The Key Determinants of Undernutrition

Children of the preschool age are considered to be the most nutritionally vulnerable population simply because most of our growth occurs during the first five years of our lives. Infant nutritional status largely determines our health in the subsequent years as an adolescent and later as an adult. And for this very reason, the stagnant rates of undernutrition in children of preschool age are a strong cause for concern in India, especially considering the long-term effects that underweightedness, stunting, and wasting can have. Declining numbers of children who suffer from undernutrition in India has indicated some efficiency in the current interventions, but comparative rates project that India will continually house the largest number of undernourished children under the age of five in the world. When considering potential interventions for these stagnant rates and even identifying the issues with the current plans, biological, social and cultural, environmental, economic, and political determinants are integral in understanding the cause of undernutrition in India.


Most undernutrition cases in preschool aged children can be attributed to the individual and biological determinants that are manifested in the health of the human being either directly or indirectly. An individual’s nutritional status can be connected to primarily to the nutritional health of the mother. According to a study conducted in Mysore, Karnataka, the number of children of preschool age who maintained a normal nutritional status doubled if the mother could be categorized as having a normal Body Mass Index (BMI). Conversely, if a mother had Chronic Energy Deficiency, her child was three times more likely to be severely malnourished (Lakshmi A. et al. 53).


These findings can be linked to the maternal nutrition kept during the time of pregnancy, as well. An inadequate BMI of an expecting mother could compromise the amount of weight gained during pregnancy to support the child’s neonatal growth. A low BMI, mostly determined by undernutrition in a mother herself, can lead to a preterm birth (a cause of low birth weight) or a low birth weight in her child. In India, 30% of preschool children are born with a low birth weight (“6.5. Nutritional Status During Infancy and Early Childhood”). This, in addition to poor nutrition, can consequently affect the first two years of growth, as seen by the decreasing physical stature of Indian children compared to other developing regions.


Individual biological determinants like age and sex of the child can also affect his or her nutritional status in the first five years of life – however, not to the extent that low birth weight and maternal nutritional health does. As a child’s age increases, the incidence of stunting and wasting seems to decrease, but underweightedness appears to have an arbitrary trend, which is meager evidence for its effect on undernutrition in India (Lakshmi A. et al. 47).


A child’s sex, though, is a key determinant of his or her nutritional status. In many ways, this determinant is socially influenced, as well. The study conducted in Mysore, Karnataka mirrors most of India’s national data. Girls have a consistently higher rate of undernutrition (underweightedness, stunting, and wasting) than boys do during the preschool, adolescent, and the adult years. Nutritionists note that negligence of girls is the root of the problem (Lakshmi A. et al. 50). Negligence in food distribution may occur, but more so, inattentiveness to ill girls is often a social practice as a result of a cultural stigma against females. Acquired illness during infancy can lead to weight-loss, especially if treating a female child is not a priority.


Socioeconomic determinants are also cofactors in several of these biological contributors to undernutrition in India. Health in India is largely determined by the remnants of the caste system (for lack of a better term). The large differences between the wealthiest quintile and the poorest quintile in India also accounts for the high levels of undernutrition within the population. In 2005, it was estimated that 41% of the Indian population falls below the international standard poverty line (World Bank Report 2005). Out of India’s population of roughly over one billion in 2005, 442,908,399 people were impoverished. While this outstanding number of people below the international poverty line has decreased, it is still reflective of the levels of undernutrition within different economic sectors of the population.


When families are limited by money, options for food and healthcare are reduced. A family in the lowest quintile in India may not be able to provide adequate food for pregnant women and, later, their children, contributing to his or her low nutritional status. This is reflected in the statistics: 60% of preschool age children in the lowest economic quintile are undernourished versus the 33% in the richest quintile (“6.5. Nutritional Status During Infancy and Early Childhood” 170). Although the difference between the two is demonstrative of the impact of money on access to foods, even the richest quintile struggles with undernourishment. However, low castes, poorer states, rural areas, and urban slums are all most susceptible to housing undernourished children because they are the economically poorest regions of India.


India, though, still revolves around traditional practices, which preserve culture, but at the same time create social determinants for undernutrition. Sadly, many of these social determinants are a result of the persistent stigma against women. For example, maternal literacy has a positive association with the “body weight of the child right from conception to the rapid stages of the development period” (Lakshmi A. et al. 52). Mothers who have been educated even for a short time (8-10 years) had a 20% lower rate of undernourished children (52). Unfortunately, the rate of literacy for women in rural India is significantly lower than in urban sectors, which further perpetuates the economic determinants of undernutrition.


Culturally, the practice of breastfeeding can also largely contribute to an infant’s health and nutritional status. And while breastfeeding is almost exclusively practiced among educated groups in India, faulty feeding practices are a key determinant of undernutrition. A mother’s Colostrum is rich in antibodies that are vital for a developing infant. The subsequent breastfeeding for the first six months of infancy reduces a child’s risk of gastrointestinal problems that may contribute to high weight-loss and the undernourishment that follows. Exclusive breastfeeding can null some of the effects of undernourishment during the first six months of infancy, and later when supplemented with nutritional foods, can help a child attain a normal weight-to-height reading (“Faulty Feeding Practices and Malnutrition”).


But nutrition is not limited to just the actions or inactions of the individual, culture, or society. Politics and the environment in which a person lives also contribute to the determinants of undernutrition in preschool aged children. For example, India lacks adequate environmental policy, especially when it involves sanitation. Several rural villages in India still use open defecation sites, where water contamination is nearly guaranteed. A sanitary living situation can obviously increase the physical, mental, and social comfort of individuals. However, when these provisions are lacking, children who are still in the most crucial stages of development are highly prone to contracting infectious diseases, which can result in weight loss and malnutrition. Because of the lack of policy in India, these unsanitary environments often go unacknowledged, and create another risk factor for undernutrition.


Undernutrition cannot be limited to any one single key determinant category because of its complex nature. But this very combination of contributing factors is what makes it difficult to structure an effective intervention. However, it is clear that certain determinants are more impactful than others, and if an intervention can be fashioned to prevent a determinant from occurring in the first place, Public Health will be successful. The astonishing 55% of childhood deaths due to malnutrition must be reduced, and taking preventive measures to rapidly decrease the rate of undernutrition in India is integral to the process.


(Note: works are cited parenthetically for the time being)

Numbers: The Immensity of Undernutrition

Some of us like to think in terms of numbers. It is a way of rationalizing what typically seem to be abstract concepts in the world. Hence, it only makes sense that we seek qualitative evidence to support our claims, especially when gauging the immensity of a situation.

In Public Health, these numbers are used in the very same way. Data is collected, analyzed, interpreted, and disseminated in a process called surveillance. And through surveillance, Public Health agencies can monitor health events and be better prepared to plan and implement different interventions when trends reveal a problem.

The start of the new millennium in 2000 marked the beginning of a new generation of philanthropy. Sustainable development placed a renewed emphasis on the concepts of prevention, which in turn sparked our interests in the trends plotted by surveillance. Just ten years before in 1990, several developing countries faced problems with a high number of undernutritutioned children, who either were not eating nutritionally effective foods or were limited in their access to food in general. With the hope of decreasing these upward trends, the Millennium Development Goals encompassed halving the number of undernutritioned children by 2015. While most countries have comparatively succeeded in this fifteen-year escapade, South-Asia seems to have stagnated in their efforts.

This is particularly the case for India. Compared to global efforts, rates of undernutrition in Indian children under the age of five from 1999 onwards has been decreasing, but too slowly to make any significant difference in the number of consequential health problems that undernutrition brings.

The National Family Health Survey is the primary method of collecting data for Public Health incidence and prevalence studies within the country. However, even though it has released three rounds of data since 1992, it focuses on obtaining data from a representative sample of households, which compromises the accuracy of the estimates. Within the several categories of the survey, recording information about nutrition, access to food, and undernutrition-related disorders (like anemia) has helped track the progress of the Millennium Development Goal [1]. To address the growing concern of nutritional health in 1972, the National Nutrition Monitoring Bureau also began collecting data through a self-reporting survey [2].

Quantitatively, it is quite obvious that India’s progress nutritionally is stunted. In 1990, an estimated 53.3% of the children under the age of three were underweight. By 1998, this number had fallen to around 47% [3]. More recent studies published estimate the number of children under five who are underweight in India to remain around 47% and 46%, with stunting at 45% in 2000 [3]. When this rate was observed again for change in 2005 and 2006, it remained stagnant. It is expected for it to only drop to 40% by 2015, missing the target for the Millennium Development Goal by close to 14% [4].

Yet, the measure of the number of underweight children is not the only indicator of undernutrition. Realizing the stagnation of the rates depends on the comparative data available for different economic brackets of India and other countries. In urban India the percentage dropped from 44% to 38% between 1992 and 1998. In rural India, however, the percentage dropped from 55% to 50%. The rates of change are similar, suggesting that the current interventional method is dissociated with the economy. As of 2000, 24% of African children under the age of five suffered from underweightedness. Latin America, the same year, reported that only 6% of the population of the children under the age of five were underweight. These countries are all exhibit a similar pattern of economic development; in fact, India may even be growing at a faster rate than others in the developing world [3].

This is where indirect indicators play a crucial role in exposing the magnitude of the problem. India’s Gross Domestic Product (GDP) information allows us to determine the comparative effect of the country’s economy in relation to the health needs provided. Yet, by looking at indirect indicators like vitamin deficiency and iron anemia, we can gauge what type of effect undernutrition has on the population. According to recent data, 74% percent of the population of 6 month-olds to 36 month-olds have some form of Iron Deficiency Anemia (IDA) [3].

However, the fundamental problem with all the data is that it is from a survey-based study, which are self-reported. This compromises the accuracy in the numbers, as they are only estimates of the prevalence and incidence.

It seems like numbers define parts of our lives. But, when they can be used to help us create an intervention in Public Health, why not when surveillance can save lives?


Sources: 
[1] http://www.nfhsindia.org/
[2] http://www.nnmbindia.org/aboutus.html
[3] MDG Report 2007
[4] MDG Report India 2009

Public Health 2015: Decrease High Undernutrition in India

We are an undeniably goal-oriented world.  Of course, it is perfectly normal to measure our successes by the fulfillment of our goals. However, when our goals forget to incorporate the vicissitudes of reality, we have somewhat of a problem.

Goal for 2015: Eradicate extreme poverty and hunger by halving the proportion of people whose income is under one dollar a day and still suffer from hunger.

This is no doubt an altruistic goal that relies on the integration and communication of a global network of infrastructures and healthcare systems. But just like every other of its Millennium Development Goal kind, it seems ambitious, especially when 80% of the Earth’s population lives on less than ten dollars per day and 28% of children in developing countries suffer from being underweight or stunted in growth (World Bank Development Indicators 2008).

But even reducing the economic “gap” largely relies on the health and well being of a population, further affirming the role of Public Health issue-resolutions in any circumstance. And while the monetary disparities between socioeconomic groups have decreased due to fiscal growth in developing countries, the same cannot be said for the number of people who are undernourished.

In fact, the Millennium Development’s target for halving the hunger-stricken population may not even be achieved due to very slow progress in Sub-Saharan Africa and Southern Asia for addressing underweighted children, a key indicator of program efficacy. In India alone, over 60 million children are underweight (World Bank). Between 1992 and 1998, the rates have decreased in India, yet the current interventions have been unsuccessful in dramatic changes; in some rural Indian populations, the number of undernutritioned children remains the same as it was in 1992 – in other words stagnant (Millennium Development Goals Report 2007). It seems as though India’s economic growth has had meager effects in its Public Health prowess.

But why is undernutrition such a large Public Health issue? Undernutrituion is a facet of malnourishment, which encompasses not eating enough, not eating the nutritionally effective types of food, or simply not being able to use food resources that are available. Undernutrition particularly is characterized protein and micronutrient deficiencies, attributable to low levels of food consumption. Without adequate energy and vitamins, both mental and physical development can be stunted. This in turn can compromise a child’s immune system, making them susceptible to contracting other infectious diseases, especially when the environment of a developing country houses several.

In 1998, 47% of children under the age of three were suffering from being underweight, and while this has decreased to a certain extent, malnutrition has contributed to other problems like iron deficiency anemia (75% of preschoolers) and Vitamin A deficiency (57% of preschoolers) (World Bank 2005). The implications for undernutrition in India are obvious.

India child-weight distribution curve (below) exemplifies this Public Health problem.

Yet, the questions still persist: What can be done?

With planned interventions and preventative methods in India and other countries with similar health issues, Public Health may be able to reach the looming 2015 deadline. International Health seems to be overwhelmingly important, as we become more dependent on globalization. And in the interest of pursuing how we all can be contribute to undernutrition and other international health problems, I am ready to set some goals.

Ten Weeks and A Potential Lifetime: A Reflection

Time is a strange phenomenon. It is an indefinite progress of existence that is paradoxically both measured and relative. Time makes the past, present, and future seem hopelessly intertwined. Perhaps that explains how ten weeks ago seems like just yesterday.

Ten weeks ago, blogging was just one of those many new ventures waiting to be explored by a college freshman looking to leave her minute mark in the world. And now, two months later, blogging has become a weekly tradition and Public Health has become a blossoming passion.

Two-thirds of my “Introduction to Public Health” survey course has finished, and I find myself to be completely enchanted by what Public Health has to offer. We have built upon the ever-expanding definition of Public Health by exploring its multiple facets and endless implications in the local and global community. Essentially, we could extract that Public Health is a broad term, meant to preside over all the factors that contribute to the wellbeing of the Earth’s population. But, throughout the course, I began to realize how heavily Public Health relies on the connection between epidemiological knowledge and policy to place Public Health measures into effect.

Epidemiology, medically, focuses on the incident and prevalent distribution of certain diseases in populations. However, Public Health takes the biological importance of disease and examines its context. Interestingly, by looking at a combination of demographics and social and economic details of a population, Public Health can begin working preventively.

At this point, policy plays an integral role in shaping the efficacy of Public Health. Increasing the accessibility and availability of health resources and creating structural, physical, and cultural changes largely determines how successful and Public Health endeavor will be. With epidemiological data, policy can be structured as a primary prevention mechanism.

In this respect, I definitely underestimated Public Health’s social influence. When we consider “health,” we think “medicine.” Yet, medicine is only one aspect of Public Health, as the rest is nestled in the web of our environment and our behaviors. The social determinants of Public Health are extraordinary. Simply by bettering the environment in which we live or altering a mindset through education or structural improvements, Public Health can play an active role in our lives without explicitly being present.

This is the beauty of Public Health – every discipline is linked to each other. And moreover, in Public Health, everyone is linked to each other; it’s global and social.

Health, and everything it encompasses, is interconnected and dependent on our collaborative efforts. Of course, this breadth complicates Public Health. But at the same time, it heightens my interest in it. In my very first blogging escapade, I had said that understanding the implications of healthcare on an international level and interacting with global communities would be my path to reconnecting with the zeal that life has to offer. And after ten weeks, International Health and Development intrigues me even more. If anything, realizing the immensity of the term Public Health and gathering knowledge about its diverse aspects has inspired to me learn even more.

Time is indeed a strange phenomenon. Ten weeks have flown by. But ten weeks in the second row of Mergenthaler 111 have helplessly intertwined Public Health with my life, for the better.