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Malnutrition in children under 5 seasonal, highest in monsoon. But Indian surveys miss that

To avoid biased results, direct comparisons of malnutrition should not be made unless seasonality bias is addressed.

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Globally an estimated 13 per cent of under-five child deaths are attributed to wasting each year. In India, 20 per cent of under-five deaths and disabilities are provoked by growth faltering. The mortality risk rises exponentially with the severity of malnutrition. India has achieved consistent improvements in under-five mortality. For those children who survive, each wasting experience increases the risk of stunting, which is associated with reduced cognition, educability, and economic productivity and increased risk of high body fat/obesity, cardiovascular disease, and increased risk of having low birth weight babies in women.

Acute malnutrition increases during the monsoon due to the well-recognised effect of seasonality on feeding and caring practices, disease patterns, and food security. Data from longitudinal studies show that wasting was highly seasonal with the highest wasting prevalence in the rainy season across all of South Asia. Intra-household analyses of nutritional status in India find that women and children under five are the most vulnerable populations to malnutrition and thus to the effects of seasonal wasting. In Uttar Pradesh, a longitudinal sample of birth weights showed that infants conceived from April to September were significantly lighter than those conceived from October to March.

India experiences significant variations in agro-climatic conditions throughout the year. Seasonality has a strong effect on temperature, air quality, diets, food and water availability, vitamin A deficiency, disease, labor conditions/incomes,  sanitation, caring practices, infant and young child feeding and even health seeking behaviors. Analysis and presentation of wasting results without accounting for seasonal patterns can lead to misinterpretation. Seasonality encompasses a complex interplay of factors that can heighten the risk of acute malnutrition in children, demonstrated by wasting.

New National Family Health Survey (NFHS5) data show improvements on demographic and health indicators in India with exceptions in anaemia, overweight obesity, and child wasting. In India, national estimates of wasting remain high compared to international standards with one in five children found to be wasted (19.3 per cent in NFHS-5). Wasting in children under-five is the most dangerous form of acute malnutrition. It is a predictor of under-five child mortality and of increased risk of future episodes of malnutrition. New research from United Nations Children’s Fund (UNICEF) and Indian Statistical Institute (ISI-D) demonstrates that care is needed interpreting wasting prevalence.

The prevalence of wasting in India is found to double from the winter to monsoon seasons.

National level analyses show the prevalence of wasting is lowest in January and highest in June to August. National surveys are complex logistical operations and most often not planned or implemented in a manner to control for seasonality. Collection of survey data across differing months across states can introduce seasonal bias in interpretation. Cross-sectional surveys are not designed to collect data on seasonality, thus special methods are needed to analyse the effect of data collection by month.

Also read: Anaemia, obesity on the rise in India as NFHS-5 reveals falling nutritional indicators

National-adjusted estimates show declining trend of wasting

The new statistical analyses were developed to estimate and prevalence of wasting by month and an overall weighted survey estimates controlling for the socio-demographic variation of data collection across states and populations over time. After accounting for seasonal patterns in data collection across surveys, the trends show no change between 2005 and 2015 followed by a decline in wasting in 2016-18.

From the unadjusted results of NFHS-5, wasting increased from 17 per cent to 19 per cent and severe wasting increased from 5 per cent to 8 per cent compared to CNNS but seasonality must be considered in interpreting trends of acute malnutrition. The lesson for NFHS5 is that seasonality may have been compounded in the presentation of national results. There were 22 state and UT with data collection before COVID-19 lockdown (from June 2019 until January 2020 ) & 14 state and UTs after lockdowns eased (from Jan 2020 until April 2021). More data collection may have taken place during monsoon than in prior surveys, inflating estimates of wasting. The NFHS-5 data will be analysed for seasonality as soon as the unit level data are released.

Also read: Not just Global Hunger Index, India’s own govt data shows how worried we should be

Seasonality of malnutrition is not caused by lack of food

Most interpret the seasonal differences in nutrition to be exclusively caused by availability of food. If this was the case, there would be evidence of seasonal malnutrition in all ages of the population. This is not the case. Seasonality of malnutrition in children is caused by changes in caring practices, feeding behaviors, quality or diversity of diet, disease, labor conditions/income generating activities, water availability and sanitation, and health-seeking behaviors. Often young children are left with older or younger family members for care when seasonal labor demands are highest. This period corresponds with the highest seasonal peaks of malnutrition.

Stronger policy can prevent it

Aggressive policy and program action needs to strengthen the caregiving practices and resilience of families and communities against the severe effects of seasonal wasting on the health of children under five. In India, the population is provided with extensive social safety nets including a focus on counselling on optimal care, feeding practices, public health and nutrition services, food subsidies and distribution—indicating that the infrastructure is in place to protect against the seasonal effects of malnutrition. Eliminating the seasonal variation in wasting would reduce the prevalence by half and provide guidance towards further reduction in acute malnutrition.

Our results demonstrate that seasonality must be controlled for in the planning, data collection and analysis. It is recommended that surveys must collect data during the same month every year to ensure comparability in the analysis and presentation of results.  Global trends of wasting need to account  for the effect of seasonal patterns when presenting national estimates compared across geographies and time. To have more timely and accurate measures of seasonality of wasting and the subsequent effects on the burden of wasting in children under-five, improved, regularly conducted, cost-effective methods are needed to effectively eliminate seasonal threats to children and to reduce incidence of wasting to its minimal acceptable level.

Populations must be protected from seasonal deprivations that provoke acute malnutrition. In India, a broad range of social services are available to protect the population from hunger and food insecurity. Greater efforts are needed to ensure that children are protected from the dangerous effect of seasonal acute malnutrition by ensuring the full range of entitlements for families of young children and ensuring caregivers have the knowledge, skills and resources protect their children from malnutrition.

Prof. Mudit Kapoor teaches Economics at ISI-D. Prof. Gaurav Dhamija teaches Economics at IIT Hyderabad. Arjan de Wagt is Chief of Nutrition at UNICEF India. Robert Johnston is Nutrition Specialist at UNICEF India. Dr. Praween Agrawal is Senior Monitoring Evaluation, Learning Specialist and MEL Team Lead at IPE Global. Views are personal.

This article was first published on Plos One.

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