An estimated 26 million children aged under five years are wasted in South Asia, which is over half of the global burden of wasting. India is home to four out of five of these children and lies at the epicentre of this global public health problem, with 22 million children wasted, and over eight million severely wasted at any one time, according to the UNICEF, WHO and World Bank Group, 2018.
In 2015 India committed to reducing the proportion of children suffering from wasting to less than 5%, a nutrition target of Sustainable Development Goal (SDG) 2. However, the prevalence of wasting (21.0%) and severe wasting (7.5%) remain very high in the country (National Family Health Survey-4 2015-2016) and have not fallen in the past decade, despite a 10 percentage point decline in stunting during the same period. This lack of progress towards the wasting target, and the persistently high numbers of children with wasting, is of immense concern.
In India, the prevalence of wasting is witnessed highest at birth (37%) and declines with age, a pattern seen in other South Asian countries such as Bangladesh. Over 30% of infants aged less than six months are wasted in India, underlining the imperative to address growth failure in early life. In comparison, data from selected countries in West and Central Africa show the prevalence of wasting is relatively low at birth and increases in infancy, reaching a peak at around 12 months of age.
These contrasting patterns suggest that poor maternal nutrition and health may play a larger role in the causes of wasting in early life in India (and Bangladesh) than it does in other settings. Almost one quarter (23%) of women of reproductive age in India are thin (body mass index (BMI) <18.5 kg/m2), 11% have a low stature (height
Maternal thinness, low stature and anaemia predict low birth weight (LBW) and wasting in India. These findings indicate that a comprehensive response to wasting in India must include a strong focus on the prevention and management of growth faltering in infants under six months, including interventions to improve the nutritional status of women before and during pregnancy.
Another significant finding is the relationship between wasting and mortality in India and South Asia, which appears to be affected by different factors than in other regions of the world. The prevalence of wasting and severe wasting is higher in India and South Asia than in other regions, yet the Under-Five mortality rates are comparatively lower. These comparisons need careful interpretation and more research is needed to understand the relationship between mortality and wasting in India.
India has an array of government schemes and programmes to counter malnutrition and its underlying causes. However, it is evident from the continuing high prevalence of wasting that these schemes and programmes are not designed to address the burden adequately, or are not functioning optimally.
Currently the main approach to treat severe wasting in India is facility-based treatment, known as F-SAM. The guidelines for F-SAM, which provides inpatient treatment of SAM (Severe Acute Malnutrition) with medical complications, were released in 2011. A network of 1,151 nutrition rehabilitation centres (NRCs) has since been established across the country and these manage approximately 180,000 cases annually, which represents a small fraction of the annual caseload.
This existing inpatient infrastructure is neither sufficient nor intended to manage all children with severe wasting. Approximately 85-90% of children with severe wasting do not have medical complications and can safely be managed at community level. Indeed, the national guidelines on F-SAM recognise the need for the community-based management of severe wasting without medical complications. However, community-based management has been challenging to operationalise in the absence of national guidelines, which are currently in the process of being developed by the Government, although their content remains unclear.
India has well designed community-based public health systems and delivery platforms at facility and community level that can be leveraged by POSHAN Abhiyaan to support a comprehensive response to severe wasting. This should include four components: (i) the prevention of wasting and severe wasting, including relapse after successful treatment; (ii) early case detection of wasting through active screening; (iii) facility-based management of severe wasting with medical complications; and (iv) community-based management of severe wasting without medical complications.
Many nutrition-specific interventions to prevent wasting and other forms of malnutrition are delivered at community-level in India through Anganwadi Services under the umbrella of the Integrated Child Development Services (ICDS) scheme. Anganwadi centres, a nationwide network of rural community centres, provide health and nutrition services and pre-school education to a population of up to 1,000.
There are a host of schemes, programmes and services that target pregnant and breastfeeding women (PLW) with nutrition interventions. These include a take-home ration from Anganwadi centres; anaemia prevention and control under the Anaemia Mukt Bharat programme; antenatal care services, including dietary counselling through VHSNDs; and schemes such as Pradhan Mantri Surakshit Matrutva Abhiyaan that provide quality antenatal check-ups. Institutional deliveries are promoted through conditional cash-transfer schemes (Janani Suraksha Yojna and Pradhan Mantri Matru Vandana Yojna) and free services for delivery and early neonatal care (Janani Shishu Suraksha Karyakaram), and provide an important opportunity to support mothers in establishing good breastfeeding practices.
Under POSHAN Abhiyaan there is huge ambition to ensure that every child has access to quality services to address wasting across the continuum of care. This requires a cost-effective, integrated and sustainable approach that successfully prevents the development of wasting and provides care for those with wasting.
The infrastructure to deliver a comprehensive, community-based programme to prevent and treat wasting already exists in India; a vertical programme to address wasting is therefore unnecessary. There is an extensive network of community-based Anganwadi centres and community-health workers, together with health and nutrition schemes and programmes, into which components of a comprehensive approach can be integrated at scale.
Context-specific solutions to prevent children from developing wasting must be the priority. These solutions should be grounded in an understanding of the specific causes and drivers that lead to wasting. The high prevalence of wasting at birth in India suggests the need to improve the nutritional status of women before and during pregnancy and to ensure mothers have access to skilled support for early and exclusive breastfeeding. From six months of age, counselling on complementary feeding and continued breastfeeding and the prevention and treatment of diseases become important components of preventive approaches. These interventions are already part of existing health and nutrition schemes and programmes, but are not reaching children and women with the desired Coverage, Continuity, Intensity and Quality (C2IQ).
The introduction of monthly height measurements for all children during growth monitoring at Anganwadi centres will increase opportunities for the early detection of wasting. However, it is necessary to ensure that community health workers have the capacity (equipment, skills, time and motivation) to add this responsibility to their roles and increase community demand for services.
The Anganwadi centres currently cater to children with severe underweight and any children identified by health workers as having severe wasting with medical complications are admitted to inpatient care. The forthcoming community-based guidelines on the prevention and management of wasting will guide how treatment reaches children with severe wasting without medical complications at community level. Optimising the quality, production and distribution of rations under the Supplementary Nutrition Programme (SNP) and identification of the nutritional treatment that will be used to manage severe wasting at community level are needed so that treatment puts children back on the path to healthy growth. A strong referral system and tracking of individual children across the different programme components, from the community through to the inpatient facility, are also essential to ensure that children receive the full continuum of care on offer.
It is important to build the evidence base around this comprehensive approach to managing children with acute malnutrition in India and delivering services across the continuum of care. This learning could inform both India and other country contexts with a similar profile of wasting. Key evidence questions include a context-specific understanding of wasting in India; how to scale up screening using Weight For Height (WFH) at community level effectively; the modalities of managing growth failure in infants under six months old; and the cost-effectiveness of forthcoming guidelines to care for children with severe wasting at community level. In addition, a better understanding is needed of how to address challenging issues such as linkages and referrals between various programmes and schemes to ensure a continuum of prevention and care.
(The article, that first appeared in Emergency Nutrition Network, has been edited by Outlook. The authors of the piece are: Arjan de Wagt, Eleanor Rogers, Praveen Kumar, Abner Daniel, Harriet Torlesse and Saul Guerrero)
(Arjan de Wagt is Chief of the Nutrition section, UNICEF India; Eleanor Rogers is a Nutrition Specialist in the Nutrition Division of UNICEF India; Dr Praveen Kumar is a paediatrician and Professor of Paediatrics at Lady Hardinge Medical College and Kalawati Saran Children’s Hospital in New Delhi; Harriet Torlesse (PhD) is Regional Nutrition Advisor at the UNICEF Regional Office for South Asia; Saul Guerrero is a Nutrition Specialist at UNICEF HQ; Abner Daniel is a medical doctor with an MD in Community Medicine, working as Nutrition Specialist in UNICEF, New Delhi. The findings, interpretations and conclusions in this article are those of the authors. They do not necessarily represent the views of UNICEF).