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A L i t e r a t u r e R e v i e w o f G o v e r n m e n t N u t r i t i o n a l P r o g r a m a n d T h e i r E f f e c t on Childhood Nutrition

I N T R O D U C T I O N

Malnutrition is a silent crisis in South Asia. Without adequate resources to ensure proper health education nor to purchase life-saving treatments, many South Asian countries, such as India and Bangladesh often fail to even recognize that malnutrition afflicts its children.

India, specifically, is burdened by a large proportion of malnutrition in South Asia. In fact, more than one-third of the world’s malnourished children are located in India. Every year, almost half of children in India suffer from malnutrition and nearly a million children die before surpassing one month of age. 1 About 60 million Indian children are underweight, about 45 million are stunted, 20% are wasted, and 57% are Vitamin-A deficient. 1 Stunting is defined as a low height for weight whereas wasting is defined as having a low weight for age. 2 Despite growing to the sixth largest economy by GDP in the latter half of the 20th century, India has experienced growth in rates of malnutrition, especially in its most impoverished states. 1

However, governmental work on malnutrition throughout South Asian countries has bolstered in the last 30 years. For example, Bangladesh has implemented a national nutrition policy, pledging to control and prevent malnutrition. 3 The government of Pakistan also has programs such as the Micronutrient Initiative and the School Health Programme, which are focused efforts of larger development schemes to improve the health and economy

Amith Umesh & Varun Mahadevan

of its country. 4 Specifically, these programs are aimed at delivering healthy food options to children and mothers in order to prevent and treat malnutrition.

The most cohesive of these schemes, the Integrated Child Development Services Program (ICDS), was developed by the government of India. It provides health check- ups, vaccinations, food and preschool education to children up to six years of age. 5 Furthermore, nutritional rehabilitation centers provide primary care inpatient services to children who are severely malnourished. 5, 6 Admitted children receive energy-dense supplementary feedings, micronutrient supplementation, and consultation with dietitians to develop long-term health goals. 5

Although literature has examined the broad efficacy of these governmental initiatives, often in terms of education delivery or referral services, a rigorous and focused inspection of nutritional delivery, such as supplementary feeding, through governmental institutions is lacking. Furthermore, many systematic reviews on nutritional feeding strategies for malnourished children have studied delivery through non-governmental organizations such as United Nations Children’s Fund (UNICEF) or the World Health Organization (WHO). We seek to understand whether the long-term prevention and solution to malnutrition in South Asia involves the cohesive integration of supplemental nutrition delivery with governmental institutions to reach the greater population burdened with malnutrition. To this end, a focused examination of past successes and failures of such an integration is paramount to guiding future efforts in alleviating this crisis. Therefore, in this review, we aim to examine the relationship between government programs that deliver nutrition in South Asia and malnutrition in their beneficiary children.

M E T H O D S Eligibility Criteria

All reviewed articles examined the effect government deliveries of nutrition on how children responded to these treatments. Responsiveness was measured using anthropometric changes in measures such as weight and height. Eligibility criteria included the type of program, specifically government nutritional intervention programs, including those delivered in conjunction with non-profit organizations that played a non-primary role in delivery of program. Childhood malnutrition as an outcome was another eligibility criterion screened for. The age range was restricted to studies examining participants under 18, and the type of malnutrition examined by studies included the following: moderately (<2SD) or severely (<3SD) undernourished, and stunted (low height-for-age), wasted (low weightfor-height), and underweight (low weight-for-age) in the WHO Anthro Survey Analyzer, which includes globally agreed upon normal weight distribution among children under five. 2

Study Quality Assessment

The method used to assess the strength of the study design was the abridged version of the Downs and Black tool. 10 Quality for each study was determined by analyzing whether the Downs and Black criteria were met for each study. The criteria evaluate the quality of each study by using a ten-question scale that assesses study quality, external validity, study bias, confounding and selection bias, and study power. The denominator for the Downs and Black tool is eight for experiments, and six for nonexperiments.

R E S U L T S Study Characteristics

Of the eight articles reviewed, seven were from Karnataka, Maharashtra, Kerala, West Bengal, Madhya Pradesh, Uttar Pradesh. 6, 8–13, and the remaining article were in Bangladesh. 14 The population of all studies included children that were malnourished to some degree, as defined by undernourishment, wasting, or stunting. Furthermore, some studies assessed all children (both healthy and malnourished), but others only sampled malnourished children. The age range also varied between studies. For example, some selected for school children specifically between the ages of six to ten years old while others chose for children between six months and 59 months. 11, 13 Four of the studies were experiments, three of which were controlled trials, 8,10,14 and the remaining experiment was a quasiexperimental trial. 9 The remaining four studies used a cross-sectional study design. 6,11–13

All studies included programs that delivered nutritive foods either fortified with micronutrients or high in fat content. All studies measured anthropometric measures such as height and weight. These were then converted to formal indices for malnutrition such as height for age z-scores, weight for age z-scores, body mass index z-scores, or composite index of anthropometric failure, generally using the online WHO Anthro Survey Analyzer. These indices were then used to classify children into levels of malnutrition such as wasted, stunted, severely malnourished or moderately malnourished. Additionally, one study measured biochemical values of micronutrients such as vitamin levels. 14 Only one study measured mortality of children. 6 Synthesis

Seven of the eight studies showed significant improvements in either weight or height gain, and subsequent recovery from malnutrition as a byproduct for all the subjects. 6,8–11,13,14 A range of 40% to 50% growth in weight was observed in all these studies. The one study that administered fortified biscuits and measured micronutrients observed statistically significant levels of increase in micronutrients and hemoglobin. Although Devara et. al reported decreases in the proportion of underweight children compared to baseline, no statistical significance was observed between the intervention and control group. Of the eight studies, Jayalakshmi et. al reported no benefits from government intervention for child malnutrition as none of the outcomes differed between treatment and control group, showing the ICDS government program was not sufficient in bringing children out of malnutrition.

D I S C U S S I O N

In this review, we sought to elucidate the nature of the relationship between government nutritional intervention programs and childhood malnutrition in South Asian countries.

We found that the delivery of nutritional interventions through governmental programs in South Asian countries, specifically, India and Bangladesh, was successful in alleviating malnutrition in children as compared to their baseline status or compared to control groups. This finding was consistent with nearly all studies (seven out of eight), especially since all of them scored highly on the Downs and Black scale due to their strength in generalizability.

Reviewed studies indicate that governmental nutrition programs provide a source for both primary prevention (for children at high risk for malnutrition) and secondary prevention (for malnourished children) of childhood malnutrition. The strength of these government programs comes from their extensive reach into communities and a general sense of trust from the community in the programs. 15 With regular attendance at the programs, children can receive a consistent supplemental feeding. 15 Although spot- feeding services of meals or take-home rations are also employed by non-governmental organizations or community-based management programs, the aforementioned strengths of the governmental programs give them an advantage in mobilizing these supplemental feeding schemes. 15

We found differential seasonality to be a prominent contributor to confounding in the assessed studies. Large variabilities in seasons in South Asia, primarily observed from monsoons, that affect farming and availability of food can significantly affect weight gain or loss in children. 16 None of the reviewed studies specifically controlled for this confounder. Therefore, future studies should aim to procure anthropometric measurements during the same season or account for seasonality. This may include allocating case and control groups to multiple seasons to be run in a parallel manner.

Furthermore, only one of the eight studies specifically assessed biochemical measures such as micronutrient levels. Although assessing weight gain serves as a broad marker of malnutrition, changes in micronutrient levels are critically important to proper biological function and should be addressed in future studies.

Additionally, varying age ranges for participants were included across reviewed studies: 6 months to 59 months, zero to six years old, 6 to 11 years old, 10 to 14 years old, 15 to 18 years old. Although recruiting participants in such constrained age ranges allow researchers to derive specific conclusions to that age group, literature in the field of malnutrition lack a comprehensive review of programs that range the entirety of childhood from birth to 18 years. This may be the result of either a lack of government programs or a limitation of studies to recruit participants from a wide age range. However, efforts to analyze outcomes from government

programs that provide such continuity of care is critically important to understanding their long-term efficacy and susceptibility to relapse for different populations and thus should be a focus of future studies and policy development.

C O N C L U S I O N

Our review sought to uncover the effects of governmental nutrition programs in South Asian countries on childhood malnutrition. Although our review faces limitations in only assessing a small number of studies from a single database (PubMed), it is the first review to examine how governmental nutritional delivery programs in South Asia affect childhood malnutrition. Previous reviews have assessed the broad effectiveness of governmental programs on malnutrition (i.e. maternal advising, primary care support, and preschool education), but none have focused, specifically, on the efficacy of supplemental nutrition to alleviate childhood malnutrition through these programs. Another strength of our review is that it utilizes a highly refined search strategy. Developing the search strategy was a rigorously iterative process that aimed to capture a large pool of articles while keeping the topic of inquiry in focus.

On average, we found that these programs were effective in decreasing wasting or stunting, or both, in children by supplementing their regular diets with additional nutrition. Overall, as a result, children recovered from wasting or stunting. However, future programs can better their services by aiming to assess micronutrient malnutrition and providing continuity of care until beneficiaries reach adulthood. Nevertheless, the success of these government programs as points of access for supplemental nutrition to malnourished children are indicative of a long-term solution to the crisis of malnutrition in South Asia.

R E F E R E N C E S

1. Motedayen M, Dousti M, Sayehmiri F, Pourmahmoudi AA. An Investigation of the Prevalence and Causes of Malnutrition in Iran: a Review Article and Meta-analysis. Clin Nutr Res. 2019;8(2):101-118. 2. Helping India Combat Persistently High Rates of Malnutrition. https://www.worldbank.org/ en/news/feature/2013/05/13/helping-india-combat-persistently-high-rates-of-malnutrition. Accessed November 22, 2019. 3. Akhtar S. Malnutrition in South Asia-A Critical Reappraisal. Crit Rev Food Sci Nutr. 2016;56(14):2320-2330. 4. UNICEF Helps Malnourished Children With Ready-to-Use-Therapeutic Food | UNICEF USA. https://www.unicefusa.org/stories/whatready-use-therapeutic-food/32481. Accessed November 22, 2019. 5. Bazzano AN, Potts KS, Bazzano LA, Mason JB. The Life Course Implications of Ready to Use Therapeutic Food for Children in Low-Income Countries. Int J Environ Res Public Health. 2017;14(4):403. Published 2017 Apr 11. 6. Segre J, Liu G, Komrska J. Local versus offshore production of ready-to-use therapeutic foods and small quantity lipid-based nutrient supplements. Matern Child Nutr. 2017;13(4). 7. Borg B, Mihrshahi S, Laillou A, et al. Development and testing of locally-produced ready-touse therapeutic and supplementary foods (RUTFs and RUSFs) in Cambodia: lessons learned. BMC Public Health. 2019;19(1):1200. 8. Wali N, Agho K, Renzaho AMN. Past drivers of and priorities for child undernutrition in South Asia: a mixed methods systematic review protocol. Syst Rev. 2019;8(1):189. 9. Schoonees A, Lombard MJ, Musekiwa A, Nel E, Volmink J. Ready-to-use therapeutic food (RUTF) for home-based nutritional rehabilitation of severe acute malnutrition in children from six months to five years of age. Cochrane database Syst Rev. 2019;5:CD009000. 10. Downs SH, Black N. The feasibility of creating a checklist for the assessment of the methodological quality both of randomised and non-randomised studies of health care interventions. J Epidemiol Community Health. 1998;52(6):377 LP - 384. 11. WHO | Severe Acute Malnutrition. WHO. 2009. 12. Hudson JI, Pope HGJ, Glynn RJ. The cross-sectional cohort study: an underutilized design. Epidemiology. 2005;16(3):355-359. doi:10.1097/01. 13. Ministry of Women & Child Development, India https://icds-wcd.nic.in/. Accessed November 22, 2019. 14. Jadhav AR, Karnik P, Fernandes L, Fernandes S, Shah N, Manglani M. Indigenously Prepared Ready-to-use Therapeutic Food (RUTF) in Children with Severe Acute Malnutrition. Indian Pediatr. 2019;56(4):287-293. 15. Sigh S, Roos N, Chamnan C, Laillou A, Prak S, Wieringa FT. Effectiveness of a Locally Produced, Fish-Based Food Product on Weight Gain among Cambodian Children in the Treatment of Acute Malnutrition: A Randomized Controlled Trial. Nutrients. 2018;10(7):909. 16. Thapa BR, Goyal P, Menon J, Sharma A. Acceptability and Efficacy of Locally Produced Ready-to-Use Therapeutic Food Nutreal in the Management of Severe Acute Malnutrition in Comparison With Defined Food: A Randomized Control Trial. Food Nutr Bull. 2017;38(1):18-26. 17. Bhandari N, Mohan SB, Bose A, et al. Efficacy of three feeding regimens for home-based management of children with uncomplicated severe acute malnutrition: a randomised trial in India. BMJ Glob Heal. 2016;1(4):e000144. 18. Bashir A, Zaman S. Effectiveness And Acceptability Of Ready-To-Use Therapuetic Foods Among Malnourished Children In A Tertiary Care Hospital. J Ayub Med Coll Abbottabad. 2016;28(3):501-505. 19. Shewade HD, Patro BK, Bharti B, Soundappan K, Kaur A, Taneja N. Effectiveness of Indigenous Ready-to-Use Therapeutic Food in Community-based Management of Uncomplicated Severe Acute Malnutrition: a Randomized Controlled Trial from India. J Trop Pediatr. 2013;59(5):393-398. 20. Thakur GS, Singh HP, Patel C. Locally-prepared ready-to-use therapeutic food for children with severe acute malnutrition: A controlled trial. Indian Pediatr. 2013;50(3):295-299. 21. Singh AS, Kang G, Ramachandran A, Sarkar R, Peter P, Bose A. Locally made ready to use therapeutic food for treatment of malnutrition a randomized controlled trial. Indian Pediatr. 2010;47(8):679-686. 22. Ireen S, Raihan MJ, Choudhury N, et al. Challenges and opportunities of integration of community based Management of Acute Malnutrition into the government health system in Bangladesh: a qualitative study. BMC Health Serv Res. 2018;18(1):256. 23. Schulz KF, Grimes DA. Blinding in randomised trials: hiding who got what. Lancet (London, England). 2002;359(9307):696-700.

VARUN MAHADEVAN

Class of 2021. Varun is a junior from Oakland, California, studying biophysics. Varun is interested in domestic as well as global healthcare inequities. He hopes to pursue a medical degree to address these inequities in clinical settings. Additionally, he is involved in nutrition research with a focus on India’s malnutrition crisis.

AMITH UMESH

Class of 2020. Amith is a senior majoring in biophysics. Born in India, Amith has a strong interest in global health. Additionally, he is working to pursue pediatric medicine. His research stems from his experience working in the non-profit organization he founded in 2018, where he helped develop lowcost supplementary food for malnurished children in India.