|Year : 2021 | Volume
| Issue : 2 | Page : 134-139
Micro-nutrient deficiencies among children in India
Kanchan Gawande, Nishu Jha, Ajeet Singh Bhadoria, Gaurika Saxena, Sweta Yadav
Department of Community and Family Medicine, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India
|Date of Submission||25-Sep-2020|
|Date of Decision||27-Mar-2021|
|Date of Acceptance||27-Mar-2021|
|Date of Web Publication||30-Aug-2021|
Dr. Ajeet Singh Bhadoria
Department of Community and Family Medicine, All India Institute of Medical Sciences, Rishikesh, Uttarakhand
Source of Support: None, Conflict of Interest: None
The article provides a comprehensive review of the current situation of micronutrient deficiencies (MND) among children in India. It provides information of common MND with its prevalence and geographical distribution. The review includes a nationally representative survey, nutritional reports and studies conducted in the different regions of India. Iron deficiency anaemia, Vitamin A deficiency (VAD) and iodine deficiency disorder are found to be the most prevalent MND among children. The prevalence of anaemia ranging from 21% to 59.2%, VAD reported as a maximum of 10.2% in one of the recent Indian studies while the total goitre rate of highest as 21.9%. With the implementation of various nutritional programs for children, these deficiencies are found to be significant mainly among pre-school children. The recommendation on strengthening existing nutritional health programmes with some new intervention strategies to improve the micronutrient status among children and to reduce the economic burden to MND in the coming years.
Keywords: Health programmes, iodine-deficiency disorder, micronutrient, micronutrient deficiencies, prevalence, Vitamin A deficiency
|How to cite this article:|
Gawande K, Jha N, Bhadoria AS, Saxena G, Yadav S. Micro-nutrient deficiencies among children in India. J Med Evid 2021;2:134-9
| Introduction|| |
Micronutrient is one of the major groups of nutrients which produces various enzymes and hormones required for energy production, immune function, blood clotting, normal growth, bone health, fluid balance and several other processes (WHO nutrition report). Even required in minuscule amounts, their deficiency leads to various health problems such as low productivity, vicious cycle of malnutrition, underdevelopment and poverty. As micronutrient deficiencies (MND) (hidden hunger) is global problem affecting about two billion worldwide accounting for 80% of worlds populations, but the problem is more prevalent in low- and middle-income countries with multiple MND due to the factors such as infection, poor personal hygiene, less diversity in diet and poor bioavailability. Even though South East Asia Region (SEAR) shows success in field of agricultural growth, economic output and health care, MND's prevalence is particularly high in this region. Among all iron, Vitamin A and iodine deficiencies serve as major public health problem as their deficiency is a major threats to the health and development of all population especially children (WHO). It was observed that, iron deficiency leads to impaired mental development of approximately 40%–60% of children aged 6–24 months globally. While in India, 75% of children under 5 years of age and 60% of children aged 1–6 years National Institute of Health and Family Welfare (NIHFW) are suffering from nutritional iron deficiency. Vitamin A deficiency (VAD) is affecting the immune system of almost 40% of under five children. While 57% of under-five children were suffering from sub-clinical VAD. Iodine-deficiency disorder (IDD) has lowered intellectual level of all people worldwide by around 10 to 15 points, in India about 6,600,000 children were reported to born with mental impairment contributing to iodine deficiency. UNICEF estimates that, about 66% of household has accessed to iodised salt worldwide, while in India, the proportion for the same is 50%.
Apart from health consequences, micronutrient deficiency has also caused significant economic impact on the country. At present, India spends 1.15% of GDP on health care. As per the UNICEF report 2004, about 1% of India's GDP lost to vitamin and mineral deficiencies. It costs around 0.8%–2.5% of gross domestic product in 2007. This article aimed to review recent studies and national surveys reflecting the prevalence of common MND in India among children.
| Methodology|| |
Search strategy and data extraction
The literature search was conducted in the databases of Indian Journals Online, Google scholar, PUBMED, Medline and the Cochrane Library. Online search was conducted for national nutritional surveys and reports. The following search terms/MeSH words were used: Micronutrient, deficiencies, iron, iodine, Vitamin A, iron-deficiency anaemia (IDA), VAD, IDD, India, children, infants, pre-school children and school children. The selected search terms were combined alternatively using the Boolean logic (AND, OR & NOT).
Inclusion and exclusion criteria
This review includes all the nationally available nutritional survey since 1990 reflecting prevalence of at least one of the MND (either IDA, VAD or IDD) among children (infants, pre-school children and school age children). Recent (from year 2000 till date) Indian studies with the prevalence of at least one micronutrient deficiency among children were included. National survey and studies which did not met eligibility criteria were excluded.
Current situation of micronutrient deficiencies in India
The section focuses on extent and nature of MND among children in India. The literature search identified four National surveys and one National Nutritional Report that met inclusion criteria. Of the included studies, ten studies on the prevalence of anaemia, six on prevalence of VAD and seventeen on IDD met inclusion criteria.
Anaemia and iron deficiency
As per NIHFW 2004 report on prevalence of Nutritional Anaemia in India, 65% of infant plus toddlers and 60% of children aged 1–6 years were having severe anaemia (Hb <7 gm/dl). National Family Health Survey (NFHS) surveys show a reduction in the prevalence of anaemia over period of time; i.e., NFHS2 (1998–1999), NFHS3 (2005–2006) and NFHS4 (2015–2016), overall prevalence of anaemia (Hb <11 gm/dl) among children aged 6–35 months is 74.3%, 68.9% and 58.5%, while, the prevalence of severe (Hb <7 gm/dl) anaemia as 5.4%, 2.9% and 1.6%, respectively. The National nutritional Monitoring Bureau (NNMB) conducted a survey in 2004 to assess the prevalence of MND in the rural area of eight states, namely Kerala, Tamil Nadu, Karnataka, Andhra Pradesh, Maharashtra, Madhya Pradesh, Orissa and West Bengal. The prevalence of IDA (Hb <11 gm/dl) among children aged 1–5 years was 66.9% with severe (Hb <7 gm/dl) anaemia reported as 2.1%. The report also noted that 3.8% of children aged 1–5 years received iron folic acid (IFA) tablets in the preceding 1 year. Recent Comprehensive National Nutrition Survey (CNNS) 2016–2018 survey conducted in 30 states of India with multistage random sampling covering all rural and urban children and adolescent aged 0–19 years. As per survey, the prevalence of overall anaemia among children aged 1–5 years was 40.4% with 1.2% of children with severe anaemia (Hb <7 gm/dl). 10.9% of children aged 1–4 years were reported with Iron deficiency (Serum Ferritin <12 gm/dl) but not anaemia while 20.8% of children with same age group were anaemic (Hb <11 gm/dl) but no iron deficiency was reported. The details of methodology of some recent studies conducted among children with information on the prevalence of anaemia in the different states of India are summarised in [Table 1].
Vitamin A deficiency
According to UNICEF report, 57% of children under 6 years of age were suffering from sub-clinical VAD (Serum Retinol <20 μgm/dl). The NNMB survey conducted in eight states of India reported the prevalence of clinical signs of VAD (serum retinol <20 μgm/dl) as Bitot's spot 0.8% ranging from minimum (nil) in state of Kerala to maximum (1.3%) in state of Madhya Pradesh. The other clinical signs of VAD reported were night blindness (0.3) and conjunctival xerosis (1.8%). 57.5% of children aged 1–5 years received massive dose of vitamin supplement in past 1 year. NFHS 3 (2005–2006) and NFHS 4 (2015–2016) surveyed on intake of Vitamin A rich food consumption among children aged 6–35 months in last 24 h which was 47.1% and 44.1%, respectively, while Vitamin A supplements among children aged 6–59 months in the last 6 months as 18.1% and 59.5%, respectively. According to global nutrition database 2019, 66% of children aged 6–59 months in South Asia received two massive doses of Vitamin A supplements in year 2017. However, the recent CNNS 2016–2018 report on VAD among children aged 1–9 years, the prevalence of VAD (Serum Retinol <20 μgm/dl) among age group of 1–4 years and 5–9 years was 18% and 22%, respectively. The details of methodology of some recent studies conducted among children with information on the prevalence of VAD in different states of India are summarised in [Table 2].
|Table 2: Studies with prevalence of Vitamin A deficiency among children in India|
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Iodine deficiency is world's most prevalent yet easily preventable public health problem which can starts even before birth. Its deficiency causes mental impairment that reduces intellectual capacity at home, in school and at workplace. India about 6,600,000 number of children were reported to born with mental impairment contributing to iodine deficiency. The reported total goitre rate (TGR) in India was 26%. By the year 2000, iodine was added to approximately two- thirds of developing world's salt preventing approximately 70 million new borne against mental impairment. India stands 50th in the list of survey conducted by UNICEF to assess country wise percentage of iodised salt consumption by household. In 1962, GOI launched National Goitre Control Programme which was renamed as National IDD Control Program (NIDDCP) in 1962. The target of the program was to achieve 100% consumption of Iodised salt (15 ppm) at household level. According to NFHS 2 (1998–1999), NFHS 3 (2005–2006) and NFHS 4 (2015–2016), the percent of household consuming iodised salt (iodization level >15 ppm) reported was 32.6%, 51.1% and 95.9%, respectively. As per the NNMB survey 2004, 30.7% of household consumed iodised salt (iodization level >15 ppm). The survey also reported the prevalence of clinical signs of IDD among children aged 6–12 years, namely goitre as 3.8%, with minimum prevalence of 0.9% in West Bengal to maximum of 11.9% in state of Maharashtra. The prevalence of deaf mutism and mental retardation due to iodine deficiency among children aged 6–12 years reported as 0.1% each. The recent (CNNS 2016–2018) report on MND deficiencies among children aged 1–9 years, the prevalence of iodine deficiency (mean urinary iodine excretion ≤50 μg/lit) was 4.6% (1–4 years) and 4.4% (5–9 years). Some recent studies reporting the prevalence of IDD among children with study methodology are mentioned in [Table 3].
|Table 3: Studies with prevalence of iodine-deficiency disorder among children in India|
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| Conclusion|| |
Although various nutritional programmes for the control of MND are functional in India, evidences show that the prevalence of iron, Vitamin A and iodine deficiencies are significantly high, especially among children under 5 years of age. National Nutrition Anaemia Prophylaxis Programme was launched in 1970 to prevent anaemia among mother sand children. As reported by multiple nutritional surveys conducted over years, the prevalence of anaemia was significantly high, especially among children aged 1–5 years, even though periodic supplementation of IFA is being followed under program. In India, UIP was launched in 1985 under which all under-five children were supplemented with massive dose of Vitamin A. However, more than 50% of under-five children still suffering from subclinical VAD. Of which Bitot spot, night blindness and conjunctival xerosis are the most common reported signs of VAD. In 1962, NIDDCP was launched with objective to control iodine deficiency and its health consequences. In 1982, Government of India made a policy decision to iodate edible salt all over the country by the year 1992. Furthermore, various programs are functioning for double fortification of salt with iron and iodine. It was observed that the prevalence of household consumption of iodised salt has increased over year since the launch of the program; however, the TGR reported as 26% in one of the recent researches in India. Considering the current situation, existing nutritional health programme need further strengthening. It also raises the questions for identifying other factors for causing these deficiencies in spite of functioning nutritional program in the country. Furthermore, some new intervention strategies could be implemented to improve the micronutrient status among children. It will also help to reduce economic burden contributing to micronutrient deficiencies.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3]