The Cycle Of Undernutrition

A few weeks back, my roommate and I had an argument about the taste of food. She argued that it’s only our hunger that makes the food delicious. While I argued that delicious food will taste delicious irrespective of whether the person is hungry or not. By the time we came to some conclusion, we were both taking a third serving of biryani. Not sure whether it was hunger or taste! I mean who doesn’t love to eat? 

But why do we eat? While some of us might say to satisfy our taste buds or craving, fundamentally it is for us to function optimally and to survive.

How does food give us the energy to survive? Food that we consume has the macronutrients like proteins, carbohydrates, fats, and water and micronutrients like vitamins and minerals that the body requires for physical and mental growth. From birth to adulthood and beyond, the right amount of nutrients fuels the proper growth and functioning of all our body systems. A particular level of nutrition is necessary for our body to function.

What is undernutrition and what can be its impact?

When an individual does not meet these necessary requirements or exceeds them, we term it malnutrition. It is common for us to use the term malnutrition and undernutrition interchangeably. 

Malnutrition includes both those who do not receive proper nutrition and those who receive it exceedingly. It includes both undernutrition and overnutrition.

While undernutrition continues to be a burden of third world countries, overnutrition, and resulting obesity are growing to be a global health threat, especially in the USA. Not consuming sufficient amounts of nutrients affect the general immune system of the person. Thus causing fatigue, poor appetite, and recurring illness. It also delays the physical and mental development of the person.

In the longer term, it will lead to poor learning ability and poor school performance. And in adulthood, it means reduced work capacity and increased risks of chronic diseases. Intergenerational undernutrition can result in stunting as well. For the whole of the country, undernutrition is a serious public health issue. And it is not different for the tribal groups. 

How can we assess the nutritional status?

There are 4 major indicators of nutritional status. The variables built using the basic anthropometric measurements (height and weight) in combination with age and sex are the indicators. These indicators will help in determining the nutritional status of a person. Other indicators include the use of middle upper arm circumference and skin folds.

1. Low weight for height is known as wasting. It usually indicates recent and severe weight loss, because a person has not had enough food to eat and/or they have had an infectious disease, such as diarrhoea, which has caused them to lose weight. A young child who is moderately or severely wasted has an increased risk of death, but treatment is possible.
2. Low height for age is known as stunting. It is the result of chronic or recurrent undernutrition, usually associated with poor socioeconomic conditions, poor maternal health and nutrition, frequent illness, and/or inappropriate infant and young child feeding and care in early life. Stunting holds children back from reaching their physical and cognitive potential.
3. Children with low weight-for-age are known as underweight. A child who is underweight may be stunted, wasted, or both.

In adulthood, since they have stopped attaining height, BMI (weight in kilograms divided by the square of height in meters) is more appropriate. Additionally, mid-upper arm circumference (MUAC) is also used to measure wasting in both children and adults.

What does the data say and what have been the efforts on this front?

According to the NFHS 5-data, the nutrition indicators for children under 5 years have improved as compared with NFHS-4 (2015-16). Stunting has reduced from 38.4% to 35.5%, Wasting has reduced from 21.0% to 19.3% and Underweight prevalence has reduced from 35.8% to 32.1%.

Scheduled tribes or Adivasis make up 8.6% of India’s population and are officially India’s poorest people, with 5 out of 10 falling in the lowest wealth bracket. A systematic review of 41 studies across under-five tribal children of India found an average prevalence rate (PR) of underweight, stunting, and wasting to be 43%, 45%, and 23% varying from 9% to 91%, 13% to 67%, and 8% to 60%, respectively.

The government has accorded high priority to the issue of malnutrition and is implementing several schemes like Anganwadi Services, Scheme for Adolescent Girls, and Pradhan Mantri Matru Vandana Yojana (PMMVY) under the Umbrella Integrated Child Development Services (ICDS) Scheme as direct targeted interventions to address the problem of malnutrition in the country. Children with Severe Acute Malnutrition are treated at the Nutrition Rehabilitation Centres established by the Ministry of Health and Family Welfare. POSHAN Abhiyaan launched on 8th March 2018, aims to reduce malnutrition in the country by adopting a synergised and result-oriented approach.

Unraveling the causes of undernutrition

Although at first look of it, it might seem like the problem of undernutrition can be solved by simply providing nutritious food and supplements, it does not solve the problem. To understand why cracking this challenge is difficult, understanding the underlying causes is imperative. The problem cannot be understood from only one perspective as it is more complicated and multi-factorial. Understanding this complex problem through a systems thinking approach will help us understand it more completely. Here I am using a causal-loop diagram to examine the socio-cultural-economic-political reasons for the problem of undernutrition among tribals.

Understanding the problem of undernutrition among tribals through causal loop

Note: The loop is not exhaustive. It is based on the understanding I have developed of undernutrition in the last several months of working at Swasthya Swaraj. It is definitely possible that I have overlooked some aspects of it.

I would like to thank Dr. Shriram and Dr. Ashish, my colleagues at Swasthya Swaraj. They have helped me build a deeper understanding of this complex problem.

References:

1. Key Facts on Malnutrition
2. Dey U, Bisai S. The prevalence of under-nutrition among the tribal children in India: A systematic review. Anthropol Rev. 2019;82:203–17. [Google Scholar]
3. Malnutrition among Children