Malnutrition and Child Survival, Growth of Under Nourished Girls
Item
- Title
- Malnutrition and Child Survival, Growth of Under Nourished Girls
- Creator
- Kamala Jay Rao
- Date
- 1987
- extracted text
-
COMMUNITY HEALTH CELL
47/1.(Fjrs: Floor)St. Marks Road
0 P.!G • • o ■ GCJ U JI
Background Paper II
^8
XIV ANNUAL MEET OF MFC
..MALNUTRITION & CHILI SURVIVAL.
& # $$ * * * * * * *
* * * ¥ * *# *
PART -I
❖ * 4-
Kamala J ay Rao.
While we know much about the immediate effects of
malnutrition on the growth of a child ana its physiological
functions, it is equally essential to know the long-term
sequelae. Only 2 -U-% of the under-five children suffer from
severe grades of malnutrition, and some of them survive the
ravages. A large majority (nearly 8($) suffer from mild to
moderate degrees of malnutrition, and many of them survive
and reach adulthood. What is the ’quality of life’ of these
survivors? The under-five mortality rate is around 20 percent.
Of the 8Cfi> survivors, one may expect atleast three-fourths or
more, to be children suffering from various grades of malnutrition
In absolute numbers it would mean that more than 300
million Indians may be survivors of child hood malnutrition.
Hence the question of the ’quality of life’, of these is of
crucial importance. Are these normal or near-normal adults 9
or do they suffer any handicap?
Answers to the above question are not easilty available.
Socio economic conditions have not improved much for a
majority of this population, so that the economic and
nutritional constraints that operated during childhood
continue through adolescence and adulthood also, So, it
becomes difficult to distinguish between the effects of
current undernutrition and the long-term consequences of a
past episode of malnutrition. Nevertheless there are some
studies which indicate some significant points.
In a study conducted by the National Institute of
Nutrition (Nil.), a large number of children, whose weights
and heights were recorded when they were 1-5 years old
were followed-up ten years later (1). The study reveal ed
the following:
1.
The actual increase in height,9 during the ten year perjc.i,
was 60-62 cm and was similar to that seen in well-t.j-do
Indian children and in Western Children. However, the
peak appeared about two years later,. In other words 7
these children took a longer period to reach their
maximum height.
...2.. .
2
2.
It must however be remembered that during the underfnve
age period, these children were shorter than the wellto-do groups. Therefore, the actual height attained at
adoescence was much less, hoys with severe malnutrition
were about 1U- cm shorter and those with mild and moderate
undernutrition were 8 cm shorter. Even the so-called
normal children were about h- cm shorter than well-to-do
Indian children of similar age-.
3.
The increases in body weight, on the other hand,were
much less. While well-to-do Indian and western children
gained UO-^-5 kg between 5 - 18 years of age, the mild
and moderately undernourished gained only around 30 kg
and the severely malnourished, 25 kg.
The above observations show that the physiological
mechanisms are geared in such a manner as to allow a normal
increase in height. However, the handicap which the child had
is not overcome, that is, there is no 'catch-up growth'.
Weight increment is equally dependent on current mutritipn.
Therefo-.e at is difficult to say whether the weight deficit
is entirely a relflection of current status or whether it
is partly the consequence of childhood undernutrition.
Anyway, the result is, we are left with a population
of short, under-weight individuals
The question that may arise is, de. short and lean
adults suffer any handicap, Loes this perse heve any adverse
effect? (Remember, we are discussing populations who are short
and lean, and are not concerned with a single Individual who
is short and lean.) There have been theories, put forward
by western Scientists, that sm2s.ll size per se is not
disadvantageous and in fact 'small is healthy'. The small
size we are discussing here is a consequence of undernutriu
caused by the lack of opportunity for the physiological growth
process to proceed on a natural path. This itself is
therefore a pathology and cannot be considered 'healthy'.
The 'small is alright' theory implies - and has alsobeen
explicity stated at times - that Indians and other Thirdworld population need not grow to the same extent as the
population of the rich nations and therefore they do not
3
1
-3 need as. much food (and as a corollary the poor need, not be
provided the ways and means-' to buy that much food1.).
Ap_i-t i’lom the above policy implication, there is an
equally serious fall-out. Studies by Nik and also in other
parts of the developing world have shown that people with a
small size do not possess the same capacity to work as those
with better body size (2). Some of these aspects have been
recently•discussed by C.Gopalan (3).
In the study conducted by NIN (U), adolescent boys
employed as farm labour were studied and it was found that;
1.
Among boys of the same age, those who were better built
were employed for such farm work for w ich higher wages
were paid.
2.
ifost of the toys who had. better body size 7 had better
weights and heights even during the under-five period.
The interpretation would th .refore be that most of the
children who were malnourished during early childhood,
continued to be short and lean in adolescence and the smaller
the body size, the less were the wages paid (by experience 5
the lar. i.?. ou"1'?> wld make out who had better body-build) .
Studies in an industry, where wages were paid piece-race
*.a certain amount of money for a certain amount of work
turned out) revealed similar findings ($). Ibis is not only
important for individual economy but also for national
economy, because workers with small body size do not have
enough physical capacity to work and nehce efficiency par
w or ,:er, suffers.
Generally, and for obvious reasons, the well-fed (and
therefore the rich) perform light tasks whereas the malnourA.shea and poor have to undertake heavy chores. It is also
true that the rich cannot carry a heavy burden or perform
a heavy chore with the same felicity as the poor,
undernourished man (for eg. pulling a rickshaw). The
argument therefore goes that work capacity is more a matter of
habit than of muscle strength. It is no doubt true that
habit plays an important part, but it is equally important
to know,9 at what expense the heavy chore is being done. The.
..A....
- 14- -
study by NIK showed that for the same.work load, small-sized
boys had higher heart rares - that is, their hearts had to
function harder (2). I do not know whether there are any
in-depth studie on the incidence and nature of heart diseases
among the poor. This would definitely be an extremely-worth
while study.
.
The NIN study also revealed another significant,
but disturbing, observation. Among those who had similar
weights and heights as children, those who later worked as
child labour attained less adult heights and weights, than
those who went to sclTOol, JOf course, those who could go to
school might have been placed''*!^.®. better socio-economic status.
Never theless, if o,ne assumes, that socio-economic differences
may not be that different, .^because growth status at $ years
was similar, one may not be' too far off in suggesting that
physical labour (out of proportion to the child's age and
food intake ) had an adverse effect on growth.
This study s^ai-S^tot jayen severe under nutrition does
not damage the capacity of the"'body_to grw during adolescence,
particularly the linear growth, but the children cannot
make-up the handicap suffered during early childhood. Whether
the latter is a permanent effect of childhood under-nutrition
cr whether it is a consequence of current undernutrition cannot
be differentiated. A small adult body size results in a
decreased work capacity, and hence the earning capacity. The
study also indicates that physical labour during late childhood
in undernourished children,9 may adversely affect subsequent g
growth.
O*I*r*^l* **£>/§J 8
1. Satyanarayana, K. etal: Annals Human Bj.ol, 7*359? 1980.
2. Satyanarayana, K. etal? Indian J.Nutr. Diet. lGs'J7G, 1979
3. Gcpalan, C; Heights of Population, NFI Bull. July 1987
k. Satyanarayana, K.etal: Indian J. Nutr. Diet. 17*281, 1980.
5. Satyanarayana, K. etal; Human Nutrition kOC; 131, 1986.
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hW-
. SIKi-V-iVAlT
PART ... II
*
Kamala -Jay Rao.
The first part of ’Malnutrition and child Survival’
health a with growth of boys alone. I am dealing with the
girls..separately due to some unexpected differences been
... .between the sexes.
I had in an earlier paper (1), discussed in detail the
sex discrimination in India.. Therein I referred to the distorted
sex ratio and to the studies which showed that' although
malnutrition was higher among female children, more malnourished
boys boys- were brought to the hospitals for treatment. A
recent paper by -Shanti Ghosh (2) also confirms this. A study
from Ludhiana (3) showed that mothers breast fed their male
babies for a longer period than the female infants. Shanti
Ghosh has also referred to another study, confirming this.
A. recent paper by Gopalan wherein he has analysed, the
data cf the National Nutrition Monitoring Bureau (NNMB) (>+),
shows that in fact the percentage of children with malnutri
tion is not -very different between the sexes and the grades
of mainucrition are also not very different. I too had
analysed NNMB data ($) which showed that as far as food
intake (.more conecti.y, evorgy intake) goes, therd are not
any striking differences between the children. However it
appears that medical care may be sought less for girls and
boys,. The distorted sex ratio at all ages (.1,2) indicates
that more females die than males, confirming the general
neglect of female health and life. It is also well to point
put-that,...whatever be the sociocultural reasons, sex di sci-i ,sination against girls in whatever sphere - is seen more in
the Northern belt of Rajasthan, M.P., U.P, and Bihar. There
are mere deaths among the females at all ages (1, 2).
With this background, we may now try to see the growth
performance of girls during late childhood and adolescence.
In the same study which I referred to in part I of the paper,
girls were also studied (6).
...2...
!
J.,.;;
.
■
2
1.
Surprisingly,-the^jincTease in-height of girls who
suffered from severe grades of malnutrition increase
(between 1-5 and 10-15 years of age) was much greater than
not only chose who were in mild and moderate grades, but even
than in American girls. The boys, on the other hand, had
similar height increments. Thus in girls with severe
malnutrition, we may say, that there was an attempt at
’Catch-up1 . However the increments were not sufficient to
allow them to attain a normal height. Hence they were still
shorter than American and well-to-do Indian girls.
2.
Unlike the boys, where body weight increments were less
with increasing grades of malnutrition, the girls had similar
weight increments irrespective of the degree of malnutrition.
Despite this, however, at adolescence the girls were
still shorter and leaner than American girls.
My analysis of the NMMB data (5) showed that adult
females have less calorie defict than adult males, or in
other words the food intake of women is better than that in
men or energy untakes are similar. In the underfive age
group there are no sex differences. However the under-five
girls had a greater body deficit. This difference was lost
when the girls grew up, and body deficit in women is less
than in men. That is, women are not as underweight as men.
The reasons for these differences, where girls appear
to perform better in late childhood, are not easily forthcoming.
We have already seem that the better paid, heavy agricultural
tasks were given to better built boys. We have also seen that
physical labour during the growth period can have an adverse
effect on growth. Perhaps, because of the nature of the
task aa well as the higher wages, such chores may not be
given to girls. Moreoever, growing girls are generally left at
home to do the household chores and to look after the
younger siblings. Perhaps this is not as energy consuming
and detirmental to health a the heavy agricultural work
(Feminists to kindly pardon me). Thirdly, it was observed
in this study (7), that girls who were shorter at age 5
(the more undernourished being generally the more short), had
menarche at a later age around 15 years, compared to those
who had normal height at age 5 (1*+ years). Irrespective of
the age at menarche, the event itself occured when the girls
■ 1.
had
cm, height and 36 - 38 kg. body weight. Thus
perhaps the girls had a sightly longer period to grow, before
epiphysial fusion took place. This hcwever, is and inadequate
explanation since we cannot explain why, if this is true, this
mechanism does not operate among boys. Moreover, We also saw
that undernourshed boys too, took a longer time to grow.
I may here be permitted to remable a bit on the so-called
neglect of the female child and the preference for the male
child. At birth, the male child is more vulnerable than the
female. There are more still births among male foetuses (2).
In healthy affluent populations, more male infants are born (
(10M3M and 1000 F), but by age 20 or. so, females outnumber
males (1015F to 1000M). Thus the natural age - specific death
rates are always higher in the males. In a community where
infant and child mortality is excessively high due to
malnutrition, infections and lack of medical care, the comm
unity perhaps by experience has realised that the male child
needs greater attention. I feel that we do need to look at
this in an objective manner and see, whether this may be
true. However, as Gopalan (b-) had said corectly 'Our Concern
is not just to ensure that boys and girls in our poor
households suffer equally from ill-health and undernutrition,
but that both of them enjoy adequate health care and
nutrition, As he says there may not be a deliberate
reglect and discrimination against the female child, but
the households trapped as they are in poverty and out of
reach of good health care, may have tb make some painful
and difficult chocies. Thus as far as food is concerned there
appears to be no discurimination, but perhaps the female
child is given second preference as far as seeking medical
care and spending money for it, are concerned.
References:
1. <Taya Rao, K.S: who is Malnourished? Mother or woman?
Health care-which way to go? M.F.C. Anthology III.
2. Ghosh,
h, S.L
<
The female child in India. NFI Bull. Oct.1987
3. Das, D.
D. etal: NFI Bull. April 1982.
4. Gopalan , C.; Gender bias in Health and Nutrition care
NFI Bull. Oct. 1987.
5. Jaya Rao, K.S; Undernutrition among Adult Indian males.
NFI Bull. July 1984.
6. Satyanarayana, K.et al: Amer. J. clin Nutr.
7. Satyanarayana, K.and Naidu,A.N: Nutrition and menerche
in rural Hyderabad. Annals of Human Biol.6? 163, 1979.
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