Introduction

Malnutrition, as WHO defines, refers to the deficiencies or excesses in nutrition intake, essential nutrient imbalances or nutrition utilization impairment. (1)

The key outcomes that help us assess the impact of nutritional interventions are:

• Stunting

• Wasting

•  Underweight

• Anaemia

• Low-Birth weight

According to the WHO Child Growth standards, Underweight (low-weight-for-age) is categorized as Moderate underweight (MUW) and Severe Underweight (SUW) and Wasting (low-weight-for-height) as Moderate Acute Malnutrition (MAM) and Severe Acute Malnutrition (SAM) based on Z-scores.

According to a Joint report by WHO, UNICEF and World Bank in 2022 on trends of child malnutrition, 22.3% were found to be stunted while 6.5% were wasted among the under-five children. (2) The rates of stunting and wasting in India are higher than the average of all the Asian countries.(3)  As per NFHS-5, among the under five children 35.5% are stunted, 19.3% are wasted, while 32.1% are underweight. (4) The Sustainable Development Goal (SDG) 2.2 has been framed with an aim to have all children free from malnutrition in any form. Recognizing the impact of undernutrition on childhood morbidity and mortality and its contribution to chronic illnesses in adulthood, the United Nations (UN) General Assembly declared 2016 to 2025 as the UN Decade of Action on Nutrition. (5) Despite global and national commitments, there have been modest improvements in nutrition indicators over the last few years.

Evolution of nutrition management in India

Nutritional management of malnutrition has evolved over the years. With its initial focus on protein-deficiency and energy-deficiency, to its focus on type I and type II nutrient deficiency, years of extensive biochemical, clinical and population-level research have led to the development of standardized nutritional requirements for management of different stages of malnutrition. It took decades to convert research findings to policy changes as present guidelines of management of malnutrition. The road from policy to action continues. (6)

Fig 1. Evolution of Policy actions to address Nutrition (7)

 Management of severe acute malnutrition (SAM) is one of the recommendations for addressing wasting under the Poshan Abhiyaan. (8)

Facility-based Management of SAM

It began as an innovative scheme of Nutritional Rehabilitation Centres (NRCs) in Madhya Pradesh and was gradually scaled up. (9)The grass root healthcare workers ( ASHAs and AWWs) actively identify the SAM children during Home based newborn and young child care visits, vaccination and weight monitoring at Anganwadi or at schools and refer them to the nearest health centres where they are screened and referred to NRCs. Children are admitted for medical and nutritional care based on certain criteria.

In spite of the progress that the country has made, the challenge of managing malnutrition lies in its multifactorial causation resulting from the complex interaction of multiple systems.

Fig - 2. Determinants of Undernutrition (Ref: UNICEF conceptual framework)

We tried to identify certain aspects of the challenges, understanding the perspectives of the stakeholders in this article.

A narrative analysis of perspectives of mothers of malnourished children and community health workers in an urban poor community in Delhi.- (insights from field visit)

As is evident from the narratives, there is a gap in the caregiver’s perception and the actual status of nutrition of the children. Qualitative studies have found that if the child is eating and thriving well, some caregivers assume this as an indicator of their child’s nutritional status. Those who perceive their child to be thin or “skinny”, they don't consider it important enough to seek a healthcare provider or worker’s support. (10,11)

The health-seeking behavior is affected by the caregiver’s perceived need, mother’s educational status, family income, birth order of child among many others. (6)

Attempts to improve the health-seeking behavior have been made through various nutrition education programs in India. The National Nutrition Mission and POSHAN Abhiyaan 2.0 focuses on Behavior Change Communication using educational messages, provided either through group or as mass media.

Behavior change needs more than delivery of nutrition education messages. It requires evidence and research-based means of communication to have a sustained effect in the form of actual change in actions and habit formation. Counselling is one such evidence-based communication method.

The major issue lies with the mode of communication to the beneficiaries and lack of proper monitoring and supervision within our healthcare system. Although the Mother’s Absolute Affection (MAA) program and Reproductive, Maternal, Newborn, Child and Adolescent Health + Nutrition (RMNCHA+N) focuses on counselling as an important strategy for behavior change, availability of trained IYCF counsellors is limited to a few states. The community health workers (ASHAs and ANMs) are trained in counselling. But with the increasing workload, the quality of the service provided, including counselling, is affected.

During field visits, it was observed that unwillingness to seek care, upon being advised to visit the NRC, was also related to

●      previous experiences in health care facility  

●      loss of wages on missing a day at work

Such reasons increase the gaps to access healthcare among those most vulnerable to malnutrition- adding further to the inequalities in accessing healthcare services.

With the current standards, a very small proportion of the SAM children are being managed effectively.

Current updates in management of malnutrition (Community-based management of SAM)

Through evidenced based research, some states and districts have developed their own innovative approaches towards prevention of malnutrition. Community-based management of acute malnutrition has developed into a common theme that holds potential in addressing the issue of the gaps to management of acute malnutrition.

In October 2023, the Ministry of Women and Child Development, launched the ‘PROTOCOL FOR ASSESSMENT AND MANAGEMENT OF MALNUTRITION IN CHILDREN’. It emerges as a solution to some of the above discussed challenges. The figure below depicts the steps for community-based management of malnutrition.

*Children to be enrolled under Supplementary Nutrition Program

Conclusion

This structured guidelines for management of malnutrition is a step forward towards increasing the access to effective management of malnutrition. Conducting initial screening and management at AWCs, utilizing simplified assessment steps as mentioned, would enhance the identification of malnourished children as well as expand the coverage of effective management within this population.

Way forward

The core delivery platforms for nutrition in India are the

●      ICDS

●      NHM

●      PM-POSHAN (mid-day meal scheme)

Leveraging technology and innovations, various approaches have been used to deal with the challenges faced at each step of implementation.

The POSHAN Tracker, introduced in 2021, is a mobile application developed for supportive supervision that has undergone improvement over the years to  ensure quality functioning of Anganwadi.

While challenges persist, we continually innovate and develop new approaches to overcome them as we move forward. The Poshan Innovation Platform is one example of Public-Private partnership, under the initiative of India Nutrition Collaborative which aims to bring in innovative ideas from multiple sectors together at one place aiming towards a nourished and hunger-free India.

References

1. Malnutrition (2024) World Health Organization. Available at: https://www.who.int/health-topics/malnutrition#tab=tab_1 (Accessed: 10 April 2024).

2. World Health Organization (2024) ‘Levels and Trends in Child Malnutrition: UNICEF/WHO/World Bank Group Joint Child Malnutrition Estimates: Key Findings of the 2023 Edition.’ https://www.who.int/publications-detail-redirect/9789240073791 (Accessed: April 10, 2024).

3. Global Nutrition Report (2024) '2022 Global Nutrition Report: Stronger commitments for greater action.' https://globalnutritionreport.org/resources/nutrition-profiles/asia/southern-asia/india/ (Accessed: April 10, 2024).

4. International Institute for Population Sciences (IIPS) (2022) 'National Family Health Survey (NFHS 5), 2019-21.' https://rchiips.org/nfhs/NFHS-5Reports/National%20Report%20Volume%20II.pdf (Accessed: April 10, 2024).

5. Webb, P. (2024). ‘Nutrition and the Post 2015 Sustainable Development Goals: A Technical Note.’ [online] United Nations System Standing Committee on Nutrition. Available at: https://www.unscn.org/files/Publications/Briefs_on_Nutrition/Final_Nutrition%20and_the_SDGs.pdf [Accessed 11 Apr. 2024].

6. Golden, M. H (2010) 'Evolution of Nutritional Management of Acute Malnutrition,' Indian Pediatrics, 47, pp. 667–678. https://doi.org/10.1007/s13312-010-0103-5.

7. Dev, M., Kumar, G. and Pandey, V. Laxmi (2024) Achieving zero hunger in India challenges and policies [Print]. India Studies in Business and Economics. https://doi.org/10.1007/978-981-99-4413-2.

8. Accelerating progress on nutrition in India: What will it take? Third Progress report (2020) NITI Aayog. India: Women and Child Development Division, NITI Aayog. https://www.niti.gov.in/node/318 (Accessed: April 12, 2024).

9. Dasgupta, R., Ahuja, S. and Yumnam, V. (2014) 'Can nutrition rehabilitation centers address severe malnutrition in India?' Indian Pediatrics, 51, pp. 95–99. https://doi.org/10.1007/s13312-014-0341-z.

10. Burtscher, D. and Burza, S. (2015) 'Health-seeking Behaviour and Community Perceptions of Childhood Undernutrition and a Community Management of Acute Malnutrition (CMAM) programme in Rural Bihar, India: a Qualitative study,' Public Health Nutrition, 18, pp. 3234–3243. https://doi.org/10.1017/S1368980015000440.

Ditsungnoen, D. et al. (2020) 'Caregiver’s perceptions of nutritional status in children aged under five years in Nakhon Phanom Province of Thailand,' Asia-Pacific Social Science Review, 20, pp. 29–38. https://doi.org/10.3390/children9111784