Protein Energy Malnutrition

Prevention & Control

 Prevention and Control

Immediate
Ensuring Adequate Quantity, Quality & Frequency of food

Treatment / Control of infections / diseases

Long Term

Creating a supportive environment both for the child & mother

WHO (2000) Global Database on Child Growth and Malnutrition: Forecast of Trends.
 The problem … worldwide
% of Low
Birth
Weight % of <5 children who are
1990 - 94
Underweight Wasted Stunted
Severe + Severe Severe + Severe +
moderate moderate moderate

India 33 53 21 18 52
Sub-Saharan
Africa 16 30 10 8 42

South Asia 33 51 19 17 52

World 17 30 11 11 37
Least
developed 23 39 13 10 47
countries
Source : State of the world’s children 1998, UNICEF
 The problem … in India

Under weight Stunting Wasting

% below % % below % below % below % below

-3 SD below -3 SD -2 SD -3 SD -2 SD
-2 SD

Tamilnadu 10.6 36.7 12.0 29.4 3.8 19.9

Kerala 4.7 26.9 7.3 21.9 0.7 11.1

India 18[21] 47[53] 23 45.5[52] 2.8 15.5[18]

Bihar
25.5 54.4 33.6 53.7 5.5 21.0

Source : N F H S 2 India 1998 – 99, IIPS

 Under Five Proportional Mortality

Perinatal 20 %
Pneumonia 19 %

HIV / AIDS 3 %

Malnutrition
54 % Diarrhoea 15 %

Others 28 %

Measles 8 %

Malaria 7 %
 What's wrong ? Don’t we grow enough food ?
WE DO !
“On its part, mother nature has provided this unique planet of ours with such abundant
resources and human beings with such intelligence that the global production can easily
feed the present and future population of this entire world.
Yet, the way human society has got organised,
organised one fifth of the population of the
developing countries i.e. about 800 million people suffer from chronic under nutrition”
(FAO 1992).
All these millions can be said to be food insecure and others can be said to be enjoying
food security.

Food Security Access by all people at all times to enough food for a healthy life

FAO Committee on World Food Security formalised the definition in 1983 and
incorporated following three specific goals for food security:

i) ensuring adequacy of food supplies;

ii) maximising stability of supplies; and

iii) securing access to available supplies to all who need them.

 Do we Eat Enough ?
Availability of food can be assessed on the basis of dietary energy supply (DES), which
generally measures availability in terms of calories per capita per day.

DES for some selected developing and developed countries

CALORIES SUPPLIES PER CAPITA

COUNTRY 1972-74 1975-77 1978-80 1981-83 1986-88

India 2203 1999 2100 2113 2104
Pakistan 2049 2188 2232 2208 2167
China 2029 2087 2275 2460 2637
Bangladesh 1907 1910 1911 1923 1925
Brazil 2487 2514 2595 2621 2703
Egypt 2566 2727 2941 3184 3347
Mexico 2680 2780 2940 3099 3123
Belgium 3507 3511 3577 3765 3901
France 3124 3162 3249 3216 3312
Australia 3105 3280 3286 3258 3347
Germany 3370 3486 3605 3711 3855

(FAO Annual Report, 1992)

 The concept of household food & nutrition security
It is now being increasingly appreciated that food security is primarily a matter
of ensuring effective demand rather than a problem relating to food supply

A country may be food surplus but all its citizens may not be enjoying food
security as some may have no purchasing power

Every household should either have capacity to produce adequate food for all
the members or have purchasing power to acquire it

Although national food security is important as providing a foundation, in the

ultimate analysis what is more important is food security for each and every
household and within it, to every member of the family

Household Food Security : "at the household level, food security

is defined as access to food that is adequate in terms of quality,
quantity, safety and cultural acceptability for all household
members." (Gillespie, and Mason, 1991)
FAO (1999) The State of Food Insecurity in the World 1999. FAO, Rome.
 So, Why is the battle so long and so difficult ?
The multi-dimensional nature of malnutrition has made most of our nutritional
(or even otherwise) intervention programs under-achievers

Every one seems to know whats needed….

a comprehensive multisectoral participatory approach

Government actions to improve household food security

Food security may be influenced by anything that governments do,

- to improve income and reduce poverty;

- to increase agricultural production, especially by poor rural families;

- to ensure prices that are fair to producers and consumers;

- and to make services available to people.

 Nutrition-relevant Actions In Tamilnadu
I - Direct Nutrition Interventions
A - The Integrated Child Development Services Scheme (ICDS)
B - The Tamil Nadu Integrated Nutrition Programme (TINP) TINP-II
C - The Midday Meals Programme
D - Vitamin A Prophylaxis Programme
E - Anaemia Prophylaxis Programme

II - Food Interventions
The Public Distribution System (PDS)

III - Poverty Alleviation Programmes

A - The Integrated Rural Development Programme (IRDP)
B - The National Rural Employment Programme (NREP)
C - The Rural Labour Employment Guarantee Programme (RLEGP)
 Digging into the causes for Effective solutions
Promotion and protection of nutritional well-being: The ICN approach
The International Conference on Nutrition developed nine common areas for
action to promote and protect the nutritional welfare of the population:

Improving household food security,

Protecting consumers through improved food quality and safety,

Preventing specific micronutrient deficiencies,

Promoting breastfeeding,

Promoting appropriate diet and healthy lifestyles,

Preventing and managing infectious diseases,

Caring for the economically deprived and nutritionally vulnerable,

Assessing, analysing and monitoring the nutrition situation.

Incorporating nutrition objectives into development policies and programmes

 The Six P’s causing all the Problems
By shedding the sectoral perspective and adopting a multisectoral,
multidisciplinary one, it is possible to see the causes of malnutrition in a
different guise. Six determinants of malnutrition are especially important,
although none is usually the only cause of malnutrition or the only discipline that
needs to be involved in nutrition strategies.

· production , mainly agricultural and food production;

· preservation of food from wastage and loss, which includes the addition of
economic value to food through processing;
· population , which refers both to child spacing in a family and also to
population density in a local area or a country;
· poverty , which suggests economic causes of malnutrition;
· politics , as political ideology, political choices and political actions influence
nutrition;

· pathology which is the medical term for disease, since disease, especially
infection, adversely influences nutritional status.
 Prevention and Control
Immediate
Ensuring Adequate Quantity, Quality & Frequency of food

Treatment / Control of infections / diseases

Long Term
Creating a supportive environment both for the child & mother

Control of PEM should happen in 3 Major fronts

1) Food 2) Health Care 3) Caring ambience

Action against malnutrition must come from,

Government Public Sector

NGOs Community Groups

 The Role of Medical treatment in malnutrition

The ultimate objective of most comprehensive nutrition programmes should be

to reach a stage where no children require treatment for malnutrition in
hospitals, in other centres or as outpatients.

No country has reached that goal, so treatment must remain a part of control.

Treatment of malnutrition can be viewed as taking place at three levels:

First, hospital treatment for severe and life-threatening malnutrition;

Second, nutritional rehabilitation or similar treatment for moderate malnutrition

or after severe cases are discharged from hospital;

Third, preventive care and treatment of mild malnutrition in maternal and child
health and nutrition clinics or growth monitoring centres. At each level,
prevention should be a component of the services offered.

Not all countries have an organized system for providing all three levels of
treatment.
 Major nutritional survey data sources in India
Criterion NSSO NNMB

Objective Collection of information of

household consumer To assess nutritional To assess nutritional
expenditure status of individuals status of households

Method of
Recall Recall Weighment
collection

Sample
Stratified two-stage Stratified three-stage Stratified three-stage
design

Sample size Very small (one fourth of Small (one thirty third of
Large, varying size weighment) fixed size for NSSO) fixed size for
each state each state

Reference
One month preceding the day One day preceding the day Day of visit
period visit of visit

Unit of data
Household Individual Household
collection
 Assessment Of Interventions Vis A Vis Need
Intervention Target Group Coverage Services/ Quality Program Impact
Objectives

Does It Target The Right What % Of Vulnerable Do The Is It Well Has Convincing
Group? Group Did It Cover?* Services Implemented Impact? Been
Offered Demonstrated?
Match The
Needs?

Area Beneficiary Al AP TN Al AP TN Al AP TN
targeting targeting

ICDS 1 3 51% 34% 18% 3 2 2 3 1 1 1

TINP 3 5 - - 53% 4 - - 4 - - 4
MDM 0 1 - - NA 1 - - 3 - - 4
VIT A 3 4 ? ? ? 3 ? ? ? ? ? ?
PROPH.

ANEMIA PR 3 4 ? ? ? 3 ? ? ? ? ? ?
OPH.

PDS 2.5 024# ? >100 >100 5 1 3 3 1 3 3

% %
IRDP 1 233# 7.7 ? ? 3 1 2 2 2 ? ?
%
NREP/RLEGP 1? 233# NA NA NA 4 1 2 2 7 ? ?

1. Al = ALL INDIA NATIONAL AVERAGE; AP = ANDHRA PRADESH; TN = TAMIL NADU.

2. Rankings are made on a scale of 0 to 5 (Worst to best). 3. # Numbers refer to Al, AP & TN respectively.
 Assessment Of Nutrition-relevant Actions In The Context Of The Triple A Strategy

INTERVENTION WAS "NEED" IDENTIFIED? WAS PROGRAM WAS COMMUNITY WAS

(ASSESSMENT) TARGETED TO NEED? "EMPOWERED"? INSTITUTIONAL
(ANALYSIS OF (ACTION & COMM. SUPPORT BUILT IN
RESOURCES AND INVOLVEMENT) TO PROGRAM
NEEDS) DESIGN

ICDS 3 (Poverty criteria) 3 1 3

TINP 4 (Poverty & 4 2 5

Nutritional criteria)
MDM 0 (No) 0 0 1
PDS 3 (Poverty criteria) 3 0 3

IRDP 3 (Poverty criteria) 2 3 2

NREP/RLEGP 3 (Poverty criteria) 3 3 2

Rankings are made on a scale of 0 to 5 (Worst to best).

 Community Involvement In Direct & Indirect Nutrition Interventions

Needs Organi Leader Training Resource Manage Orientati Monitoring

Assessment/ zation ship Mobilization ment on Of Evaluation
Action Choice Actions /Information
Exchange
INTERVENTION

ICDS 2 2 2 3 1.5 2 3 1.5

TINP 2 3 2.5 5 1.5 2 5 3
MDM 1 1 1 1 1 1 1 1
PDS 2 1 1 1 1 1 3 2
IRDP 2.5? 2 2.5 ? 1 2 3 2

NREP/ 2.5? 2 2.5 ? 1 2 3 2

RLEGP

1. Ratings are based on the matrix for ranking Nutrition-Relevant Actions with respect to levels of
community involvement
 The Food Path & the Blocks
Farmers & family too
Cash crops grown; not
Farmers too malnourished pests Rain sick to work in the fields
food crops

Clearing Planting Growing Harvesting

Too many people; Wrong crops / varieties grown

Lack of knowledge
not enough land Left farms, moved to town
Pop growing too
Wholesalers make
fast for too
everyone No lorries for transport
large profits pests
to have a paid job

Wholesaling Transporting Storing

Earning
Food bought Diarrhoea
No / bad roads Lack of knowledge
expensively in
Lack of jobs Worms
Drunken fathers, small amounts
Lack of &
widows Measles
knowledge
divorced women Unequal
Retailers make inter-family
Lack of fuel
too large profits
Budgeting
Retailing Eating
& Cooking Sharing
& using
Shopping
Not enough
money budgeted Mothers not Food notToo
cooked
many children
for food knowing the right often enough
Advts persuade people Too little food
to buy – feeding bottles food
fizz for children
drinks & not food
 UNITED NATIONS
Administrative Committee on Coordination
SUB-COMMITTEE ON NUTRITION
KEY GLOBAL TARGETS SET DURING THE 90S

Reduce the number of food insecure people to half the 1996 level by 2015

Reduce severe and moderate malnutrition among under fives by half of the 1990 levels by 2000

Eliminate famine deaths by 2000

Eliminate vitamin A deficiency and iodine deficiency disorders by 2000

Reduce the rate of low birth weight to less than ten per cent by 2000.

Reduce iron deficiency anemia in women by one third the 1990 levels by 2000

Empower all women to exclusively breastfeed for the first four to six months of life and to continue
breastfeeding with complementary food up to and beyond two years, by 2000

Reduce extreme poverty in developing countries by at least one half by 2015

These global targets were set at the World Summit for Children, the International Conference on Nutrition,
the World Food Summit and the World Summit for Social Development. Some of these targets are being
updated, and new ones developed, by ACC/SCN Working Groups.