This section presents actionable insights for practitioners from our collaboration of experts.
India leads the burden of wasting with 25 million wasted children under the age of five, which is more than the combined burden of the next nine high-burden countries. In India, 30% of children are wasted and 13% are severely wasted before six months of age; one in five children is wasted under the age of five. The prevalence of wasting shows some improvement in the 2013-14 Rapid Survey on Children (RSOC), but continues to be critical (equal to or more than 15% ) or serious (10-14%) in most Indian states. The statistics are a consequence of poor prenatal nutrition compounded by poor infant and young child feeding practices and high rates of illnesses and disease.
The proportion of wasting is very similar in urban and rural areas while the efforts by the government to address child malnutrition are focused more in the rural areas. Wasting is slightly higher among the male children and among the scheduled tribes and children from the lowest wealth index.
Misconceptions link child malnutrition to rural areas and Africa, whereas the problem is widespread in Asia and hits urban poor just as hard as rural poor. While rural poor may have opportunities of land farming and housing extension, such solutions for urban poor are constrained by congested spaces and dependency on food purchase.
The National Nutrition Monitoring Bureau (NNMB) survey conducted for urban population in 2017 finds that 16% of urban children are born with low birth weight. This ranges from 30% in Delhi to 10% in Puducherry. As per NFHS 4 data, only half of the children under the age of three (42%) in urban areas are breastfed within one hour of birth while 52% are exclusively breastfed and 50% are introduced to solid or semi-solid food at six months of age. According to the NNMB survey 42% are initiating breastfeeding within one hour of birth and 34.4% are introducing complementary food at six months of age.
The urban poor population (including the slums in urban areas) has a high prevalence of under-nutrition as almost one third (29%) of urban poor children are reported to be underweight and an equal percentage (31) as stunted (NFHS 4). Among urban poor, the burden of child malnutrition is considerable. Analysis of NFHS 3 data reveals that only 11% slip through the trap of malnutrition while as many as 72% are both stunted and underweight. In the absence of community cohesiveness in the urban poor communities, and the hitherto lack of community workers other than the Anganwadi worker, malnutrition has been much neglected among the urban poor. Nearly half of the urban pregnant women and under five children are anemic (45.8% and 56% respectively).
The NNMB survey focusing specifically on urban population finds that the overall prevalence of underweight, stunting and wasting among under-five age group children were 25, 29 and 16 percent respectively. There were no significant differences observed among the genders for underweight, although stunting was marginally higher among boys compared to girls.
The assessment further measured thinness among school going children and found that prevalence was more among the boys.
Figure: Prevalence of Thinness among School age Children and Adolescents. Source NNMB report 2017
NFHS 4 finds that 15% of urban men and women are below the normal range of Body Mass Index (BMI) and one third of women (31%) and quarter of men (26%) are overweight or obese. The more recent NNMB report finds that while 13 % of men and 11% of women suffer from chronic energy deficiency, the prevalence of overweight or obesity was 34% and 44% among men and women respectively (BMI > 25). According to WHO Asian cutoffs (BMI > 23), 52% of men and 59% of women were overweight or obese. Rajasthan, Puducherry, Tamil Nadu and Delhi had the highest proportion of overweight men and Puducherry and Tamil Nadu had more overweight women.
Consequently, about 31% of men and 26% of women above the age of 18 suffered from hypertension; the highest proportions were recorded in Kerala for both men (46.6%) and women (38%).
Figure: Prevalence of Hypertension among Urban Men and Women, Source NNMB report 2017
Child malnutrition is multifactorial and is dependent on maternal nutritional status, diet diversity, water and sanitation. Fighting child malnutrition necessarily means addressing all its causes in an integrated manner. Malnutrition appears early with low birth weight, compounded around the time of diet diversification (6-12 months), and keeps worsening with age, suggesting the need for strengthened medical supervision of urban poor children. While the Integrated Child Development Scheme (ICDS) is responsible for ensuring prevention of malnutrition, the associated morbidities fall under the purview of the health department, thus requiring a close coordination between the Anganwadi worker and the ASHA/ANMs. However, operational challenges exist to create effective coordination. The jurisdiction of ASHAs and the Anganwadi centres (AWCs) do not coincide; there are more ASHAs than AWCs, which leads to nutrition not being an inherent agenda for the ASHA where AWCs are not present. The Mahila Aarogya Samitis (MAS) have been linked to the AWCs in some states; others will need to prioritize this as well.
The space deficit in the urban settings mean that the Urban Health and Nutrition Days (UHNDs) which are meant to be a platform for such coordination are not implemented in a comprehensive manner. This will require that NUHM teams coordinate effectively with the Urban Local Bodies and local representatives to identify room for conducting comprehensive UHNDs as per the guidelines.
The AWC worker is mandated to refer the severely malnourished child to the health centre. The UPHCs do not have a nutrition corner or standard guidelines for managing the children. Thus the children are generally referred to the tertiary hospital. There are approximately 9% severely malnourished children as per the NFHS 4 data. One tenth of these (with complications) will require secondary or tertiary care management. Most can be managed at the community level (support feeding, health education, support in the form of crèche) or at the UPHC level (infection management, immunization and deworming).
Africa has successfully implemented small scale fortification to address decentralized management of malnutrition. The rural Self-help Groups (SHG) of erstwhile Andhra Pradesh successfully managed crèche and nutrition centres for women and children. This strategy could be explored in the urban context as well where AWCs are not available.
According to WHO, NCDs contributed to an estimated 61% of all deaths in 2014 in India. Projections indicate that rate will rise to 67% by 2030. NCDs impact people at younger ages at a higher rate in India when compared to the high-income countries, increasing the healthy life years lost and the risk of premature death. About 29% of NCD-related deaths in low and middle-income countries occur among people under the age of 60, compared to 13% in high-income countries. Health care in India is mainly financed by out of pocket expenditure. NCDs have a huge socioeconomic impact due to the required long-term treatments, which is particularly difficult to bear for the urban poor and can have a negative impact on poverty alleviation (Rajan & Prabhakaran, 2012). For India alone, the costs incurred by the treatment of cardiovascular diseases, diabetes, cancer, chronic respiratory diseases and mental health disorders between 2012 and 2030 have been estimated at US$6.2 trillion. The urban primary health facilities will need to focus on screening for overweight and obesity and address the changing lifestyles of the urban population resulting in the burden of NCDs. While NUHM is committed to screening, identifying and managing diabetes and hypertension as an immediate action, more focus will be required on introducing preventive measures, which include promoting healthy dietary habits, implementation of interventions which promote physical activities, behavior change communication and support groups for community members who are dealing with overweight or obesity.
The Prime Minister’s Overarching Scheme for Holistic Nutrition (POSHAN Abhiyaan) or National Nutrition Mission is Government of India’s flagship programme to improve nutritional outcomes for children, pregnant women, and lactating mothers. The National Nutrition Strategy, released by NITI Aayog in September 2017 presents a micro analysis of the problems persisting within this area and chalks out an in-depth strategy for course correction. Most of the recommendations presented in the Strategy document have been subsumed within the design of the POSHAN Abhiyaan.
The four-point strategy of the POSHAN Abhiyaan are-
1. Inter-sectoral convergence for better service delivery
2. Use of technology (ICT) for real time growth monitoring and tracking of women and children
3. Intensified health and nutrition services for the first 1000 days
4. Jan Andolan: Leveraging various platforms and community resources to promote nutrition actions and behaviors
Deriving from these strategies the urban health apparatus can push the Mission for the following actions that can strengthen how nutritional interventions are implemented in the urban areas:
1. Focused on reducing stunting and under-nutrition among children; low birth weight; and prevalence of anemia among children, adolescent girls and women, the POSHAN Abhiyaan lays down operational plans for convergence. While state, district and block level convergence committees have been proposed, ensuring the participation of medical and NHM officials, the participation of medical/public health teams of Urban Local Bodies (ULB) and NUHM officials at city and ward levels has not been delineated.
2. Establishment of city and ward level convergent committees, especially in large metropolitan and tier II cities in each state may thus be considered as a first step to facilitate urban specific focus.
3. Convergent actions planning at city and ward levels could result in co-location of AWCs with ASHA coverage areas, leveraging of MAS for monitoring and supporting undernourished children; supporting community level activities to address complementary feeding, anemia prevention and care and dietary interventions to prevent under-nutrition, stunting, low birth weight and anemia.
4. Alternatively, the district level committees envisaged by the scheme may consider the participation of ULB representatives, and city program management representatives of NUHM. However, there will still remain the need for ward level focus on convergent actions for promoting nutrition.
In addition, while NUHM envisages the establishment of ‘Nutrition Corners’ within the UPHCs, it will need to develop referral and follow up mechanisms between ICDS and UPHC functionaries. The two departments can consider issuing a joint directive to states to ensure adequate convergence and coordination to make the scheme a success in urban areas.
Actionable Items within the urban program
As our primary health centres are transformed into health and wellness centres, systematic nutritional interventions to address malnourishment (under and over) need to be designed and implemented. These may include and not limited to:
1. Diet demonstration and behavior change communication for both malnutrition and obesity at the community and facility level
2. List of actions to be taken at the UPHC and community level for addressing malnutrition and obesity
3. Delineated referral pathway for severely malnourished children
4. Exploring pilots for MAS-managed nutrition crèche/weight reduction centres/fortified food production
5. Along with Yoga, introducing cardio-vascular exercises such as walking groups led by ASHAs
6. Monitoring of weight of overweight/obese adults and children, especially those on diabetes or hypertension medication to prevent complications from the disease
Dr. Ranjani Gopinath is a Public Health Specialist with 26 years of subject experience in maternal and child health, nutrition, urban health, TB, infectious diseases, and health system strengthening. She has international experience in program planning, design and evaluation design and has led large scale qualitative evaluations/analysis of maternal child survival and TB/HIV programs in Southeast Asia, Asia and Africa. She currently leads the establishment of an Alliance for Comprehensive Primary Health Care (CPHC) in India on behalf of Swasti – the Health Catalyst.