How Can We Address the Rising Incidence of Wasting among Children in India?

Wasting among children, typically a temporary phenomenon occurring due to food shortage and diseases, has shown an increase in India over the last decade. This has happened even in rich states. Existing literature does not offer much explanation for this. Besides wasting audits, what measures can be taken within the existing systems to effectively deal with the issue of undernutrition in general and wasting in particular?

Malnutrition has been identified as one of the three national emergencies by the recently released study on burden of disease (ICMR, PHFI, and IHME 2017). Malnutrition is an all-encompassing term that covers both ends of the nutrition spectrum. Along with undernutrition, India now also faces the burden of overnutrition or obesity, which is a contributory factor in one of the other two national emergencies of lifestyle related diseases. The recently released National Family Health Survey as well as other surveys measure the prevalence of malnutrition in children under the age of five in the country, providing a snapshot as well as facilitating trend analysis (Pandey 2016). 

The Problem

While the term malnutrition encompasses both under- and over-nutrition, this article focuses more on undernutrition in children below the age of 5 years since it still affects a larger proportion of the population and also the most vulnerable. The traditional, and globally recognised, measures of undernutrition are stunting (height for age) and wasting (weight for height). These measures are typically obtained through large surveys while the Integrated Child Development Services (ICDS) measures underweight or weight for age. Stunting and wasting have serious implications for the development of the child into adulthood. The costs of stunting in terms of cognition and productivity are very high. However, on average, for every dollar that governments around the globe invest in nutrition to reduce stunting, they see a return of 16 times as much (IFPRI 2014). Undernutrition, measured whichever way, is basically a manifestation of how systems work—there are a host of immediate and proximate causes, not related only to food intake, that impact the levels of stunting and wasting. A series on maternal and child nutrition in Lancet (2013), identified nutrition-sensitive and nutrition-specific interventions affecting undernutrition as depicted in the figure below.


Proven Interventions for Malnutrition Reduction (Adapted from Lancet [2013])

From the last National Family Health Survey in 2005–06 to the most recent one of 2015–16, the prevalence of stunting among children under 5 years has declined from 48% to 38.4%. While this decline is appreciable, it hides large interstate variations. A worrying trend is the increase in wasting among children less than 5 years of age. For the country as a whole, the percentage of wasted children under 5 has increased from 19.8 to 21 in the last decade. 

Wasting or thinness indicates in most cases a recent and severe process of weight loss, which is often associated with acute starvation and/or severe disease. However, wasting may also be the result of a chronic unfavourable condition. Provided there is no severe food shortage, the prevalence of wasting is usually below 5%, even in poor countries. The Indian subcontinent, where higher prevalences are found, is an important exception. A prevalence exceeding 5% is alarming given a parallel increase in mortality that soon becomes apparent. On the severity index, prevalences between 10% and 14% are regarded as serious, and above or equal 15% as critical. (WHO nd a)

The prevalence of 21%, and more alarmingly, the increase, is indeed an emergency, especially when we consider the implications for mortality and morbidity, which have both human and financial dimensions. 

It is paradoxical that the proportion of wasted children in India has gone up in the decade of economic growth (IMF 2018). Indeed, stunting has reduced in the period, in spite of it being a more “chronic” condition and more dependent on macro factors. Wasting is traditionally regarded as a more “acute” condition, occurring as a direct result of food shortages and famines. Given that this is not the situation in India, why is there an increase in wasting? Wasting may not, after all, be an episodic or acute condition and there could be other causal factors (Sharma 2017). Factors that affect stunting, as identified in the figure above, could also be impacting wasting. Additionally, emphasis on single cereal consumption through PDS, protein deficiency, actual food scarcity, increasing consumption of processed and packaged foods, and intra household food distribution as it impacts women, could all be contributors. 

The Current Policy

Undernutrition has traditionally been the domain of the Ministry of Women and Child Development (MWCD). The mechanism or apparatus to ensure nutrition in children under 5 is the ICDS. 

Undernutrition is tackled under the ICDS through supplementary nutrition through a network of anganwadi centres across the country. These centres give take-home rations to children under three years of age and hot cooked meals to those over three. The anganwadi worker (AWW) measures the “weight for age” of children on a growth chart, thus measuring underweight children. This is easier to measure and more doable. However, the process misses children who fall under the cracks: the wasted children, or as we call them, children who suffer from moderate acute malnutrition (MAM) and severe acute malnutrition (SAM). Typically, children suffering from SAM are identified through surveys or a simple method of mid upper arm circumference (MUAC). A paper tape with markings, when wound around the child’s upper arm, indicates if the child has MAM or SAM. The cut-off for severe acute malnutrition, measured using the MUAC tape, is 115 mm and affected children will have very thin arms (WHO nd b). This reduced muscle mass increases the risk of death during infections and also in many pathological situations. 

However, not all states use MUAC tapes, not all identify children with SAM, and even where this happens, not all children with SAM are effectively treated. Besides, the identification through MUAC is only the curative aspect as it identifies children after they are already wasted. The prevention aspect would need convergence with a large number of actors, especially those that impact household incomes, women’s education and empowerment, and other nutrition sensitive and specific interventions. 
However, at the very basic level, convergence is more an assumption than a reality in the context of wasting. This non-convergence at the field level and lack of adequate mechanisms to ensure the same have emerged as major challenges. The national nutrition strategy seeks to address undernutrition through a number of interventions that cut across departments, as well as identify districts for focused attention (NITI Aayog nd). MWCD is the nodal ministry for this.

How the System Actually Works

In the system at present, the wasted, or rather the severely wasted, child is brought to the nutrition rehabilitation centre (NRC) via the AWW, auxiliary nurse midwife (ANM) route. The NRCs are set up under the health department, where the child is treated, given nutritious food, and then discharged after getting well. The mothers are counselled and trained for follow-up, as are the AWWs and Accredited Social Health Activists (ASHAs), to ensure that the child does not have a relapse. 

At this stage, the child is, in a way, abandoned, in a nowhere zone between two departments. Somewhere between the NRC and the community, the child with SAM falls between the cracks. The system treats malnutrition as a disease in the NRC. After recovery, uncoordinated follow-up implies that the child is seen as a patient, instead of being seen in the context of the family, community, and village. The socio-economic factors affecting wasting get ignored in a medicalised approach to children with SAM. Similarly, the preventive aspect of ensuring that more children do not fall prey to wasting and/or are neglected is even more ignored in this approach. The non-convergence of ICDS and health, and more importantly of the family and community implies that more wasted children are neglected and wasting is not prevented. 

Some Suggested Interventions 

In the present scenario, the child with SAM is plucked from the community, treated and sent back with the assumption that all will be well, and any underlying causes that led to the problem in the first place will no longer exist. Thus, a systemic change in the way we deal with the issue is needed. 

Focus on Prevention: Two different prevention approaches can be thought of.
i) In each state, including the rich ones, there are pockets and families with deprivation. The families and communities where wasting exists can be identified, and their vulnerabilities addressed through focused interventions at the village level itself. These could be “red flag” households with a history of malnutrition, of infant death, low incomes, or migrant families, and single parent headed households. Through such prior identification and then redressal of those weaknesses through the local community/panchayati raj institutions (PRIs) network, much of undernutrition can be prevented. This will require major interventions by the government to induce community ownership of vulnerable families and incentivising prevention of malnutrition.  

ii) The huge out-of-pocket expenditure on health shows us that families are willing to spend on their loved ones’ health. Undernutrition is often so insidious that families may not even recognise it for what it is, leave alone address it. Behavioural economics can be applied by nudging families and communities to recognise malnutrition and ensuring that wasting is not seen as a disease to be treated, but as a condition to be tackled at home. Given the right identification mechanisms and support, the families can take over the “treatment.” The parallel of oral rehydration salts (ORS) comes to mind, where diarrhoea was once a condition only treated at the hospital and the advent of ORS made treatment at home possible. 

While a one-shot NRC treatment is required for a severely malnourished child, it is not a solution that can address the underlying causes unless families are empowered and villages take ownership of each child. This can be done effectively through already existing, well designed, and proven systemic structures and interventions within the country.

Making Wasting Reduction Sustainable: As noted above, reduction in undernutrition is possible through preventive action at the community level. In the context of wasting, there are good examples of sustainable local practices. Many states have in the recent past taken up community management of acute malnutrition (CMAM), where children with SAM are identified through routine MUAC screenings, the sick children are sent to the NRC, while the non-sick are retained at the village but given additional food through the anganwadi centres. In Odisha, this was started in 2014 in Kandhamal district, which then had the highest under-5 mortality in the country, and the emphasis was given on locally produced (by self-help groups), locally sourced and contextual energy-dense, nutrition-rich food (EDNRF). Independent evaluations showed an appreciable decline in SAM percentage (Valid India Trust 2016). There was a built-in element of community follow-up and more importantly, early recognition and prevention of the SAM status. Company manufactured and packaged ready-to-use therapeutic food has been used in emergency wasting situations in Africa and elsewhere, but it has the danger of becoming an aspirational product (like breast milk substitutes), hence locally sourced and locally produced EDNRF, which is more sustainable, was used and proven effective. Without the community element of CMAM, the family may be led to believe that malnutrition is a sickness only to be cured by taking the child to the NRC and that their responsibility ends after coming back from there. CMAM ensures proper identification, follow-up in case the child is sick, ensuring that children who are not sick remain in the village, and integrating local diet habits and community practices in follow-up. The success of CMAM has been demonstrated and need to be scaled up in affected pockets. 

Create Institutional Structures That Facilitate Convergence: Countries such as Brazil, Peru and Sri Lanka have shown the way in creating overarching, cross departmental structures with a focus on malnutrition (IFPRI 2016). Africa has been successfully using the malaria score cards that bring departments and countries together and assess their progress on common indicators (ALMA 2018). The NNM and the “aspirational” districts identified for focused interventions are a step in the direction, but will not be effective unless synergy is achieved where it matters most—at the village level. Appropriate frameworks at the village level with devolution of responsibilities to field level workers of different departments can be created, and incentive and monitoring systems can be designed to ensure accountability. 

Create Evidence for Decision-making: Existing literature does not currently provide an answer to the increase in wasting, especially in prosperous states. It is imperative to get a clear understanding of the causes and then take an  evidence-based decision. The health department currently does maternal and child death audits. These are quite structured, and provide an insight into the background of the mother or child, and give a human and social context to the death. In the case of a child coming to the NRC, there is an even greater social context to the wasting which needs proper investigation. A death audit is required in the system; a wasting audit of the alive, but severely malnourished child will not only help prevent that death, but also help in preventing more malnourished children and more deaths. The current NRC guidelines need to incorporate a wasting audit. NRM machinery that supports NRCs can easily do this. As with all such exercises, the question “why” needs to be asked multiple times to get to the bottom of the matter. Was it because the mother had an early pregnancy? Does the family have food stress? Did they not get work? Are they landless? Are they migrants? Do they not have food diversity?  Is there something else that is happening, maybe something related to soil quality, use of certain kinds of fertilisers or pesticides? Maybe there are some other factors at play altogether, such as single cereal promotion under PDS or lack of nutrients in the soil due to overuse of pesticides?  The audit results will give a local picture and also provide a snapshot of why the phenomenon of wasting is on the rise. In addition to this, GIS (geographic information system) mapping could help us identify pockets of neglect. 

Evidence-based decision-making has many benefits. At the micro level, the community leaders, PRIs and the health and AWW workers get structured inputs to address the basic issues of vulnerable families with/without currently malnourished children. At the macro level, we can start seeing in how many children wasting and stunting is a concurrent situation. A proper audit of children with SAM in NRCs will shed light on the causal factors behind wasting, and the increased trend of wasting.

Simultaneously, at the macro level, there is also learning from within the country. There are states that have achieved a reduction in both wasting and stunting. The factors at play in those states can be understood and replicated elsewhere, within the local context. 

Conclusions 

A policy is only as good as its implementation. A policy that is designed in a vacuum will lead to yet another symbolic gesture that does not translate into real impact. The increase in wasting in children under 5 is an enigma and is especially unexplainable in richer Indian states. In order to tackle growing incidence of wasting, it is necessary to understand the causal factors. Malnutrition audits are likely be helpful to that end. However, while that is done, some improvements in the existing way of functioning can also be taken up through preventive steps rooted in the community, and community management of malnutrition. Above all, malnutrition needs convergent action across various departments and stakeholders, for which robust mechanisms will have to be set up from grass-roots to the top. 

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