1. UTPAL GANGULY
UNDERSTANDING MALNUTRTION IN
CHILDREN

2. POOR NUTRTION; THE SILENT ENEMY
Poor nutrition in the first 1,000 days of children’s lives can
have irreversible consequences. It means they are -
• forever, stunted.
• susceptible to sickness
• more likely to become overweight when they enter
adulthood.
• and more prone to non-communicable disease.
• About one third of under-five mortality is attributable to
under-nutrition.

3. Under-nutrition contributes to child mortality
and morbidity
• Stunting and other forms of under-nutrition are clearly a
major contributing factor to child mortality, disease and
disability.
• For example, a severely stunted child faces a four times
higher risk of dying, and a severely wasted child is at a nine
times higher risk.
• Specific nutritional deficiencies such as vitamin A, iron or
zinc deficiency also increase risk of death.
• Under-nutrition can cause various diseases such as
blindness due to vitamin A deficiency and neural tube
defects due to folic acid deficiency

4. What are the first 1000 days?
• 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.

5. What is stunting, wasting and underweight?
• Stunting (inadequate length/height for age) captures early
chronic exposure to under-nutrition;
• wasting (inadequate weight for height) captures acute
under-nutrition;
• underweight (inadequate weight for age) is a composite
indicator that includes elements of stunting and wasting

9. Mid upper arm circumference (MUAC)
• The circumference of the child’s upper arm half way
between their shoulder and elbow provides an indication of
acute malnutrition independent of the child's age. If the
child’s arm is less than 11.5cm in circumference, she is
severely malnourished; if the child’s arm is between 11.5 and
12.5cm in circumference, she is moderately malnourished.
These values are appropriate for children from 6 months to
60 months.

10. Understanding standard deviation

11. Weight-for-Length Reference Card (below
87 cm)
Weight for length reference table page 7 annex 1
• When assessing weight-for-height, infants and children under
24 months of age should have their lengths measured lying down
(supine).
• Children over 24 months of age should have their heights
measured while standing.
• For simplicity, however, infants and children under 87 cm can be
measured lying down (or supine) and those above 87 cm
standing.
• A z-score is the number of standard deviations (SD) below or
above the reference median value.

12. What is stunting?
• Stunting reflects chronic under-nutrition during the most
critical periods of growth and development in early life.
• It is defined as the percentage of children aged 0 to 59
months whose height for age is below minus two standard
deviations (moderate and severe stunting) and minus three
standard deviations (severe stunting) from the median of
the WHO Child Growth Standards.

13. What is under weight?
• Underweight is a composite form of under-nutrition that
includes elements of stunting and wasting. It is defined as
the percentage of children aged 0 to 59 months whose
weight for age is below minus two standard deviations
(moderate and severe underweight) and minus three
standard deviations (severe underweight) from the median
of the WHO Child Growth Standards.

14. What is wasting?
• Wasting reflects acute under-nutrition.
• It is defined as the percentage of children aged 0 to 59
months whose weight for height is below minus two
standard deviations (moderate and severe wasting) and
minus three standard deviations (severe wasting) from the
median of the WHO Child Growth Standards.

15. DIAGNOSTIC CRITERIA FOR SAM IN CHILDREN
AGED 6–60 MONTHS
• Indicator Measure Cut-off
• Severe wasting Weight-for-height < -3 SD
• Severe wasting MUAC < 115 mm
• Bilateral oedema Clinical sign (may not be considered)

16. Overweight???
• Overweight is defined as the percentage of children aged 0
to 59 months whose weight for height is above two standard
deviations (overweight and obese) or above three standard
deviations (obese) from the median of the WHO Child
Growth Standards.

17. Low birth weight??
• Low birth weight is defined as a weight of less than 2,500
grams at birth.

18. Understanding under nutrition changing
focus…
• In tackling child under-nutrition, there has been a shift from
efforts to reduce underweight prevalence (inadequate weight for
age) to prevention of stunting (inadequate length/height for
age).
• There is better understanding of the crucial importance of
nutrition during the critical 1,000-day period covering pregnancy
and the first two years of the child’s life, and of the fact that
stunting reflects deficiencies during this period.
• 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.

19. How big is the problem?
• Stunting
• 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.
• Sub-Saharan Africa and South Asia are home to three
fourths of the world’s stunted children. In sub-Saharan
Africa, 40 per cent of children under 5 years of age are
stunted; in South Asia, 39 per cent are stunted.
• 80% of the worlds stunted children live in 14 countries
(Figure 5 page 9 unicef report)

20. • Underweight
• Globally in 2011, an estimated 101 million children under 5
years of age were underweight, or approximately 16 per cent
of children under 5.
• As per Hungama report 2011, 42 per cent of children under
five are underweight and 59 percent are stunted. Of the
children suffering from stunting, about half are severely
stunted.

21. Wasting: Burden estimates in the 10 most
affected countries
• Figure 12 page 13 unicef
reportNutrition_Report_final_lo_res_8_April.pdf

22. • Low birth weight
• The World Health Assembly has set a new target to reduce
low birthweight by 30 per cent between 2010 and 2025. In
2011, more than 20 million infants, an estimated 15 per cent
globally, were born with low birth weight. India alone
accounts for one third of the global burden. South Asia has
by far the greatest regional incidence of low birth weight,
with one in four newborns weighing less than 2,500 grams at
birth (Figure 17).

23. • Overweight
• Rates of overweight continue to rise across all regions.
Overweight was once associated mainly with high-income
countries, but in 2011, 69 per cent of the global burden of
overweight children under 5 years old were in low- and
middle-income countries. However, the prevalence of
overweight remains higher in high-income countries (8 per
cent) than in low-income countries (4 per cent).
• Globally, an estimated 43 million children under 5 years of
age are overweight, or 7 per cent of children under 5 years
old.

24. Global focus on nutrition….
• Recognizing that investing in nutrition is a key way to advance global
welfare, the G8 has put this high on its agenda. The global nutrition
community is uniting around the Scaling Up Nutrition movement.
• The United Nations Secretary-General has included elimination of stunting
as a goal in his Zero Hunger Challenge to the world.
• The 2013 World Economic Forum highlighted food and nutrition security as
a global priority.
• And a panel of top economists from the most recent Copenhagen Consensus
selected stunting reduction as a top investment priority.
• The World Health Assembly has set the goal of achieving a 40 per cent
reduction in the number of stunted children
• The global nutrition community is uniting around the Scaling Up Nutrition
(SUN) movement, which supports nationally driven processes for the
reduction of stunting and other forms of malnutrition.

25. Nutrition-specific interventions
• Promoting optimal nutrition practices, meeting
micronutrient requirements and preventing and treating
severe acute malnutrition are key goals for nutrition
programming
• Maternal nutrition and prevention of low birth weight
• Infant and young child feeding (IYCF) Breastfeeding, with
early initiation (within one hour of birth) and continued
exclusive breastfeeding for the first six months followed by
continued breastfeeding up to 2 years

26. Nutrition-specific interventions
• Safe, timely, adequate and appropriate complementary
feeding from 6 months onwards
• Prevention and treatment of micronutrient deficiencies
• Prevention and treatment of severe acute malnutrition
• Promotion of good sanitation practices and access to clean
drinking water
• Promotion of healthy practices and appropriate use of
health services

27. Nutrition-specific interventions
• Key proven practices, services and policy interventions
for the prevention and treatment of stunting and other
forms of undernutrition throughout the life cycle
• Figure 18 page 18 Unicef report

28. Nutrition-specific interventions
• Anganwadi centers are charged with regularly measuring
the weight of children to determine if they are underweight.
The age and weight are plotted on the WHO charts.
Children are severely underweight if their age and weight
put them below the line marked “-3”; they are moderately
underweight if their age and weight put them between the
line marked “-2” and the line marked “-3”

29. Conceptual framework
• Unicef 1990 Page 4 figure 1

30. Key findings of the Hungama report 2011
• Household socio-economic status has a significant effect on
children’s nutrition status: 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.
• Children from households identifying as Muslim or
belonging to Scheduled Castes or Schedule Tribes generally
have worse nutrition.

31. • Girls’ nutrition advantage over boys fades away with
time: Girls seem to have a nutrition advantage over boys
in the first months of life; however this advantage seems to
be reversed over time a s girls and boys grow older,
potentially indicating feeding and care neglect vis-à-vis girls
in infancy and early childhood;

32. • Mothers’ education level determines children’s nutrition:
In the 100 Focus Districts,
• 66 per cent mothers did not attend school;
• rates of child underweight and stunting are significantly higher
among m others 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 percent.
• T he corresponding figures f or child stunting are 63 and 43 per
cent respectively.

33. • Giving colostrum to the newborn and exclusive
breastfeeding for first 6 months of a child’s life are not
commonly practised:
• In the 100 Focus Districts 5 1 per cent mothers did not give
colostrum to the newborn soon after birth and 58 per cent
mothers fed water to their infants before 6 months.

34. • Hand washing with soap is not a common practice:
• In the 100 Focus Districts 11 per cent mothers said they
used soap to wash hands before a meal and 1 9 per cent do
so after a visit to the toilet;

35. • Anganwadi Centres are widespread but not always
efficient:
• There is a n Anganwadi centre in 9 6 per cent o f the villages in
t he 1 00
• Focus Districts, 61 per cent o f them in pucca buildings;
• the Anganwadi service accessed by the largest p roportion of m
others (86 p er c ent) i simmunization;
• 61 per cent of Anganwadi Centreshad dried rations available and
• 5 0 p er c ent provided f ood on the day of s urvey;
• only 19 p ercent of the mothers reported that the Anganwadi
Centre provides nutrition counseling to parents.

36. Complex problems …simple solutions…
• Most of the solutions to the complex problems of under
nutrition in India are simple
Why are they not simply practiced?