize 13.17 lakh. This left a shortfall of 0.54 lakh. Similarly, out of 7075 sanctioned ICDS projects, 7005 projects were operationalized.

•    61 percent of the test-checked AWCs did not have their own buildings and 25 percent were functioning from semi-pucca/ kachcha buildings or open/ partially covered space. Separate space for cooking, storing food items and indoor and outdoor activities for children was not available in 40 to 65 percent of the test-checked AWCs.

•    Poor hygiene and sanitation were noticed in the AWCs due to the absence of toilets in 52 percent of the test checked AWCs and non-availability of drinking water facility for 32 percent of the test checked AWCs.

•    Functional weighing machines for babies and adults were not available in 26 and 58 percent, respectively, of the test-checked AWCs. The essential utensils required for providing supplementary nutrition to the beneficiaries were also not available in several test-checked AWCs.

•    Medicine kits were not available in 33 to 49 percent of the test checked AWCs due to failure of the state governments in spending the funds released to them by the Centre.    

•    53 percent of the test checked AWCs did not receive annual flexi-fund of Rs. 1000 from the state governments during the period 2009-2011.

•    There were shortages of staff and key functionaries at all levels.

•    The shortfall under various categories of training ranged from 19 to 58 percent of the targets fixed under the State Training Action Plan (STRAP).

•    The shortfall in expenditure on Supplementary Nutrition (SN) ranged between 15 percent and 36 percent of the requirements during the period 2006-2011. The average daily expenditure per beneficiary on SN was Rs. 1.52 to Rs. 2.01 against the norm of Rs. 2.06 during 2006-09 and Rs. 3.08 to Rs. 3.64 against the norm of Rs. 4.21 during 2009-2011.

•    33 to 47 percent children were not weighed for monitoring their growth during 2006-07 to 2010-11. The data on nutritional status of children had discrepancies and were not based on WHO's growth standards.

•    There was a gap of 33 to 45 percent between the number of eligible beneficiaries identified and those receiving the SN during 2006-07 to 2010-11.

•    The Wheat Based Nutrition Programme suffered from lack of proper coordination among the Ministry of Women and Child Development, the Department of Food and Public Distribution and the state governments. The Ministry could allocate 78 percent of foodgrains demanded by the states. The actual take-offs by the states was merely 66 percent of total demand placed by them.

•    Pre-school education (PSE) kits were not available at 41 to 51 percent of the test-checked AWCs during the period 2006-11.

•    In 6 of the test checked states (Bihar, Haryana, Jharkhand, Madhya Pradesh, Uttar Pradesh and West Bengal) data on beneficiaries of PSE who joined mainstream education were not available. In 5 states (Andhra Pradesh, Chhattisgarh, Odisha, Rajasthan and Karnataka) shortfall in the number of children who actually joined the formal education during 2006-2011 ranged between 7 and 30 percent.      

•    Shortfall of 40 to 100 percent was noted on the expenditure against the funds released for Information, Education and Communication (IEC) in many states.

•    Against the total release of Rs. 1753 crore to 13 states during 2008-09 and 15 states during 2009-2011 for meeting the expenditure on salary of ICDS functionaries, the actual expenditure was Rs. 2853 crore indicating unrealistic budgeting and consequent diversion of funds from other critical components of the scheme.

•    Rs. 57.82 crore were diverted to activities not permitted under the ICDS in 5 of the test-checked states and Rs. 70.11 crore were parked in civil deposits/ personal ledger accounts/ bank accounts / treasury resulting in blocking of funds.

•    The Central Monitoring Unit (CMU) under the ICDS failed to efficiently carry out assigned tasks, which included concurrent evaluation of the scheme, monitoring through the progress reports received from the states.

•    Impact assessment of the services under the SN and the PSE based on outcome indicators, such as nutritional status of the children, was not being done.

•    The follow-up action on internal monitoring and evaluation by the Ministry was inadequate and resulted in recurrence of shortcomings and lapses in the scheme implementation.    
 

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The per capita per diem calorie intake is higher in the rural areas compared to urban areas, as could be deciphered from the graph below. However, both have seen a decline over the various rounds of National Sample Survey. 

 

Per capita per diem intake of Calorie  (in Kcal)

Per capita per diem intake of Calorie  (in Kcal)

Source: Nutritional Intake in India: 2004-2005, NSS 61st Round, July 2004- June 2005

 

 

According to the [inside]2012 Global Hunger Index[/inside] - The Challenge of Hunger: Ensuring Sustainable Food Security under Land, Water, and Energy Stresses, produced by IFPRI, Concern Worldwide and Welthungerhilfe, 

http://www.ifpri.org/sites/default/files/publications/ghi12.pdf 

http://www.ifpri.org/sites/default/files/publications/ghi2012fsasia.pdf:  

 

The 2012 Global Hunger Index (GHI) is calculated for 120 developing countries and countries in transition for which data on the three indicators of hunger are available. This year’s GHI reflects data from 2005-2010—the most recent country-level data available on the three GHI measures. It is thus a snapshot of the recent past. 

The GHI combines three equally weighted indicators into one score: the proportion of people who are undernourished, the proportion of children under five who are underweight, and the mortality rate of children younger than age five.

The GHI ranks countries on a 100-point scale in which zero is the best score (no hunger) and 100 the worst, although neither of these extremes is reached in practice. An increase in a country’s GHI score indicates that the hunger situation is worsening, while a decrease in the score indicates improvement in the country’s hunger situation.

India's 2012 GHI score is 22.9 (rank: 65) as compared to China's GHI score of 5.1 (rank: 2), Bangladesh's score of 24.0 (rank: 68), Pakistan's score of 19.7 (rank: 57), Nepal's score of 20.3 (rank: 60) and Sri Lanka's score of 14.4 (rank: 37). 

India's GHI score has improved from 30.3 in 1990 to 24.2 in 2001 and further to 22.9 in 2012.  

India has lagged behind in improving its GHI score despite strong economic growth. After a small increase between 1996 (GHI 22.6) and 2001 (GHI 24.2), India’s GHI score fell only slightly, and the latest GHI returned to about the 1996 level. 

India's stagnation in GHI scores occurred during a period when India’s gross national income (GNI) per capita almost doubled, rising from about 1,460 to 2,850 constant 2005 international dollars between 1995–97 and 2008–10 (World Bank 2012).

In India, 43.5 percent of children under five are underweight, which accounts for almost two-thirds of the country’s alarmingly high GHI score. From 2005-2010, India ranked second to last on child underweight— below Ethiopia, Niger, Nepal, and Bangladesh. 

Bangladesh has also closed the gender gap in education through targeted public interventions and has overtaken India on a range of social indicators, including the level and rate of reduction of child mortality.

In India, 43.5 percent of children under five are underweight, which accounts for almost two-thirds of the country’s alarmingly high GHI score. From 2005-2010, India ranked second to last on child underweight— below Ethiopia, Niger, Nepal, and Bangladesh. 

Bangladesh, India, and Timor-Leste have the highest prevalence of underweight children under five, more than 40 percent in each of the three countries.

According to surveys during 2000–06, 36 percent of Indian women of childbearing age were underweight, compared with only 16 percent in 23 Sub-Saharan African countries (Deaton and Drèze 2009).

Though India has worked to improve food security and nutrition in recent years through government-operated nutrition-relevant social programs, program effectiveness remains uncertain due to the absence of up-to-date information.

When comparing GHI scores with GNI per capita, it must be emphasized that India’s latest GHI score is based partly on outdated data: although it includes relatively recent child mortality data from 2010, FAO’s most recent data on undernourishment are for 2006–08, and India’s latest available nationally representative data on child underweight were collected in 2005–06.

Given that the Government of India has failed to monitor national trends in child undernutrition for more than six years, any recent progress in the fight against child undernutrition cannot be taken into account by the 2012 GHI.

Home to the majority of the world’s undernourished children, India is in dire need of monitoring systems for child undernutrition and related indicators that produce data at regular intervals, in order to improve program performance and scale up impact (Kadiyala et al. 2012).

The 2012 world GHI fell by 26 percent from the 1990 world GHI, from a score of 19.8 to 14.7. South Asia and Sub-Saharan Africa have the highest levels of hunger with regional scores of 22.5 and 20.7, respectively. 

 

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The Nutrition Barometer produced by Save the Children provides a snapshot of national governments’ commitments to addressing children’s nutrition, and the progress they have made. It looks at 36 developing countries with the highest levels of child undernutrition. The Barometer measures governments’ political and legal commitment to tackling malnutrition (eg, whether they have a national nutrition plan), as well as their financial commitment. Countries’ progress in tackling malnutrition is measured by children’s nutritional status – the proportion who are underweight, stunted or suffering from wasting – and children’s chances of survival. Countries are then ranked according to both their commitments and their nutritional and child survival outcomes.

 

According to the report titled [inside]The Nutrition Barometer: Gauging national responses to undernutrition (2012)[/inside] by Save the Children and World Vision, http://www.savethechildren.in/images/resources_documents/nutrition_barometer_asia.pdf:

•    The Democratic Republic of Congo (DRC), India and Yemen show the weakest performance, with frail commitments and frail outcomes. Outcomes for India are dated as they are based on the National Family and Health Survey-3 from 2005–06. However, since the country has not had a nationally representative survey since then, these figures are still generally used.

•    India urgently needs a new population-based, nationally representative survey to check what has happened to nutrition since 2005–06. The fourth National Family Health Survey was about to take place in 2014.

•    Spectacular economic growth has not translated into better nutrition outcomes for many of India’s children. Growth has lifted millions out of poverty but it has also been largely unequal, with the benefits accruing to a small segment of the population. Many sources of data show that almost half its children are underweight and stunted, and more than 70% of women and children have serious nutritional deficiencies such as anaemia.

•    Children in the poorest households are more than twice as likely to be stunted as those in the richest households in India. However, even in the wealthiest 20% of the Indian population, one child in five is undernourished.

•    India's showing on commitments was set back by the lack of nutrition-specific commitments to Every Woman Every Child and not being a member of Scaling up Nutrition movement (SUN) as yet.

•    A criticism of the Integrated Child Development Services (ICDS) was its failure to target children between the ages of 0 and two years, which is the crucial growth period. One reform involves increasing the number of Anganwadi [community health] workers in the 200 districts with the highest levels of undernutrition.

•    In 13 of the countries (just over a third of the sample of 36 countries) the Nutrition Barometer study looked at, commitments and outcomes point in exactly the same direction. Three countries – Guatemala, Malawi and Peru–have both sound political and financial commitments and sound outcomes relative to the other countries in the group in this study.

•    The Barometer shows 12 countries where there are high political, legal and/or financial commitments to nutrition, yet outcomes are lower.

 

The report titled [inside]A Life Free from Hunger: Tackling child malnutrition (2012)[/inside], which has been brought out by Save the Children http://www.savethechildren.org.uk/sites/default/files/docs/A%20Life%20Free%20From%20Hunger%20UK%20low%20res.pdfanalyses the causes of malnutrition, focusing on chronic malnutrition and stunting in children. It identifies solutions that are proven to be effective in containing child malnutrition: a. direct interventions, such as exclusive breastfeeding, micronutrient supplementation and fortification; b. indirect interventions, such as introducing social protection programmes, and adapting agricultural production to meet the nutritional needs of children.

Key findings of the report are as follows: 

48% of children in India are stunted. 450 million children around the world will be affected by stunting in the next 15 years, if current trends continue.

The economic losses due to undernutrition are pervasive–experimental evidence suggests that tackling malnutrition in early life can lead to as much as a 46% increase in earnings as an adult. Productivity loss due to foregone waged employment was estimated to be US$2.3 billion a year in India.

A study by Ravi and Engler (2009) on the impact of the Mahatma Gandhi NREGA in India, which guarantees poor households 100 days of paid employment, found the scheme increased food spending by 40% on average, and that the effect is strongest for the poorest households who participated in the scheme the longest.

It’s estimated that 2–3% of the national income of a country can be lost to malnutrition. Childhood malnutrition can lessen productivity – stunted children are predicted to earn an average of 20% less when they become adults

Staple food prices hit record highs globally in February 2011 and may have put the lives of upto 400,000 more children at risk.

One in four of the world’s children are stunted. In developing countries this figure is as high as one in three. That means their body and brain has failed to develop properly because of malnutrition.

Every hour of every day, 300 children die because of malnutrition. Malnutrition is an underlying cause of the death of 2.6 million children each year–one-third of the global total of children’s deaths.

Global progress on stunting has been extremely slow. The proportion of children who are stunted fell from 40% in 1990 to 27% in 2010 – an average of just 0.6 percentage points per year.

In 2008 the Lancet medical journal identified a package of 13 direct interventions – such as vitamin A and zinc supplements, iodised salt, and the promotion of healthy behaviour, including handwashing, exclusive breastfeeding and complementary feeding practices– that were proven to have an impact on the nutrition and health of children and mothers. This cost-effective and affordable package could prevent the deaths of almost 2 million children under five and a substantial amount of illness if it was delivered to children in the 36 countries that are home to 90% of the world’s malnourished children.

At a cost of just over US$1 per person per year, the World Bank has estimated that more than 4 billion people would be able to benefit from access to fortified wheat, iron, complementary food and micronutrient powders. Fortification, or the process of adding vitamins and minerals to food, is one of the most cost-effective direct interventions.

 

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For the report named [inside]HUNGaMA: Fighting Hunger & Malnutrition (2011)[/inside], Naandi Foundation deployed a trained team of over 1000 surveyors who interviewed 74,020 mothers and measured 109,093 children in 4 months. The HUNGaMA (Hunger and Malnutrition) survey that covered 73,670 households across 112 districts spanning nine states in India provides reliable estimates of child nutrition covering nearly 20% of Indian children. Of the 112 districts surveyed, 100 were selected from the bottom of a child development district index developed for UNICEF India in 2009, referred to as the 100 Focus Districts in this report.

Key findings of the report titled: HUNGaMA: Fighting Hunger & Malnutrition (2011), http://hungamaforchange.org/HungamaBKDec11LR.pdf, which has been prepared by the Naandi Foundation, are as follows:

In the 100 Focus Districts, 42 percent of children under five are underweight and 59 percent are stunted. Of the children suffering from stunting, about half are severely stunted.

In the 100 Focus Districts, the prevalence of child underweight has decreased from 53 per cent (DLHS, 2004) to 42 per cent (HUNGaMA 2011); this represents a 20.3 percent decrease over a 7 year period with an average annual rate of reduction of 2.9 per cent. 

By age 24 months, 42 percent of children are underweight and 58 percent are stunted in the 100 Focus Districts.

The prevalence of malnutrition is significantly higher among children from low-income families, although rates of child malnutrition are significant among middle and high income families.

In the 100 Focus Districts, 66 per cent mothers did not attend school; rates of child underweight and stunting are significantly higher among mothers with low levels of education; the prevalence of child underweight among mothers who cannot read is 45 percent while that among mothers with 10 or more years of education is 27 per cent.

In the 100 Focus Districts 51 per cent mothers did not give colostrum to the newborn soon after birth and 58 percent mothers fed water to their infants before 6 months.

In the 100 Focus Districts 11 percent mothers said they used soap to wash hands before a meal and 19 per cent do so after a visit to the toilet.

There is an Anganwadi centre in 96 percent of the villages in the 100 Focus Districts, 61 per cent of them in pucca buildings; the Anganwadi service accessed by the largest proportion of mothers (86 percent) is immunization; 61 percent of Anganwadi Centres had dried rations available and 50 percent provided food on the day of survey; only 19 percent of the mothers reported that the Anganwadi Centre provides nutrition counseling to parents.

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According to the [inside]World Disaster Report 2011: Focus on Hunger and Malnutrition[/inside], which has been produced by International Federation of Red Cross and Red Crescent Societies, http://www.indiaenvironmentportal.org.in/files/file/WDR-2011-FINAL.pdf:   

•    There has been progress in feeding more people than ever before even as the world’s population has grown by around 50 per cent since the mid-1970s. Even so, the number of undernourished people in the world was higher in 2010 – 925 million according to the Food and Agriculture Organization of the United Nations (FAO)–than in the early 1970s. There was a record peak of more than 1 billion hungry people in 2009 following dramatic food price rises in 2007–2008.

•    The majority of the hungry are in the Asia Pacific region, especially the Indian subcontinent, and in sub-Saharan Africa. Most of the hungry live in rural areas. A substantial and growing number of the world’s hungry also lives in urban and peri-urban areas.

•    In 2005 the World Bank estimated that malnutrition costs the global economy around US$ 80 billion a year. The loss to the Indian economy alone is at least US$ 10 billion a year, or 2 to 3 per cent of GDP.

•    The United States Department for Agriculture (USDA) reports that in 2010 about US$ 68 billion was spent through its Supplemental Nutrition Assistance Program – also known as ‘food stamps’ – to reach just over 40 million people – compared to US$ 250 million (1969 prices) in 1969 that benefited some 2.9 million people.

•    At least 1 billion people are undernourished and lack key vitamins and minerals, while at the same time a staggering 1.5 billion people are overweight or obese.

•    India’s public distribution scheme technically caters to 316 million people who are in the ‘below the poverty line’ category. Add the ‘above the poverty line’ category and the scheme is supposed to provide food to more than 900 million people. But the way the below the poverty line (which should be dubbed the ‘starvation line’) has been drawn, the distribution scheme fails to provide them with their minimal daily food intake. If the scheme had been even partially effective, there is no reason why India should be saddled with the largest population of hungry people in the world.

•    Despite four ministries administering 22 programmes to alleviate hunger and poverty, the budget allocation for which is enhanced almost every year, the poor still go hungry and hundreds of children die every day in India from malnourishment.

•    According to the recommendations of the Indian Council of Medical Research, each able-bodied adult needs a minimum of 14 kilograms (kg) of grains a month. Given that an average family comprises five members, the household allocation would be 70kg. The distribution scheme at present provides only 35kg of wheat and rice to each family, so the hungry remain perpetually hungry.

•    In a country that has emerged as the world’s fifth largest economy with a growth rate of almost 9 per cent, more than 700 million people remain food insecure.

•    One problem in India, according to the Deccan Development Society and others, is the neglect of small farmers – especially women – who are the main producers of local foods and traditional grains such as millet and sorghum. The Deccan Development Society has been working with poor, illiterate dalit (untouchable) women to help them to restore the fertility and productivity of the almost barren lands they received from the government as a result of land reforms and to have the means to communicate about their needs. It also works to get the government to include the millets and sorghums, which grow so well in drier areas such as the Deccan, into the national food distribution system and to consider actions to promote their production and consumption as a priority.

•    In New Delhi, India, a research project which gave thin and anaemic pregnant women a multiple micronutrient supplement in addition to their regular iron and folic acid, found a mean increase of 98 grams in the birth weight of their babies and a 50 per cent reduction in illness among the newborns compared to a placebo.

•    India has been a net exporter of agricultural and food products since 1995. It is also a net exporter of meat and dairy products. India, Pakistan, Thailand, the US and Viet Nam represent 80 per cent of world rice exports.

•    In countries with public procurement systems in place, such as Bangladesh and India, the governments were able to support farmers by procuring rice at a higher price and providing subsidies to poor and marginal farmers to mitigate higher costs of production for irrigation and fertilizer.

•    Evidence from India and elsewhere in Asia shows that smallholders consistently produce higher yields than larger capital-intensive farms. Small farmers generally use their land more intensively than larger operations, because they utilize every scrap and corner. Most importantly, there is an inverse relationship in low- and middle-income countries’ economies between farm area and both labour and output per hectare, because smallholders aim to maximize food production.

•    The Indian dairy industry has gone from being the 78th largest in the world to number one in just a few decades, almost entirely on the basis of cooperative dairies collecting milk from small farmers whose small herds are fed with home-grown fodder crops.

•    Globally, human nutrition has come to depend upon very few crops as its staples. Just three crops–rice, wheat and maize–account for more than half the energy intake from plants. Another six–sorghum, millet, potatoes, sweet potatoes, soybean and sugar–take the total to more than 75 per cent, while 90 per cent of humanity’scalorie intake comes from just 30 crops.

•    From 1988 to 1997, foreign direct investment in the food industry increased from US$743 million to more than US$2.1 billion in Asia and from US$222 million to US$3.3 billion in Latin America, significantly outstripping the level of investments in agriculture. At the same time, sales through supermarkets grew as much as they had in the United States over 50 years.

•    Much development policy has focused on industrialization and has neglected rural and agricultural development over the last 30 years. Attention has shifted away from agriculture in the big development agencies, such as the World Bank, which lent about 26 per cent of its total budget to agriculture in the 1980s but only 10 per cent in 2000.

•    Every year some 9 million children across the world die before they reach their fifth birthday, and about one-third of these untimely deaths is attributed to undernutrition.

•    Some 178 million children under the age of 5 suffer from stunted growth as a result of undernutrition. About 55 million under 5 years of age are acutely undernourished, which means that their bodies are wasted – they are underweight for their height – and 19 million of these children are severely wasted.

•    Anaemia in children has only relatively recently been recognized as a widespread problem, and there are almost no data before 1995. Haemoglobin is now one of the elements measured in demographic and health surveys, and they show that in sub-Saharan Africa around 60 per cent of children are anaemic compared with a global average of nearly half of all preschool-age children. Some 40 per cent of women in low- and middle-income countries are believed to suffer from anaemia, which affects a total of around 2 billion people worldwide.

•    Vitamin A deficiency, which is the most common cause of blindness in low- and middle-income countries, affects around 30 per cent – some 163 million – of children in poor countries. Two-thirds of affected children are in South and central Asia, which along with West Africa have the highest prevalence of childhood vitamin A deficiency, at more than 40 per cent. Latin America and the Caribbean have the lowest prevalence, at 10 per cent. Nearly 14 million children with the condition have some degree of visual loss, and 250,000 to 500,000 are blinded every year, half of them dying within 12 months of losing their sight.

•    More than 1.7 billion of the world’s people (of whom 1.3 billion live in Asia) suffer from iodine deficiency , which can lead to stunted growth and other developmental abnormalities and which is one of the commonest causes of mental impairment and retardation in children worldwide.

•    More than 3 billion people, or 31 per cent of the world’s population, are deficient in zinc, which increases the risk for children of diarrhoea, pneumonia and malaria, and is thought to contribute to more than 450,000 child deaths annually worldwide.

•    According to Save the Children, deficiency in vitamin A and zinc could be prevented with supplements costing just 6 US cents and US$ 1.6 per child per year respectively.

•    A multi-country study reported in The Lancet in 2007 found that for every 10 per cent increase in the prevalence of stunting in the population, the proportion of children reaching the final grade of school fell by 8 per cent.

•    The causes of hunger and undernutrition are complex and include structural factors such as lack of investment in agriculture, climate change, volatile fuel prices, commodity speculation and the ebb and flow of global market forces

•    About one-fifth of the world’s 185 million undernourished people live in towns and cities and the root cause of their hunger is overwhelmingly poverty.

•    Families in many countries consider their girls an economic burden and marry them off young, occasionally even before puberty. The practice is most common in sub-Saharan Africa and South Asia. Girls who become pregnant in their teens stop developing physically themselves and are at increased risk of delivering low birth weight babies, thus setting in motion the cycle of deprivation described earlier. In India, where 40 per cent of the world’s low birth weight babies are born, 8 per cent of women aged 20–24 years in 2006 had given birth to her first child before she was 16 years old.

•    Save the Children estimated that in 2008 alone, a minimum of 4.3 million (and potentially as many as 10.4 million) additional children in low- and middle-income countries may have become malnourished as a result of food price rises.

 

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According to [inside]Common Wealth or Common Hunger? Malnutrition and its impact on Child Survival in the Commonwealth (2010)[/inside], Save the Children,

http://www.savethechildren.in/custom/recent-publication/Report--Common_Wealth_or_Common_Hunger%282%29.pdf:  

India, host to the 2010 Commonwealth Games, has both the highest number and the highest proportion of malnourished children in the world. Nearly half of all under-fives in India–55 million children–are malnourished, almost 7 million of them with severe acute malnutrition.

The estimated number of severe acute malnutrition (SAM) children in India is 6941387, which is roughly 6 percent of total children in the age group 6-59 months. The prevalence of SAM among children in the age group 6-59 months is 6 percent in Pakistan and 3 percent in Bangladesh. 

In Chhattisgarh, a ‘child protection month’ is celebrated twice a year (April and October) and delivers a package of services to more than 85% of children.The services include vitamin A supplementation, deworming, growth monitoring, immunisation focused on children never or only partially vaccinated, and salt testing for iodine content in households and community feeding centres.

There are three measures of child malnutrition:

* Chronic, long-term malnutrition can result in children being too short for their age (stunted).

* Acute, fast-onset malnutrition results in a child being dangerously thin for their height (wasted).

* An underweight child has a low weight for their age and could be chronically and/or acutely malnourished. It is also the key indicator for MDG 1.

More than two-thirds of stunted children (88.5 million, 68.6%) and nearly half of those who are underweight (95 million, 48.7%) live in just seven Commonwealth countries–India, Bangladesh, Pakistan, Nigeria, Tanzania, Kenya and Uganda. India, alone, has 55.5 million underweight children.

A major cause of malnutrition is a poor diet, which makes newborn babies and infants more vulnerable to infection and less able to recover from common childhood illnesses such as pneumonia and diarrhoea. Poverty; household food insecurity; the low status of women; poor hygiene, sanitation and access to clean water; and inadequate public health services all contribute to malnutrition and are a threat to children’s survival.

Bangladesh and Pakistan have high rates of malnourished children – 41% and 31% respectively.

In India, 36% of women are malnourished with a body mass index of less than 18.5 kg/m2 compared with 12% in Nigeria. Malnourished mothers often give birth to smaller children. India, Pakistan and Bangladesh all have significantly higher levels of children being born at low birth weight than developing countries in other parts of the world. In these three countries, between 22% and 32% of babies are born weighing less than 2.5kg. They begin life already malnourished and at a disadvantage. Many are unable to catch up and therefore remain underweight.

Breast milk provides all the energy and nutrients an infant needs during the first six months of life. Rates of exclusive breastfeeding (children below 6 months) are poor at 37%, 43% and 46% in Pakistan, Bangladesh and India respectively, but are even lower in Nigeria and at 13%.

An estimated one third of children under five years old in the developing world are stunted–that’s 195 million–and 129 million are underweight.

Globally, more than 3 million children die every year from undernutrition related causes.

An estimated one-third of children under five years old in the developing world are stunted–that’s 195 million children–and 129 million are underweight.

The critical period, when malnutrition can have the most irrevocable impact, is during the 33 months from conception to a child’s second birthday – the first 1,000 days. After two years of age, it is much harder to reverse the effects of chronic malnutrition, particularly its impact on the development of the brain.

Thirty per cent of the world’s population lives in the 54 diverse countries that make up the Commonwealth–and at least 64% of the world’s underweight children.

Malnutrition is also an underlying cause in 35% of all preventable deaths in children under five each year. Even those who survive are likely to suffer from recurring sickness, impaired physical and mental development, and reduced productivity.

The success of vitamin A supplementation programmes targeting children 6–59 months of age has been proven, with an estimated 24% reduction in all-cause mortality.

In May 2008, the Copenhagen Consensus, a panel of top economists, determined that providing micronutrients in the form of iodised salt, vitamin A capsules and iron-fortified flour for 80% of the world’s malnourished children would cost US$347 million a year and yield US$5 billion from avoided deaths, improved earnings and reduced healthcare spending.

 

According to [inside]Investing in the future: A United Call to Action on Vitamin and Mineral Deficiencies-Global Report 2009[/inside],
http://www.unitedcalltoaction.org/documents/Investing_in_the_future.pdf:

• Vitamin A, iodine, iron, zinc and folate play pivotal roles in maintaining healthy and productive populations.

• Approximately one third of the developing world’s children under the age of five are vitamin A-deficient, and therefore ill-equipped for survival.

• Iron deficiency anaemia during pregnancy is associated with 115,000 deaths each year, accounting for one fifth of total maternal deaths.

• Research has shown that, where a population is at risk of vitamin A deficiency, vitamin A supplementation reduces mortality in children between six months and five years of age by an average of 23%. Global efforts to provide young children with twice-yearly supplements have involved 103 countries. In 1999, just 16% of children in these countries received full supplementation. By 2007, that number had more than quadrupled to 72%.

• In communities where iodine intake is sufficient, average IQ is shown to be on average 13 points higher than in iodine-deficient communities. Between 1993 and 2007, the number of countries in which iodine-deficiency disorders were a public health concern was reduced by more than half, from 110 to 47.

• In 2008, the Copenhagen Consensus panel determined that vitamin A and zinc supplementation for children provided the very best return on investment across all global development efforts.

• Iron supplementation during pregnancy lowers the risk of maternal mortality due to haemorrhage, the cause of more than 130,000 maternal deaths each year.

• Eliminating anaemia in adults can result in productivity increases of up to 17%. These increases are equivalent to 2% of GDP in the worst affected countries.

• Iron-deficiency anaemia during pregnancy is associated with 115,000 women’s deaths each year, which account for one fifth of total maternal deaths

• Deficiencies in vitamin A and zinc are particularly dangerous for children who are fighting measles, diarrhoea and malaria.

• Iron-deficiency anaemia is also estimated to cause almost 600,000 stillbirths or deaths of babies within their first week of life.

• In developing countries, 38 million newborns each year are at risk of iodine deficiency.

• In 2006, approximately 1.62 billion people had anaemia.

• In China, vitamin and mineral deficiencies represent an annual GDP loss of US$ 2.5-5 billion. In India, they may be costing the country US$ 2.5 billion annually – equivalent to approximately 0.4% of GDP.

 

 

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According to [inside]Tracking Progress on Child and Maternal Nutrition: A survival and development priority[/inside], UNICEF (2009),
http://www.unicef.org/publications/files/Tracking_Progress_on_Child_and_Maternal_Nutrition_EN_110309.pdf:

• A child’s future nutrition status is affected before conception and is greatly dependent on the mother’s nutrition status prior to and during pregnancy. A chronically undernourished woman will give birth to a baby who is likely to be undernourished as a child, causing the cycle of undernutrition to be repeated over generations.

• Children with iron and iodine deficiencies do not perform as well in school as their well-nourished peers, and when they grow up they may be less productive than other adults.

• In the developing world the number of children under 5 years old who are stunted is close to 200 million, while the number of children under 5 who are underweight is about 130 million.

• In Africa and Asia, stunting rates are particularly high, at 40 per cent and 36 per cent respectively. More than 90 per cent of the developing world’s stunted children live in Africa and Asia.

• The level of child and maternal undernutrition remains unacceptable throughout the world, with 90 per cent of the developing world’s chronically undernourished (stunted) children living in Asia and Africa.

• Low birthweight is related to maternal undernutrition; it contributes to infections and asphyxia, which together account for 60 per cent of neonatal deaths. An infant born weighing between 1,500 and 2,000 grams is eight times more likely to die than an infant born with an adequate weight of at least 2,500 grams. Low birthweight causes an estimated 3.3 per cent of overall child deaths.

• Supplementation of micronutrient can reduce the risk of child mortality from all causes by about 23 per cent.

• Children from communities that are iodine deficient can lose 13.5 IQ points on average compared with children from communities that are non-deficient

• Stunting affects approximately 195 million children under 5 years old in the developing world, or about one in three. Africa and Asia have high stunting rates – 40 per cent and 36 per cent, respectively – and more than 90 per cent of the world’s stunted children live on these two continents.

• Of the 10 countries that contribute most to the global burden of stunting among children, 6 are in Asia. These countries all have relatively large populations: Bangladesh, China, India, Indonesia, Pakistan and the Philippines.

• Due to the high prevalence of stunting (48 per cent) in combination with a large population, India alone has an estimated 61 million stunted children, accounting for more than 3 out of every 10 stunted children in the developing world.

• Of countries with available data, Afghanistan and Yemen have the highest stunting rates: 59 per cent and 58 per cent, respectively.

• Since 1990, stunting prevalence in the developing world has declined from 40 per cent to 29 per cent, a relative reduction of 28 per cent. Progress has been particularly notable in Asia, where prevalence dropped from 44 per cent around 1990 to 30 per cent around 2008. This reduction is influenced by marked declines in China.

• An estimated 129 million children under 5 years old in the developing world are underweight – nearly one in four. Ten per cent of children in the developing world are severely underweight. The prevalence of underweight among children is higher in Asia than in Africa, with rates of 27 per cent and 21 per cent, respectively.

• In 17 countries, underweight prevalence among children under 5 years old is greater than 30 per cent. The rates are highest in Bangladesh, India, Timor-Leste and Yemen, with more than 40 per cent of children underweight.

• Progress towards the reduction of underweight prevalence has been limited in Africa, with 28 per cent of children under 5 years old being underweight around 1990, compared with 25 per cent around 2008. Progress has been slightly better in Asia, with 37 per cent underweight prevalence around 1990 and 31 per cent around 2008.

• 13 per cent of children under 5 years old in the developing world are wasted, and 5 per cent are severely wasted (an estimated 26 million children).

• A number of African and Asian countries have wasting rates that exceed 15 per cent, including Bangladesh (17 per cent), India (20 per cent) and the Sudan (16 per cent). The country with the highest prevalence of wasting in the world is Timor-Leste, where 25 per cent of children under 5 years old are wasted (8 per cent severely).

• Although being overweight is a problem most often associated with industrialized countries, some developing countries and countries in transition also have high prevalence of overweight children. In Georgia, Guinea-Bissau, Iraq, Kazakhstan, Sao Tome and Principe, and the Syrian Arab Republic, for example, 15 per cent or more of children under 5 years old are overweight.

• Some countries are experiencing a ‘double burden’ of malnutrition, having high rates of both stunting and overweight. In Guinea-Bissau and Malawi, for example, more than 10 per cent of children are overweight, while around half are stunted.

• In developing countries, 16 per cent of infants, or 1 in 6, weigh less than 2,500 grams at birth. Asia has the highest incidence of low birthweight by far, with 18 per cent of all infants weighing less than 2,500 grams at birth. Mauritania, Pakistan, the Sudan and Yemen all have an estimated low birthweight incidence of more than 30 per cent.

• A total of 19 million newborns per year in the developing world are born with low birthweight, and India has the highest number of low birthweight babies per year: 7.4 million.

• Iron deficiency affects about 25 per cent of the world’s population, most of them children of preschool-age and women.

• Vitamin A deficiency is widespread throughout India, but particularly so in rural India, where up to 62 per cent of preschool-age children are deficient, according to the latest estimates. Moreover, the high prevalence of wasting (20 per cent), stunting (48 per cent) and anaemia (70 per cent) in children under 5 years old indicates widespread nutritional deprivation.

 

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According to The State of Food Insecurity in the World Report 2009: Economic Crises-Impacts and Lessons Learnt, http://www.fao.org/docrep/012/i0876e/i0876e00.htm

• In the case of India, proportion of undernourished in the total population has increased from 21% in 2000-02 to 22% in 2004-06. The number of undernourished people in India has increased from 223.0 million in 2000-02 to 251.5 million in 2004-06.

• The economic turmoil sweeping the globe has led to a sharp spike in hunger affecting the world’s poorest, uncovering a fragile global food system requiring urgent reform. The combination of the food and economic crises have pushed more people into hunger, with the number of hungry expected to top 1 billion this year

• The World Food Summit target of reducing the number of undernourished people by half to no more than 420 million by 2015 will not be reached if the trends that prevailed before those crises continue.

• Strides in improving access to food were made in the 1980s and early 1990s, thanks to stepped up agricultural investment after the global food crisis of the early 1970s. However, official development assistance (ODA) fell between 1995-1997 and 2004-2006, resulting in surges in the number of undernourished in most regions.

• The increase in the number of the world’s hungry in times of both low prices and economic prosperity as well as periods of price spikes and recessions shows how weak the global food security governance system is

• Even before the consecutive food and economic crises, the number of undernourished people in the world had been increasing slowly but steadily for a decade. The most recent FAO undernourishment data covering all countries in the world show that this trend continued into 2004–06.

• The number of hungry people increased between 1995–97 and 2004–06 in all regions except Latin America and the Caribbean. Even in this region, however, the downward trend was reversed because of the food and economic crises. While the proportion of undernourished continually declined from 1990–92 to 2004–06, the decline was much slower than the pace needed to meet the hungerreduction target of the first Millennium Development Goal (MDG).

• The current economic crisis emerged immediately following the food and fuel crisis of 2006–08. While food commodity prices in world markets declined substantially in the wake of the financial crisis, they remained high by recent historical standards. Also, food prices in domestic markets came down more slowly, partly because the US dollar, in which most imports are priced, continued to appreciate for some time, but also, more importantly, because of lags in price transmission from world markets to domestic markets. At the end of 2008, domestic prices for staple foods remained, on average, 17 percent higher in real terms than two years earlier. This represented a considerable reduction in the effective purchasing power of poor consumers, who spend a substantial share of their income (often 40 percent) on staple foods.

• The number of undernourished in the world will have risen to 1.02 billion people during 2009, even though international food commodity prices have declined from their earlier peaks. If these projections are realized, this will represent the highest level of chronically hungry people since 1970.

• During the 1990s and the current decade, however, the number of undernourished has risen, despite the benefit of slower population growth, and the proportion of undernourished increased in 2008.

• Because the world energy market is so much larger than the world grain market, grain prices may be determined by oil prices in the energy market as opposed to being determined by grain supply.

• Although domestic prices for most countries declined somewhat during the second half of 2008, in the vast majority of cases, and in all regions, their decline did not keep pace with that of international food commodity prices. At the end of 2008, domestic staple food prices were still 17 percent higher in real terms than two years earlier, and this was true across a range of important foodstuffs.

• India will be less affected than many other Asian countries because its cautious financial policies have reduced the country’s exposure to external financial shocks. In addition, continuing government support to the agriculture sector has transformed India from a net importer of grains to a net exporter.

• Investing in agriculture in developing countries is key as a healthy agricultural sector is essential not only to overcome hunger and poverty, but also to ensure overall economic growth and peace and stability in the world.

 

According to the [inside]Nutritional Intake in India: 2004-2005[/inside], NSS 61st Round, July 2004- June 2005:

 

 The consumer expenditure survey shows that the percentage share of food expenditure in total expenditure by Indian population was 55.0% in the rural areas and 42.5% in the urban areas. Relative to the comparable survey results for 1993-94, the share of food expenditure has dropped by 8.2 and 12.2 percentage points in rural and urban areas, respectively.

 Average daily intake of calories by rural population has dropped by 106 kcal (4.9 percent) from 2153 kcal to 2047 Kcal from 1993-94 to 2004-05 and by 51 Kcal (2.5 percent) from 2071 to 2020 Kcal in the urban area.

 Population reporting a calorie intake level of “less than 100%” of the norm of 2700 kcal, formed 66 percent of the total in rural areas and 70 percent of the total in urban areas.

 Some states at the higher end of the average intake of calorie per consumer unit per diem were Punjab (2763), Uttar Pradesh (2743) and Rajasthan (2714) in the rural areas and Jharkhand (3013), Bihar (2683) and Punjab (2614) in the urban areas. On the other hand, Karnataka (2276) and Tamil Nadu (2294) in the rural areas and Maharashtra (2261), Karnataka (2385) and Tamil Nadu (2394) in the urban areas were found to have much lower intake of calorie than the Indian average. In terms of per capita calorie intake, Assam, Bihar, Haryana, Punjub, Rajasthan, West Bengal and Uttar Pradesh were higher than the national average of 2047 Kcal.

 In the rural areas, the people of Orissa (79%), Chhatisgarh (78%) and Jharkhand (75%) reportedly derived around 75% of actual intake of calorie from cereals.  On the other hand, people of Punjab (50%), Haryana (54%) and Kerala (54%) reported a smaller percentage of calorie intake from cereals

 Average daily intake of protein by the Indian population has decreased from 60.2 to 57 grams in the rural area between 1993-94 and 2004-05 and remained stable around 57 grams in the urban area during the same period. 

 While the intake of calorie was observed to be lower, the level of protein and fat consumption was considerably higher than the standard minimum requirement per diem per consumer unit in both the sectors.  A higher intake of calorie and protein was observed in the rural India (2540 kcal and 70.8 gms.) as compared to urban India (2475 kcal & 69.9 gms.) whereas, the consumption of fat was relatively much lower in rural areas (44.0 gms.) compared to that in urban areas (58.2 gms.).

 A significant rise in per capita daily average intake of fat is observed during the decades (1993-94 to2004-05) in both rural and urban areas. It has increased from 31.4 gms. to 35.5 gms. (13.1 percent) in rural areas and from 42 gms. to 47.5 gms. (13 percent) in urban areas.

 At national level, the number of meals taken at home had decreased by 0.57%, major states having undergone similar declines were Karnataka (-13.0%), Gujarat (-75%), Andhra Pradesh (-7.37%) whereas in West Bengal it remained unchanged in the rural India. In the urban India, prevalence of home-cooked meals had gone down by 1.66% over last eleven years. The leading contributors were Karnataka (-13.2%), Andhra Pradesh (-9.35%), Assam (-8.56%) whereas the it had increased for states like Haryana (8.81%), Gujarat (1.46%) and West Bengal (0.42%).

 At the national level, the number of meals eaten at home by household members had decreased by 0.57% in the rural areas between 1993-94 and 2004-05. In urban India popularity of home kitchen had declined by 1.66% over last ten years. 

 Meals taken outside home were mainly concentrated among the age group 5-9 and 10-14 years for both the sex in all the sectors. Among the meals taken outside home in these age groups, most were from schools or Balwadi, might be in the form of ‘Mid-day Meals’. Both in rural and urban area, meals taken on payment were a rare phenomenon. 

Notes

Consumer unit:  Consumer unit is the rate of equivalence of a normal person determined on the basis of age-sex composition  of a person. It is usual to assess the calorie needs of men, women and children in terms of those of the average man by applying various coefficients to the different age-sex groups. Consumer unit of  a normal male person doing sedentary work and belonging to the age group 20-39 is taken as one unit and the other coefficients are worked out on the basis of calorie requirements. Alternatively consumer unit is a normative rate of equivalence of a given age-sex specific person in relation to a ‘standard’ male person aged 20-39 years and doing sedentary work who is taken to be equivalent to one consumer unit. Nutritionists, attempting to assess calorie requirements per consumer unit, differ in their approaches to the problem, some specifying calorie requirement as function of body weight, while others assign requirements depending on nature of work (sedentary/moderate/heavy). From  the 26th round, the NSS has been using a level to the tune of 2700 calories per consumer unit per day as a standard and measure of actual intake may be compared with it.  This level (2700 calories per consumer unit per day) is referred to & reported as the "norm" level of calorie intake.
 
Monthly per capita consumer expenditure (MPCE):  For a household, this is the total consumer expenditure over all items divided by its size and expressed on a per month (30 days) basis. A person’s MPCE is understood as that of the household to which he or she belongs.

 

According to the World Bank:
http://web.worldbank.org/WBSITE/EXTERNAL/NEWS/0,,contentMDK:20917151~pagePK:64257043~piPK:437376~theSitePK:4607,00.html
  


• The prevalence of underweight children in India is among the highest in the world, and is nearly double that of Sub-Saharan Africa, the report says.. It also observes that malnutrition in India is a concentrated phenomenon. A relatively small number of states, districts, and villages account for a large share of the burden - 5 states and 50 percent of villages account for about 80 percent of the malnutrition cases.

• Reductions in the prevalence of malnutrition over the last decade have been small – the prevalence of underweight has only fallen from 53 percent to 47 percent between 1992/93 and 1998/99

• More than 75 percent of preschool children suffer from iron deficiency anemia (IDA) and 57 percent of preschool children have sub-clinical Vitamin A deficiency (VAD).  Iodine deficiency is endemic in 85 percent of districts.
 
• Child malnutrition is a leading cause of child and adult morbidity, mortality, and cognitive and motor development. Malnutrition is estimated to play a role in about 50 percent of all child deaths, and more than half of child deaths from malaria (57 percent), diarrhea (61 percent) and pneumonia (52 percent). Overall, child malnutrition is a risk factor for 22.4 percent of India’s total burden of disease.

• In India, child malnutrition is responsible for 22 percent of the country’s burden of disease. Undernutrition also affects cognitive and motor development and undermines educational attainment; and, ultimately impacts on productivity at work and at home, with adverse implications for income and economic growth. Micronutrient deficiencies alone may cost India US$2.5 billion annually.
 
•  In India, child malnutrition is mostly the result of high levels of exposure to infection and inappropriate infant and young child feeding and caring practices, and has its origins almost entirely during the first two to three years of life. However, the commonly held assumption is that food insecurity is the primary or even sole cause of malnutrition. Consequently, the existing response to malnutrition in India has been skewed towards food-based interventions and has placed little emphasis on schemes addressing the other determinants of malnutrition.

• States with the highest levels of malnutrition have the lowest levels of ICDS program funding and a smaller percentage of their villages covered by ICDS centers than states with less malnutrition - The five states with the highest underweight prevalence, namely Rajasthan, Uttar Pradesh, Bihar, Orissa and Madhya Pradesh, all rank in the bottom ten in terms of ICDS coverage

• Underweight prevalence during NFHS-II was higher in rural areas (50 percent) than in urban areas (38 percent); higher among girls (48.9 percent) than among boys (45.5 percent); higher among scheduled castes (53.2 percent) and scheduled tribes (56.2 percent) than among other castes (44.1 percent); and, although underweight is pervasive throughout the wealth distribution, the prevalence of underweight reaches as high as 60 percent in the lowest wealth quintile. Moreover, during the 1990s, urban-rural, inter-caste, male-female and inter-quintile inequalities in nutritional status widened.

 

According to the [inside]National Family Health Survey-III (2005-06)[/inside], http://www.nfhsindia.org:


• Percentage of children (under 3 years) who are stunted declined from 45.5 during NFHS-II (1998-99) to 38.4 during NFHS-III at the all-India level. The prevalence of stuntedness (during NFHS-III) among children below 3 years was highest in Uttar Pradesh (46.0%), to be followed by Chattisgarh (45.4%) and Gujarat (42.4%).

• Percentage of children (under 3 years) who are wasted increased from 15.5 during NFHS-II to 19.1 during NFHS-III at the all-India level. The prevalence of wastedness (during NFHS-III) among children below 3 years was highest in Madhya Pradesh (33.3%), to be followed by Jharkhand (31.1%), Meghalaya (28.2%) and Bihar (27.7%).  

• Percentage of children (under 3 years) who are underweight declined meagerly from 47.0 during NFHS-II to 45.9 during NFHS-III at the all-India level. The prevalence of underweightedness (during NFHS-III) among children below 3 years was highest in Madhya Pradesh (60.3%), to be followed by Jharkhand (59.2%), Bihar (58.4%), Gujarat (47.4%) and Uttar Pradesh (47.3%). 

 

Life cycle approach to inter-generational malnutrition

life cycle nutrition

Source: ncbi.nlm.nih.gov  

 


According to [inside]Facilitating Improved Nutrition for Pregnant and Lactating Women, and Children 0–5 Years of Age[/inside] by Kathryn G. Dewey (2003), PhD, University of California, Davis, USA, http://www.enfant-encyclopedie.com/Pages/PDF/DeweyANGxp.pdf:
 

* Nutrition during childhood and adolescence influence a woman’s pre-conceptional nutritional status, which subsequently influences the outcome of pregnancy and the health of her child. Malnutrition is perpetuated across generations via this cycle. For this reason, programs to improve the nutrition of women and children must be comprehensive, targeting all stages of the life cycle.

* Why are maternal and child nutrition important in the context of early childhood development? There are numerous linkages between adequate prenatal and postnatal nutrition and a child’s physical, cognitive, emotional, and motor development. For example, low birthweight resulting from intrauterine malnutrition is a key predictor of developmental delay, among other adverse outcomes. Duration of breastfeeding has been positively associated with a child’s cognitive and motor development. Maternal nutritional status, such as iron-deficiency anaemia, may affect the degree and quality of child caregiving. Lastly, maternal dietary practices and weight status are strongly related to a child’s risk of being overweight, a condition that can have lasting consequences on emotional and physical development.

* Ensuring adequate diets prior to pregnancy, during pregnancy and lactation, and during early childhood (particularly the first two years) is essential. Such interventions have the potential to substantially enhance child development, as well as the general health of women and children.