IJDTSA Vol.3, Issue 3, No.1 pp.1 to 11, December, 2018
Malnutrition (Undernutrition) and Its Treatment – Tribal Children Perspective Jharkhand
As per the recent report published by the Unicef “Nourishing India’s Tribal Children” – India’s tribal communities1 continue to remain the most nutritionally deprived social groups in the country. It is undeniable that their deprivation is influenced by a cobweb of factors ranging from poverty and hunger, due to loss of forest land and livelihood, poor re-habitation measures, poor reach and quality of essential food and nutrition services during critical periods of life, geographical remoteness. More than half of tribal children under five years of age in India are stunted and fail to meet their potential for growth and development. Child stunting is potentially the biggest threat to children’s growth and development. Stunted children have stunted bodies, stunted brains and stunted lives. Present study tries to find out the reasons for high malnutrition among tribal children specially “HO” tribes and strategies to reduce malnutrition from the tribal and local perspectives.
Malnutrition occurs due to poor diet or a lack of food. It happens when the intake of nutrients or energy is too high, too low, or poorly balanced2. Both under nutrition and over nutrition can lead to Malnutrition. Undernutrition can lead to delayed growth or wasting, while a diet that provides too much food, but not necessarily balanced, leads to obesity. Undernutrition mainly results from lack of food. In some cases, however, undernourishment may stem from a health condition, such as an eating disorder or a chronic illness that prevents the person from absorbing nutrients. According to the World Health Organization (WHO), malnutrition is the gravest single threat to global public health4. Globally, it contributes to 45 percent of deaths of children aged under 5 years. Undernutrition severely hammers child survival, growth and development, and it even slows down the national growth in the long run.
Malnutrition involves a dietary deficiency. People may eat too much of the wrong type of food and have malnutrition, but this paper will focus on undernutrition, when a person lacks nutrients because they do not consume enough food. Poor diet may lead to a lack of vitamins, minerals, and other essential substances. Too little protein can lead to kwashiorkor, symptoms of which include a distended abdomen. A lack of vitamin C can result in scurvy. Scurvy is rare in industrialized nations, but it can affect older people, those who consume excessive quantities of alcohol, and people who do not eat fresh fruits and vegetables. Some infants and children who follow a limited diet for any reason may be prone to scurvy. NFHS 4 reports indicate that in India 35.7% under five years children are underweight and 38% under five children are stunted, whereas in Jharkhand 47.8 % of children are malnourished (underweight – weight for age) and 45.3 % children are stunted (Height for age)4. Percentage of underweight children in West Singhbhum District is 66.9 and stunting is 59.4 %, which is quite high as per the national average of 35.7 % and 38% respectively. Malnutrition during childhood can lead not only to long-term health problems but also to educational challenges and limited work opportunities in the future. Malnourished children often have smaller babies when they grow up. It can also leads to slow recovery from wounds and illnesses, and it can complicate diseases such as measles, pneumonia, malaria, and diarrhea. It can leave the body more susceptible to disease.
As per the recent report published by the Unicef “Nourishing India’s Tribal Children” – India’s tribal communities continue to remain the most nutritionally deprived social groups in the country. It is undeniable that their deprivation is influenced by a cobweb of factors ranging from poverty and hunger due to loss of forest land and livelihood, poor re-habitation measures, poor reach and quality of essential food and nutrition services during critical periods of life, geographical remoteness, weak governance and inadequate accountability mechanisms. Malnourished children are underweight and stunted / wasted or both (Moderate malnutrition. Moderate malnutrition (MM) is defined as a weight-for-age between -3 and -2 z-scores below the median of the WHO child growth standards. It can be due to a low weight-for-height (wasting) or a low height-for-age (stunting) or to a combination of both). More than half of tribal children under five years of age in India are stunted and fail to meet their potential for growth and development. Child stunting is potentially the biggest threat to children’s growth and development. Stunted children have stunted bodies, stunted brains and stunted lives. Stunted children are more likely to fall ill, fall behind in class and when they start work, do not perform as well and earn less than their non-stunted peers. Present study tries to find out the reasons for high malnutrition among tribal children and strategies to reduce malnutrition.
Material and Methods
The Sample: Sample for the present cross sectional study was collected from two blocks of West Singhbum District, Jharkhand, India covering 97 villages. A sample of 488 ‘HO’ tribal children aged 6 month to 5 years was selected for the present study.
Anthropometric measurements: the anthropometric measurement of height and weight of ‘HO’ tribal boys and girls were taken. The same investigators collected all the measurements to avoid the observational errors, and for maintaining uniformity and accuracy in techniques. Equinox digital weighing scales with 100g graduations, calibrated regularly were used to measure weight. Infantometers (Seca 210 with 0.5cm graduation) and Stadiometers (Seca213 with 0.01cm graduation) were used to measure heights. The standard WHO definitions for Wasted (WHZ is <-2 SD), Moderately Wasted (WHZ is <-2SD and >-3SD) and Severely Wasted (WHZ is <-3SD) are used. Severe Acute Malnutrition (SAM) is defined as being severely wasted (WHZ is <-3SD).
Interview questionnaire: Data was collected using a pre tested semi structured Interview scheduled through house to house visit and mothers of infants were interviewed. Since the age group of the study population is 6 month to 5 years, mothers were chosen as the respondent; in some cases if the child’s mother was not available father / close relative become respondent. Respondent were asked questions like name, age, their Income status, occupations, feeding practices, cultural norms that they follow, and four specific determinant were asked; occurrence of Illness / disease, care provided to the children during the sickness, food habit, and hygienic practices etc. FGD’s were conducted amongst the villagers and village leaders of that particular community and locality to find out common practices and believes taboos and cultural practices followed since ages.
Age estimation: age of the children was ascertained form the mother and child protection card (MCP), provided by the health department and subsequently confirmed by the mothers and Aganwadi workers.
Analysis: Analysis was done using the statistical package SPSS (Version 11) and the “igrowup” macro provided by WHO Anthro. Statistical analyses of the data were performed using the IBM Statistical Program for Social Sciences (SPSS). The z-score values of weight for age (WAZ), height for age (HAZ) and weight for height (WHZ) was computed using the WHO Anthropometric tool. A descriptive analysis was used to compare the socio-economic characteristics, household food security status, child’s dietary intake, and caregiver variables between exposed and not exposed. Chi squared test and t-test was used to examine the relationship between childhood malnutrition and study variables.
As per the reports published there are approximately 20 lakh children who are malnourished in the state of Jharkhand. NFHS 4 reports also states that 47.8 % of children are malnourished (underweight) in Jharkhand and 45.3 % children are stunted. Condition is worst in the West Singhbhum District where percentage of underweight children is 66.9 and stunting is 59.4 %, which is quite high as per the national average of 35.7 % and 38% respectively. These figures are quite alarming and raises question on the government mechanism and programs that are run by the government. As per the government records there are 5 Malnutrition Treatment Centre (MTC), 2339 Aganwadi Centers and 307 Mini Aganwadi centers to cater to the Malnutrition and to reduce or control Malnutrition. As per the census 2011 (JH_Factsheet_368_Pashchimi Singhbhum), there are 261493 children below 6 years of age who are basically affected by the Malnutrition. This means approximately 2 Lakh children are malnourished (66.9% source NFHS 4) and more than 30 thousand children are severely malnourished (13% of the children; source NFHS 4) in West Singhbhum District of Jharkhand.
Various studies and reports suggest that malnutrition is condition where a person lacks necessary proteins and vitamins required for the body. Many studies have come up with various suggestion and solutions to overcome malnutrition, this paper also suggests various methods to reduce or overcome malnutrition among the tribal people.
Results and Findings
Results from the current study indicate that tribal (“HO”) people (Sample size of 488, “HO” Tribes) have different life style, different food habits and different religious and cultural beliefs. People living in West Singhbum District of Jharkhand generally prefer to eat Mard Baat (overnight soaked Rice) with or without vegetable or dal (75%). Study data reveals that very few families prefer to eat chappati / roti (1%) due to various reason (large size of the family, availability of wheat etc.), consumption of dal is very negligible (5%) may be due to its high cost and consumption (Meat / Fish etc) item is rare, surprisingly consumptions of non vegetarian increases to 91% during festivals or when guest are at home. Consumption of seasonal fruits like mango or guvava etc. are on yearly basis. Thus non consumption of vegetable, dal, meat / fish, and fruits in required quantity results in non availability of required nutrition in the body, which results in malnutrition.
Strategies to reduce Malnutrition among Tribal Children (“HO” Tribes)
Eating Khichdi instead of Mard Baat
Study data shows that tribal parents mainly provided mard baat to their children in breakfast and lunch on daily basis (75%); Fig 1 Fig 2 and Fig 3. Mard baat is generally served without dal, with or without sabji. It may be because cooking dal is time taking and costly. Mard baat is served early in the morning because no any extra preparation time is required for it, as Mard baat (Basi Baat) is prepared by soaking rice in water overnight. In most cases it is served with a piece of onion and chilli or chatni. Mard baat contains only starch and fats. One of the major reason observed for preference of tribal people to prefer mard baat is due to their tight schedule early morning. Tribal person (mainly farmer) has to complete most of the activities early in the morning. In the later part of the day a tribal person is mostly free and takes rest. This is the time tribal women cooks food and prepare it sufficient enough, so that their family can eat early morning also; mainly rice. Government under ICDS program recommend that a child has to be provided Khichdi1 (rice cooked with mixing vegetables and dal), after child attains six month of age and above. Khichdi is a whole meal and it provides sufficient calories and Macronutrients. Khichdi should be promoted among tribal children instead of Mard baat.
Use of Pressure Cooker
Pressure cooker is one of the finest and most useful inventions of the modern days. It is easy to handle and is able to cook many food items quickly while retaining its nutrient value also. Cooking Khichdi is much easier in pressure cooker and it saves time. Pressure Cooker is also useful for cooking Dal. Use of pressure cooker is one of the quickest means cooking foods and it simplifies cooking. Adivasi / Tribal people living in the rural area use fire woods for cooking food, which is time taking and lots of effort has to be taken. Use of pressure cooker can help them save time and effort. A child can be immediately fed with khicdhi, whenever needed with the help of pressure cooker. It is also hygienic and there is no loss of any nutrients. Therefore it is recommended that every villager / tribal people to use pressure cooker. Cooking Dal is also a time consuming when cooked in a conventional way. Some dal take almost an hour.
Current study shows that only 5.3% (Fig 4) of the tribal people have pressure cooker at home. This could be due to its high cost or lack of knowledge in terms of its usefulness. Time taken to cook could be reason for child being not provided khichdi and dal.
Consumption of non veg (Meat) items
Tribal people love to live with pet animals; they always have poultry farm, goat, and fish. Almost every tribal people have all this animals throughout the year. Study data shows that even though tribal people have these animals, they don’t eat their meat on regular basis. Thus they don’t get valuables nutrients that they can easily get from them. Meats of these animals are generally consumed only during the festivals or when there are visitors at home (Fig – 5). If these animals are consumed as a meat on a regular basis, it can provide valuable nutrients to them. In most cases these animals are sold off to get some extra earnings and in many cases these animals die due to sickness and other reasons, resulting in loss of valuable nutrients. Major reason for not consuming these animals for meat seems to be lack of awareness among tribal’s regarding importance of meat and its nutrition value. Therefore it is recommended and suggested that huge awareness drive to be undertake inorder to make tribal people consume meat.
Consumption and Promotion of fruits
Consumption of fruits among the tribal people is very less or negligible; data shows that only 5% (Fig – 6) of the tribal people consume fruits. Fruits that are available in their garden or in their locality like mango, guvava, bari bari, Papaya, jack fruit etc are being consumed. Many other fruit trees which where earlier available have gone missing due to deforestation. Moreover current generation of tribal people are not planting new trees and few fruit trees whose fruits are not regularly eaten are not at all being planted. There were many fruit trees in earlier days which use to be eaten on occasional basis, have gone missing. Due to poverty and high cost, most of the tribal people can’t afford to purchase fruits like apple orange banana and many other fruits which are market driven. Thus non consumption of fruits is leading to lack of valuable nutrient in their body. Even if tribal people could regularly consume fruits available locally they may get required nutrition. This could be mainly because of lack of awareness and knowledge about importance of nutrient available in fruits. Therefore it is needed that these people are made aware of the nutritional value available is these fruits and make them consume fruits on regular basis.
Consumption of Cow Milk
Mother’s milk contains valuable nutrients; a child should be provided only mother’s milk till 6 month of age and can continue till one to two years. After one year of age mother’s milk can be substituted with cow’s milk, cow milk also contains valuable nutrients and is rich source of calcium and potassium. Milk is whole food and contains most of the nutrients required for a child. Tribal people mostly use to keep cattle; cows and buffalo at home for milk, manure and for ploughing field. With advent of technology and deforestation, grazing, rearing and keeping these animals are becoming a tough task. Earlier milk use to be consumed on regular basis by tribal people but now since these animals have decreased a lot, therefore availability and consumption of milk has reduced to negligible. Though in some cases it is reported that tribal people don’t prefer to have cow milk, considering that the milk is mainly for the calf. Since milk is not being provided to the children or the family members, thus valuable nutrients are missing in their body. Study data shows that consumption of milk among tribal people is only 1% (Fig 7). Interestingly milk is being sold and supplied in every town and, urban people especially children are greatly being benefited.
Therefore it is necessary that cow and buffalo rearing is promoted and deforestation is avoided, so that tribal children are not deprived of milk and milk products which is rich source of valuable nutrients. This can drastically change the malnutrition status of the tribal children.
Promotion of Kitchen garden
Tribal people live in village and have ample of land among their surroundings. Every tribal house has little or some land which is sufficient for making a kitchen garden. Kitchen garden plays a very important role in providing vegetables on regular basis and ensures easy availability of vegetables. Waste water from kitchen can be used for watering vegetables and waste food items can be used as manure, thus benefitting from the available waste resources. Most of the tribal people generally cultivate paddy and other cash crops but only few grow vegetables. Vegetable are important source of vitamins, minerals and many micronutrients, it is necessary to eat vegetable on regular basis. Earlier many local green leafy vegetables were available locally and in nearby forest but due to deforestation and change in preference towards local vegetable, local vegetables are not given due importance. Though many researchers had acclaimed that tribal people use to eat locally available green leafy vegetable which were rich in nutrient value and most of the nutrient requirement were used to be fulfilled. Tribal people can still cultivate vegetables in their kitchen garden and get most of the nutrient required for their body without much investment and cost. Currently most of the tribal people don’t seems to make kitchen garden even though they have sufficient land for it. This could be mainly because of lack of awareness and knowledge about importance of nutrient available in vegetables. It is needed that tribal people are made aware of the importance of vitamins and minerals for the body and sources of these vitamins and minerals.
Hand washing practices or Cleaning Practices
It is observed that the children in village generally spend whole day playing in the sand or soil / mud. It is a natural and practical environment for them. Most of them remain naked throughout the day. It’s not because parents can’t afford cloths but because children are mostly left with their siblings or elder kids in the village, and when the child urinate or defecates; he she remains dirty for long time until his/her parents realize, which can result in other problems. Therefore they prefer to leave their child naked so that these types of issue dosent arise. It is also noticed that children mostly don’t wash their hand before eating food, even if children washes hand they tend to touch mud / floor or soil while eating. As a result hand remains dirty and chances of infection remains high, therefore it is recommended that a child should be trained to eat with spoon and also should be fed with spoon to ensure infection control.
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Graphical Representation of 488 respondents (Khuntpani and Chaibasa Sadar Block, West Singhbhum District, Jharkhand)
a). Morning / Breakfast
b). Afternoon / Lunch
c). Evening / Dinner
d). Availability of House Hold Items
e). Consumption of Non Vegetarian Item
f). Consumptions of Fruits
g). Consumption of Milk