Insights Beyond Numbers: Composite Indexing as a Lens to Illuminating the Nutritional Status of Karnataka

Introduction

Adequate nutrition in the first years of a child’s life provides the essential building blocks for brain development, healthy growth, and a strong immune system, and prevents future non-communicable diseases associated with overweight.¹ A healthy diet and nutrition is a fundamental human right as recognised by the second Sustainable Development Goal of the United Nations.² Poor nutrition in the early childhood causes deficiencies in essential nutrients, such as vitamin A deficiency, which impairs children’s immunity, increasing their risk of blindness and leading to death from common childhood illnesses. Undernutrition and infection can combine to produce a potentially fatal cycle of sickness and declining nutritional status. A child’s development can be hindered during the first five years of life due to poor nutrition, and stunted growth is linked to cognitive decline and poor performance.³ Catering to children’s dietary demands in early life can be difficult, and many guardians face barriers to securing safe, affordable, nutritious, and appropriate diet for their children. These challenges are even exacerbated during wars, natural catastrophes and other humanitarian emergencies.⁴ Even if it does not lead to death, malnutrition including micronutrient deficiencies lead to permanent damage, including impairment of physical growth and mental development, and added healthcare expenditure.⁵

According to National Family Health Survey (NFHS-5) data in Karnataka, only 80% of children under six years received some form of services from an Anganwadi centre.⁶ Additionally, exclusive breastfeeding was observed in only 61% of babies aged less than six months, with fewer than half (49%) initiating breastfeeding within the first hour of life. Furthermore, merely 13% of children’s caretakers followed WHO recommendations on infant and young child feeding (IYCF) practices. Vitamin A-rich foods were consumed by only 48% of the children aged 6-23 months living with their parents. The prevalence of stunting was reported at 35% among children under the age of five, severe wasting at 8%, and one-third of children were found underweight. Lastly, two-thirds of children aged 6-59 months were found to be anaemic.⁶

Despite concentrating on multiple programmes, significant efforts are necessary to address the causes of childhood malnutrition. Owing to the alarming rates of malnutrition in India, children between the ages of 0 and 5 have received significant programme attention. The Government of India’s Integrated Child Development Service (ICDS) programme was introduced in 1975, and it quickly became the best initiative to reduce the prevalence of malnutrition.⁷ In the state of Karnataka, 204 ICDS projects are currently operational, comprising 62580 Anganwadi centers (AWCs) and 3331 small Anganwadi centers, across 175 talukas (12 tribal, 181 rural, and 11 urban projects). About 56.50 lakh people benefitted from the programme in 2017-18.⁸ Multiple sources of data indicate that significant disparities persist in the nutritional conditions across districts in Karnataka. This study was conducted to develop a nutritional index aimed at identifying these differences and facilitating comparisons.

Materials and Methods

Based on twelve significant factors connected to nutrition, a nutritional index for thirty of Karnataka’s largest districts has been developed using the NITI Ayog Health book.⁹ These twelve indicators were divided into two groups: primary nutritional result indicators and input indicators. The scaled value of every indicator was computed for each district.

The scaled value for the positive indicators, including the percentage of five-year-old children who attended pre-primary school during the 2019-20 school year, the percentage of children who received a vitamin A dose in the previous six months, the percentage of children who were fully vaccinated, the percentage of children who were breastfed within one hour of birth, the percentage of children who received an adequate diet, the percentage of children who were exclusively breastfed till the age of six months, was calculated using following formula:

Where, Si = Scaled value for the positive indicator, and Xi = Data value of the indicator.

Similarly, the scaled value for the negative indicators, including the percentage of children under five who are stunted (source: NFHS 5), the percentage of wasted children under five who are severely wasted (source: NFHS 5), the percentage of underweight children under five who are overweight (source: NFHS 5), and the percentage of anaemic children under five who are stunted (source: NFHS 5), was calculated as follows:

Where, Si = Scaled value for the negative indicator, and Xi = Data value of the indicator.

Based on the output values for the indicators across the districts, the minimum and maximum values for each positive and negative indicator were established. Lastly, a composite nutrition index was derived by taking the mean of all the scaled values, based on the above-scaled values.

Results

To represent the key contributions to reducing malnutrition, a total of six input indicators were chosen for each state. The district-specific list of important input indicators is shown in Table 1. Similarly, six outcome indicators were chosen to assess the nutritional outcome for each district (Table 2). Every one of the six nutritional outcome indicators was considered negative that is, the lower the value, the higher the performance. District rankings according to the final composite score for nutrition are displayed in Figure 1 and Table 3

Districts were ranked according to the final nutrition index score, indicating their nutritional status. Mandya topped the list of 30 major districts, followed by Chitradurga and Ramnagara in second and third place, respectively. Gadag received the lowest ranking, followed by Yadagir and Bagalkot in second and third place from the bottom (Figure 2).

Table 4 enumerates the categorisation of districts based on the composite score obtained. Districts with the highest one-third scores (score >56.858) were considered to be performing well, districts with the middle one third scores (score between 45.167 and 56.858) were considered to be performing moderately, and districts with the lowest one-third scores (score < 45.167) were considered to be performing poorly.

Discussion

The current study compared the disparities in nutritional status throughout Karnataka in an attempt to assemble the malnutrition data from NFHS-5. Underweight denotes both acute and chronic malnutrition, while stunting denotes acute malnutrition and wasting denotes chronic malnutrition. Launched on October 2, 1975, the Integrated Childe Development Services (ICDS) plan is the largest community-based initiative in the world. It aims to improve the health, nutrition, and education of women aged 16-44 years, pregnant and nursing mothers, and children under the age of six.¹⁰ According to NITI Ayog, while POSHAN Abhiyaan plays a pivotal role in India’s battle against malnutrition, it is necessary to step up efforts on various fronts and shift to an approach, which not only reinforces the existing mechanisms but also emphasises on other social determinants. Additionally, it demands addressing challenges within NHM/ICDS delivery mechanisms.¹⁰ Despite India’s remarkable gains in agricultural productivity and economic wealth, the country’s rate of nutritional progress has not kept up, according to the India Health Report on Nutrition. Ignoring undernutrition puts children’s development at risk and might have serious negative effects on future generations’ health, the economy, and society.¹¹

According to United Nations International Children’s Emergency Fund (UNICEF), in Karnataka, the prevalence of stunting exceeded 50% in Gulbarga, Yadgir, and Koppal districts, while it ranged between 40% and 50% in six other districts. These high-stunting districts are mainly situated in the northern part of Karnataka.

Early initiation of breastfeeding ranged from 42% in Shimoga to 72% in Davanagere, with less than 57% of babies breastfed within an hour of birth in half the districts. Vitamin A supplementation coverage ranged from 65% in Bijapur to 95% in Kolar. Household access to improved toilet facilities was extremely low, and ranged from 18% in Yadgir to 92% in Dakshina Kannada. Fully immunized children aged 12 to 23 months ranged from 47% in Mysore to 76% in Bagalkot, which is similar to the results obtained in this study.¹²

According to a study conducted in 2015 by Ukrande et al., it was noted that the proportion of undernutrition was higher in children who were not exclusively breastfed. In a survey conducted by Garg et al., in Manipal, it was found that exclusive breastfeeding for six months was done only for 9% of the children and maternal compliance with IYCF practices was very low.¹³ In another study by Davalgi et al., in Davangere, only 26% of the mothers were observed to be giving the WHO recommended minimum sufficient diet to their children.¹⁴ The study conducted by Bhagwat et al., in Bangalore revealed a high consumption of gripe water (68.8%) and bottle feeding (40.4%), which leads to malnutrition.15 In the study conducted by Khandelwal et al., it was found that a significant percentage (33.8%) of babies in Belagavi were not given fruits or vegetables until they were 12 months old. Consumption of ultra processed meals high in sugars, trans fat, and salt was high (85.8%), whereas consumption of sweet beverages was 4.8%.16 Anthropometric measurements of the children in a Hubli urban slum by Godbole et al., showed that 58.3% of them were underweight, 40% were wasted, and 59.1% were stunted. These findings are strikingly similar to the NHFS data.¹⁷

Limitations

Only a limited set of input and output indicators could be utilised due to the absence of other data. Therefore, the indicators of diseases, accidents, abuses, and infections that lead to malnutrition could not be included in the study. It is difficult to examine the relative impact of each of the indicators on nutrition because they are all given the same weight while creating the composite nutritional index.

Conclusion

The study provides a composite index, an essential tool combining 30 districts onto a single framework, providing a fair visualization for assessing and comparing the current nutritional status. Under health programmes such as the National Creche Scheme, Ksheera Bhagya, SRUSTI, Supplementary Nutrition Programme, and Balasnehi, ICDS has been implemented successfully. The Karnataka government has revised the menu of Anganwadis and has provided supplementary nutritious food, some of which are millet-based, on a pilot basis to improve the quality of nutrition provided in Anganwadi centres. These plans place strong emphasis on technology utilization, convergence, focused strategies, and the delivery of services for the initial six years of life. Other factors like domicile, illiteracy, household income, maternal malnutrition, birth order, poor sanitation, diseases, and infections should also be included in nutritional programs. Only until social and economic development are combined will the country’s health and nutritional issues be substantially resolved.

Financial Support and Sponsorship

Nil

Conflicts of Interest

No conflicts of interest