The sixth National Family Health Survey (NFHS-6, 2023-24) data was released by the Ministry of Health and Family Welfare on May 29. As NFHS-6 reveals, Assam has the highest prevalence of severe wasting among children under five years of age in the country.
The World Health Organisation (WHO) defines malnutrition as deficiencies, excesses, or imbalances in a person’s intake of energy and/or nutrients. In children, it encompasses both undernutrition (wasting, stunting, underweight and micronutrient deficiencies) and overnutrition (overweight and obesity).
Although overnutrition is an emerging problem—largely due to the nutrition transition occurring in the country with cheap and easy access to refined carbohydrates, sugars and unhealthy fats—for the scope of this discussion, we would specifically be focusing on undernutrition in children, which, for Assam, continues to be a pressing challenge.
The NFHS-6 nutritional indicators for children below five years in Assam show marginal improvement.
Wasting (low weight for height) and severe wasting (very low weight for height) prevalence stand at 21.4% and 8.5%, respectively, and show a marginal drop of 0.3 and 0.5 percentage points as compared to NFHS-5 (2019-20).
To put this in context, as per NFHS-6, Assam has the highest percentage of severely wasted children in India and has the fourth-highest prevalence of wasting among all the states.
Underweight (low weight for age) among children has dropped from 32.8% (NFHS-5) to 30.7% (NFHS-6). Stunting (low height for age) remains the only child health nutritional indicator showing a substantial decline from 35.3% (NFHS-5) to 30.3% (NFHS-6).
The reduction in stunting, a measure of chronic malnutrition, despite very little change in acute malnutrition indicators like wasting, requires careful consideration.
A conservative estimate of severe wasting, using publicly available data on the number of children aged 0-5 years in Assam and the prevalence rate of 8.5%, translates into 1,57,260 severely wasted children in Assam. This is indeed a significant figure.
Malnutrition follows a vicious inter-generational cycle, where an undernourished society or community risks perpetuating malnutrition across generations. Children are the most vulnerable in this loop.
For example, a severely wasted child is up to 11 times more likely than a well-nourished child to die of common childhood illnesses such as pneumonia.
The WHO estimates that nearly half of all deaths among children under five years are linked to undernutrition and mostly occur in low- and middle-income countries.
To bring down the malnutrition figures for Assam would require working on two specific fronts. First, it would require systemic efforts to prevent the onset of malnutrition in children.
Second, it would entail the timely identification of existing malnourished cases and facilitating their management. There is enough evidence to show that strengthening Infant and Young Child Feeding (IYCF) practices helps prevent malnutrition.
This includes early and timely initiation of breastfeeding, exclusive breastfeeding until six months of age, timely initiation of complementary feeding at six months, and age-appropriate, adequate and diverse complementary feeding.
The NFHS data for Assam shows that the proportion of children aged 6-8 months receiving complementary feeding along with breastmilk has increased from 51.7% (NFHS-5) to 66.6% (NFHS-6).
The percentage of children aged 6-23 months receiving an adequate diet has more than doubled to 16.4% (NFHS-6) from 7.2% (NFHS-5), a figure that still remains far from satisfactory. Moreover, a lot of ground remains to be covered when it comes to establishing breastfeeding in the early hours of a child’s birth.
As the data indicate, although institutional deliveries in Assam are around 87.6%, the proportion of children breastfed within one hour of birth is only around 55%. Exclusive breastfeeding among children aged 0-6 months continues to be a challenge and has, in fact, gone down from 63% (NFHS-5) to 54% (NFHS-6).
Taking into account the wide geographical and cultural variations in the state and the varying degrees of vulnerability among tea garden populations, char areas, Sixth Schedule areas and forest villages, strengthening IYCF practices in Assam would require community-specific approaches with targeted social and behaviour change communication models.
Prevention requires a multi-pronged approach. At one level, the quality and quantity of calorie intake and nutrient levels in the population have to be maintained, and, therefore, food and nutrition security become a priority.
Existing support mechanisms like the Supplementary Nutrition Programme (SNP) for children, pregnant women and lactating mothers should be revamped to meet community-level acceptance standards. Further, the state can also support nutritionally at-risk mothers by providing extra nutritional support, as is the case with severely malnourished children.
A holistic approach to preventing malnutrition would require a life-cycle perspective with simultaneous interventions across domains of food and nutrition, health, education, water and sanitation, among others.
With the government already recognising this, under Mission Saksham Anganwadi and POSHAN 2.0, there is an ongoing effort to work collaboratively among various government departments to address the cross-sectoral determinants of malnutrition. It is imperative here that convergence in policy translates into convergent action and reaches the last mile.
The second way to deal with the problem is to manage or treat the existing malnourished cases. At the population level in Assam, it is the Anganwadi Worker (AWW) who performs growth assessment of children under five years of age and identifies them as malnourished or normal.
Identification has to be accurate, and timely linkages with health facilities must be ensured. Institutionalising capacity-building exercises for AWWs on growth monitoring and related subjects could help improve quality and ensure timely identification.
For a state with a prevalence of 8.5% severe wasting, it is also essential that community-level management of malnutrition for medically uncomplicated cases complements facility-based management in Nutrition Rehabilitation Centres (NRCs).
The National Protocol for Management of Malnutrition, which focuses on community-level management, should be prioritised, streamlined and implemented with equal ownership by the Health and WCD Departments. Successful implementation of this protocol could be a significant step towards managing malnutrition in the state.
Over the years, Assam has done particularly well in improving the maternal and child health status of its population. It is time we prioritise nutrition planning and interventions to improve the nutritional outcomes of children in the state.
The author is a development professional working in the public health nutrition sector in Assam for the last seven years.
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