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 an article by 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 that can be reached and hence the shockingly huge numbers that are projected regarding the scenario of malnutrition in India . With regard to this I decided to read the available literature on the net regarding this claim . Mr Arvind Panagariya in a recent article in Economic times ( http://bit.ly/12WO4ON ) And more clearly in an article in ToI in 2011 ( http://bit.ly/1cjZRxC ) 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 countries in terms of malnutrition , which does not seem to be puzzling. 2.Even well developed states such as Kerala which otherwise have high HDI and is up on many social indicators lags behind on the malnutrition numbers 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 prebalence 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 ones age, > wasting low weight for ones height, and > underweight low weight for ones 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 childs weight or height deviates from the standard for healthy child growth set by the World Health Organization. The closer a childs 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 660 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 Hence , the debate arises are there ethnic differences given that India pointedly lags behind in Child undernutrition as compared to other indicators . The basic objection to Mr.Panagariyas 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 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 6ft is considered the ideal height then the diagnosis for dwarfness would be much less than that and if the normal height of Indians is 5ft on an average it wont affect the diagnosis of dwarfness as it would be lets say 3 ft which would be abnormal even for Indians. 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. 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 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 peoples 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 but rather as social investment . This will put things in a better perspective . In this regard the HUNGaMA report 2012 makes some pertinent observations. It carried out research not only regarding malnourishment but also the affect of certain other factors like KAP knowledge , attitude , practices of mothers , education status of mothers and undernutritions. Not surprisingly , better education level and awareness among mothers correlated with less undernourishment levels of 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 Indeed the situation is alarming and necessary steps must be taken in a war-footing and the debate over whether Undernourishment is severe or not seems irrelevant . 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. Thus this is no hype or myth of malnutrition but a stark reality and a national shame as our PM describes it. 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 4. https://en.wikipedia.org/wiki/Malnutrition_in_India 5. http://articles.timesofindia.indiatimes.com/2011-10-01/edit-page/30230007_1_underweightchildren-maternal-mortality-mortality-rate 6. http://economictimes.indiatimes.com/opinion/comments-analysis/confronting-amartya-sens-viewone-size-fits-all-methodology-on-malnutrition-is-hopelessly-flawed/articleshow/21443094.cms