The Malnutrition Debate – Truth or Hype ?
In the recent debate that has ensued between stalwart economists Amartya Sen and Jagdish
Bhagwati over growth models , there was also argument made in an article by noted economist Arvind Panagariya
about the validity of the WHO criteria for assessing undernutrition in which he
claims that the WHO model is "flawed" since it is based on a study that ignores
ethnic differences in the height and weight and hence the
shockingly huge numbers that are projected regarding the scenario of
malnutrition in India are over-estimations .
With regard to this I decided to read the available
literature regarding this claim .
Mr Arvind Panagariya in a recent article in Economic
times ( http://bit.ly/12WO4ON )(5)
And more clearly in an article in ToI in 2011 ( http://bit.ly/1cjZRxC
)(6)
argues the following points :
1.While India is ahead w.r.t most vital indicators such as
Life expectancy , IMR , MMR , it is surprisingly behind every single of the 48
Sub Saharan African (SSA) countries in terms of malnutrition , which seems to
be “puzzling”.
2.Even well developed states such as Kerala which otherwise
have high HDI and is high up on many social indicators lags behind on the malnutrition
numbers in comparison to some SSA countries.
3.Quoting the study done by WHO to determine the criteria
which brushed aside the ethnic differences as not so significant and adopted
the “below two standard deviations “ criteria , says Mr Panagariya ignores the
genetic potential of the Indian children and hence over assessment of the no.
of malnourished .
4 . He quotes a NFHS – 3 survey done in this regard which
studied the children from the elite households which found the prevalence of
malnutrition as per the WHO criteria to be 15 % much higher than the 2.14
% that can be expected (those many lie
below 2 S.D)
While these arguments make some sense , the question that
naturally arises is – what then are the numbers ? and What criteria should be applied to Indian
children ?
To understand the debate first we must understand basic
concepts of malnutrition . Malnutrition includes both undernutriton and
overnutrition . For our purpose we shall restrict ourself to understanding
Undernutrition.
Child undernutrition can manifest itself in different ways,
depending on the cause, severity, and duration. The three main measures (1) of
child undernutrition are
> stunting – low height for one’s age,
> wasting – low weight for one’s height, and
> underweight – low weight for one’s age.
Stunting is a good overall indicator of undernutrition
because it reflects the cumulative effects of chronic undernutrition. Wasting
reflects acute undernutrition resulting from inadequate food and nutrient
intake and/or repeated or severe disease.Underweight reflects either stunting
or wasting, or both.
Researchers measure these indicators using Z scores. These scores
reflect how much a child’s weight or height deviates from the standard for
healthy child growth set by the World Health Organization. The closer a child’s
Z score is to zero, the closer he or she is to the median of the international growth
reference standard. This standard is based on the fact that children of all
races and ethnicities have the capacity to reach a healthy weight and height.
In 2006, the World Health Organization updated its child growth standards, showing
that global child undernutrition was even more severe than previously thought.
For all three indicators, undernutrition (as represented by stunting, wasting,
or underweight) is defined as a Z score below -2 and severe undernutrition as a
Z score below -3.
Another form of undernutrition consists of deficiencies of
essential micronutrients – vitamins and minerals, especially iron, iodine, zinc
and vitamin A. Deficiencies of micronutrients are also referred to as “hidden
hunger” because they are often
present without showing any clinical signs. In the absence of blood tests, they
may remain undetected until they become very severe and life-threatening.
To this extent when we examine the WHO document on the
criteria (can be downloaded here - http://bit.ly/1e8qGCS )
It explains the rationale for the criteria adopted thus –
“The reasons for the choice of this cut-off are as follows:
1) Children below this cut-off have a highly elevated risk
of death compared to those who are above;
2) These children have a higher weight gain when receiving a
therapeutic diet compared to other diets, which results in faster recovery;
3) In a well-nourished population there are virtually no
children below -3 SD (<1%).
4) There are no known risks or negative effects associated
with therapeutic feeding of these children applying recommended protocols and
appropriate therapeutic foods.
It goes on to explain the rationale for the new growth
standards of 2006 –
“ Rationale - The WHO Child Growth Standards -In
2006, WHO published child growth standards for attained weight and
height to replace the previously recommended 1977 NCHS/WHO child
growth reference. These new standards are based on breastfed infants and
appropriately fed children of different ethnic origins raised in
optimal conditions and measured in a standardized way
(1). The same
cohort was used to produce standards of mid-upper arm circumference
(MUAC) in relation to age
(2).The new
WHO growth standards confirm earlier observations that the effect of ethnic
differences on the growth of infants and young children in populations is small
compared with the effects of the environment. Studies have shown that there may
be some ethnic differences among groups, just as there are genetic differences
among individuals, but for practical purposes they are not considered large
enough to invalidate the general use of the WHO growth standards population as
a standard in all populations.
Notably the document also states , "When using the WHO child
growth standards to identify the severely malnourished among 6–60 month old
children, the below -3SD cut-off for weight-for-height classifies two to four
times as many children compared with the NCHS reference”
(Th NCHS reference were first introduced in 1970s and are being gradually replaced by the WHO criteria worldwide.)
(Th NCHS reference were first introduced in 1970s and are being gradually replaced by the WHO criteria worldwide.)
Why Mr Panagariya may not be right ? ...
- The basic objection to Mr.Panagariya’s contention is that the small variations in the growth charts is not going to affect the overall definition of malnutrition because since the child has to be 2 S.D below ( for moderate and below 3 S.D for severe ) the normal to be diagnosed as malnourished and thus even if ethnic differences do account smaller heights and weights to Indian children it does not in any way mean that they have to lie 2 S.D below the ideal growth features.
- To illustrate – suppose 6 feet is considered the ideal height then the diagnosis for “dwarfness” would be much less than that say < 3 feet and if the normal height of Indians is 5ft on an average it wont affect the diagnosis of “dwarfness” as it would be < 3 ft which would be abnormal even for Indians in this case.
- Moreover another point of contention would be the inter- generational aspect . Since malnourished mothers would near children which are small there is some reason to believe that such children would be “constitutionally small” i.e. their genetic potential itself would be less . But this still would be higher than the abnormality i.e. that of the stunted child. Also as it is explained in the WHO document the criteria also correlates with other factors like high likelihood of morbidity and mortality.
Hence , although the figures of IMR ,MMR and life expectancy
at birth for India are better than SSA countries it remains a stark reality
that a vast proportion of our children are undernourished.
Coming to the question of social spending on nutrition
interms of Mid Day Meal or the recent National Food Security Ordinance or Act , two noteworthy points are made
in the Global Hunger Index Report of 2010.
- “ Thailand, for example, halved child malnutrition from 50 to 25 percent in less than a decade during the 1980s. The country achieved this remarkable success by using targeted nutrition interventions to eliminate severe malnutrition and by creating a widespread network of community volunteers to help change people’s behavior to prevent mild to moderate malnutrition……... The Thai government took the view that investments in nutrition are not welfare, but rather investments in development, and it integrated nutrition into its National Economic and Social Development Plan (Tontisirin and Winichagoon 1999). At the same time, it invested heavily in health, sanitation, and education during this period.”
- "As part of the Copenhagen Consensus 2008, a panel of experts consisting of eight leading economists critically examined and ranked the world's biggest problems and concluded that the greatest development good would come from a nutrition intervention (the provision of micronutrient supplements for children – vitamin A every four to six months for children six months to five years old and therapeutic zinc supplementation for diarrhea). They calculated that investments in micronutrient supplements for children yield returns of between $14 (zinc) and $17 (vitamin A) for every $1 spent (Horton et al. 2008)."
Hence spending on malnutrition should not only be considered
as spending on social welfare or "doles" but rather as “social
investment ” . This will put things in a better perspective .
In this regard the HUNGaMA report 2011-12 makes some pertinent
observations. It carried out research not only regarding malnourishment but
also the effect of certain other factors like KAP – knowledge , attitude , practices
of mothers , education status of mothers on undernutrition in children.
Not surprisingly , better education level and awareness among mothers correlated with less undernourishment levels in their children .
Not surprisingly , better education level and awareness among mothers correlated with less undernourishment levels in their children .
The GHI report also says , "In South Asia, the low
nutritional, educational, and social status of women is among the major factors
that contribute to a high prevalence of underweight in children under five”
The 2011 Global Hunger Index (GHI) Report
ranked India 15th, amongst leading countries with hunger situation.
It also places India amongst the three countries where the GHI between 1996 and
2011 went up from 22.9 to 23.7, while 78 out of the 81 developing countries
studied, including Pakistan, Nepal, Bangladesh, Vietnam, Kenya, Nigeria,
Myanmar, Uganda, Zimbabwe and Malawi, succeeded in improving hunger condition.(4)
Thus this is no hype or “myth” of malnutrition but a stark reality and a “national
shame” as our PM describes it and needs to be dealt with on a war-footing.
References :
1. GHI report 2010 and 2011 by IFPRI
2. HUNGaMA report dec 2011
3. WHO criteria - http://www.who.int/nutgrowthdb/about/introduction/en/index5.html
