1. Magnitude of multiple micro-nutrient malnutrition among the rural children in India
DR. N.ARLAPPA MD
Division of Community Studies
National Institute of Nutrition (NIN)
Indian Council of Medical Research (ICMR)
Hyderabad- India

2. In spite of the green revolution and implementation of several national nutrition programmes for more than 3 decades, the prevalence of undernutrition continues to be a major public health nutrition problem in India.
All most all the age and physiological groups in general, and under five and school-age children in particular, are most vulnerable to malnutrition.
Globally, India has the highest percent of underweight and stunted children.
45% of child deaths were attributable to malnutrition (WHO -2015)
The under-five mortality rate (U5MR) in India (1 in 21) is about 7 times higher than in high-income countries (1 in 147).
1 in 5 global under five deaths took place in India in 2015 (20% of the global deaths) - corresponding to 1.2 million children (Lancet-2015).

3. However, in comparison to 126 deaths per 1,000 live births (3
However, in comparison to 126 deaths per 1,000 live births (3.4 million) in 1990, the U5MR in India dropped to 48 per 1,000 live births (1.2 million) in 2015 (reduction is 62%).
The burden of hidden hunger i.e. multiple micro-nutrient malnutrition among the children of under five and school-age (7-12 years) children is a major nutritional problem of public health concern in India.
The adverse consequences of hidden huger include decreased immunity, mental impairment, poor health, low productivity, and even death. 
Its adverse effects on child health and survival are particularly acute, especially within the first 1,000 days of a child’s life, resulting in serious physical and cognitive consequences. 
It is also burden on out-of pocket health expenditure among the rural households as well as on national economy.

4. Objective
The objective of this communication is to assess the magnitude of multiple-micro-nutrient malnutrition among the rural pre-school and school-age children in India.

5. Materials and Methods
A community based cross-sectional study adopting multi-stage random sampling procedure was carried out by the National Nutrition Monitoring Bureau (NNMB) during
The study was carried out in rural areas of 10 major states constituting two-thirds geographical area of India.
A one-day 24-hour recall diet survey was carried out in 11,910 households, from 1195 villages 120 villages per State)
A total of 12,004 (1-6 years: 5,810 and 7-12 years: 6,194) rural children were covered for Diet Survey.
Similarly, a total of 16,599 (1-5 years: 9,038 and 6-12 years: 7,561) rural children were covered for Anthropometry.
Anthropometric measures such as length (Infanto-meter)/height (anthropometric rod) and weight (SECA Digital weighing scale) of all children were recorded adopting standard procedures.

6. The median intakes of nutrients were calculated and compared them with the Recommended Dietary Allowances (RDAs) for Indians .
The deficit intake of each nutrient (Against their RDAs) and Adequacy (consumption ≥ 70% of RDA) status of various nutrients were assessed.
Prevalence of underweight (weight for age< Median – 2SD) and stunting (height for age < Median – 2SD) was calculated for under 5 children (WHO).
Body Mass Index (BMI)-Z Scores were calculated for 6-12 year children (WHO) .
Study was approved by Indian Council of Medical Research (ICMR) Scientific Advisory Committee.
Ethical clearance was obtained from the Institute’s Ethic Review Board.
Written informed consent was obtained from parents of all children.

7. Table 1: Distribution (%) of 1-3 year children by median and deficit (against RDAs) intakes of nutrients
Nutrients
Median
RDA
<RDA
≥ 70% RDA
Deficit
Protein (g)
19.7
16.7
38.3
78.4
No deficit
Total fat (g)
11.8
27.0
87.8
28.2
-56.3
Energy (Kcal)
733
1060
80.2
49.0
-30.9
Calcium (mg)
166
600
92.5
15.5
-72.3
Iron (mg)
4.7 9
81.2
34.8
-47.8
Vitamin A (µg) 61
400
92.2
-84.8
Thiamine (mg)
0.5
47.2
66.5
0.0
Riboflavin (mg)
0.3
0.6
78.5
32.8
-50.0
Niacin (mg)
4.8 8
81.3
39.6
-40.0
Vitamin C (mg) 40
91.5
14.6
-77.5
Folic acid(µg)
48.1 80
99.4
41.4
-39.9

8. Table 2: Distribution (%) of 4-6 year children by median and deficit (against RDAs) intakes of nutrients
Nutrients
Median
RDA
<RDA
≥ 70% RDA
Deficit
Protein (g)
27.9
20.1
24.7
91.4
No deficit
Total fat (g)
15.0 25
78.8
39.8
-40.0
Energy (Kcal)
1033
1350
78.2
59.7
-23.5
Calcium (mg)
198
600
92.3
16.4
-67.0
Iron (mg)
7.2 13
79.9
36.6
-44.6
Vitamin A (µg) 74
400
90.5
13.7
-81.5
Thiamin (mg)
0.7
45.2
76.6
0.0
Riboflavin (mg)
0.4
0.8
83.5
34.4
-50.0
Niacin (mg)
7.6 11
78.9
48.1
-30.1
Vitamin C (mg) 15 40
83.6
26.6
-85.0
Folic acid(µg)
71.9
100
99.6
51.3
-28.1

9. Table 3: Distribution (%) of 7-9 year children by median and deficit (against RDAs) intakes of nutrients
Nutrients
Median
RDA
<RDA
≥ 70% RDA
Deficit
Protein (g)
33.4
29.5
38.1
86.0
No deficit
Total fat (g)
17.1 30
82.7
36.6
-43.0
Energy (Kcal)
1241
1690
82.4
55.8
-26.6
Calcium (mg)
226
600
91.9
18.6
-62.3
Iron (mg)
8.6 16
81.5
35.4
-46.25
Vitamin A (µg) 79
93.6
9.3
-86.8
Thiamin (mg)
0.8
42.5
77.4
0.0
Riboflavin (mg)
0.5 1
89.0
23.2
-50.0
Niacin (mg)
9.4 13
77.7
51.9
-27.7
Vitamin C (mg) 19 40
78.9
32.6
-52.5
Folic acid(µg)
86.9
120
99.9
52.3
-27.6

10. Table 4: Distribution (%) of year Boys by median and deficit (against RDAs) intakes of nutrients
Nutrients
Median
RDA
<RDA
≥70 % RDA
Deficit
Protein (g)
37.4
39.9
55.8
74.1
-6.3
Total fat (g)
18.1 35
85.6
31.4
-48.3
Energy (Kcal)
1405
2190
92.4
40.7
-35.8
Calcium (mg)
248
800
96.4
11.2
-59.0
Iron (mg)
9.8 21
87.4
27.8
-53.3
Vitamin A (µg) 87
600
91.9
11.0
-85.5
Thiamin (mg)
0.9
1.1
58.5
66.7
-18.2
Riboflavin (mg)
0.6
1.3
95.6
14.0
-53.9
Niacin (mg)
10.8 15
77.9
52.2
-28.0
Vitamin C (mg) 22 40
73.9
38.5
-45.0
Folic acid(µg)
95.2
140
99.8
47.8
-32.0

11. Table 5: Distribution (%) of year Girls by median and deficit (against RDAs) intakes of nutrients
Nutrients
Median
RDA
<RDA
≥70% RDA
Deficit
Protein (g)
35.1
40.4
61.6
68.4
-13.1
Total fat (g) 17 35
87.4
27.0
-51.4
Energy (Kcal)
1330
2010
88.3
43.1
-33.8
Calcium (mg)
230
800
96.6
10.5
-71.3
Iron (mg)
9.3 27
95.6
13.6
-65.6
Vitamin A (µg) 81
600
92.6
10.3
-86.5
Thiamin (mg)
0.9 1
55.4
63.3
-10.0
Riboflavin (mg)
0.5
1.2
94.6
17.9
-58.3
Niacin (mg) 13
70.6
59.6
-20.8
Vitamin C (mg) 21 40
76.0
36.3
-47.5
Folic acid(µg)
92.2
140
99.8
45.5
-34.1

12. Table 6: Distribution (%) of 7-12 year children (boys &girls) by median and deficit (against RDAs) intakes of nutrients
Nutrients
Median
RDA
<RDA
≥70 % RDA
Deficit
Protein (g)
34.9
35.1
48.8
78.3
-0.6
Total fat (g) 17 33
84.7
32.8
-48.5
Energy (Kcal)
1307
1905
86.6
48.5
-31.4
Calcium (mg)
233
704
94.3
14.6
-66.9
Iron (mg)
9.1
20.1
86.7
27.8
-54.7
Vitamin A (µg) 82
600
92.9
10.0
-86.3
Thiamin (mg)
0.9
50.1
71.0
0.0
Riboflavin (mg)
0.5
1.1
92.2
19.4
-54.5
Niacin (mg)
13.5
75.9
53.9
-25.9
Vitamin C (mg) 20 40
76.8
-50.0
Folic acid(µg)
90.5
130.4
99.8
49.4
-30.6

13. Proportion (%) of 1-3 year children by consumption of nutrients < 50% of RDA

14. Proportion (%) of 4-6 year children by consumption of nutrients < 50% of RDA

16. Prevalence (%) of underweight (Weight for Age <Med-2 SD) among under 5 year children by states

17. Prevalence (%) of Stunting (Height for Age <Med-2 SD) among under 5 year children by States

19. Conclusions
In general, the rural children in India were subsisting on inadequate diets with deficit in multiple micronutrients.
The intakes of vitamin A, vitamin C, riboflavin, iron, calcium and total fat were grossly deficit as against their RDAs.
Similarly, the proportion of children not meeting even 50% of their RDs was very high with respect to vitamin A, vitamin C, riboflavin, iron, calcium.
The poor diet is reflected in high prevalence of underweight and stunting among under 5 year children and about 41% of thinness among school age children.
In general, the prevalence of undernutrition was significantly higher among the children belonged to marginalized communities, illiterate parents, labourer parents , those residing in HHs where family income was low and HHs with no electricity and sanitary latrine.

20. Recommendations
Appropriate nutrition interventions to be initiated for rural children to meet the suggested levels of all micronutrients.
Government should strengthen the existing supplementary feeding programmes : ICDS supplementary feeding programme and Mid-Day Meal (School lunch) programme.
Government should provide employment and fix minimum wages for agricultural and non- agricultural labours and control the prices of food commodities to improve purchasing power of poor.
Health and nutrition education to be imparted to the rural communities to increase the utilization of Govt nutrition programmes.
Strengthening of Public Distribution System (PDS) by inclusion of more food commodities.
Employment guarantee to rural poor.
Women empowerment, female literacy and equal wages for both genders.
All these interventions would facilitate food and nutrition security and minimize the hidden hunger among the rural children to meet the New Sustainable Development Goals (SDGs) of NO POVERTY and ZERO HUNGER.

21. Acknowledgements
I wish to thank DG, ICMR and Director, NIN for giving me the opportunity to attend this conference.
I am also very grateful to SIGHT and LIFE and Dr. Klaus Kraemer for the TRAVEL GRANT.
I also wish to thank Field Staff of NNMB state units and staff of Division of Community Studies, NIN.