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

2. Nutrition transition and assessment nutritional status in children
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.

3. Dimensions of dual nutrition burden
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

4. Why focus on nutritional status in early childhood?
Under-nutrition in early childhood will
adversely 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

5. METHODS USED FOR ASSESSMENT OF NUTRITIONAL STATUS IN CHILDREN
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 deficiency
Height and weight measurements
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

6. Dual nutrition burden begins in utero

7. Dual nutrition burden begins in utero
Low birth weight (<2.5kg ) rate in India about 30 %; about 2 % of Indian infants have high birthweight
Low maternal height, low prepregnancy weight , low maternal weight gain and anaemia in pregnancy are major factors associated with low birthweight in India - trans-generational impact of maternal undernutrition
Gestational diabetes with maternal overnutrition predisposes to large for date babies – trans-generational impact of maternal overnutrition
Pregnancy induced hypertension with or without diabetes is emerging as an important obstetric factor predisposing to LBW
Effective antenatal care including treatment for anaemia , PIH & food supplements when needed can reduce LBW by about 5 %

8. Low birth weight – consequences

9. 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%.

10. Year 1967 - Dr Shanti Ghosh’s 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.

11. 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.

12. Birth-weight is a critical determinant of growth
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

13. 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.

14. The thin -fat neonate
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 categories
Indian’s proneness for adiposity begins in utero

15. Infant and young child feeding and nutritional status

16. Infant feeding practices
Semisolid complementary feeds
Household food
Breast milk +other milk
Exclusive breast feeding
Not breast fed
Not breast fed
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 months

17. IYCF - Key for reduction in undernutrition
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.
Nutrition education on appropriate infant feeding is critical to prevent rise in undernutrition rates between 3-11 months

18. How do we improve intra family distribution of food ?
Age groups
Males
Females
Kcals
RDA
% RDA
Pre-school
889
1357
65.5
897
1351
66.4
School Age
1464
1929
75.9
1409
1876
75.1
Adolescents
2065
2441
84.6
1670
1823
91.6
Adults
2226
2425
91.8
1923
1874
102.6
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

19. 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

20. Intra-family dual nutrition burden ( NFHS -3)
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.
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

21. Morbidity due to infections

22. 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.

23. 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

24. Nutritional Status of children by Income
Source: NFHS
Under-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.

25. Nutrition education is the critical intervention
Prevention of under-nutrition in 0-59 months
Nutrition education is the critical intervention
Exclusive 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.

26. WEIGHING INFANTS AND YOUNG CHILDREN

27. ZERO ERROR CORRECTION SCREW
ZERO ERROR CORRECTED
ZERO ERROR CORRECTION SCREW

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

29. WEIGHING THE BABY

30. DETECTION OF UNDERNUTRITION USING WHO 2006 WEIGHT FOR AGE CHARTS

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

32. GROWTH MONITORING

33. Advantages of serial weight measurement

34. Normal growth trajectory in children with different birth weight3 4 1 2
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.

35. 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.

36. 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 .

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

38. 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.

39. 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?

40. 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

41. 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 .

42. Normal height low Wt &low BMI
Normal height, weight & BMI
Normal height low Wt &low BMI
Stunted, low wt & normal BMI
Stunted , low wt & low BMI

43. 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…..

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

45. Between NHFS 1 and 2 there was reduction in stunting and wasting
Between NHFS 1 and 2 there was reduction in stunting and wasting . So there was a reduction in stunting , underweight and wasting
Between 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

46. 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.

47. Nearly half the preschoolchildren are stunted and underweight
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

48. Nutritional status of school age children

49. 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?

50. Dual nutrition burden increases during school age
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.

51. Numerous studies in India including NFI’s 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.

52. Newer dimensions of dual nutrition burden

53. Under-nutrition in early childhood may
Does undernutrition in early childhood increase the risk of overnutrition in adult life?
Under-nutrition in early childhood may
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

54. Long term consequences of LBW and undernutrition
Age
Men
Wt (Kg)
Women
At birth
803
2.89
561
2.79
2 yrs
834
10.3
609
9.8
12 yrs
867
30.9
625
32.2
30 yrs
886
71.8
640
59.2
BMI> 25
47.4
638
45.5
Central Obesity (%)
65.5
639 31
Impaired GTT
849 16
539 14
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.

55. Undernutrition in childhood and risk of NCD in adults
Hypertension
Diabetes F A T N E S
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 .

56. Assessment of nutritional status of children in dual nutrition burden era

57. 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 over- nutrition in children

58. WHO Child Growth Standards 2006, 2007
WHO 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

64. Standards for BMI have not been available in the past.64

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

67. 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

68. 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
4Normal height & BMI
1.Normal height
2.Short
3.Tall

69. All these children have high 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

70. Combating dual nutrition burden in India

71. 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 and
vertical programmes to convergence of related sectors to provide integrated comprehensive services to improve nutrition and health status
A beginning has been made in implementation of the paradigm shift

72. Combating dual nutrition burden – challenge or opportunity?
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 regimen

73. Combating 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

74. 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

75. THANK YOU