**8. Web of factors maintaining malnutrition in Indian communities**

'Asian enigma' is a phenomenon of persistent and unusually high prevalence of child undernutrition in South Asia as compared to countries at similar levels of income or economic growth. In-depth analysis into why malnutrition is so resistant to improvement shows its complex aetiology. The immediate causes of undernutrition reflect a negative synergy between inadequate food intake and repeated infectious diseases. Underlying these causes is a constellation of factors particularly salient to India [13]. These include especially poor sanitation and high rates of open defecation that leads to various kinds of infestations, infections and environmental enteropathy; poor coverage of health services and half-hearted implementation of nutritional programs and policies; no political commitment and will, and economic, social determinants including economic growth and income distribution, deficiencies in governance and strategic leadership and the status of women [14, 15].

A new study from Harvard Chan School of Public Health has now pinpointed the five top risk factors responsible for more than two-thirds of the problem. Short maternal stature, extreme poverty, poor dietary diversity and mother's lack of education are among the top five risk factors for malnutrition in children in India. Examining an array of 15 well-known risk factors for chronic undernutrition among children in India, the study found that the five top risk factors were essentially markers of poor socioeconomic conditions as well as poor and insecure nutritional environments in children's households [16].

Economic conditions definitely play a crucial role. On the one hand, money is required to look after food, water and sanitary living conditions, whereas on the

#### *Childhood Malnutrition in India DOI: http://dx.doi.org/10.5772/intechopen.89701*

other hand, approximately 22% of the Indian population live below the poverty line. Rural population, a major chunk (especially agriculturists) is mostly dependent on rains for their income. They always live in a state of uncertainty of income. Apart of income, illiteracy plays a crucial role. Most of the people are not aware about their health, nutrition, balanced diet and breastfeeding practices. Without these, effective nutrition communication campaign cannot succeed in their purpose.

India ranked 97 among a list of 118 countries on hunger as per Global Hunger Index (GHI). It concludes that Indian population does not have access to sufficient and nutritious food. National Food Security Act is a great step in the direction of ensuring greater access to adequate quantity of quality food at affordable cost via Targeted Public Distribution System (PDS). Desired outcomes were not achieved due to corruption in PDS [17]. Wastage of food grains (theft, rotting) in Food Corporation of India (FCI) warehouses has also dented the access of food to common man. Greater efforts are needed to strengthen the existing initiatives to make them as corruption free and efficient institutions to get better results.

State of maternal health illiteracy is an important determinant of child nutritional status. The type of care a mother provides to her child depends to a large extent on her knowledge and understanding of some aspects of basic nutrition and health care [18].

Millions of beneficiaries have benefitted by ICDS Scheme however, problems are being observed in ensuring supply of quality food, and its uniform distribution. Anganwadi Workers (AWWs) and Anganwadi Helpers (AWHS) at Anganwadi centres are often dissatisfied by low wages. Thus they fail to play an effective role in tackling the problem of malnutrition.

#### **8.1 Scam in ICDS project unearthed**

Dibrugarh, Assam: two organizations have brought charges of rampant corruption in the Integrated Child Development Scheme (ICDS) amounting to more than Rs. 37 lakh in Panitola ICDS project of the district. While the officer-in-charge of the ICDS project in Panitola development block has drawn the money for 2007– 2008 through two cheques (Nos. 107,895 and 017896) from UCO Bank, Dibrugarh after collecting the cheque from the district social welfare department, All India Youth Federation and All Assam Mottock Yuba Chatra Sanmilan unearthed through Right to Information (RTI) Act that the money has not been utilized till date. Suspecting misuse of the allotted money, the two organizations have demanded that the district administration institute an enquiry into the anomaly immediately. They have also demanded exemplary punishment on the erring officials (source: The Assam Tribune, 12 May 2008).

Village Health, Sanitation and Nutrition committee (VHSNC), one of the key elements of the National Rural Health Mission are non-functional in many of the states due to lack of funds. Similarly, Village Child Development Centres (VCDCs) were set up by state government of Maharashtra to provide malnourished children with medical care and nutritious meals. These centres are mostly non-functional due to lack of funds [19].

#### **8.2 Toffees in the name of nutritious food**

In Nigoha, the hot food scheme has stopped functioning due to lack of funds. The condition of Rampura AWC is also the same. The centre does not open on regular basis. The AWH, Sarvesh Kumari, distributes toffees instead of proper nutritional food to the limited number of children who come to the centre. Villagers are not even aware of the facilities provided to them by the AWC. Community

**8. Web of factors maintaining malnutrition in Indian communities**

*Diagrammatic representation of child undernutrition with Hunger Index.*

*Perspective of Recent Advances in Acute Diarrhea*

'Asian enigma' is a phenomenon of persistent and unusually high prevalence of child undernutrition in South Asia as compared to countries at similar levels of income or economic growth. In-depth analysis into why malnutrition is so resistant to improvement shows its complex aetiology. The immediate causes of undernutrition reflect a negative synergy between inadequate food intake and repeated infectious diseases. Underlying these causes is a constellation of factors particularly salient to India [13]. These include especially poor sanitation and high rates of open defecation that leads to various kinds of infestations, infections and environmental enteropathy; poor coverage of health services and half-hearted implementation of nutritional programs and policies; no political commitment and will, and economic, social determinants including economic growth and income distribution, deficiencies in governance and strategic leadership and the status of women [14, 15].

A new study from Harvard Chan School of Public Health has now pinpointed the

Economic conditions definitely play a crucial role. On the one hand, money is required to look after food, water and sanitary living conditions, whereas on the

five top risk factors responsible for more than two-thirds of the problem. Short maternal stature, extreme poverty, poor dietary diversity and mother's lack of education are among the top five risk factors for malnutrition in children in India. Examining an array of 15 well-known risk factors for chronic undernutrition among children in India, the study found that the five top risk factors were essentially markers of poor socioeconomic conditions as well as poor and insecure nutritional

environments in children's households [16].

**Figure 6.**

**16**

participation is also lacking as parents do not sent their children to the centres (source: Dainik Jagran, Lucknow, 1 November 2009).

targets: child overweight, child wasting, child stunting, exclusive breastfeeding, diabetes among women, diabetes among men, anaemia in women of reproductive age, obesity among women and obesity among men. Data for 194 countries was analysed. As per this report, India is listed among those countries, which are on track for none (zero) of the nine targets. The key driver behind the goal to reach Zero Hunger and malnutrition is to ensure that no one is left behind in the pursuit of food and nutrition security. In the Indian context, this will also mean greatly

The causes of malnutrition in India are several and multifaceted, from direct factors to underlying contributors. Malnutrition in children occurs as a complex interplay among various factors like socio-demographic, maternal, gender, home environment, dietary practices, hand washing and other hygiene practices, etc. **Figure 7** depicts factors significantly associated with malnutrition among under-5

*Socio-economic and demographic factors*: literacy status of parents especially mother's education, caste, birth order of child, gender of household head, residence,

improving the health of women and children.

*Childhood Malnutrition in India*

*DOI: http://dx.doi.org/10.5772/intechopen.89701*

**10. Determinants of child malnutrition**

children in India.

**Figure 7.**

**19**

*Factors significantly associated with malnutrition among under-5 children [36].*

Social and cultural factors may also affect malnutrition. State government of Uttar Pradesh launched Hausla Poshan Yojana in 2016 to combat malnutrition among mothers and children by providing food cooked by Anganwadi Workers. Surprisingly beneficiaries refused to consume food because lower caste people prepared it [20]. Upper caste community considers lower caste as untouchables. Another cultural practice still prevalent in Indian communities is child marriage that is acting as limiting factor in improving health of children. 27% of girls in India are married before their 18th birthday and 7% are married before the age of 15. According to UNCIEF, India has the highest absolute number of child brides in the world [21]. A weak mother is likely to give birth to a weak child. This maintains the cycle of undernourishment.

As discussed earlier that poor sanitation is directly linked to malnourished children. The Census 2011 told us only 32% of India's rural households had toilets. 59% of the 1.1 billion people in the world who practice open defecation live in India. On 2 October 2014, Swachh Bharat Mission was launched throughout country with an aim to achieve the vision of a 'Clean and Open Defecation-Free India' by 2 October 2019 [22]. These targets are difficult to achieve, as implementation is poor, as observed from the slow progress in meeting the targets, and the existence of several newly constructed but non-functional toilets [21, 23].

Diarrheal disease kills an estimated 300,000 children less than 5 years of age (13% deaths in this age-group) in India each year. Most mortality related to diarrhoea occurs in less developed countries, and the highest rates of diarrhoea occur among malnourished children under-1. The case fatality rate is highest among children aged 6–12 months because at this age the immune system is not yet fully mature, maternal antibodies are waning, and the foods introduced to complement breastfeeding may be contaminated. Among children who survive severe diarrhoea, chronic infections can contribute to malnutrition. In turn, malnutrition makes children vulnerable to diarrhoea infections. Better access to clean water and sanitation is the key, with fewer weak and malnourished children becoming infected [24, 25].

#### **9. Commitments and targets to track progress to end malnutrition**

Recognizing the seriousness of malnutrition for global health, in 2012 and 2013, the member states of the World Health Organization (WHO) adopted a series of targets to significantly reduce the burden of many of these forms of malnutrition by 2025 (**Table 1**).

Progress to tackle all forms of malnutrition remains unacceptably slow. The 2018 Global Nutrition Report [10] tracks country progress against the following global


**Table 1.** *Global nutrition targets 2025 [12].* *Childhood Malnutrition in India DOI: http://dx.doi.org/10.5772/intechopen.89701*

participation is also lacking as parents do not sent their children to the centres

Social and cultural factors may also affect malnutrition. State government of Uttar Pradesh launched Hausla Poshan Yojana in 2016 to combat malnutrition among mothers and children by providing food cooked by Anganwadi Workers. Surprisingly beneficiaries refused to consume food because lower caste people prepared it [20]. Upper caste community considers lower caste as untouchables. Another cultural practice still prevalent in Indian communities is child marriage that is acting as limiting factor in improving health of children. 27% of girls in India are married before their 18th birthday and 7% are married before the age of 15. According to UNCIEF, India has the highest absolute number of child brides in the world [21]. A weak mother is likely to give birth to a weak child. This maintains the

As discussed earlier that poor sanitation is directly linked to malnourished children. The Census 2011 told us only 32% of India's rural households had toilets. 59% of the 1.1 billion people in the world who practice open defecation live in India. On 2 October 2014, Swachh Bharat Mission was launched throughout country with an aim to achieve the vision of a 'Clean and Open Defecation-Free India' by 2 October 2019 [22]. These targets are difficult to achieve, as implementation is poor, as observed from the slow progress in meeting the targets, and the existence of

Diarrheal disease kills an estimated 300,000 children less than 5 years of age (13% deaths in this age-group) in India each year. Most mortality related to diarrhoea occurs in less developed countries, and the highest rates of diarrhoea occur among malnourished children under-1. The case fatality rate is highest among children aged 6–12 months because at this age the immune system is not yet fully mature, maternal antibodies are waning, and the foods introduced to complement

diarrhoea, chronic infections can contribute to malnutrition. In turn, malnutrition makes children vulnerable to diarrhoea infections. Better access to clean water and sanitation is the key, with fewer weak and malnourished children becoming

**9. Commitments and targets to track progress to end malnutrition**

Recognizing the seriousness of malnutrition for global health, in 2012 and 2013, the member states of the World Health Organization (WHO) adopted a series of targets to significantly reduce the burden of many of these forms of malnutrition by

Progress to tackle all forms of malnutrition remains unacceptably slow. The 2018 Global Nutrition Report [10] tracks country progress against the following global

**Child health goals under NHP-2017 and SDG-2030 Child health indicator Current status NHP 2017 SDG 2030** Neonatal mortality rate (NMR) 24 16 by 2025 <12 Infant mortality rate (IMR) 34 28 by 2019 — Under-5 mortality rate (U5MR) 39 23 by 2025 ≤25

breastfeeding may be contaminated. Among children who survive severe

several newly constructed but non-functional toilets [21, 23].

(source: Dainik Jagran, Lucknow, 1 November 2009).

*Perspective of Recent Advances in Acute Diarrhea*

cycle of undernourishment.

infected [24, 25].

2025 (**Table 1**).

*Source: Ref. [33]*

*Global nutrition targets 2025 [12].*

**Table 1.**

**18**

targets: child overweight, child wasting, child stunting, exclusive breastfeeding, diabetes among women, diabetes among men, anaemia in women of reproductive age, obesity among women and obesity among men. Data for 194 countries was analysed. As per this report, India is listed among those countries, which are on track for none (zero) of the nine targets. The key driver behind the goal to reach Zero Hunger and malnutrition is to ensure that no one is left behind in the pursuit of food and nutrition security. In the Indian context, this will also mean greatly improving the health of women and children.

## **10. Determinants of child malnutrition**

The causes of malnutrition in India are several and multifaceted, from direct factors to underlying contributors. Malnutrition in children occurs as a complex interplay among various factors like socio-demographic, maternal, gender, home environment, dietary practices, hand washing and other hygiene practices, etc. **Figure 7** depicts factors significantly associated with malnutrition among under-5 children in India.

*Socio-economic and demographic factors*: literacy status of parents especially mother's education, caste, birth order of child, gender of household head, residence,

**Figure 7.** *Factors significantly associated with malnutrition among under-5 children [36].*

type of house, type of family (single/joint) lower socio-economic status, poverty, food insecurity, etc. are such important factors.

determinant. Hand washing before preparation, serving and eating meals and after

*Diarrhoeal disease*: diarrhoea is a leading cause of malnutrition in children under 5 years old. Poor sanitation, lack of access to clean water and inadequate personal hygiene are responsible for an estimated 88% of childhood diarrhoea in India. Based on current evidence, washing hands with soap can reduce the risk of diarrheal diseases by 42–47%. A survey conducted by UNICEF in 2005 on well-being of children and women had shown that only 47% of rural children in the age-group

**Figure 8** depicts the underlying drivers of malnutrition. They are complex and multidimensional which include inter alia poverty, inequality and discrimination. Control of malnutrition will require a comprehensive approach targeting all these

The challenge of malnutrition calls for a multidisciplinary approach that targets multiple underlying factors. Crucial stages in people's lives have particular relevance for their health, and the life-course approach recognizes the same. Taking a life-course perspective to tackle malnutrition emphasizes its

Intervening in the preconception period is fundamental to improve nutritional status and health behaviours in young people and adolescents and to prevent the transmission of risk to the next generation. Adopting a combination of top-down approaches through policy initiatives and bottom-up engagement of key stakeholders such as young people is recommended to prevent malnutrition over the first 1000 days of life. Targeting pregnancy and preconception periods increases nutri-

It is an established fact that preventing undernutrition during the first 1000 days of a child's life, i.e. from conception to the second birthday is quite important. This time period is very precious because child may not be able to grow to her or his full potential in the future and even irreversible damage may occur, if foundation for good nutrition is not properly established during this time period. However it does not mean that there are no other entry points to improve nutrition. Moreover, even with coverage of 90% of direct nutrition interventions, only 20% of stunting deficits would be addressed [29]. It is essential that preconception services are incorporated into a continuum from childhood to antenatal care, involving both partners and linked to interventions to promote school attendance in young girls, and the

The life course approach underlines the dynamic nutritional needs at different stages of life, this holds true especially with women. It also explains that at each stage of life, nutrition can and should be addressed in order to break the cross-

**Figure 9** depicts the life course approach which explains how the first 1000 days are critically important. Investments in nutrition must extend as per the changing needs and risks at later stages in life, such as adolescent girls and women of reproductive age. It also points towards underlying causes of malnutrition and the need to address them. Underlying causes can only be satisfactorily addressed with intersectoral co-ordination and involvement like health, agriculture, water and sanitation, social protection and education. These sectors should be involved taking into account the specific needs and roles of women in order to work towards

going to toilets can prevent malnutrition to a great extent.

causes and contributors across sectors and stakeholders.

**11. The life-course approach on malnutrition**

tion awareness and influences dietary habits.

planning of first and subsequent pregnancies [30].

generational cycle of malnutrition [31].

sustainable and inclusive solutions.

**21**

5–14 wash hands after defecation [28].

*DOI: http://dx.doi.org/10.5772/intechopen.89701*

*Childhood Malnutrition in India*

intergenerational effects.

*Gender*: female gender is vulnerable to severe forms of malnutrition across all ages due to socio-cultural factors (responsible for child bearing and rearing, last one to consume food in the family). Undernourished girls grow up to become undernourished women who give birth to a new generation of undernourished children [26].

*Maternal factors*: short stature, mother's nutrition, mother's age, antenatal and natal care, infections, smoking and exposure to second hand smoke are important maternal factors.

*Breastfeeding practices*: inadequate, insufficient, inappropriate breastfeeding practices lay down foundation of malnutrition. Breastfed children are protected from infections in better way than who are not breastfed. Early initiation of breastfeeding and right timing of initiation of complementary feeding are also quite important [27].

*Home environment*: large family size, food insecurity, toilet facility, sanitation and hygiene practices, water storage and handling practices are extremely important factors.

*Open air defecation*: open defecation, the practice of people defecating out in the open wherever it is convenient, is one of the main factors leading to malnutrition. Approximately in the urban setting, 12% of the population open defecate and rural areas that number is 72%. Open defecation leads to polluted water; up to 75% of India's surface water is polluted.

*Poor hand hygiene*: role of hand hygiene is quite important in prevention of infections and thereby malnutrition. Availability of soap and water is an important

#### **Figure 8.**

*Underlying drivers of malnutrition (source: Reproduced from the Global Nutrition Report 2016. International Food Policy Research Institute. 2016. Global Nutrition Report 2016: From promise to impact: Ending malnutrition by 2030. Washington, DC).*

#### *Childhood Malnutrition in India DOI: http://dx.doi.org/10.5772/intechopen.89701*

type of house, type of family (single/joint) lower socio-economic status, poverty,

*Breastfeeding practices*: inadequate, insufficient, inappropriate breastfeeding practices lay down foundation of malnutrition. Breastfed children are protected from infections in better way than who are not breastfed. Early initiation of

breastfeeding and right timing of initiation of complementary feeding are also quite

*Home environment*: large family size, food insecurity, toilet facility, sanitation and hygiene practices, water storage and handling practices are extremely impor-

*Open air defecation*: open defecation, the practice of people defecating out in the open wherever it is convenient, is one of the main factors leading to malnutrition. Approximately in the urban setting, 12% of the population open defecate and rural areas that number is 72%. Open defecation leads to polluted water; up to 75% of

*Poor hand hygiene*: role of hand hygiene is quite important in prevention of infections and thereby malnutrition. Availability of soap and water is an important

*Underlying drivers of malnutrition (source: Reproduced from the Global Nutrition Report 2016. International Food Policy Research Institute. 2016. Global Nutrition Report 2016: From promise to impact: Ending*

*Gender*: female gender is vulnerable to severe forms of malnutrition across all ages due to socio-cultural factors (responsible for child bearing and rearing, last one to consume food in the family). Undernourished girls grow up to become undernourished women who give birth to a new generation of undernourished children [26]. *Maternal factors*: short stature, mother's nutrition, mother's age, antenatal and natal care, infections, smoking and exposure to second hand smoke are important

food insecurity, etc. are such important factors.

*Perspective of Recent Advances in Acute Diarrhea*

maternal factors.

important [27].

tant factors.

**Figure 8.**

**20**

*malnutrition by 2030. Washington, DC).*

India's surface water is polluted.

determinant. Hand washing before preparation, serving and eating meals and after going to toilets can prevent malnutrition to a great extent.

*Diarrhoeal disease*: diarrhoea is a leading cause of malnutrition in children under 5 years old. Poor sanitation, lack of access to clean water and inadequate personal hygiene are responsible for an estimated 88% of childhood diarrhoea in India. Based on current evidence, washing hands with soap can reduce the risk of diarrheal diseases by 42–47%. A survey conducted by UNICEF in 2005 on well-being of children and women had shown that only 47% of rural children in the age-group 5–14 wash hands after defecation [28].

**Figure 8** depicts the underlying drivers of malnutrition. They are complex and multidimensional which include inter alia poverty, inequality and discrimination. Control of malnutrition will require a comprehensive approach targeting all these causes and contributors across sectors and stakeholders.

#### **11. The life-course approach on malnutrition**

The challenge of malnutrition calls for a multidisciplinary approach that targets multiple underlying factors. Crucial stages in people's lives have particular relevance for their health, and the life-course approach recognizes the same. Taking a life-course perspective to tackle malnutrition emphasizes its intergenerational effects.

Intervening in the preconception period is fundamental to improve nutritional status and health behaviours in young people and adolescents and to prevent the transmission of risk to the next generation. Adopting a combination of top-down approaches through policy initiatives and bottom-up engagement of key stakeholders such as young people is recommended to prevent malnutrition over the first 1000 days of life. Targeting pregnancy and preconception periods increases nutrition awareness and influences dietary habits.

It is an established fact that preventing undernutrition during the first 1000 days of a child's life, i.e. from conception to the second birthday is quite important. This time period is very precious because child may not be able to grow to her or his full potential in the future and even irreversible damage may occur, if foundation for good nutrition is not properly established during this time period. However it does not mean that there are no other entry points to improve nutrition. Moreover, even with coverage of 90% of direct nutrition interventions, only 20% of stunting deficits would be addressed [29]. It is essential that preconception services are incorporated into a continuum from childhood to antenatal care, involving both partners and linked to interventions to promote school attendance in young girls, and the planning of first and subsequent pregnancies [30].

The life course approach underlines the dynamic nutritional needs at different stages of life, this holds true especially with women. It also explains that at each stage of life, nutrition can and should be addressed in order to break the crossgenerational cycle of malnutrition [31].

**Figure 9** depicts the life course approach which explains how the first 1000 days are critically important. Investments in nutrition must extend as per the changing needs and risks at later stages in life, such as adolescent girls and women of reproductive age. It also points towards underlying causes of malnutrition and the need to address them. Underlying causes can only be satisfactorily addressed with intersectoral co-ordination and involvement like health, agriculture, water and sanitation, social protection and education. These sectors should be involved taking into account the specific needs and roles of women in order to work towards sustainable and inclusive solutions.

**12.2 Related indicators**

*Childhood Malnutrition in India*

*DOI: http://dx.doi.org/10.5772/intechopen.89701*

*anaemia pertain to children aged 6–59 months).*

6 months of age).

**12.3 Status of child mortality in India**

lakh) and Rajasthan (0.75 lakh).

within first 1 month of birth.

Development Goals (SDGs).

**23**

NFHS-4.

**Figure 10.**

• Only 41.6% newborns initiated on breastfeeding within 1 hour of birth while

*Comparison of nutrition indicators as per NFHS-3 and NFHS-4 (source: NFHS-4, 2015–2016. Note: data on*

• Complementary feeding started for only 42.7% children on time (more than

**Figure 10** shows the comparison of nutrition indicators as per NFHS-3 and

• The U5MR has declined at a faster pace in the period 2008–2016, registering a compound annual decline of 6.7% per year, compared to 3.3% compound

• As per latest Sample Registration System, 2016 Report; The U5MR in India is 39/1000 live births, IMR is 34/1000 live births and NMR is 24/1000 live births. This translates into an estimated 9.6 lakh under-5 child deaths annually.

• About 46% of under-five deaths take place within the first 7 days of birth, 62%

The state of malnutrition in India is alarming and disturbing. A lot of work has been done, progress has been made but definitely pace of improvement is too slow. Following table shows the current status of important child health indicators and time bound targets to be achieved under National Health policy and Sustainable

• Four States together contribute to 56% of all child deaths in the country, namely-Uttar Pradesh (2.45 lakhs), Bihar (1.2 lakhs), Madhya Pradesh (1.0

54.9% children breastfed exclusively till 6 months of age.

• 58.4% of children in age group 6–59 months are anaemic.

annual decline observed over 1990–2007 [33].

**Figure 9.**

*The life-course approach on malnutrition.*
