Understanding The Depth Of Child Malnutrition In India

“181 million children are not having the equal opportunity to grow, develop, and learn to their full potential. They risk falling into a cycle of malnutrition and poverty that will have consequences for them today and into the future; for their children and for generations to come.” - Catherine Russell,  UNICEF Executive Director 

Key Facts:

• Nearly 181 million children under 5 years of age live in severe food poverty, with India, China, Bangladesh, Afghanistan, and Pakistan accounting for 66% of the cases - UNICEF Child Food Poverty Report, 2024

• Worldwide, 1 out of every 4 children is affected by severe food poverty - UNICEF Press Release, 2024

• Globally, in 2022, an estimated 149 million children were stunted, 45 million were wasted and 37 million children were overweight/obese; all under the age of 5 - WHO Malnutrition Fact Sheet

• As many as half of the deaths in children below 5 years of age are a result of undernutrition and the majority of the cases come from low and middle-income countries - UNICEF DATA on Malnutrition In Children

Jauhar, my 38-year-old domestic worker, lives in the slum area near Banjara Market, Gurgaon. She often speaks fondly of her daughter and three-year-old grandson. A few days back, as I was working on this article, I talked to her and asked her what they feed the child and she shared “Maa ka doodh hee peeta hai waise to. Jo hum khaate hai khaa leta hai” (He drinks his mother’s milk mostly and eats whatever we eat). She further told me that they used infant cereal once or twice but it was very expensive. “Utne mai to sab ka khana hojayega didi. Gareeb aadmi kya kare”. Jauhar's situation is a common one faced by many families living in poverty. Her limited resources make it difficult to provide her grandson with a balanced and nutritious diet. 

Proper and adequate nutrition is the cornerstone of a child’s growth and well-being, which provides them with the nourishment to grow into healthy adults. It is the key factor that allows children to thrive and survive and the impact is both significant and enduring. Children need the right nutrition at every stage of their development as it enables them to grow, learn, play, develop, and thrive. Lack of proper nutrition in the early stage of life can increase the child’s susceptibility to various diseases and ailments, often resulting in stunted growth and decreased productivity. This is commonly termed ‘Malnutrition’. Emphasis is not only placed on ensuring regular meals but balanced and nutritious meals that support the optimal development and growth of children. 

Understanding The Meaning Of Malnutrition

The term "malnutrition" carries a deeper connotation beyond its literal definition of "bad nutrition. Often interchangeably used with undernutrition, it encompasses a wider range of problems, triggered by the insufficient, excessive, or imbalanced intake of nutrients. The problem can manifest in different ways, such as undernutrition (wasting, stunting, underweight, inadequate vitamins or minerals), obesity, and associated noncommunicable diseases. Proper and balanced nutrition is crucial for children as it impacts their overall well-being, development, and growth. Malnutrition in children below the age of 5 years, continues to be a grave concern in many low and middle-income countries as it has been and still continues to be the major cause of child mortality in these countries. 

We spoke with experts to get a better understanding of the frequency of malnutrition in Indian children between the ages of 0 and 5.

According to Dietitian & Nutritionist Rachel Deepthi, Msc RD IYCF (Lifestyle, Maternal & Child Expert), “nutritional deficiencies and malnutrition among children under the age of five are prevalent, particularly in developing nations such as India. Paediatricians and healthcare providers often come across instances of undernutrition, stunted growth, and deficiencies in essential micronutrients like iron, vitamin A, and zinc. The frequency of these cases can differ based on geographic location, socioeconomic factors, and healthcare accessibility, but it is not uncommon for practitioners in certain regions, especially in rural and underserved areas, to encounter one or two cases weekly.”

Expert Paediatrician Dr. Janardhan Reddy shared, “In paediatric practice, it's quite common to see children under the age of five presenting with some form of malnutrition or nutrient deficiency. The frequency of these cases can vary, depending on factors such as the child's environment, socioeconomic status, and the availability of healthcare services. In more resource-limited or rural areas, the incidence is typically higher. Even in urban settings, though less frequent, cases still arise, underscoring the widespread nature of this issue across different communities in India. In the urban corporate setup I practise, I see on an average 3 in 10 children malnourished.”

UNICEF’s Concept Of Child Food Poverty

The concept of child food poverty was introduced by UNICEF to stress the importance of addressing dietary deprivation and poor-quality diets in early childhood as a key focus in achieving the nutrition-related goals of attaining Sustainable Development[1]. Child food poverty has been defined as “children’s inability to access and consume a nutritious and diverse diet in early childhood (i.e., the first five years of life).”

Nearly 181 million children under 5 years of age live in severe food poverty, with India, China, Bangladesh, Afghanistan, and Pakistan accounting for 66% of the cases.

According to Catherine Russell, UNICEF Executive Director, “One in four children today is living in severe food poverty. This means that they are surviving on one or two food groups a day, and on some days even less”

Types Of Malnutrition

• Wasting - It means that a person has low weight-for-height or, simply, the person weighs lower than what is expected for their height. This is generally seen in people who have had drastic weight loss owing to an underlying illness or lack of food. In kids, moderate to severe wasting has been linked with increased mortality, however the problem can be managed. As per the 2023 Global Hunger Index (GHI), India ranks 1st among the countries with the highest child-wasting rate in the world, at 18.7%

Graph taken from the Global Hunger Index[3]

• Stunting - It means that a person has low height for age or simply the person’s height is lower than what is expected for their age. The problem has been linked with persistent or recurrent lack of proper nutrition, due to factors like poverty, inadequate maternal health/nutrition, frequent illness, and suboptimal feeding and care during the early years of life. Stunting can negatively impact a child’s physical and cognitive development. According to the 2023 Global Hunger Index (GHI), India ranks 15th in the list of countries with the highest stunting rate, at 35.5%.

• Underweight - It means that a person has low weight for their age, or simply the person’s weight is lower than what is expected for their age. Underweight children may present with both wasting and stunting. Underweight children are often at risk of developing health complications like anaemia, osteoporosis, impaired growth and fatigue. 

• Micronutrient deficiencies (Undernourishment) - These refer to the deficiencies that result from the inadequate intake of essential micronutrients which are crucial for the production of important enzymes, hormones and other important life processes. Three of the most common micronutrient deficiencies have been linked to iodine, vitamin A and iron [2]. The prevalence of undernourishment in India is around 16.6% as per the 2023 Global Hunger Index (GHI). 

• Overweight/Obesity - It means that a person has high weight for height or simply the person has more weight than what is expected for their height. Weight gain is a result of abnormal fat accumulation in the body which has been linked to consumption of energy-dense foods and drinks. 

Child Malnutrition In India

Malnutrition is a serious health problem seen in developing countries like India. It happens to be one of the leading causes of child mortality and morbidity. The impact of child malnutrition can last for years and may even be permanent. Millions of children in India suffer from malnutrition and do not have access to proper and nutritious meals and either end up eating too little or too much. While the former is considered to be a serious issue, some may wonder how eating too much is a problem. It is because, despite getting adequate food, they lack important macro and micronutrients, quality as well as diversity. 

What Are The Primary Causes Of Malnutrition/Undernutrition In India?

The leading cause of malnutrition in India is poverty. People are not able to purchase the right quality and quantity of food. Eating less means that they do not have enough energy and as such are incapable of doing physical work, which in turn affects their earning capacity. Again, low income means less food and this results in a vicious cycle. A lot of people lack awareness when it comes to proper nutrition and balanced meals. Irrational beliefs and myths related to nutrition still persist in many parts of the country. This problem is commonly seen in the lower strata of the population.

Dietitian & Nutritionist Rachel Deepthi explains Malnutrition and undernutrition in India arise from a variety of interrelated factors, encompassing socio-economic, cultural, and environmental dimensions. Major elements contributing to this issue include poverty, food scarcity, insufficient access to clean water and sanitation facilities, and poor maternal nutrition during pregnancy. Cultural norms and a lack of knowledge regarding appropriate feeding practices for infants and young children significantly influence the situation as well. Moreover, the prevalence of frequent infections and illnesses in children, including diarrhoea and respiratory infections, worsens malnutrition by hindering nutrient absorption and elevating metabolic demands.

How To Address The Primary Causes Of Malnutrition? 

“Tackling malnutrition necessitates a comprehensive strategy. Key actions include enhancing maternal health and nutrition, advocating for exclusive breastfeeding during the initial six months, and informing parents about the significance of a balanced diet for their children. Essential public health initiatives encompass immunisation campaigns, the distribution of fortified foods, and guaranteeing access to clean water and sanitation. Furthermore, bolstering healthcare systems to detect and address malnutrition promptly, along with implementing targeted supplementary nutrition programs, can lead to substantial improvements. It is crucial for governments, NGOs, and communities to collaborate in order to develop sustainable solutions.” - Ms. Rachel Deepthi 

Dr. Janardhan Reddy laid emphasis on the following points: 

• Education: Increase awareness about the importance of balanced diets and proper feeding practices through community programs and health education.

• Improved Healthcare Access: Ensure that all children have access to regular health check-ups and growth monitoring, with nutritional supplements provided when necessary.

• Government Support: Implement and strengthen programs that provide food assistance and nutritional support to low-income families, and improve maternal healthcare services.

• Community Involvement: Engage local communities, especially mothers, by providing them with the knowledge and tools needed to improve their children's nutrition.”

We asked some mothers if they know whether their child is getting the right nutrition or not. While 75% said yes, 25% were not sure. 

One of the mother’s shared, “ My baby has a set menu for the week but some meals are skipped on certain days.”. While 75% of the moms consulted a Paediatrician to plan their baby’s meals, 12.5% resorted to specifically Paediatric Nutritionist and 12.5% depended on online research. 

Can A Child’s Malnutrition Be Linked To Mother’s Nutrition During Pregnancy?

Malnutrition can have its roots in a mother's pregnancy and can be inherited by future generations. Maternal suboptimal nutrition is a major factor influencing child malnutrition. We spoke with Dr. Sabina Nazir, a Senior Gynaecologist at JLNM Hospital, about this issue. She explained, “If the mother does not eat properly and her nutritional requirements are not met, the baby born will be IUGR (Intrauterine growth restriction) baby. Such babies are at a higher risk of being malnourished and hence require good nutrition after birth to ensure proper growth. However, in the lower strata of the society, it is difficult to cater to the normal nutritional needs, let alone the extra ones.”
Dr. Sabina further emphasised that a mother's nutrition directly affects her baby's health. “ Of course, the mother’s nutrition definitely affects the baby born. If she has iron deficiency, the baby can have problems too, if she has calcium deficiency, the baby will have weak bones. One of the reasons for malnutrition is IUGR and when the mother's nutrition is not good, she is susceptible to several other complications as well. She can go into preterm labour, so the baby born will be preterm with a low birth weight. The growth chart of such babies is often slow and if such babies belong to lower strata, the chances of being malnutrition are even higher. IUGR babies may have other complications like Kwashiorkor and Marasmus". 

UNICEF Maternal Nutrition Report

According to UNICEF Maternal Nutrition Report, “During pregnancy, poor diets lacking in key nutrients – like iodine, iron, folate, calcium and zinc – can cause anaemia, pre-eclampsia, haemorrhage and death in mothers. They can also lead to stillbirth, low birthweight, wasting and developmental delays for children. UNICEF estimates that low birthweight affects more than 20 million newborns every year. Improving women’s diets, access to nutrition services, and nutrition and care practices – before and during pregnancy and while breastfeeding – is critical to preventing malnutrition in all its forms. This is particularly true for the most vulnerable mothers and babies.”

The JAMA Report Controversy 

Early this year a study was published in the peer reviewed JAMA Network Open journal which emphasised on the importance of introducing solid and semi solid foods in children along with breastmilk and highlighted the problem of extreme food deprivation in India by highlighting the prevalence of ‘zero-food children’ in the country. For research purposes, UNICEF has defined  ‘zero-food children’ as “children aged 6 to 23 months who did not consume animal milk, formula, or solid or semisolid food during the last 24 hours.”

As per the study, “The prevalence of zero-food children was particularly high in West and Central Africa, where the overall prevalence was 10.5% (95% CI, 10.1%-11.0%), and in India, where the prevalence was 19.3% (95% CI, 18.9%-19.8%). India accounted for almost half of zero-food children in this study.”

The Ministry of Women and Child Development, in response to this, issued a press release, stating that the article published by JAMA News Network was fake based on several grounds, questioning the methodology that was followed and highlighting the fact that JAMA article did not “acknowledge importance of breast milk for infants. who are more than six months old and has instead looked at only the feeding of such infants with animal milk/formula, solids or semi-solids etc”

The Ministry further claimed that the report was prepared without referring to the data available on Poshan tracker and taking into account the effectiveness of Poshan 2.0 mission in lowering the prevalence of problems like stunting, wasting and underweight, which was acknowledged by the World Bank. 

What Is Poshan 2.0?

POSHAN 2.0 (Prime Minister's Overarching Scheme for Holistic Nourishment) is a flagship nutrition programme introduced by the Government of India to uphold its commitment towards prioritising the well being of small children, pregnant women and lactating women. Poshan 2.0 is also one of the world’s largest programmes for Early Childhood Care and Development. This encompasses 3 main programmes, Anganwadi Service Schemes, Poshan Abhiyan and SAG (Scheme for adolescent girls). 

Anganwadi Service Schemes focus on providing supplementary nutrition, nutrition, education and health education. Poshan Abhiyaan focuses on holistic nourishment of children, adolescent girls, pregnant women and lactating mothers.

The Ministry of Women and Child Development also rolled out the Poshan Tracker on 1st March 2021. The mobile application helps to monitor the nutritional intake and growth of the children in India in real time. 

What Are Some Common Dietary Mistakes Parents Make, And How Can They Be Prevented?

Ms. Rachel Deepthi shared “Frequent dietary errors consist of an overdependence on processed and packaged items, high sugar consumption, and a lack of adequate fruits, vegetables, and whole grains in the diet. Additionally, some parents may postpone the introduction of diverse foods during the weaning food phase, which can contribute to the development of selective eating behaviours. To mitigate these issues, parents should prioritise providing a wide variety of foods, promote healthy eating practices from a young age, and pay attention to portion control. Engaging children in the meal planning and cooking process can also help cultivate a favourable perspective on nutritious eating. Working parents must take 10 mins time everyday to pre-plan for the next day's meal.”

When asked about the current dietary guidelines for children, Ms. Rachel Deepthi shared “The existing dietary recommendations for children highlight the necessity of a well balanced diet that incorporates a diverse range of foods to guarantee sufficient consumption of all vital nutrients. For infants under the age of two, breastfeeding is advised, accompanied by suitable complementary foods. For children beyond this age, a diet abundant in fruits, vegetables, whole grains, protein sources such as legumes, eggs, and lean meats, as well as dairy products, is suggested. It is essential to restrict the intake of sugar, salt, and unhealthy fats. Additionally, regular physical activity is advocated to enhance overall health.”

Are There Any New Trends Or Recent Discoveries In Child Nutrition That Parents Should Know About?

“Yes, there are a few emerging trends and new findings in child nutrition that parents should be aware of” shared Dr. Janardhan Reddy. "These are:

• Personalized Nutrition:here's a growing focus on tailoring diets to the individual needs of each child, recognizing that every child has unique nutritional requirements.

• Gut Health: The importance of gut health is gaining attention, with probiotics and prebiotics being recommended to support a healthy digestive system, which plays a crucial role in overall well-being.

• Plant-Based Diets:More parents are exploring plant-based diets for their children. While these diets can be healthy, it's important to ensure they are well-balanced and provide all the necessary nutrients.

• Technology in Nutrition: Digital tools and apps are becoming popular for tracking dietary habits and providing guidance on child nutrition, making it easier for parents to monitor and adjust their children's diets."

Staying informed about these trends can help parents make better decisions regarding their children's nutrition.

What Can Be The Biggest Challenges Or Changes In Child Nutrition In The Coming Years?

“A significant challenge in child nutrition is tackling the dual issue of malnutrition, characterised by the simultaneous presence of undernutrition and obesity within the same demographic. As lifestyles evolve and processed foods gain greater availability, the incidence of childhood obesity is increasing, even in areas where undernutrition has traditionally been a concern. Additionally, ensuring food security and access to nutritious options amid climate change and economic fluctuations presents another hurdle. It will be essential to adjust dietary guidelines to meet these changing circumstances while continuing to foster education and awareness to effectively address the future of child nutrition” shared Ms. Rachel Deepthi

Management Of Malnutrition

For Mild Malnutrition: 

Promote a balanced diet with increased energy and protein-rich foods, including fruits, vegetables, and dairy products. In our survey, we found that half of the mothers prioritised only nutritional value, while the other half focussed on the quantity as well. 

For Moderate to Severe Malnutrition: 

Implement therapeutic feeding programs with ready-to-use therapeutic foods (RUTFs) or therapeutic milk. Include frequent feeding with energy-dense, nutrient-rich foods.

Micronutrient Supplementation: Provide supplements for deficiencies, such as Vitamin A, iron, and zinc, as per the child's specific needs.

Breastfeeding:

Exclusive Breastfeeding: Continue exclusive breastfeeding for the first six months.

While 75% of moms in our survey were breastfeeding, 25% were not able to, owing to underlying medical issues. 

Complementary Feeding: 

Start introducing complementary foods at around six months of age, ensuring they are nutrient-dense and appropriate for the child’s developmental stage. 4 out of 8 moms in our survey introduced complementary foods at 6 months while the other 2 did it earlier, at 3.5 months and 0 months respectively. 

Monitoring and Follow-Up:

Frequent follow-ups to monitor growth and dietary intake, and adjust feeding plans as needed along with education to caregivers on proper feeding practices, hygiene, and recognizing signs of worsening malnutrition.

Addressing Underlying Causes:

Improve sanitation and hygiene practices to prevent infections that can exacerbate malnutrition. Ensure timely access to healthcare services for early detection and treatment of illnesses that can affect nutritional status.

Sources 

1. https://data.unicef.org/resources/child-food-poverty-report-2024/ 

2. https://www.who.int/news-room/fact-sheets/detail/malnutrition?

3. https://www.globalhungerindex.org/trends.

4. https://wcd.gov.in/pregnant-lactating-women-children/nutrition-mission-saksham-anganwadi-and-poshan-2-0

5. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4367032/

6. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7906302/ 

Expert Inputs 

• Rachel Deepthi Msc RD IYCF, Registered Dietitian & Nutritionist (Lifestyle, Maternal & Child Expert)

• Dr. Sabina Nazir, Senior Gynaecologist, JLNM Hospital 

• Dr. Janardhan Reddy, Expert Paediatrician

Note: We conducted a survey in which some moms (with children below 5 years of age) participated. All the mothers came from upper and lower middle-class families.