Dual Nutrition Burden in India - Challenges in Achieving Global Targets

Nutrition morbidity interactions in pre-school children

Background & objectives

Research studies in the 1970s reported that in pre-school children, undernutrition increased the risk of infections and infections aggravated undernutrition. Over decades, there has been a reduction in prevalence of undernutrition and improvement in access to healthcare for treatment of infections. A mixed longitudinal study was undertaken to assess whether over time there were any changes from the earlier reported effect of undernutrition prior to infection on the risk of morbidity and effect of morbidity on nutritional status in pre-school children.

Methods

Pre-school (0-59 months of age) children from urban low- and middle-income families whose parents were willing to allow their participation in the study were enrolled. Information on sociodemographic profile of the families was collected at enrolment. Weight of all children and length in infants were recorded every month; length/height in children 12-59 months of age was recorded once in three months. Morbidity information was collected through fortnightly visits.

Results

3888 pre-school children were followed up in 74636 home visits. Among these children, underweight and wasting were associated with a small increase in risk of infections. The odds ratio for risk of infection for underweight children was 1.09 (95% CI: 1.02 to 1.16) and for wasting was 1.18 (95% CI: 1.08 to 1.29). The deterioration in Z scores for weight-for-age and body mass index-for-age in children during illness and convalescence was small but significant (P<0.001).

Interpretation & conclusions

The increased risk of infections in undernourished children living in overcrowded tenements in areas with poor environmental hygiene was not significant, perhaps because the risk of infection in normally nourished children was also high. The deterioration in nutritional status following infection was small because of the ready access to and utilization of health and nutrition care.

Overnutrition in Indian Children: Challenges and Opportunities

Global and Indian data indicate that children from all the segments of population face dual nutrition burden and related health consequences. Long-term cohort studies have shown that both the under- and overnutrition are risk factors for overnutrition and non-communicable diseases in adult life. Halting the rise in overnutrition is one of the Sustainable Development Goal (SDG) targets to be achieved by 2030. With the development and inclusion of body mass index (BMI)-for-age in the WHO child growth standards, it has become possible to assess over- and undernutrition in short-statured children. In India, the Annual Health Survey (AHS) (2014) and the District Level Household Survey 4 (DLHS4) (2013) undertook measurement of height/length and weight (AHS 557016 and DLHS4 295663) in the 0–18-year of school-age children from selected households. Prevalence of overnutrition in 0–18-year children was calculated from these two surveys by using the WHO standards for BMI-for-age (BMI-for-age z scores (BAZ) > +2 in 0–5 and BAZ > +1 in 5–18-year children) as well as uniform norms of either > +1 or > +2 BAZ across 0–18-year children. An attempt was made to explore the policy and program implications of using different norms for assessing overnutrition in preschool and school age children in the Indian context. Body mass index-for-age curve for the 0–18-year Indian children was calculated and compared with the WHO BMI-for-age curve. Across 0–18-year children, the mean BMI-for-age of Indian boys and girls was lower than the mean of the WHO standards, but the trajectory followed was similar. Therefore, Indian high-risk under- and overnourished children can be monitored by using the WHO BMI-for-age curve. Irrespective of the cutoff used for BMI-for-age, prevalence of overnutrition was higher in preschool as compared to school-age children. Overnourished school-age children outnumbered preschool children, especially if the WHO cutoffs were used. The school health system may find it difficult to implement programs that aimed at detection and management of large number of overnourished children. If uniform norm of BAZ > +1 was used, prevalence of overnutrition in preschool children was high and almost similar to undernutrition. Currently, nutrition programs for preschool children are focused on undernutrition and they may find it difficult to manage program focused on overnutrition in large number of children. If the uniform norm of BAZ > +2 was used, both the prevalence of overnutrition and number of children requiring intervention were relatively low in all the age groups. The existing preschool and school nutrition programs can take up an integrated program aimed at early detection and effective management of both the under- (BAZ < −2) and overnutrition (BAZ > +2) in 0–18-year children and strive to achieve the SDG targets.

A Direct Assessment of the External Domain of Food Environments in the National Capital Region of India

Data on food environments in India and other low- and middle-income countries are scarce. The objective of this study was to assess the four dimensions of the external domain of food environments (availability, price, vendor and product properties, and marketing) in food establishments in the National Capital Region of India. The assessment focused on fruits, vegetables, and ultra-processed foods. The 60 food establishments surveyed were categorized as stores, restaurants, or mobile food vendors. Only 13.3% of food establishments sold fruits and vegetables. Stores were more likely to sell vegetables than mobile food vendors (14.8 vs. 6.2%, respectively) and sold a greater variety of both fruits and vegetables as compared to mobile food vendors [mean (SD) of 8.6 (3.2) fruits and 18.6 (9.2) vegetables available at stores vs. 5.5 (5.7) fruits and 25 vegetables available at the one mobile food vendor who sold vegetables]. However, these healthy food items were more expensive at stores. The availability (100% of stores, 12.5% of mobile food vendors, and 12.5% of restaurants) and variety (156 types) of ultra-processed foods across food establishments were higher than fruits and vegetables. A greater percentage of food establishments displayed advertisements for ultra-processed foods as compared to unprocessed or minimally processed foods such as fruits and vegetables. The National Capital Region of India has an unhealthy food environment. Regulations that limit the availability of ultra-processed foods and improve the availability and affordability of fruits and vegetables are needed to reverse the rising tide of chronic non-communicable diseases in this setting.

Lessons From the Aftermaths of Green Revolution on Food System and Health

Food production has seen various advancements globally in developing countries, such as India. One such advancement was the green revolution. Notably, the World Bank applauds the introduction of the green revolution as it reduced the rural poverty in India for a certain time. Despite the success of the green revolution, the World Bank reported that health outcomes have not been improved. During the post-green revolution period, several notable negative impacts arose. Exclusive studies were not conducted on the benefits and harms before the introduction of the green revolution. Some of such interventions deviate from the natural laws of balance and functioning and are unsustainable practices. To avoid the adverse effects of some of these developments, a review of these interventions is necessary.