Magnitude of multiple micro-nutrient malnutrition among the rural children in India DR. N.ARLAPPA MD Division of Community Studies National Institute of Nutrition (NIN) Indian Council of Medical Research (ICMR) Hyderabad- India

In spite of the green revolution and implementation of several national nutrition programmes for more than 3 decades, the prevalence of undernutrition continues to be a major public health nutrition problem in India. All most all the age and physiological groups in general, and under five and school-age children in particular, are most vulnerable to malnutrition. Globally, India has the highest percent of underweight and stunted children. 45% of child deaths were attributable to malnutrition (WHO -2015) The under-five mortality rate (U5MR) in India (1 in 21) is about 7 times higher than in high-income countries (1 in 147). 1 in 5 global under five deaths took place in India in 2015 (20% of the global deaths) - corresponding to 1.2 million children (Lancet-2015).

However, in comparison to 126 deaths per 1,000 live births (3 However, in comparison to 126 deaths per 1,000 live births (3.4 million) in 1990, the U5MR in India dropped to 48 per 1,000 live births (1.2 million) in 2015 (reduction is 62%). The burden of hidden hunger i.e. multiple micro-nutrient malnutrition among the children of under five and school-age (7-12 years) children is a major nutritional problem of public health concern in India. The adverse consequences of hidden huger include decreased immunity, mental impairment, poor health, low productivity, and even death.  Its adverse effects on child health and survival are particularly acute, especially within the first 1,000 days of a child’s life, resulting in serious physical and cognitive consequences.  It is also burden on out-of pocket health expenditure among the rural households as well as on national economy.

Objective The objective of this communication is to assess the magnitude of multiple-micro-nutrient malnutrition among the rural pre-school and school-age children in India.

Materials and Methods A community based cross-sectional study adopting multi-stage random sampling procedure was carried out by the National Nutrition Monitoring Bureau (NNMB) during 2011-12 . The study was carried out in rural areas of 10 major states constituting two-thirds geographical area of India. A one-day 24-hour recall diet survey was carried out in 11,910 households, from 1195 villages (@ 120 villages per State) A total of 12,004 (1-6 years: 5,810 and 7-12 years: 6,194) rural children were covered for Diet Survey. Similarly, a total of 16,599 (1-5 years: 9,038 and 6-12 years: 7,561) rural children were covered for Anthropometry. Anthropometric measures such as length (Infanto-meter)/height (anthropometric rod) and weight (SECA Digital weighing scale) of all children were recorded adopting standard procedures.

The median intakes of nutrients were calculated and compared them with the Recommended Dietary Allowances (RDAs) for Indians . The deficit intake of each nutrient (Against their RDAs) and Adequacy (consumption ≥ 70% of RDA) status of various nutrients were assessed. Prevalence of underweight (weight for age< Median – 2SD) and stunting (height for age < Median – 2SD) was calculated for under 5 children (WHO). Body Mass Index (BMI)-Z Scores were calculated for 6-12 year children (WHO) . Study was approved by Indian Council of Medical Research (ICMR) Scientific Advisory Committee. Ethical clearance was obtained from the Institute’s Ethic Review Board. Written informed consent was obtained from parents of all children.

Table 1: Distribution (%) of 1-3 year children by median and deficit (against RDAs) intakes of nutrients Nutrients Median RDA <RDA ≥ 70% RDA Deficit Protein (g) 19.7 16.7 38.3 78.4 No deficit Total fat (g) 11.8 27.0 87.8 28.2 -56.3 Energy (Kcal) 733 1060 80.2 49.0 -30.9 Calcium (mg) 166 600 92.5 15.5 -72.3 Iron (mg) 4.7 9 81.2 34.8 -47.8 Vitamin A (µg) 61 400 92.2 -84.8 Thiamine (mg) 0.5 47.2 66.5 0.0 Riboflavin (mg) 0.3 0.6 78.5 32.8 -50.0 Niacin (mg) 4.8 8 81.3 39.6 -40.0 Vitamin C (mg) 40 91.5 14.6 -77.5 Folic acid(µg) 48.1 80 99.4 41.4 -39.9

Table 2: Distribution (%) of 4-6 year children by median and deficit (against RDAs) intakes of nutrients Nutrients Median RDA <RDA ≥ 70% RDA Deficit Protein (g) 27.9 20.1 24.7 91.4 No deficit Total fat (g) 15.0 25 78.8 39.8 -40.0 Energy (Kcal) 1033 1350 78.2 59.7 -23.5 Calcium (mg) 198 600 92.3 16.4 -67.0 Iron (mg) 7.2 13 79.9 36.6 -44.6 Vitamin A (µg) 74 400 90.5 13.7 -81.5 Thiamin (mg) 0.7 45.2 76.6 0.0 Riboflavin (mg) 0.4 0.8 83.5 34.4 -50.0 Niacin (mg) 7.6 11 78.9 48.1 -30.1 Vitamin C (mg) 15 40 83.6 26.6 -85.0 Folic acid(µg) 71.9 100 99.6 51.3 -28.1

Table 3: Distribution (%) of 7-9 year children by median and deficit (against RDAs) intakes of nutrients Nutrients Median RDA <RDA ≥ 70% RDA Deficit Protein (g) 33.4 29.5 38.1 86.0 No deficit Total fat (g) 17.1 30 82.7 36.6 -43.0 Energy (Kcal) 1241 1690 82.4 55.8 -26.6 Calcium (mg) 226 600 91.9 18.6 -62.3 Iron (mg) 8.6 16 81.5 35.4 -46.25 Vitamin A (µg) 79 93.6 9.3 -86.8 Thiamin (mg) 0.8 42.5 77.4 0.0 Riboflavin (mg) 0.5 1 89.0 23.2 -50.0 Niacin (mg) 9.4 13 77.7 51.9 -27.7 Vitamin C (mg) 19 40 78.9 32.6 -52.5 Folic acid(µg) 86.9 120 99.9 52.3 -27.6

Table 4: Distribution (%) of 10-12 year Boys by median and deficit (against RDAs) intakes of nutrients Nutrients Median RDA <RDA ≥70 % RDA Deficit Protein (g) 37.4 39.9 55.8 74.1 -6.3 Total fat (g) 18.1 35 85.6 31.4 -48.3 Energy (Kcal) 1405 2190 92.4 40.7 -35.8 Calcium (mg) 248 800 96.4 11.2 -59.0 Iron (mg) 9.8 21 87.4 27.8 -53.3 Vitamin A (µg) 87 600 91.9 11.0 -85.5 Thiamin (mg) 0.9 1.1 58.5 66.7 -18.2 Riboflavin (mg) 0.6 1.3 95.6 14.0 -53.9 Niacin (mg) 10.8 15 77.9 52.2 -28.0 Vitamin C (mg) 22 40 73.9 38.5 -45.0 Folic acid(µg) 95.2 140 99.8 47.8 -32.0

Table 5: Distribution (%) of 10-12 year Girls by median and deficit (against RDAs) intakes of nutrients Nutrients Median RDA <RDA ≥70% RDA Deficit Protein (g) 35.1 40.4 61.6 68.4 -13.1 Total fat (g) 17 35 87.4 27.0 -51.4 Energy (Kcal) 1330 2010 88.3 43.1 -33.8 Calcium (mg) 230 800 96.6 10.5 -71.3 Iron (mg) 9.3 27 95.6 13.6 -65.6 Vitamin A (µg) 81 600 92.6 10.3 -86.5 Thiamin (mg) 0.9 1 55.4 63.3 -10.0 Riboflavin (mg) 0.5 1.2 94.6 17.9 -58.3 Niacin (mg) 13 70.6 59.6 -20.8 Vitamin C (mg) 21 40 76.0 36.3 -47.5 Folic acid(µg) 92.2 140 99.8 45.5 -34.1

Table 6: Distribution (%) of 7-12 year children (boys &girls) by median and deficit (against RDAs) intakes of nutrients Nutrients Median RDA <RDA ≥70 % RDA Deficit Protein (g) 34.9 35.1 48.8 78.3 -0.6 Total fat (g) 17 33 84.7 32.8 -48.5 Energy (Kcal) 1307 1905 86.6 48.5 -31.4 Calcium (mg) 233 704 94.3 14.6 -66.9 Iron (mg) 9.1 20.1 86.7 27.8 -54.7 Vitamin A (µg) 82 600 92.9 10.0 -86.3 Thiamin (mg) 0.9 50.1 71.0 0.0 Riboflavin (mg) 0.5 1.1 92.2 19.4 -54.5 Niacin (mg) 13.5 75.9 53.9 -25.9 Vitamin C (mg) 20 40 76.8 -50.0 Folic acid(µg) 90.5 130.4 99.8 49.4 -30.6

Proportion (%) of 1-3 year children by consumption of nutrients < 50% of RDA

Proportion (%) of 4-6 year children by consumption of nutrients < 50% of RDA

Prevalence (%) of underweight (Weight for Age <Med-2 SD) among under 5 year children by states

Prevalence (%) of Stunting (Height for Age <Med-2 SD) among under 5 year children by States

Conclusions In general, the rural children in India were subsisting on inadequate diets with deficit in multiple micronutrients. The intakes of vitamin A, vitamin C, riboflavin, iron, calcium and total fat were grossly deficit as against their RDAs. Similarly, the proportion of children not meeting even 50% of their RDs was very high with respect to vitamin A, vitamin C, riboflavin, iron, calcium. The poor diet is reflected in high prevalence of underweight and stunting among under 5 year children and about 41% of thinness among school age children. In general, the prevalence of undernutrition was significantly higher among the children belonged to marginalized communities, illiterate parents, labourer parents , those residing in HHs where family income was low and HHs with no electricity and sanitary latrine.

Recommendations Appropriate nutrition interventions to be initiated for rural children to meet the suggested levels of all micronutrients. Government should strengthen the existing supplementary feeding programmes : ICDS supplementary feeding programme and Mid-Day Meal (School lunch) programme. Government should provide employment and fix minimum wages for agricultural and non- agricultural labours and control the prices of food commodities to improve purchasing power of poor. Health and nutrition education to be imparted to the rural communities to increase the utilization of Govt nutrition programmes. Strengthening of Public Distribution System (PDS) by inclusion of more food commodities. Employment guarantee to rural poor. Women empowerment, female literacy and equal wages for both genders. All these interventions would facilitate food and nutrition security and minimize the hidden hunger among the rural children to meet the New Sustainable Development Goals (SDGs) of NO POVERTY and ZERO HUNGER.

Acknowledgements I wish to thank DG, ICMR and Director, NIN for giving me the opportunity to attend this conference. I am also very grateful to SIGHT and LIFE and Dr. Klaus Kraemer for the TRAVEL GRANT. I also wish to thank Field Staff of NNMB state units and staff of Division of Community Studies, NIN.