Integrated Child DevelopmentServices (ICDS): An Assessment

B.N. Tandon

ICDS was initiated in India in 1975,and has thus been operational for over17 years. It happens to be the largestsingle programme in the area of childdevelopment anywhere in the world. Itincludes services not only to children,but also to pregnant and lactating women.In this communication, an attempt willbe made to critically examine the expe­riences gained and to identify the majorachievements and shortcomings ofthisNational Programme during the yearsof its implementation.

The objectives of ICDS have beenstated in a number of official docu­ments and reports1.lnthe ultimate analy­sis, the central objective is the reduc­tion in child mortality and the achieve­ment of optimal physical, mental andpsycho-social development of India'schildren. The programme, initially insti­tuted in just 30 rural/tribal blocks andthree urban slums, had expanded tocover 2,460 rural/tribal blocks and 236urban slums by March 1992. Such ex­pansion was undertaken in the light offeedback inputs received from periodicexternal evaluation and internal moni­toring reports. These reports not onlyserved to highlight the achievementsand successes of the programme, butalso its shortcomings and deficiencies,from time to time2•

UNIQUE FEATURES

ICDS has some important andunique features which distinguish it fromseveral other national programmes.These can be enumerated as follows:

• It is a holistic approach to child devel­opment involving the active participa­tion of the mothers.

• It serves the most underprivilegedcommunities of very backward and re­mote areas of the country.

• It delivers services at Anganwadis(AW: village centres) right at the door­steps of the beneficiaries to ensuretheir maximum participation.

• It comprises three essential compo­nents, that is nutrition, primary healthcare and education, delivered asa CO!Tl-'

posite package of services to childrenand mothers.

• It utilises local women as honoraryvillage level workers for delivery of thepackage of services.

• It makes maximum use of the exist­ing infrastructure of health, social wel­fare departments and voluntary organi­sations for the implementation, train­ing, continued education, monitoring,motivation, supportive supervision, evalu­ation and research. Only minimal addi­tional infrastructure had been created(Child Development Project Officers,Programme Officers and Mukhya Sevi­kas) specially forthe ICDS. The existingdepartments and institutions which havebeen used in different tasks in ICDSinclude: (a) the health infrastructure ofthe states from the Director of HealthServices down to the frontline Multipur­pose Worker at the subcentres; (b) thefaculty of medical colleges throughoutthe country; (c) Indian Council of ChildWelfare and other voluntary organi-

sations; (d) National Institute of PublicCooperation and Child Development;(e) the faculty of Home Science col­leges; and (f) eminent experts from thespecialities of health, nutrition, socialservices, education and child develop­ment. Medical academia drawn frommedical colleges in the country hadbeen involved in this effort, workingunder the direction of the Central Tech­

nical Committee (CTCp.

• It works through a team approach,and members of the team include ad­

ministrators, professionals in servicedepartments, academicians and volun­tary workers.

• It has tried to promote the culture ofvoluntary work and output-related hono­raria for social work.

• It has primarily used the nationalfunding mechanism with very little bilat­eral and international financial assis­tance. It is a truly Indian programme,conceived, formulated and implementedfor the country by the country.

ACHIEVEMENTS

The achievements of ICDS havebeen significant as indicated by evalua­tion and research studies. Till March1992, 784 evaluation and 140 research

CONTENTS

• Integrated Child DevelopmentServices (ICDS): An Assessment- B. N. Tandon 1

• REVIEWS AND COMMENTS:Efficacy of Megadose of Vitamin Aand Prevalence of Diabetesin Indians- C. Gopalan 6

studies had been carried out by thefaculty and students of the medical col­leges, besides several investigations bythe National Institute of Public Coop­eration and Child Development(NIPCCD), Home Science colleges,programme evaluation organisations ofthe Planning Commission and a fewvoluntary organisations. The results ofthese studies have been published injournals, books and monographs4.

Some salient conclusions ofthesestudies on the impact of ICDS can besummarised as follows:

Nutritional status of children

There is evidence of significantdecline in 'severe' and 'moderate' mal­nutrition in children. The former hadcome down in 1990 to 6.6 per cent andthe latter to 18.1 per cent from 20.5 percent and 28.9 per cent respectively in1976. As a result of this decline in 'se­vere' and 'moderate' protein-calorie un­dernutrition, the percentage of pre-schoolchildren belonging to the combinedgroups of 'Normal' and 'Grade-I nutri­tion' had increased from 50.6 per centin 1976 to 75.3 per cent in 19904.5.

Several aspects related to thedecline in undernutrition have been ex­

amined. It has been noted that youngchildren belonging to special groups,namelytribals, scheduled castes, sched­uled tribes and backward communities,had all shown beneficial impact of ICDSon their nutritional status5. Specialmulticentric research studies at differ­ent intervals during the 17 years ofICDS had confirmed that the nutritionalstatus of children in the ICDS projectareas was significantly better than thatof their counterparts in areas withoutthe benefit ofthe ICDS scheme6,7. Thusa study by the National Institute of Nu­trition had recorded better nutrition sta­tus of children attending ICDS Angan­wadis as compared to children of thesame village and similar socio-economicstatus not utilising the services of ICDS8.

There are multiple health and nu­trition intervention factors in ICDS whichcould have contributed to the decline inprotein-calorie malnutrition. Food supple­mentation providing 300 calories and10-12 gm protein daily atthe Anganwadimust have been a major contributorycomponent1. Data show that the supple­mentary nutrition coverage to pre-schoolchildren in the ICDS areas had increasedfrom 25.6 per cent in 1976 to 65.7 percent in 19904,5.While the supplemen­tary nutrition coverage in ICDS project

areas ranged from 61.1 per centto 76.3per cent, the coverage of pre-schoolchildren with supplementary feedingamounted to no more than 17.9 to 31.5per cent in those areas where ICDSwas not operational.

Anaemia and vitamin Adeficiency prophylaxis

Six-monthly mega dose adminis­trations of vitamin A and the preventionof anaemia through the distribution ofiron and folic acid are the two importantnational nutrition intervention pro­grammes now being implemented inthe country. However, it is agreed on allcounts that the implementation of theseprogrammes has been generally far fromsatisfactory. In this context, the signifi­cant improvement in the coverage ofchildren through both these programmesrecorded in the ICDS areas4 is notewor­thy. Thus vitamin A distribution increasedfrom 15.0 per cent in 1976 to 45.6 percent in 19905; and iron and folic aciddistribution has increased from 17.3 percent to 46.9 per cent5.

Immunisation coverage

Immunisation coverage of chil­dren also had significantly increased inthe ICDS areas9,10.It will be recalled

that despite efforts in the past, imm­unisation coverage of village childrenhad remained well below the desiredtargets, and the Government had there­fore to launch the UniversallmmunisationProgramme in 1985 over and above thealready ongoing activity of EPI. Thedata on the immunisation of children inICDS project areas, as assessed atperiodic intervals, provide a generallyencouraging picture.

Thus the immunisation coverage(BCG, DPT and polio - three doses) in1990 in ICDS project samples, had in­creased to 69.0 per cent, 67.6 per centand 67.7 per cent respectively from thebaseline of 21 per cent (1976), 4.9 percent (1976) and 13.7 per cent (1981)respectively5,11. In a recent study, dataon immunisation in ICDS projects werecompared with those on control chil­dren in non-ICDS areas. Significantly, ahigher coverage forthe BCG, DPT (threedoses), polio (three doses) and com­plete immunisation, was observed forchildren of one to two years in ICDSprojects. The success of immunisationin ICDS projects was noted for bothsexes, and included underprivilegedcommunities as well9. The AWW wasfound to be a very valuable functionary

for the promotion of the immunisatiordrive of the health and family welfaredepartment, and the credit for the bet­ter success of the immunisation pro­gramme in the ICDS area must largelygo to her.

Antenatal care

Mother-care through augmentedantenatal, perinatal and post-natal ser­vices has always been an integral partof ICDS. The coverage of pregnantwomen by antenatal services had showna significant improvement in ICDSprojects, as compared to non-I CDSareas. An increase from a baseline of19.5 per cent to 82.6 per cent has beennoted in areas covered by those ICDSprojects which had been operational formore then five years. Administration oftetanus toxoid (two doses) was alsonoted to be significantly higher in ICDS(68 per cent) compared to the control(non-ICDS - 40 per cent) group9,12.Individual investigators had also foundbetter nutritional status as measured byweight gain and haemoglobin levels ofpregnant women in the ICDS project13•A substantial decline in the proportionof low-birth-weight deliveries had alsobeen reported14.

The preference for home deliverycontinues to be high in rural popula­tions, but significantly more womenutilised locally available trained personsfor their delivery in ICDS projects ascompared to the controls12.

It has been noted12 that lactatingwomen utilised the ICDS services forimproving their nutritional status (throughsupplementary nutrition and iron folicacid tablets), accepting family welfareadvice and enhancing their knowledge,attitude and practice for the better careof their children.

Health care of children

There has been evidence that

management of diarrhoea, respiratoryinfections and other minor ailments atthe village, and health centres had im­proved in ICDS areas4,15.Personal hy­giene, and to a limited extent environ­mental hygiene, had also improvedthrough ICDS health education activ­ity16. ICDS apparently also had facili­tated family planning programmes insome areas17.

Child mortality

A decade after ICDS was insti­tuted, evaluation studies suggested that

decline in infant and early childhoodmortality rates, observed in areas whereICDS was operational, was significantlygreater than the decline reported in thenational data of the Sample Registra­tion Scheme4.18• Recentdata confirmedthese earlier findings and show lowerneonatal, infant and early childhoodmortality rates in ICDS-covered popu­lations as compared to the overall na­tional data19.2o•

Studies carried out at the NationalInstitute of Nutrition (NIN) suggest thatpsycho-social development of childrenattending the AW was better than ofthose who had not8. Further; schooldropout rates were lower and the edu­cational performance better in childrenwho had attended the Anganwadiprogramme21•

FACTORS POSSIBLYCONTRIBUTING TO SUCCESS

Innovative and cost-effective ap­proaches to the training of the function­aries at various levels, continued edu­cation, monitoring, evaluation and re­search have been the important factorscontributing to the success of ICDS.We will briefly discuss these below.

Training

Training for all the functionaries inthe areas pertaining to health and nutri­tion components of ICDS, was organisedthrough periodic courses conducted bythe paediatric and community medicinefaculty members of the medical col­leges (honorary consultants) nearest tothe ICDS projects. The existing infra­structure facilities of the medical col­leges were utilised to conduct this train­ing22• The curriculum and the strategyfor training were periodically reviewedand revised by experts and consultantsat national and regional meetings. Theoutput and needs of the training pro­gramme were closely monitored by theCTC of ICDS.

The present strategy is to focus onshort introductory, and periodic refreshercourses, as these are cost-effective,cause minimum disruption in the activi­ties of health and ICDS functionariesand are conducive to their maximalparticipation. The participation of theProgramme Officers, CDPOs and Su­pervisors is encouraged in each of thethree types of courses.

The training schedule is flexibleand consultants are free to make changesin the topics and the contents of the

training course, depending upon localneeds. So far, 1,761 training courseshave been held and 4,315 functionarieshave received training through hono­rary medical college consultants.

Evaluation and research

Evaluation and research studieswhich had generated data for assess­ment of ICDS were carried out by anumber of honorary consultants fromthe faculties of medical colleges. Theconsultants have been able to conductthe studies periodically at very low costbecause they were able to use the exist­ing material and manpower resourcesof their own academic departments.Apart from being cost-effective fromthe point of view of the ICDS operation,this strategy has also served to enrichthe field experience of the medical col­lege faculties.

It may be legitimately claimed thatfew other national programmes had en­listed the active involvement and par­ticipation of the academia of the medi­cal colleges to the extent that ICDS hasdone. Subjects related to ICDS opera­tion formed the basis of a large numberof MD/PhD theses and scientific publi­cations from the country's medical col­leges. It was through such a mutuallyrewarding cost-effective strategy ofexternal evaluation that valuable harddata on the programme could be gath­ered. This strategy has benefitted theprogramme, on the one hand, and, onthe other hand, has provided rich fieldexperience to medical students, con­tributing to their orientation in favour ofpublic health programmes. Nationalhealth programmes and health researchsystems have several lessons to learnfrom this valuable ICDS experience.

The data from the monthly progressreports for the field were assembled bythe CTC and monthly status reportswere regularly furnished to the Depart­ment of Women and Child Develop­ment. The procedure of monthly moni­toring of reports by CTC was initiated asfar back as 1976, and has been continu­ously revised and improved in the lightof accumulated experience. Thus theICDS operation has, ever since its in­ception, enjoyed the benefit of a Tech­nical Support and Monitoring Systemdeveloped and provided by CTC. In thisoperation, the medical academia of thecountry and the Government Depart­ment of Women and Child Welfare andCTC had throughout functioned in closeconcert and coordination.

3

CTC meetings have been heldregularly every quarter to review thetraining, evaluation and monitoring out­put, and to suggest appropriate steps toimprove performance. New approachesfortraining, continued education, evalu­ation, research, monitoring, etc, arealso discussed at these quarterly Cen­tral Technical Committee meetings.

SHORTCOMINGS

It is to be expected that a pro­gramme of the scale of ICDS, coveringan estimated population of 246 million,distributed over 2.5 lakh villages and225 pockets of urban slums in 25 statesand seven union territories, will encoun­ter difficulties and shortcomings in man­agement and implementation. The widevariations in the capabilities of pro­gramme implementation infrastructure,the relatively low priority to social-sec­tor activities in National DevelopmentProgrammes, and the large proportionof honorary workers on whom ICDS isdependent, but over whom it has noeffective executive control, are factorswhich contributed to these shortcom­ings. The important shortcomings andremedial measures thereto that havebeen identified are mentioned below.

Lack of adequate decentralisation

Centralised planning of the pro­gramme had failed to fulfil the specialneeds of the difficult areas of north­eastern,eastern and mountain regionsof the country. ICDS projects in theseregions showed low coverage of ben­eficiaries and poor impact of the ser­vices. Strengthening of the infrastruc­ture and special location-specific strat­egies for management were subse­quently attempted but with limited suc­cess. The important lesson from thisexperience is that it is necessary toinstitute decentralised planning for spe­cial and difficult regions of the countryand to adopt a flexible strategy whichpermits location-specific modifications.

Lack of adequate intrasectoralcoordination

The nodal department for the ad­ministration of ICDS is the Departmentof Women and Child Development (Cen­tral Government). Generally, atthe head­quarters of the states it is the SocialWelfare Department that is the nodaldepartment. Health and Family Wel­fare is a key department whose pro­grammes need to be coordinated withthe activities of the ICDS, since health

personnel at the field levels are directlyresponsible for the delivery of healthand nutrition services to the village com­munity. Teamwork between the ICDSand the health staff, right from the vil­lage to the highest levels at the stateheadquarters is essential for success.Continuous efforts over the last fewyears have, no doubt, improved thecoordination between the two depart­ments; but this is still much below thedesired level.

Conferences designed to promotesupportive supervision, monitoring andmotivation offunctionaries at the sector(group of 20 villages), project head­quarters (community health centre), dis­trict headquarters and divisional andstate headquarters are conducted atregular intervals and are closely moni­tored by the Central Technical Commit­tee of ICDS. The success rate for these"coordination conferences" is about

65 per cent.

Failure of team spirit has beenoften noted at places where senior of­ficers have been unable to achieve ad­justment and accommodation with theircounterparts of other departments. Apersuasive approach and moral pres­sure had b'een used to stimulate thecoordination between the functionariesat each level. Political pressure hadalso been applied in some instances. Anew experiment of a joint coordinationcommittee composed of official andnon-official persons has also been startedin the State of Orissa.

Failure to accord dignity andprestige to voluntary work

ICDS activities are highly depen­dent on honorary functionaries who in­clude approximately 3,57,279 AWWs,block advisors, and consultants. Unfor­tunately, the honorary functionaries, spe­cially AWWs, are often unable to getadequate rewards for their voluntarywork. Respect and appreciation are thetwo important rewards which must beoffered to honorary workers. Failure tocreate the culture where honorary work­ers feel proud of their jobs has resultedin demands for change-over to paidjobs as per labour laws.

If, as a result of this, ICDS be­comes yet another purely governmen­tal bureaucratic operation conductedby regular salaried employees, it wouldlose its unique character. Every effortshould be made to provide career op­portunities to AWWs but it is not moneybutthe social prestige thatthe AWW is

able to earn that will be her real reward;and this alone will give her real emo­tional satisfaction. This reward can comeonly if there is a change in the attitude ofICDS staff towards the AWW. The lat­ter must be treated not as a low-paidsubordinate in regular government em­ployment, but as a respected honorarysocial worker from the community.

Disparities in incentives forhonorary work

Advisors and consultants are drawnfrom medical colleges and health de­partments in order to ensure cost-ef­fective and competent technical exper­tise for ICDS implementation. A verymodest honorarium related to their work

is paid to this group of voluntary work­ers. These honoraria do not measureup to the sumptuous remuneration thatseveral bilateral and international pro­grammes are able to offer to their con­sultants. National interest demands thata uniform system of financial assis­tance for honorary work in all nation.alprogrammes is insisted upon, irrespec­tive of whether the programme is fundedby either national, bilateral or interna­tional sources.

Deficiencies in management andsupply logistics

The supply of material for ser­vices atthe AW is often interrupted, andis frequently of inferior quality. The lo­gistics of supply of supplementary foodcan be cited as one example. There areindeed many difficulties in the matter ofensuring continuous supply of good­quality food at the AWWs which areoften located in remote and difficultareas. Intensive efforts to solve this

problem are required. The approachneeded may vary in different situations.The Department of Food must take theoverall responsibility in this regard anddevelop aproper system for decentralisedmanagement of timely and regular dis­tribution of food supplements.

Inadequate emphasison antenatal care

Utilisation of ICDS services bypregnant women, lactating mothers andchildren below the age of three yearshas been relatively low as compared tothat by pre-school-age children. Sincepregnant women and infants are themost vulnerable groups, efforts have tobe made for their greater participationin AW activities. Since most pregnantwomen and mothers of infants are oc-

4

cupied with their family work, they areoften unable to come to AWs to avail ofhealth and nutrition services. Home vis­its by AWWs'to reach this group hadbeen stimulated; but these have notbeen very successful. The AWW, beinga part-time honorary functionary, is un­able to find much time for repeatedhouse visits. It has been suggested thatat least one day a week may be specifi­cally fixed for providing special servicesto pregnant, lactating mothers and in­fants. This suggestion is worth experi­menting with, at least in some of theICDS projects.

Inadequate performance withrespect to health/nutrition education

Health/nutrition education activityhas been generally unsatisfactory inICDS.lndeed, most of our national healthprogrammes are weak in this regard.The AWW is able to do this job only toa limited extent due to her preoccupa­tion with other activities at the AW.Attempts to involve Mukhya Sevikasand evolve a regular health and nutritioneducation activity have not really beenvery successful.

CTC is now considering the cre­ation of a new cadre of honorary work­ers, that is, Junior Consultants from theyoung faculty of medical and HomeScience colleges and to give them theresponsibility for promoting health andnutrition education through the existinginfrastructure of ICDS and primary healthcentres. Here is an area where theservices of competent non-govern­mental organisations in the countrycould be enlisted.

Failure to promote effectivecommunity leadership and

participation

ICDS, despite its strong infrastruc­ture of honorary workers, is still functi­oning as a "government scheme" andhas not become a "peoples' pro­gramme". Adequate information dis­semination and interaction of officers ofthe programme with the local commu­nity is minimal in ICDS. The CTC plansto promote this activity through the pro­posed cadre of honorary Junior Con­sultants and NGOs.

THE FUTURE

The CTC has been improving itsown operational structure in order toprovide the best possible results. It hasdecided upon several changes in the

present system in the light of additionalinputs for child developments that havebeen made available through the WorldBank and UNICEF and new programmessuch as "Child Survival" and "SafeMotherhood" that have been started.The approach here is to avoid duplica­tion of activities, prevent wastage oftime of functionaries and save unnec­essary expenditure, by suitable align­ment of these parallel efforts so thatthey converge to a common goal in­stead of functioning at crosspurposes.

To begin with, the CTC has intro­duced the subject of ICDS in all trainingprogrammes of medical and paramedi­cal staff conducted through differentnew schemes. ICDS honorary consult­ants are actively involved in these train­ing programmes. The CTC has changedits own thrust of training activity to thefrontline workers through district, blockand village level training programmes.Monitoring activity has also been modi­fied by simplifying the monthly monitor­ing reports system from the PrimaryHealth Centre. Duplication of writingwork by AWWs has been reduced andwill soon be eliminated. The CTC hopesto evolve a monitoring system which willenable the functionaries in the field tofeel that they are working for "childdevelopment" rather than for a narrowisolated component of the operation.

The CTC also hopes to simulateefforts in the following directions:

• Establishment of a Federation of"Academic Associations and VoluntaryOrganisations for Child Development",including organisations such as Nutri­tion Foundation of India, Indian Acad­emy of Paediatrics, Nutrition Society ofIndia, Indian Association of CommunityMedicine, Public Health Association ofIndia, Home Science Colleges Asso­ciation and several voluntary organi­sations which, in one way or another,are contributing to child developmentactivities. It may be useful for theseorganisations to share their experiencesfrom time to time and evolve betterapproaches for their future activities.

• Development of effective "coordi­nation groups" atthe state level, so thatnew programmes and ICDS activitiescan be properly coordinated in specificoperational areas.

• Introduction of a new programme ofhealth/nutrition education, communityparticipation, and information dissemi­nation, through a system of honoraryjunior child development consultantsdrawn from the young faculty members

of Home Science and medical collegesand NGOs.

ICDS has been a valuable experi­ence and it has made important contri­butions to child development in India. Ina democratic country, with wide varia­tions with respect to needs, infrastruc­ture and management, wide variationsin performance levels ranging from suc­cesses at one end to failures at theother, are to be expected. Profession­als, administrators, and politicians haveobligations towards the children of thecountry and must continue to contributeto the effective implementation of ICDS.(CDS should also be able to absorbsuch additional inputs that may be madeavailable by international and bilateralagencies in order to expand and im­prove the quality of the programme,which should eventually cover almostthe entire country.

The author, former Dean and Professor of Gastroen­

terology in AI/MS, New Delhi, is Chairman, TechnicalCommittee of ICDS, and has been associated with

ICDS since its very inception.

References

1. Integrated Child Development ServicesScheme (Revised), MinistrY of Social Welfare,

Government of India, New Delhi, July 1982.

2. Nutrition Foundation of India: IntegratedChild Development Services (ICDS). A studyof some aspects of the system, ScientificReport 7, Ed C Gopalan.

3. Tandon, B.N.: Participation of medical col­leges in national health programme - An ex­periment in India. Bulletin of Nutrition Found­ation of India, 1986, 7(3):1-3.

4. ICDS - evaluation and research, 1975-1988,

Central Technical Committee, Deptt of Women& Child Development, M/O. HRD, Govt ofIndia, New Delhi, 1990.

5. Integrated Child Development Services, Dataon health & nutrition parameters, ProjectwiseData Annual Survey - 1990-91, BiostatisticsCell (ICDS), Central Technical Committee, NewDelhi, 1992.

6. Patowary, A.C.: Comparative study of thenutritional status of children below six yearsof age in the ICDS and non-I CDS blocks ofKamrup District - MD Thesis, 1987, GauwahatiMedical College, Gauwahati, Assam.

7. Chopdar, A. et al: Nutritional status of

pre-school children at Subdega Tribal ICDSProject (Orissa). Indian Paedtr, 1979,46:87-91.

8. Annual Report 1990-91. National Instituteof Nutrition, Indian Council of Medical Re­

search, Hyderabad.

9. Tandon, B.N. et al: Immunisation coveragein India for areas served by the IntegratedChild Development Services Programme. Bul-

5

letin of the World Health Organization, 1992,

70(4):461-465.

10. Tandon, B.N. et al: Immunisation in India:

Contribution of Integrated Child DevelopmentServices Scheme to Expanded Programme of

Immunisation. J Trap Paedtr, 1988,34:301-304.

11. Integrated Child Development Services ­

Projectwise data on health & nutrition paramet­ers, Annual Survey, 1981-82. Central TechnicalCommittee (ICDS), New Delhi.

12. Integrated Child Development Services ­projectwise data on health & nutrition paramet­ers, Annual Survey, 1988-89. Central TechnicalCommittee (ICDS), New Delhi.

13. Bhatnagar, S. et al: Effect of food supple­ment - early post-natal period on maternal

weight and infant growth. Indian J Med Res,1983, 77:366-72.

14. Lal, S. : Incidence of low birth weight inICDS and non-I CDS blocks of Rohtak Districtin rural areas - MD Thesis, 1987, Medical

College, Rohtak (Haryana).

15. Tandon, B.N. et al: Morbidity pattern and

cause specific mortality during infancy in ICDS

projects. J Trap Paedtr, 1987, 33:190-193.

16. National evaluation of Integrated Child

Development Services, National Institute ofPublic Cooperation and Child Development,New Delhi, 1992.

17. Training in integration of population educa­

tion in ICDS. A study of its social impact byManju Jain: (unpublished); Research on ICDS:An overview, Volume 1(1975-85), NIPCCD,New Delhi, 1989.

18. Tandon, B.N. et al: Impact of IntegratedChild Development Services on infant mortalityrate in India. Lancet, 1984, ii:157.

19. A study of growth pattern in children andperinatal mortality and infant mortality in ICDSrural block - MD Thesis, S.C.B. Medical Col­lege, Cuttack, Orissa, 1990.

20. Infant mortality rate and its causes in tribalICDS blocks of Rajasthan - MD Thesis, R.N.T.Medical College, Udaipur, Rajasthan, 1990.

21. Vadhera, KK et al: A study of beneficial

impact of non-formal pre-school education com­ponent of ICDS on various psycho-social de­velopmental parameters of children. CentralTechnical Committee, Deptt of Gastroenterol­

ogy & HNU, All India Institute of MedicalSciences, New Delhi, 1990.

22. Monograph on integrated training on na­

tional programmes for mother and child develop­ment, Central Technical Com'mittee on Health

& Nutrition, Deptt of Women & Child Develop­ment, Ministry of Welfare, Govt of India, NewDelhi, 1990.

We are grateful to UNICEF fora matching grant towards the

cost of this publication

REVIEWS AND COMMENTS

1. Efficacy of Megadose of Vitamin A2. Prevalence of Diabetes in Indians

C. Gopalan

1. Efficacy of Megadose ofVitamin A: The Sudan­Harvard Study

The results of the Sudan-Harvard

study recently published1, should serve,to some extent, to restore a properperspective to the debate on "vitamin Aand childhood mortality". The study high­lights two important points:

• that massive doses of synthetic vita­min A do not bring about significantreduction in child mortality as is beingclaimed,

• that insome situations, massive dosesof vitamin A may even fail to exert asignificant beneficial effect on clinicalhypovitaminosis A.

The former finding is in line withthe observations reported by the Na­tionallnstitute of Nutrition, Hyderabad2•The latter observation, which is per­haps relatively more important, is inconsonance with earlier findings ofPereira-and Begum 3 from India. Apartfrom the possible reason for this find­ing, which were discussed in an earliercommunication 3, other possibilities alsoneed consideration.

It is known that the transport ofvitamin A to the target tissues is condi­tioned by the availability of carrier pro­tein and zinc. The possibility of concur­rent zinc deficiency in children with clini­cal hypovitaminosis A cannot be dis­missed. There is suggestive evidenceof salination and alkalisation of soilsand of depletion of micronutrients (es­pecially zinc) in soil and, consequently,in foods 5.6, in many hypovitaminosis Aendemic areas where populations sub­sist predominantly on cereal-based di­ets. It is even possible thatthe exhibitionof massive doses of vitamin A could,under these circumstances, aggravatezinc deficiency. However, this needs tobe investigated.

These considerations point to theadvisability of not playing around withsingle nutrients - and more especiallywith massive doses thereof, in popula­tions which may be expected to sufferfrom multiple nutrient deficiencies. Thiscaution may be particularly relevant withrespect to hypovitaminosis A, in the

light of the growing knowledge of nutri­ent inter-relationships involved in vita­min A metabolism.

It will be a disservice to persuadedeveloping countries, whose health sys­tems are already under great strainbecause of scarcity of material andmanpower resources, to resort to uni­versal repeated administrations of mas­sive doses of synthetic vitamin A to theirchildren as a "short-cut" to better child­survival, on the basis of currently avail­able questionable evidence.

The proposed expansion of theuse of periodic synthetic vitamin A mas­sive dosage administration, to coverinfancy and children beyond three yearsof age, is wholly unnecessary and iII­advised. And keratomalacia is not apublic health prol;>lem- at least in Asia.

Apart from the studies of West etal7 in Nepal which showed increasedrisk of mortality from respiratory dis­eases in vitamin A supplemented chil­dren, some recent studies also indicateincreased incidence of respiratory mor­bidity in vitamin A-supplemented groupsof children 8. Bhaskaram et af9 had alsoearlier shown significant reduction insecretory IgA after administration of100,000 or 200,000 IU vitamin A. It isregrettable that despite these evidences,attempts are being made to push supple­mentation vitamin A administration as

part of the EPI in poor countries of theworld. This would be clearly unethical inthe light of available knowledge.

The results of "meta analysis" ofdata from published studies have beenclaimed to justify the conclusion thatvitamin A mega doses bring down childmortality. The scientific validity of suchmeta analysis exercises may be ques­tioned. The data for such meta analysishave been derived from studies of dif­ferent designs and from different re­gions, and are of disparate quality, notall carrying the same weight. Moreover,since the majority of studies chosen foranalysis were those gathered by moreor less one and the same school, theanalysis must be considered "loaded"even to start with.

It would be highly risky to proposefar-reaching public health policies likely

to affect the lives of millions of childrenon the basis of exercises of such dubi­ous validity. Children of developing coun­tries are no expendable guinea pigs,even if they happen to be poor.

Even with respect to currently on­going programmes of periodic massivevitamin A dose administration to chil­dren between the ages of one and threeyears in hyperendemic areas, it wouldbe wise to progressively phase themout within a reasonable time-frame, whilevigorous efforts towards the promotionof an adequate intake of locally avail­able carotene-rich foods are mounted.

References

1. Herrera, M.G., Nestel, P., Amin, A.E., Fawzi,W.w., Mohamed, KA, Weld, Leisa: Vitamin

A supplementation and child survival. Lancet,1992,340:267-271.

2. Vijayaraghavan, K., Radhaiah, G., Prakasam,B.S., Sarma, K.V.R., Reddy, V.: Effect of mas­sive dose vitamin A on morbidity and mortalityin Indian children. Lancet, 1990,336:1342-45.

3. Pereira, S.M., Begum, A.: American Journalof Clinical Nutrition, 1969, 22:858.

4. Gopalan, C.: Combating vitamin A deficiency- Need for a revised strategy. Prefatory chap­ter in "Recent Trends in Nutrition". The pro­ceedings of the First International Symposiumof the Nutrition Foundation of India, Oxford

University Press 1992.

5. Bangladesh Agricultural Research Council:'Zinc in Nutrition'. Edited by Abdul Mannanand Abdur Rahim, 1988.

6. Micronutrients assessment at the countrylevel: An international study. FAD Soils Bulletin63, 1990, FAG, Rome.

7. West, K.P., Jr, Pokhrel, R.P., Katz, J. et al:Efficiency of vitamin A in pre-school childmortality in Nepal. Lancet, 1991, 338:67-71.

8. Kartasasmita, C.B., Rosmyum, 0., Soemntri,E.S.S., Deville, W., Demeds, M.: Vitamin A

and acute respiratory infections. Paediatr

Indones, Jan-Feb 1991, 31:(1-2) 41-49.

9. Bhaskaram, P. et al: Nutrition Research,

1989, 9:1017-25.

2. Prevalence of Diabetes inIndians:Urban-Rural Difference

Urban migration and rising afflu­ence often tend to induce changes inthe traditional dietary patterns of popu­lations. Prominent among such changesin Indian population groups are the fol­lowing:

• Substitution of millets by rice or wheat,as the main staple;

Table: Age-adjusted prevalence (%) ofNIDDM in Indian populationsUrban

Rural

Men

WomenMenWomen

Madras2

8.47.92.61.6

Fiji Indians3

14.412.613.713.2

Mauritian Hindus4

11.99.0--

Southall Asians58.9 (Total)---

• Substitution of undermilled rice bythe more refined, highly-milled polishedvarieties; and

• Reduction of overall intake of com­plex carbohydrates (cereals) and in­creased intake of refined sugar and fat.

On the basis of available epidemio­logic evidence, a recent WHO report1observes that such changes are "closelyrelated to the emergence of a range ofchronic diseases, including coronaryheart disease, cerebrovascular disease,various cancers, diabetes mellitus, gallstones, dental caries, gastro-intestinaldisorders and various bone and jointdiseases". The causal significance, ifany, of such an association betweenchanging dietary patterns and the emer­gence of some of the above diseases,however, has yet to be clearly estab­lished. Most of these diseases are ofmulti-factorial origin; and dietary ex­cesses and errors could be just one ofthe contributory factors.

While there is considerable epi­demiological evidence that changes inhabitual diets of populations induced byaffluence could partly contribute to theincreased prevalence of coronary heartdisease, evidence in this regard withrespect to diabetes is scarce.

The major questions that arisewith respect to diabetes are:

• What is the nature of the scientificevidence that points to the conclusionthat affluence arising as a part of devel­opmental transition is, in fact, associ­ated with an escalation of the preva­lence of diabetes; and,

• In case the evidence of such anescalation does exist, what specifically,are the "ingredients" of developmentthat contribute to such escalation? Inparticular, what is the role, if any, ofchanges in dietary pattern induced byaffluence with respect to the preva­lence of diabetes?

Answers to these questions are

obviously important for the institution ofmeaningful programmes of diabetes pre­vention and control.

The study in South India: In arecent study involving 900 urban and1,038 rural subjects in South India,Ramachandran et af2 found that theprevalence of non-insulin dependentdiabetes mellitus (NIDDM), using WHOcriteria and adjusted to the age of thepopulation, was 8.25 per cent in theurban and 2.4 per cent in the ruralpopulations. On the other hand, theage-adjusted prevalence of impairedglucose tolerance (IGT) was nearlysimilar in the urban and rural groups(8.7 per cent and 7.8 per cent respec­tively). The diagnosis of diabetes in thestudy was made if the "post-glucose"value (two hours after glucose admin­istration) was ~ 11.1 mM, and IGT wasdiagnosed if the "post-glucose" valuewas~7.8mMbut<11.1 mM.

The urban population investigatedby Ramachandran et a/was apparentlymore affluent than the rural; while therural population was largely composedof agricultural labourers of the low-in­come group, the urban population in­cluded businessmen, traders, clerks,professionals and a small number of"manual labourers".

The authors argue that the highprevalence of IGT in both urban andrural populations, regardless of theirsocio-economic status, is possibly agenetic attribute of Indian populationsand is indicative of the high risk of thedevelopment of overt diabetes. Afflu­ence and urban environment had ap­parently contributed to the expressionof this genetic trait resulting in a highprevalence rate in the urban group. Ob­servations among Indian populations inFijP and Mauritius4 and among migrantIndian populations in Southall (UK)5 alsopoint to a high prevalence of diabetes inIndians (Table).

Unfortunately Ramachandran etaI's paper does not deal in detail with

the, actual com­

position of the di­ets of the urban

and rural popula­tions and diabet­ics. However, onthe basis of suchdata as are avail­able from nationalsurveys, we maydraw some infer­ences. As wasmentioned earlier,

7

with increasing affluence there is a trendtowards decrease in the intake of com­

plex carbohydrates, accompanied ~yincreased intake of free sugars. If mil­lets are the staple cereal in the ruralsituation, urban migration often resultsin the substitution of millets by rice orwheat; in the case of populations thathad earlier subsisted on rice, there isincreasing preference for more polishedand refined varieties of the cereal inplace of the undermilled varieties.

The differences in fibre content asbetween a diet based on millets on theone hand, and one based on highlypolished rice on the other hand, couldbe substantial6• Polishing is also knownto remove important nutrients from thegrain. As a result, differences with re­spect to nutritive value as between ruraland urban diets largely based on staplecereals could be significant.

It may also be relevant to recall inthis connection the results of a studycarried out in India over three decades

ag07, in which the response of the bloodsugar levels to administration of differ­ent cereal diets containing identicalamounts of carbohydrates was investi­gated. Itwas found that the rise in bloodsugar levels following the administra­tion of a millet meal (ragi - Eeusinecoracaia) was significantly less thanthat following the administration of arice meal.

The obesity factor: 8ivariateanalysis of the data of Ramachandranet aI's study, for the identification ofassociation, if any, of body-mass index(8MI), subscapular triceps ratio (STR)and waist-to-hip ratio (WHR), with preva­lence of diabetes, revealed interestingdifferences between the urban and ru­ral groups. While this association wassignificant in the case of urban men andwomen, it was not so with rural men; inthe case of rural women, only the asso­ciation of 8MI with diabetes prevalencewas significant, while those with STRand WHR were not. We can only specu­late on the reasons for this interestingdifference. This finding could justify thereasoning that it is not obesity per se butthe actual nature and composition ofthe diets that led to such obesity in theurban population, on the one hand, andthe rural population, on the other, thatmay be important.

High caloric diets predominantlybased on millets or unrefined undermilledrice could be less diabetogenic thanisocaloric, high caloric diets based onpolished rice and refined sugar even if

ration and a 'Plan of Action', which werediscussed in-depth and finally adoptedat the ICN in Rome.

The Declaration is largely a reaf­firmation of the commitment of the par­ticipating governments to the early at­tainment of the goal of eradication ofundernutrition/malnutrition, andthe over­all upliftment of the nutritional status oftheir populations. The 'Plan of Action'that was adopted outlines this majorobjective and the policy guidelines forits achievement, and indicates strate­gies and actions that could be pursuedfor this purpose.

The 'Plan of Action' adopted atthe conference concludes with the fol­lowing statement with which few woulddisagree: 'ICN should be viewed as amilestone in the continuing process toeliminate hunger and malnutrition, es­pecially in the developing countries, andat the same time to prevent the in­creased incidence of diet-related non­communicable disease. The ICN pre­paratory process began in the countriesand to be effective, its follow-up mustnow be firmly anchored in national com­mitment and efforts to protect and pro­mote the nutritional well-being of all.'

In the ultimate analysis, the truetest of the 'success' of the conferencewill lie in the follow-up action, especiallyat the country levels, which the confer­ence is able to generate. The confer­ence had made some recommendationfor follow-up both at the national andinternational levels.

References

turn of the century. Meaningful preven­tion/control programmes will call for moreinformation with respect to the precisenature of dietary excesses and errorscontributing 'to the escalation of diabe­tes in the urban situation. Studies ofthetype reported by Ramachandran et a/therefore need to be multiplied and in­tensified. Such studies should receivehigh priority in any future National Nutri­tion Research Agenda.

4. Ohlson, L.O., Larrson,B., Svadsudd,K.,Welin, L., Eriksson, H., Wilhelmsen, L.,Bjorntorp,P.,Tibblin,G.:Theinfluenceof bodyfat distributionon the incidenceof diabetesmellitus.13.5 yearsof follow-upof the particip­antsin thestudyof menbornin 1913. Diabetes,1985, 34:1055-58.

5. Mather,H.M.,Keen,H.: The Southalldiab­etes survey:Prevalenceof knowndiabetesinAsians and Europeans.Br Med J, 1985,291 :1081-84.

3. Zimmet,P., Taylor,R., Ram,P.:Prevalenceof diabetesand impairedglucosetoleranceinthe biracialMelanesianand Indianpopulationof Fiji: A rural-urban comparison.Am. JEpidemiol, 1983, 118:673-88.

1. WHO Technical Report Series No 979,1990 (Diet, nutrition and the preventionofchronicdiseases:ReportofWHOStudyGroup).

2. Ramachandran, A., Dharmaraj, D.,Snehalatha,C., Viswanathan,M.: Prevalenceof glucoseintolerancein AsianIndians- urbanruraldifferenceand significanceof upperbodyadiposity.Diabetes Care, 1992, 15(10):1348-55.

both diets eventually result in the sameorder of obesity. However, in the presentstate of our knowledge and with thelimited data available, this far-reachinginference must remain a speculation.Clearly we need more data. Unlike inthe case of the South Indian subjectsinvestigated by Ramachandran et at,available reports do not indicate a sig­nificant difference in rates of the preva­lence of diabetes as between urban andrural Indians of Fiji (see table). This waspossibly because rural Indians in Fiji,unlike rural Indians in India, "tend toconsume foods similar to those of theirurban counterparts - rice, wheatenroti, chapatfis, highly spiced vegetables,meat or fish ... "

Unlike in the case of Indians in Fiji,there was marked rural-urban differ­ence in the prevalence of diabetes asbetween rural and urban Melanesiansof Fiji. "Rural Melanesians retain tradi­tional food patterns, consuming kasava,taro, breadfruit, tropical fruits, meat andsea foods" -while inurban Melanasians"much of the food consumed is cannedmeat and fish, polished rice, flour, sugarand processed vegetables and fruits" 3

It is reasonable to assume that thelevel of habitual daily physical activityof the rural subjects was significantlyhigher than that of the urban population.This is an important aspect that willpossibly also need to be taken intoaccount in explaining the observed ur­ban-rural difference in diabetes preva­lence in India. Zimmet et af3 conclude 6. Gopalan,C.: Dietaryguidelinesfor affluentthat "factors other than obesity, such Indians.Bulletin of the Nutrition Foundation of

as differences in physical activity, diets, India, 1988, 9(3):1-4.

stress or other as yet undetermined 7. Gopalan,C., Ramachandran,M.K.: Effect The XXV Annual Meeting of Nutri­factors" ... could contribute to the rural- of differentcerealson bloodsugar levels.Ind tion Society of India was held at theurban difference in prevalence of dia- J Med Res, 1957, 45:255. National Institute of Nutrition, Hydera­betes among Melanesians in Fiji. ,----------------, bad, on December 18 and 19, 1992.

The highlights of the programme wereDiabetes-amajorhealthprob- NUTRITION the Gopalan Oration by Dr Michael C.

lem: It seems certain that one-third of NEWS Latham; the Srikantia Memorial Lec-India's population will be urban by 2000 ture by Dr B.S. Narasinga Rao; and twoAD. While it may be rash and injudi- ••••••••••••••• symposia, one on "Development pro-cious to extrapolate the data from fThe Internatl'onal Conference grammes or women and children andRamachandran et ars limited study to th . . t t 't' "

on Nutrition (ICN)"" ICN was an I'nter- elr Impac on nu n Ion , and the otherthe entire country, to arrive at an esti- "N h d

governmental conference, whl'ch took on ewer met 0 ologies in nutritionmate of possible actual numbers of h" Td. b . place at the FAO headquarters I'nRome researc. wo "Young Scientistsla etlcs in urban India by 2000 AD, the AdS . "t d between December 5 and 11, and was war sessions were organiseds u y at least shows that given the pre- h I

.1' attended by government delegates from were severa papers on different as-vallng trends, urban migration could t f 'c .. I over 150 countrl'es and a number of pec s 0 ommunlty' and 'Experimen-Imp y a nearly four-fold increase in the t I' ..

. d scientists. During the two yearsofprepa- a nutntlon were presented.magnltu e of the prevalence of diabe-tes in the country. This could be re- ration forthe conference, eight regional XIX Kamla Puri Sabharwal Me-f1ected in the rising prevalence of coro- meetings and two meetings of a spe- moria I Lecture on December 22,1992nary heart disease (CHD) as well, since cially designated Advisory Group of was given by Prof J.S. Bajaj, Memberdiabetes is a major risk factor in CHD. Experts had been held in orderto finalise Planning Commission, on "Nutrition and

the Agenda. A preparatory meeting at Health: An Interactive Independence"Diabetes could thus emerge as a the WHO Headquarters in Geneva in at Lady Irwin College. Dr C. Gopalan

leading public health problem by the August had brought out a Draft Decla- presided.Edited by Harvinder Kaur for the Nutrition Foundation of India, B·37 Gulmohar Parle Designed and produced by Media Workshop. Printed by Vashima Printers.