Prema Ramachandran ASSESSMENT OF NUTRITIONAL STATUS IN CHILDREN Director, Nutrition Foundation of...

Prema Ramachandran

ASSESSMENT OF NUTRITIONAL STATUS IN CHILDREN Director, Nutrition Foundation of India

Developing countries are currently undergoing economic, social, demographic, health and nutrition transitions. The term dual nutrition burden was coined in the nineties to denote the phase of ongoing nutrition transition in low and middle income countries, characterized by persistent undernutrition mainly among poorer segments of population and emerging problem of overnutrition seen mostly among the urban affluent segments. Nutrition transition and assessment nutritional status in children

During last two decades, Indian scientists have been in the forefront of global efforts exploring epidemiological, clinical and biochemical dimensions and health implications of dual nutrition burden. These studies have Defined the magnitude of dual nutrition burden Shown that undernutrition & overnutrition can be seen in same family same individual at different periods of time same individual at the same time Documented trans-generational impact and Explored the challenges and opportunities India faces in in combating dual nutrition Dimensions of dual nutrition burden

Under-nutrition in early childhood willadversely affect their growth, development and health status during childhood and adolescence influence their nutrition and health status through out their life span may render them more susceptible to over-nutrition and non communicable disease risk in adult life Why focus on nutritional status in early childhood?

In the last century the focus was on undenutrition. Tools used for assessment of nutritional status in children were Dietary intake Clinical signs of nutritional deficiencyHeight and weight measurements METHODS USED FOR ASSESSMENT OF NUTRITIONAL STATUS IN CHILDREN In the current century, severe clinical forms deficiencies are rare; focus is therefore on under and overnutrition Dietary intake and physical activity measurement, Ht, wt and BMI for age, measurement of body fat and its distribution are now used for assessment of nutritional status in children

Dual nutrition burden begins in utero

Dual nutrition burden begins in utero Low birth weight (

Low birth weight consequences

Over the last three decades there is no increase in mean birth weight or reduction in LBW.Majority of LBW babies are mature.Prevalence of preterm births is about 12%.

Chart1

278532.5

2685.7930.2

2682.529.1

Source:Safdarjung Hospital

Birth weight

% LBW

Year

Birthweight

%LBW

Time trends in birth weight

Sheet1


196919891998

Birth weight27852685.792682.5

% LBW32.530.229.1

Sheet1

00

00

00

&A

Page &P

Birth weight

% LBW

Year

Birthweight

%LBW


Sheet2

Sheet3

Chart1

3312.3

31.614.7

LBW

Preterm

% prevalence

Prevalence of Low birthweight -NNF

Sheet1

1995 2002

Births 37082 66512

LBW 33% 31.6%

Preterm - 12.3% 14.7%

19952002

LBW3331.6

Preterm12.314.7

Sheet1

00

00

LBW

Preterm

% prevalence

Prevalence of Low birthweight

Sheet2

Sheet3

Year 1967 - Dr Shanti Ghoshs research findings:Low birth weight can be due to Intrauterine growth retardation (IUGR) or preterm birth.Majority of LBW babies in India are term IUGR. Their survival chances are much better than the pre-term babies with similar birth weight.With warmth, breast feeding and prevention infection most term IUGR babies will survive.Only preterm babies & those weighing below 2kg require intensive care in nurseries.

Do Indian children begin life with a disadvantage ? Birthweight is the critical determinant of trajectory of growth during infancy and child hood Birth weight is a major determinant of growth trajectory during infancy and child hood.

Birth-weight is a major determinant of growth during infancy childhood, adolescence and adult life.Focus on antenatal care will bring about a modest reduction low birth-weight especially preterm births and bring about some improvement in nutritional status Birth-weight is a critical determinant of growth

South Asian enigma: is it due to IUGR ?Prevalence of underweight in preschool children India is higher than the prevalence of under weight in sub-Saharan Africa but infant and under five mortality rates in India are low: so called South Asian enigma.Low birthweight rates in India is 30%; in sub-Saharan Africa is 15 %.Most of the Indian LBW neonates are mature and can survive with minimal essential care; they have a low growth trajectory. Most of the sub-Saharan LBW neonates are preterm and require special care; in the absence of adequate pediatric care neonatal and infant mortality rates are high.The high U5 MR and under-nutrition in the predominantly normal birth weight survivors in sub-Saharan Africa might be due to low dietary intake and poor access to health care.

Indian neonates are short and wasted; they have low muscle mass but fat mass is spared. Over the last two decades there has been no change in birthweight but there has been an increase in fat fold thickness of neonates - in boys and girls, in all gestational age and birth weight categoriesIndians proneness for adiposity begins in utero The thin -fat neonate

Chart2

3.22.53.32

3.63.33.83.2

3.93.643.5

3.93.54.23.6

4.13.94.13.8

443.83.9

boys sachdev

boys puri

girls sachdev

girls puri

Gestation (wks)

triceps (mm)

Time trends in Triceps fat fold thickness in neonates

Sheet1

males

boysgirls

sachdevpurisachdevpuri

363.22.53.32

373.63.33.83.2

383.93.643.5

393.93.54.23.6

404.13.94.13.8

41443.83.9

sachdevpuri

3.32.1

3.83.2

4.13.2

4.13.1

4.23.5

4.33.6

Sheet1

0000

0000

0000

0000

0000

0000

boys sachdev

boys puri

girls sachdev

girls puri

Gestation (wks)

triceps (mm)

Secular trends in triceps (mm)

Sheet2

Sheet3

Chart7

3.63.23.83.5

43.44.44.2

4.53.74.94.5

4.93.75.45.1

boys sachdev

boys puri

girls sachdev

girls puri

Birth weight (g)

Subscapular (mm)

Time trends in subscapular fat fold thickness (mm)

gestation

males

boysgirls


363.22.53.32

373.63.33.83.2

383.93.643.5

393.93.54.23.6

404.13.94.13.8

41443.83.9

subscapular

boysgirls


363.32.13.32.3

373.83.24.23.5

384.13.24.33.7

394.13.14.44.2

404.23.54.54.3

414.33.64.14.3

gestation

0000

0000

0000

0000

0000

0000

boys sachdev

boys puri

girls sachdev

girls puri

Gestation (wks)

triceps (mm)


brth wt

000000

000000

000000

000000

36

37

38

39

40

41

Triceps (mm)

Secular trends in triceps

Sheet3

0000

0000

0000

0000

0000

0000

boys sachdev

boys puri

girls sachdev

girls puri

Gestation (wks)

subscapular(mm)

Secular trends in subscapular (mm)

000000

000000

000000

000000

36

37

38

39

40

41

Subscapular (mm)


boysgirls


2001-25003.43.43.53.2

2501-30003.83.84.23.7

3001-35004.34.34.63.9

3501-40005.14.24.93.9

boysgirls


2001-25003.63.23.83.5

2501-300043.44.44.2

3001-35004.53.74.94.5

3501-40004.93.75.45.1

0000

0000

0000

0000

boys sachdev

boys puri

girls sachdev

girls puri

Birth weight (g)

Triceps (mm)


0000

0000

0000

0000

boys sachdev

boys puri

girls sachdev

girls puri

Birth weight (g)

Subscapular (mm)


Infant and young child feeding and nutritional status

Infant feeding practices Exclusive breast feeding Semisolid complementary feedsHousehold food Breast feeding was nearly universal; however less than 50 % of infants were exclusively breast fed upto six months Very few received semisolid complementary feeds at six months. Majority of children received household food along with breast feeding by 9-11 months Breast milk +other milkNot breast fedNot breast fed

Chart6

1.980.814.51.51.2

1.659.223.95.99.4

3.928.314.88.644.4

6.312.37.5568.9

no bf

ebf + water

bf+fluids

fluids+ss

hh foods

age in months

percent prevalence

Percent Prevalence of IF Practices

morbidity prevalence

diafeverari

0-5 months0.12112.10.12612.60.0686.8

6-11 months0.18418.40.21621.60.0848.4

12-17 months0.15915.90.20920.90.0828.2

18-23 months0.11811.80.17317.30.0666.6

24-29 months0.0969.60.18318.30.0676.7

30-35 months0.0797.90.15150.0535.3

36-41months0.0535.30.13513.50.0535.3

42-47 months0.0515.10.12612.60.0494.9

48-53 months0.0454.50.11511.50.0454.5

54-59 months0.0363.60.1100.0393.9


000

000

000

000

000

000

000

000

000

000

dia

fever

ari

Perecnt Prevalance

Percent Prevalence of Diarrhea, Fever and ARI in different age groups

IFP 1yr

age in monthsno bfebf + waterbf+fluidsfluids+sshh foods

0-21.980.814.51.51.2

3-51.659.223.95.99.4

6-83.928.314.88.644.4

9-116.312.37.5568.9


0-51.868.519.945.9

6-11521.211.6755.3

IFP 1yr

00000

00000

00000

00000

no bf

ebf + water

bf+fluids

fluids+ss

hh foods

age in months

percent


un in ai's

00000

00000

no bf

ebf + water

bf+fluids

fluids+ss

hh foods

Age in Months

Percent Prevalence

Infant feeding Practices

ifpvswt

HT/AWT/AWT/HTBMI/A

UN4842.519.816.9

NORMAL50.157.178.681.2

OVERNOURISHED1.90.41.51.9

HT/AWT/AWT/HTBMI/A

UNNORMALONUNNORMALONUNNORMALONUNNORMALON

0-520.472.76.929.569.5130.365.64.133652

6-1128.667.73.735.564.20.42968.62.531.266.52.2

12-1746.950.72.440.359.40.323.3751.818.478.92.7

18-2357.940.91.24653.80.222.376.61.216.481.32.4

24-295444.31.743.156.50.416.2830.812.785.71.6

30-3557.940.61.546.752.90.417.181.81.112.885.41.7

36-4152.546.5143.456.30.315.583.4112.286.21.7

42-4756.4430.648.251.60.115.583.4111.686.61.8

48-5350.149.10.843.656.10.315.183.61.411.387.11.7

54-5951.248.60.246.653.20.21682.81.112.286.51.2

ifpvswt

000

000

000

000

UN

NORMAL

OVERNOURISHED

ANTHROPOMETRIC INDICES

PERCENT PREVALENCE

UNDERNUTRITION AND OVERNUTRITION BY VARIOUS INDICES

Sheet1

000

000

000

000

000

000

000

000

000

000

HT/A UN

HT/A NORMAL

HT/A ON

000

000

000

000

000

000

000

000

000

000

WT/A UN

WT/A NORMAL

WT/A ON

000

000

000

000

000

000

000

000

000

000

WT/HT UN

WT/HT NORMAL

WT/HT ON

000

000

000

000

000

000

000

000

000

000

BMI/A UN

BMI/A NORMAL

BMI/A ON

000

000

000

000

000

000

000

000

000

000

WT/A UN

WT/A NORMAL

WT/A ON

nbfebfpbf

028.932.335.8

136.137.435.9

246.246.345.4

349.651.652

451.756.657.9

557.161.261.7

659.762.765

768.465.868.5

875.36771.2

974.570.472.4

1076.872.874.4

1177.773.376.4

111

#REF!

#REF!

#REF!

age in months

weight 1 decimal

ifp vs weight

nbfebfpbf

0-5mon24.611.213.2

6-11mon18.417.218.8

nbfebfpbf

0-5mon26.212.212.8

6-11mon1820.422.2

ebfpbf

06.610.5

173.9

211.613.2

31212.4

415.815.7

511.913.7

620.622.6

715.419.2

812.719.4

92018.4

1014.515.1

1118.818

ebfpbf

03.3

187.9

29.58.9

312.915.7

417.515.4

518.412.9

62317.9

723.624.3

818.521

97.623.5

102523.1

1120.822

000

000

nbf

ebf

pbf

age

prevalence

diarhea vs ifp

000

000

nbf

ebf

pbf

age

%prevalence

fever vs ifp

00

00

00

00

00

00

00

00

00

00

00

00

ebf

pbf

00

00

00

00

00

00

00

00

00

00

00

00

ebf

pbf

age

prev

fever vs ifp

Most women exclusively breast feed in the first three months and this ensures that there is no further increase in underweight rates during this period After 3 months underweight rate rises due to early introduction of milk supplements and higher morbidity rates due to infections,Between 6 and 11 months underweight rate further rises to 45% - partly due to inadequate complementary feeding and partly due to increase in morbidity due to infections.IYCF - Key for reduction in undernutrition Nutrition education on appropriate infant feeding is critical to prevent rise in undernutrition rates between 3-11 months

Chart1

28.8877266991

34.6026096377

42.8583237426

45.4939384275

WHO

The gap between RDA and the actual energy intake is greatest in preschool children and lowest in adults.Poor intrafamilial distribution rather than poverty appears to be the major factor responsible for low energy intake in children. Nutrition education on appropriate intra-family distribution of food holds the key for combating childhood under-nutrition How do we improve intra family distribution of food ?

Age groupsMalesFemalesKcalsRDA% RDAKcalsRDA% RDAPre-school889135765.5897135166.4School Age1464192975.91409187675.1Adolescents2065244184.61670182391.6Adults2226242591.819231874102.6

Over years there has been a increase in the number of households where adults are getting adequate food but children are not; poor child feeding and caring practice rather (not poverty) are major factors responsible for undernutrition in preschool child

Chart1

31.131

25.442.9

19.17.2

24.418.9

Source:NNMB

1975-80

1996-97

Percentage

Comparison of Energy Adequate Status of Preschool Chidren and Adults

Intake

Nutrient Intake (CU/Day) By Community

Protein(g)Energy(kcal)Iron(mg)Vit.A(ug)

SC55.1212526361

ST49.8203624.3237

BC53.3209423.7291

Others56.2216925.6328

Landless A.L.51.7198923.6198

Other lab.47.9204224.7381

Ccultivators55.2220526.6362

Others54.4218723308

Status

% of 1-5 year Children with Severe Undernutrition

by Gomez Classification

State1975+1988+1996+

Kerala10.322

Tamil Nadu12.64.22.9

Karnataka14.38.36.2

Andhra pr.15.47.57.1

Maharashtra21.97.87.7

Gujarat13.81316.7

Orissa14.910.74.1

Pooled158.76.2

1975-801996-97

+ + +31.131

+ + -25.442.9

- - -19.17.2

Others24.418.9

Status

00000000

00000000

00000000

Kerala

Tamil Nadu

Karnataka

Andhra pr.

Maharashtra

Gujarat

Orissa

Pooled

percent

Sheet3

00

00

00

00

Fig.4.24

1975-80

1996-97

Percentage

Comparison of Energy Adequate Status of Preschool Chidren and Adults - Distribution (%) of Households

Dietary

Intake

Adult

Male

Adult

Female

Preschool

Children

+ + +

Adequate

Adequate

Adequate

+ +

-

Adequate

Adequate

Inadequate

-

-

-

Inadequate

Inadequate

Inadequate

Child undernutrition rates are higher in families in which mother is undernourished. But even if mother is normal, over 40 % of children are underweight. Poor IYCF, intrafamily distribution of food and poor health care rather than poverty is increasingly responsible for undernutrition in preschool children. Intra-family dual nutrition burden ( NFHS -3) Nutrition & health education on balanced adequate food , and physical activity hold the key for optimal health and nutrition for all age groups in the family

Morbidity due to infections

Prevalence of morbidity due to infections in relation to age Prevalence of morbidity is low in the first three months when infants are mostly solely breast fed and are relatively not exposed to poor environmental hygiene Diarrhea is the most common infection; prevalence of diarrhea and fever increase between between 6 and 23 months perhaps due to introduction of food other than breast milk and greater exposure to bacterial contamination and poor environmental hygiene After the first two years there is some reduction in morbidity due to infection.

Children who had morbidity during the last fortnight weighed less than those did not have morbidity during that period This could either because undernutrition predisposed to infection or infections had an adverse effect on body weight

Chart11

55.2

7.17

8.38.1

98.8

10.110

10.810.6

11.811.6

12.312.2

13.313

13.813.7

no

yes

Body weight in children with and without morbidity

Sheet1

noyesnoyesnoyes

0-5 months55.20.60.614.414.4

6-11 months7.170.70.715.515.3

12-17 months8.38.10.70.715.515.3

18-23 months98.80.80.815.214.9

24-29 months10.1100.80.81514.9

30-35 months10.810.60.90.814.914.7

36-41months11.811.60.90.914.814.6

42-47 months12.312.20.90.914.614.4

48-53 months13.3131114.414.3

54-59 months13.813.71114.214.1

Sheet1

000000

000000

000000

000000

000000

000000

000000

000000

000000

000000

no

yes

no

yes

no

yes

Sheet2

00

00

00

00

00

00

00

00

00

00

no

yes

weight and morbidity

Sheet3

00

00

00

00

00

00

00

00

00

00

no

yes

Source: NFHS 1998-99 Nutritional Status of children by IncomeUnder-nutrition rates among poor in Kerala are similar to under-nutrition rates among the rich in UP. Appropriate feeding and health care are critical for reduction in under-nutrition rates.

Chart4

124.72.5

1683.5

18126

26.51610

29.5219.9

30.1154.9

Low

Medium

High

Fig10

Andhra Pradesh31.5

Assam43.8

Bihar54.6

Gujarat41.1

Haryana41.6

Himachal Pradesh33.3

J&K50.3

Karnataka33.6

Kerala21.1

Madhya Pradesh52.8

Maharashtra39.2

Orissa42.9

Punjab39.6

Rajasthan52.9

Tamil Nadu23.2

Uttar Pradesh58.1

West Bengal36.5

Fig10

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

Figure 13: Interstate differences in birth order 3 and Above

Fig 14

LowMediumHigh

Kerala124.72.5

Tamil Nadu1683.5

Punjab18126

Orissa26.51610

Uttar Pradesh29.5219.9

Gujarat30.1154.9

Fig 14

000

000

000

000

000

000

Low

Medium

High

Figure 14: Nutritional Status of children by Income

Sheet3

Source: NFHS II

MBD00004039.xls

Chart1

47.826086956521.739130434813.04347826098.69565217398.6956521739

13.043478260947.826086956517.39130434788.695652173913.0434782609

06.97674418616.279069767437.209302325639.5348837209

36.842105263221.052631578910.526315789531.57894736840

5.882352941241.176470588217.647058823517.647058823517.6470588235

502516.66666666678.33333333330

4020151015

85.71428571437.14285714297.142857142900

11.111111111142.222222222222.22222222226.666666666717.7777777778

46.66666666673.3333333333202010

26.666666666750106.66666666676.6666666667

5.882352941217.647058823529.411764705941.17647058825.8823529412

3.3333333333013.33333333335033.3333333333

43.47826086964.34782608730.434782608717.39130434784.347826087

02.941176470633.823529411820.588235294142.6470588235

5.263157894742.105263157921.052631578915.789473684215.7894736842

TOP 20%

20-40%

40-60%

60-80%

80-100%

Figure16: Distribution of Districts as per 1 or 2 IFA Tablets regularly - Major States (RHS 1998-99)

Sheet1

Source: RCH Survey, Department of Family Welfare

Sheet1

47.826086956521.739130434813.04347826098.69565217398.6956521739

13.043478260947.826086956517.39130434788.695652173913.0434782609

06.97674418616.279069767437.209302325639.5348837209

36.842105263221.052631578910.526315789531.57894736840

5.882352941241.176470588217.647058823517.647058823517.6470588235

502516.66666666678.33333333330

4020151015

85.71428571437.14285714297.142857142900

11.111111111142.222222222222.22222222226.666666666717.7777777778

46.66666666673.3333333333202010

26.666666666750106.66666666676.6666666667

5.882352941217.647058823529.411764705941.17647058825.8823529412

3.3333333333013.33333333335033.3333333333

43.47826086964.34782608730.434782608717.39130434784.347826087

02.941176470633.823529411820.588235294142.6470588235

5.263157894742.105263157921.052631578915.789473684215.7894736842

TOP 20%

20-40%

40-60%

60-80%

80-100%

Fig.8-Distribution of Districts as per 1 or 2 IFA Tablets regularly - Major States

Sheet2

Sheet3

Prevention of under-nutrition in 0-59 months Nutrition education is the critical interventionExclusive breast feeding for first six months,Appropriate adequate complementary feeding 3-5 times a day from six months of age,Continued breast feeding and feeding family food 4-5 times a day upto 24 months,Feeding 2-5 year old children 4-6 times a day from family food consisting of cereals, pulses and vegetables.Advise regarding timely immunisation, measures to prevent infections, and care during illness and convalescence.

Weighing infants and young children WEIGHING INFANTS AND YOUNG CHILDREN

ZERO ERROR CORRECTED ZERO ERROR CORRECTION SCREW

CHECKING ACCURACY OF THE BALANCE USING STANDARD WEIGHT OF ONE KILO GRAM

WEIGHING THE BABY

DETECTION OF UNDERNUTRITION USING WHO 2006 WEIGHT FOR AGE CHARTS

AWW has marked weight for age on the WHO 2006 standard chart. There are 3 children with severe , 8 children with moderate under-nutrition. Ten children are normally nourished .Assessment of nutritional status of children by plotting weight for age

GROWTH MONITORING

Advantages of serial weight measurement

Normal growth trajectory in children with different birth weight Birth weight is a major determinant of growth in infancy. If serial measurements are not taken child 3 and 4 will be classified as under-nourished; but serial measurements show that they are growing normally according to their trajectory. 1234

Growth faltering detected through serial measurements of weight for age Serial measurements enable early detection of deviation from growth trajectory; correction at this early stage is easy.

Excessive weight gain detected through growth monitoring Serial measurement enable early detection of overnutrition, as soon as the growth deviates from the normal trajectory . Correction at this time is easy .

Are we using the right index for assessing nutritional status in the dual nutrition burden era ?

Data from NNMB surveys indicate that there has been a steady decline in stunting and underweight. As the decline in these indices have been happening at similar rates, there has not been much change in reduction in wasting rates. The lack of decline in wasting rate has not been viewed with concern.

Are we using right indicators to assess under-nutrition Between NFHS 1 and 2 there was substantial reduction in stunting and underweight and some reduction wasting. These were interpreted as improvement in nutritional status of children.In the last five years there had been no decline in underweight rates (NFHS2-NFHS3), stunting rates had shown substantial decline and wasting rates have shown an increase. If the three indices of under-nutrition move in different directions how do we interpret results?

Chart1

5245.538.4

53.44745.9

17.315.519.1

NFHS-1

NFHS-2

NFHS-3

percent

Nutritional status of children in India

time trends-NNMB, NFHS

NNMBNFHS (1992-93)NFHS (1998-99)

1975-791988-901996-972000-01RuralRural

Weight-for-age

Prevalence of under-nutrition in relation to age Between three and twenty four months, there is a progressive increase in stunting and underweight rates.Wasting and low BMI rates are highest in the first three months; this is because stunting rates in the first six months are lower than underweight rates. With the progressive and relatively steeper increase in stunting rates as compared to underweight rates between six and 24 months, the wasting and low BMI rates decline.This decline should not be interpreted as improvement in nutritional status

Chart1

0.2130.2730.3150.328

0.1980.3090.2950.331

0.2590.3450.2910.327

0.320.3660.2890.294

0.4690.4030.2330.184

0.5790.460.2230.164

0.5590.4480.1660.128

0.5440.4580.1550.119

0.5060.4510.1550.117

HT/A

WT/A

WT/HT

BMI/A

AGE GROUP IN MONTHS

PERCENTAGE PREVALENCE

Sheet1

AGE moHT/AWT/AWT/HTBMI/A

0-221.3%27.3%31.5%32.8%

3 TO 519.8%30.9%29.5%33.1%

6 TO 925.9%34.5%29.1%32.7%

10 TO 1132.0%36.6%28.9%29.4%

12 TO 1746.9%40.3%23.3%18.4%

18 TO 2357.9%46.0%22.3%16.4%

24 TO 3555.9%44.8%16.6%12.8%

36 TO 4754.4%45.8%15.5%11.9%

48 TO 5950.6%45.1%15.5%11.7%

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0000

0000

0000

0000

0000

0000

0000

0000

0000

HT/A

WT/A

WT/HT

BMI/A

AGE GROUP IN MONTHS



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There is a socio-economic gradient in prevalence of under-nutrition; however even in the highest income groups (families who had not known food insecurity or lacked access to health care for some generations) about 1/4th are stunted,1/5th underweight but only 10% are wasted .

Chart2

59.954.348.940.825.3

56.649.241.433.619.7

252218.816.612.7

Lowest

Second

Middle

Fourth

Highest

% Prevalence

Nutritional Status of Children vs Wealth Index- NFHS 3

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LowestSecondMiddleFourthHighest

Stunting59.954.348.940.825.3

Underweight56.649.241.433.619.7

Wasting252218.816.612.7

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00000

00000

00000

Lowest

Second

Middle

Fourth

Highest

% Prevalence

Fig. Nutritional Status of Children vs Wealth Index- NFHS 3

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Normal height, weight & BMI Normal height low Wt &low BMIStunted, low wt & normal BMI Stunted , low wt & low BMI

Chronic Energy Deficiency (CED )in children initially leads to wasting. Slow growth is an adaptation to continued CED and child becomes stunted; stunted children have normal BMI. If energy intake is too low even to meet the requirements of stunted children, wasting occurs and the cycle continues..

Normal height, weight & BMI Normal height low Wt &low BMIStunted, low wt & normal BMI Stunted , low wt & low BMI NFHS 2-3 NFHS 1-2

Between NHFS 1 and 2 there was reduction in stunting and wasting . So there was a reduction in stunting , underweight and wastingBetween NFHS 2 and 3 there was reduction in wasted children becoming stunted . So there is a reduction in stunting , not much change in underweight and increase in wasting This the natural process of improvement in nutritional status and should not cause any alarm

Use of BMI for detection of under and over nutrition In India stunting rates in preschool children are very high. Reversal of stunting after the first two years is rare. Many short children with high BMI are classified as underweight.India has entered the dual nutrition burden era.Shifting over to BMI-for-age will enable early detection of both under- and over-nutrition so that appropriate interventions can be initiated.

Nearly half the preschoolchildren are stunted and underweight . However only 1/6th have low BMI for age Among preschool children about 2% have high BMI for age; dual nutrition burden begins right in early childhood

Chart1

4850.11.9

42.557.10.4

19.878.61.5

16.981.21.9

UN

NORMAL

OVERNOURISHED


PERCENT PREVALENCE

Nutritional status of preschool children


diafeverari

0-5 months0.12112.10.12612.60.0686.8

6-11 months0.18418.40.21621.60.0848.4

12-17 months0.15915.90.20920.90.0828.2

18-23 months0.11811.80.17317.30.0666.6

24-29 months0.0969.60.18318.30.0676.7

30-35 months0.0797.90.15150.0535.3

36-41months0.0535.30.13513.50.0535.3

42-47 months0.0515.10.12612.60.0494.9

48-53 months0.0454.50.11511.50.0454.5

54-59 months0.0363.60.1100.0393.9


000

000

000

000

000

000

000

000

000

000

dia

fever

ari

Perecnt Prevalance

Percent Prevalence of Diarrhea, Fever and ARI in different age groups

IFP 1yr


0-21.980.814.51.51.2

3-51.659.223.95.99.4

6-83.928.314.88.644.4

9-116.312.37.5568.9


0-51.868.519.945.9

6-11521.211.6755.3

IFP 1yr

00000

00000

00000

00000

no bf

ebf + water

bf+fluids

fluids+ss

hh foods

age in months

percent


un in ai's

00000

00000

no bf

ebf + water

bf+fluids

fluids+ss

hh foods

Age in Months

Percent Prevalence

Infant feeding Practices

ifpvswt

HT/AWT/AWT/HTBMI/A

UN4842.519.816.9

NORMAL50.157.178.681.2

OVERNOURISHED1.90.41.51.9

HT/AWT/AWT/HTBMI/A

UNNORMALONUNNORMALONUNNORMALONUNNORMALON

0-520.472.76.929.569.5130.365.64.133652

6-1128.667.73.735.564.20.42968.62.531.266.52.2

12-1746.950.72.440.359.40.323.3751.818.478.92.7

18-2357.940.91.24653.80.222.376.61.216.481.32.4

24-295444.31.743.156.50.416.2830.812.785.71.6

30-3557.940.61.546.752.90.417.181.81.112.885.41.7

36-4152.546.5143.456.30.315.583.4112.286.21.7

42-4756.4430.648.251.60.115.583.4111.686.61.8

48-5350.149.10.843.656.10.315.183.61.411.387.11.7

54-5951.248.60.246.653.20.21682.81.112.286.51.2

ifpvswt

000

000

000

000

UN

NORMAL

OVERNOURISHED


PERCENT PREVALENCE

UNDERNUTRITION AND OVERNUTRITION BY VARIOUS INDICES

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000

000

000

000

000

000

000

000

000

000

HT/A UN

HT/A NORMAL

HT/A ON

000

000

000

000

000

000

000

000

000

000

WT/A UN

WT/A NORMAL

WT/A ON

000

000

000

000

000

000

000

000

000

000

WT/HT UN

WT/HT NORMAL

WT/HT ON

000

000

000

000

000

000

000

000

000

000

BMI/A UN

BMI/A NORMAL

BMI/A ON

nbfebfpbf

028.932.335.8

136.137.435.9

246.246.345.4

349.651.652

451.756.657.9

557.161.261.7

659.762.765

768.465.868.5

875.36771.2

974.570.472.4

1076.872.874.4

1177.773.376.4

28.932.335.8

36.137.435.9

46.246.345.4

49.651.652

51.756.657.9

57.161.261.7

59.762.765

68.465.868.5

75.36771.2

74.570.472.4

76.872.874.4

77.773.376.4

nbf

ebf

pbf

age in months

weight 1 decimal

ifp vs weight

nbfebfpbf

0-5mon24.611.213.2

6-11mon18.417.218.8

nbfebfpbf

0-5mon26.212.212.8

6-11mon1820.422.2

ebfpbf

06.610.5

173.9

211.613.2

31212.4

415.815.7

511.913.7

620.622.6

715.419.2

812.719.4

92018.4

1014.515.1

1118.818

ebfpbf

03.3

187.9

29.58.9

312.915.7

417.515.4

518.412.9

62317.9

723.624.3

818.521

97.623.5

102523.1

1120.822

000

000

nbf

ebf

pbf

age

prevalence

diarhea vs ifp

000

000

nbf

ebf

pbf

age

%prevalence

fever vs ifp

00

00

00

00

00

00

00

00

00

00

00

00

ebf

pbf

00

00

00

00

00

00

00

00

00

00

00

00

ebf

pbf

age

prev

fever vs ifp

Nutritional status of school age children

Is there a nutritional rationale for MDM School age children have relatively very low morbidity and morality rates.Growth rates of Indian school age children are comparable to the growth rates of school age children in developed countries. It is assumed that school age children have overcome their earlier nutrition and health problems. Are these assumptions backed by facts?

Chart1

1.11.72.32

1.412.51.8

0.40.50.91.7

0.30.50.62.1

10-14 yr Females

10-14 yr Males

15-19 yr Females

15-19 yr Males

mortality rate

Age specific mortaliy rates of adolescents by sex & age group

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197119811991200120112016

10-14(M)33.8143.1752.4963.5753.9856.70

15-19(M)27.7636.1843.4857.6858.6653.79

10-14(F)31.2439.3746.7559.3451.2353.76

15-19(F)26.0433.1038.7051.3956.4251.08

DAER of infants and children

WHO

DAER(kcal)weight(kg)

3-6 mths7007

6-9 mths8108.5

9-12 mths9509.5

1-2 years115011

2-3 years135013.5

3-5 years155016.5

5-7 years180020.5

7-10 years195027

Boys

10-12220034.5

12-1424004410-14 yr15-19 yr

14-16265055.5FemalesMalesFemalesMales

16-18285064Bangladesh1.101.702.302.00

10-12195036India1.401.002.501.80

12-14210046.5Sri Lanka0.400.500.901.70

14-16215052Thailand0.300.500.602.10

16-18215054

10-14 yrs15-19 yrs

MaleFemaleMaleFemale

Bangladesh6.005.805.505.20

Bhutan6.206.005.705.50

India5.405.105.204.80

Indonesia4.904.704.904.70

Maldives6.205.905.905.60

Myanmar5.305.204.904.90

Nepal6.205.805.505.10

Srilanka4.204.104.404.20

Thailand4.204.104.304.20

Sheet1

33.807927.7565731.2430326.04026

43.1732636.1779239.36933.099

52.4943.4846.7538.7

63.5757.6859.3451.39

53.9858.6651.2356.42

56.753.7953.7651.08

Source: Population projections for India and states, 1971-2016, RGI

10-14(M)

15-19(M)

10-14(F)

15-19(F)

No. in million

Figure: Adolescent population

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0000

0000

0000

0000

Source: Adolescent nutrition: A review of the situation in selected SEA countries, WHO, 2006

10-14 yr Females

10-14 yrs Males

15-19 yr Females

15-19 yrs Males

Figure: Age specific mortaliy rates of adolescents by sex & age group

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In preschool children prevalence of undernutrition is 17% and overnutrition is 2 %.In adults prevalence of under-nutrition is about 30% and over-nutrition is about 10% .There has been a rise in prevalence of both under and over-nutrition between preschool age and adult years.This rise could be prevented/minimised by MDM and physical activity in school age children. Dual nutrition burden increases during school age

Chart1

Preschool children17812

Men34579

Women365213

Undernutrition

Normal

Overnutrition

Nutritional stauts of children and adults-NFHS 3

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Nutritional status of children and adults

Preschool childrenMenWomen

Undernutrition173436

Normal815752

Overnutrition2913

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0000

0000

0000

Undernutrition

Normal

Overnutrition

Nutritional stauts of children and adults-NFHS 3

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Numerous studies in India including NFIs studies in school children in Delhi have shown that while under-nutrition is the problem in children from lower income group over-nutrition is the problem in high income group children.Studies from Delhi cohort have shown that infants with low BMI who gain BMI in childhood become overweight adults, with high risk of non-communicable diseases.

Newer dimensions of dual nutrition burden

Under-nutrition in early childhood mayinfluence their nutrition and health status through out their life span may render them more susceptible to over-nutrition and non communicable disease risk in adult life Does undernutrition in early childhood increase the risk of overnutrition in adult life?

Children belonging to Delhi cohort had low mean birth weight, were undernourished during infancy, childhood and early adolescence; as young adults they had become over weight and had high diabetes and hypertension rates.Long term consequences of LBW and undernutrition

AgeMen Wt (Kg)Women Wt (Kg)At birth8032.895612.792 yrs83410.36099.812 yrs86730.962532.230 yrs88671.864059.2BMI> 2588647.463845.5Central Obesity (%)88665.563931Impaired GTT8491653914

HypertensionDiabetesFATNESS

Data from the Delhi cohort indicate that risk of hypertension and diabetes was higher in adults who gained more weight (mainly body fat) in childhood and adolescence.Early under-nutrition followed by over-nutrition later may predispose to hypertension and diabetes early in adult life .Undernutrition in childhood and risk of NCD in adults

Assessment of nutritional status of children in dual nutrition burden era

Assessment of nutritional status in children and adolescents

Indices used for assessment are Height for age Weight for age and BMI (Weight/Height2 ) for age

Of these weight for age is the most commonly used in all settings Weight/Height2 for age has not yet found wide usage even in teaching hospital settings

In the current phase of ongoing nutrition transition in India and developing countries it is imperative that BMI for age is used for early identification of both under and overnutrition in children

WHO Child Growth Standards 2006, 2007WHO growth standards provide standards for assessment of nutritional status using height, weight and BMI for age in 0-5 year children based on growth of breast fed infants in six countries (MGRS standards ) 5+ to 18 years based on NCHS data base

Children with normal BMI can be normal in height , tall or short. Children with normal BMI do not require nutritional interventions

A third of Indian children are born with low birth weight& length .Over the next two years there is further increase in underweight and stunting rates. After first 2 years reversal of stunting is difficult. About half of Indian children are short by current WHO norms.But there are tall lean children whose wasting is missed if weight for age is used for assessment of nutritional status India has entered dual nutrition burden era; if weight for age is used as the criterion many short children who are overweight for their height will also be missed BMI for age is an index that enables early detection of both under and over nutrition in children because it takes into account the current age, gender, weight and height for assessment of nutritional status It thus provides a method for early detection and correction of both under and over nutrition which is critical in Indian context

Children 1, 2 & 3 have low BMI. Children with low BMI can have normal height , be tall or short . They all require additional energy intake to ensure their linear growth trajectory 1.Normal height 2.Short 3.Tall4Normal height & BMI

All these children have high BMI. Children with high BMI can have normal height , be tall or short They all require adequate physical activity to reach normal BMI

Combating dual nutrition burden in India

Paradigm Shift in Tenth Five Year Plan Tenth Five Year Plan envisaged a paradigm shift from household food security and freedom from hunger to nutrition security for the family and the individual;untargeted food supplementation to screening of all the persons from vulnerable groups, identification of those with various grades of under-nutrition and appropriate management;lack of focused interventions on the prevention of over-nutrition to the promotion of appropriate lifestyles and dietary intakes for the prevention and management of over-nutrition and obesity andvertical programmes to convergence of related sectors to provide integrated comprehensive services to improve nutrition and health statusA beginning has been made in implementation of the paradigm shift

Combating the dual nutrition burden has generally been viewed as a major challenge but in the Indian context it may in fact be an opportunity because

Poverty and household food insecurity are no longer the major determinant of under-nutrition; nutrition education on appropriate IYCF, how to prepare inexpensive balanced diet for the family and health education on how to access needed health care are the key interventions to reduce undernutrition overnutrition rates are still low; Overnutrition can be combated through adequate balanced diet and appropriate exercise regimenCombating dual nutrition burden challenge or opportunity?

Nutrition and health education can be be communicated through all modes of communication As coverage under health and nutrition services are universal, the needed nutrition and health care can be provided by improving the content and quality of health and nutrition services The rational, responsible and responsive population can be expected to utilise the knowledge and access needed services to improve their nutritional and health status

Combating dual nutrition burden challenge or opportunity?

The country should take this opportunity to show case how it can cope with major challenges in health and nutrition sectors effectively within a short period, at an affordable cost

*****************************************************************Standards for BMI have not been available in the past.***********

Prema Ramachandran ASSESSMENT OF NUTRITIONAL STATUS IN CHILDREN Director, Nutrition Foundation of...

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Transcript of Prema Ramachandran ASSESSMENT OF NUTRITIONAL STATUS IN CHILDREN Director, Nutrition Foundation of...