Nutritional Status Of Children And WomenIn India: Recent Trends
H.P.S. Sachdev
Over the past two decades,there has been a substantial andprogressive decline in infant andchild mortality rates in India1• Therehas also been a significant reduction in the prevalence of florid nutritional deficiency disorders. It is therefore important that increasing attention is now paid to the nutritional status of the survivors. Thealarming reports of some international agencies2 which have placedIndia at about the bottom-rung ofan arbitrary world development scale,have raised apprehensions that thenutritional status of women andchildren in India shows no signs ofimprovement. Recent trends withrespect to the nutritional status ofwomen and children in India havebeen analysed and evaluated, soas to address this issue.
This paper is based partially onpublished information but more importantly on non-indexed publicationsand reports, culled from several institutions and individual scientists inthe country. The information on changing trends gathered from these datais being presented here.
PROTEIN ENERGY NUTRITION
The most outstanding achievement on the national nutrition frontduring the last four decades has beenthe virtual 'banishment' of acute largescale famines, of the type that usedto decimate sizable sections of thecountry's population with distressingregularity for centuries3.
The personal experiences ofpaediatricians throughout the country indicate that in the past three decades there has been a significantdecline in severe protein energy malnutrition (classical kwashiorkor andextreme forms of marasmus) inhospitalised children. The decline hasbeen particularly dramatic in relationto classical kwashiorkor, which hasvirtually disappeared from numerousregions. This change in the spectrumhas been occasionally quantified4.
Reliable community-based data
generated by the National NutritionMonitoring Bureau (NNMB) from eightcentral and southern states (AndhraPradesh, Gujarat, Karnataka, Kerala,Madhya Pradesh, Maharashtra, Orissaand Tamil Nadu) also confirm a decline in clinical deficiency signs in preschool children (one to five years old)from 1975-79 to 1988-90 in rural areas5. The overall prevalence of marasmusdecreased from 1.3 to 0.6 per cent andkwashiorkor from 0.4 to 0.1 per cent.Amongst the 12,000 children evaluated in the 'repeat surveys', Gujaratshowed the highest prevalence of bothforms (1.1 per cent kwashiorkor and4.9 per cent marasmus), while in theother states their prevalence was below1 per cent. In the NNMB and NationalCouncil for Applied Economic Research (NCAER) linked survey conducted in 1994 in the same eightstates but in different sampled areas6, among 1,828 preschool children the overall prevalences ofkwashiorkor and marasmus were 0.2and 0.4 per cent, respectively. In fact,
cases of kwashiorkor were seen onlyin Madhya Pradesh, where the prevalence was about 1.4 per cent. Fortunately, a similar declining trend wasdocumented in the under-privilegedurban slums? of these six states (citiesincluded Ahmedabad, Bangalore,Bhubaneswar, Cuttack, Hyderabad,Nagpur and Trivandrum). The overallprevalence of marasmus diminishedfrom 3.7 per cent in 1975-79 (n=519)to 0.2 per cent in 1993-94 (n=334).No case of kwashiorkor was observed.
LOW BIRTH WEIGHTS
It is generally believed that therehave been no differences in the reported mean birth weights and theproportion of newborns with LBW (lowbirth weight8; <2,500 g) in the threedecades between the late 1960s andthe late 1980S8,9. These inferenceswere based on a comparison of datafrom disparate settings at various timepoints. Given the expected marginalmagnitude of change in birth weightin two to three decades in a nation
CONTENTS• Nutritional Status Of
Children
And Women In India: Recent Trends
1
- H.P.S. Sachdev •Iodine Deficiency Diseases
In India
6
• Nutrition News
7
- N. Kochupillai• Foundation News
8
• Universal Salt lodisationProgramme (USI) In India -Progress And Achievements
8I- S. Vir
TABLE 2Changes in Prevalence (%) of MalnutritionSurvey
MalnutritionNNMB5NNMB5NNMB6NFHS19
Index1975-791988-9019941992-93 *
(n=6,428)(n=13,422)(n=1,832)(n=25,578)
Weight-far-age(underweight)<2SD
77.568.663.653.4<3 SD (severe)
38.026.624.720.6
Height-far-age(stunting) 52.0
<2SD 78.665.163.0<3 SD (severe)
53.336.835.828.9
Weight-far-height(wasting)<2SD
18.119.916.717.5<3 SD (severe)
2.9.2.42.63.2
* For weight-for-age assessment only. The sample size for the other two indices was
lower.
TABLE 1Trends in Intrauterine Growth
Ref
Area SettingComparison Period Observed Changes(Mean gap in yr)
WeightGestationIUGC
10
Rourkela Industrial1963 & 1986MBW +74gNANA(Orissa)
Hospital(23) LBW -34 vs 25%11
Delhi Hospital1969 & 1989NATerm +*0(Poor)
(20)13
Delhi Hospital1973-74&1985-87NANA+(Better-off) (12.5) 14
North Arcot(Tamil Nadu)
Rural1969-73 & 1989-93MBW+78gM+0.7W+p(20)
LBW -27 vs 16%PT -21 vs 16%Urban
1969-73 & 1989-93MBW+52gM+0.8W+p(20)
LBW -19 vs 11%PT -20 vs 15%15
Veil ore Hospital1969 & 1994MBW+126gMe+0.3WNA(25)
LBW -27 vs 15%PT -14 vs 10%16
Mumbai Hospital1988 & 19.95LBW -60 vs 38%0NA(Poor)
(8)17
Delhi Hospital1986 & 199600NA(Poor)
(11)
+: significant increase; + p: significant at some gestations; -: significant decline; 0: no
significant change; IUGC: Intrauterine Growth Curves; M: Mean; Me: Median; MBW:Mean Birth Weight; NA: Not Available; Ref: Reference number; W: Gestation in weeks; *Calculated by comparison with earlier study values cited in reference 12.
commencing epidemiologic transition,these inferences from such a researchdesign are not surprising. It would,however, be more valid to analysedata from the same area at differenttime points.
In analyses of this nature (Table1), a positive time trend for birth weightis evident in most hospital-based dataand the solitary community study. The
mean magnitude of improvement ismarginal (52 to 126g). However, thishas resulted in a greater reduction ofLBW prevalence (by 8 to 12 per cent).These calculated mean improvementsin birth weight are probably underestimates since concomitant changesin other important associates havebeen ignored. With time, the meanbirth order has also decreased andcorrection for this factor alone'5 en-
2
hanced the magnitude of change inthe community study (rural and urban areas combined) from 70g to1DOg (first-borns have lower weightsthan later births). The absence of atime trend in the two Delhi hospitalsmay be related to the relatively shortgap in one report17 and the fact thatthese institutions primarily cater tothe underprivileged population in whomthe transition is expected to commence last of all. In one of thesestudies11, the higher percentage ofterm births could be regarded as thebeginning, since term new-borns havethe best intrauterine growth as a group.
The small improvement in birthweight is probably contributed to byan increase in both the overall gestation period and an increase in birthweight at different gestation periods(intrauterine growth curves).
GROWTH OF CHILDREN
In developing countries, anthropometry,despite its inherent limitations, stillremains the most practical tool forassessing the nutritional status ofchildren in the community. In thiscontext, there have been several smallscale surveys but the data from thesemay not be representative ofthe countryas a whole. The two major nationalsurveys which provide data related tonutrition and cover large segments ofIndia's population are:• the periodic surveys carried out bythe NNMB5.7.18of the National Institute of Nutrition, Hyderabad, and• the recent National Family HealthSurvey (NFHS) initiated by the Ministry of Health and Family Welfare, Government of India19.
It is important to be aware ofseveral factors, notably the samplingframework, which can potentially influence the estimates of malnutritionprevalence from these surveys20.
Table 2 compares the estimatedprevalence of various indices of malnutrition in these surveys as per thecurrent international recommendationand nomenclature. A distinct improvement in the prevalence of underweightand"stunting (including in the severecategory, namely, below 3 SD) is evident from the NNMB data at an average rate of 1 per cent per annum. TheNFHS19estimates were still lower thanthe NNMB-NCAER6 prevalences atcomparable time periods. This couldbe partly related to differences insampling design, areas surveyed (whole
FIGURE 2: Secular Trend in Weights of Women
4237
interest in the Indian setting, has alsobeen analysed. A positive trend in allthese anthropometric parameters isevident at virtually all the ages examined (statistically significant atmost points) with each successivesurvey recording higher mean values than the preceding one. However, the differences in height (Figure 1) between the NNMB 1988-90and NNMB 1994 surveys were negligible at several ages.
The positive time trends in heightin the 'repeat surveys' (1988-90) weremore marked in the age group 12 to14 years (mean differences between1.7 to 3.0 cm) than later (mean differences between 0.3 to 1.4 cm). Themean increase in adult stature between 1975-79 and 1988-90 was calculated to be 1.2 cm26. The quantumof difference (marginal) in height maybe related to the relatively short interobservation period (average 12 years)
for documenting seculartrends in this parameter.The usual differences inmean weight ranged from0.7 to 2.2 kg between the1975-79 to 1994 surveys andthe corresponding figuresfor mean triceps fat foldthickness were 1.5 to 2.5mm. These differences toowere not striking for an average inter-observationperiod of 17 years, but theydo represent the initiationof a positive nutritional trend
3211 22 27
AGE IN Co)lPLETID YEARS
• NNMB(1975-79) [J Nl'MB (198'·90) [J NNMB(1994)
FIGURE 3: Trend in Fat Fold of Women
The time trends in NNMB
data5,6,18for height, weight andtriceps fat fold thickness in females between the ages of 12 to47 years are depicted in Figures1-3. The adolescent age group(12 to 18 years), of particular
TABLE 3Trends in Body Mass Index in Adult Women
Survey (values in %)
Body MassNNMB5NNMB5NNMB6NNMB7
SlumIndex1975-791988-9019941993-94
Definition(value)(n=6,428)(n=13,422)(n=1,832)(n= 1 ,319)
Chronic Energy Deficiency Third
«16) 12.711.310.49.5Second
(16-17)13.212.911.29.2First (17-18.5)25.925.125.518.0All «18.5)51.849.347.136.7Normal
(18.5-25)
44.846.646.351.7Obese
(>25)
3.44.16.611.6
* Body Mass Index (BMI) is defined as weight (kg) / height2(m).The percentages for NNMB surveys 1975-79 and 1988-90 for the various categorieswere taken from reference 26.The percentages for different categories for BMI < 18.5 for NNMB survey 1994 wererecalculated from the total adult sample.
for all the states) on heights, weightsand body mass index over the periodshows a definite improvement. Theaverage values of measurements, ingeneral, for almost all the age groupsin both sexes show an increase; heightincrements tended to be more in children, with weight increments morevisible in adults and adolescents. Statewise data clearly indicate that the
heights of children and adolescents, and weights of adults andadolescents in the state of Keralaand, to some extent, in Maharashtra and Gujarat were distinctly better as compared tothe 1970s9.
42
"T
R 13I
CEPII
F
0L07
(mm)
42
,12
o
37
373227
o
32
22
o
17
17
AGE IN COMPLETED YE..\RS
• NNMB (1975·79) 0 NNMB (1988·90) I!J NNMB (1994)
22 27 32
AGE 11';COMPLETED YEARS
.NNMB(1975·79) CNNMB(1988·90) I:INNMB(1994)
'55
13012
so
M45E
AN ..,W EI
35G HT 30
(kg) "12
FIGURE 1: Secular Trend in Heights of Women
NUTRITION OF WOMEN
country versus eight states and urban plus rural versus rural) and theage groups analysed (zero to fouryears versus one to five years).
Fortunately, a similar overalldeclining trend was also documentedin the underprivileged urban slums?of six states between the periods 197579 and 1993-94 for weight-far-age(Gomez classification based on National Centre for Health Statisticsreference).
It must be noted that there isvirtually no change in the profile ofwasting in this period and the NNMBand NFHS estimates are also identical (Table 2), indicating thereby thatthe improvement in the weight-forage index is predominantly due to anincrease in the height.
A few studies have attempted toquantify the secular trends in heightby comparison of mothers and daughters8,21·25.No positive trend was discerned in women from poor socioeconomic strata8,23.25whereas a significant increase, even up to a meanvalue of 5 cm18, was documented inwell-to-do communities21,22.
An analysis of the NNMB 'repeat survey5' aggregate data (pooled
TABLE 4Changes in Prevalence of Bltot Spots in PreschoolersSurvey
PeriodPrevalence (%)
leMR 1977 (28)
1965-694,2NNMB 1975-79 (5)
1975-791.8NNMB 1988-90 (5)
1988-900.7
NNMB 1992-93 (29)1992-931.9*
NNMB 1994 (6)
19941.1
NNMB Slum (7)1993-940.9 to 2.5%*
* This rural survey included two additional states (Uttar Pradesh and West Bengal) than
earlier NNMB surveys.* Bitot spots documented in only three of six cities surveyed.Figures within parentheses are references.
in the relatively poor rural population.A similar analysis was not feasible forthe urban poor as the published reporF did not provide comparative figures for this purpose.
Body Mass Index (BMI): BMI isbeing increasingly used as a measure of nutritional adequacy in adultsand is considered to be a better indicator of chronic energy deficiency(CED)9. The time trends in BMI ofadult women from the NNMB data aresummarised in Table 3. A distinctshift of the distribution to the right isevident in the rural population. Interestingly, the underprivileged urbanslum population had the best values.However, even now CEO is prevalentin 37-47 per cent of the women withthe severe variety being documentedin 10 per cent. Obesity is also nowbeginning to emerge (7 to 12 per cent).
MICRONUTRIENTS
Vitamin A: Since preschool children bear the brunt of the deficiency,nationally representative surveys haveprimarily focussed on this age group.A nationwide survey conducted bythe ICMR during 1971-74 showed that2 per cent cases of blindness wereattributable to corneal disease caused
by vitamin A deficiency9. In the subsequent (1985) national survey of blindness, carried out under the auspicesof the Government of India and theWorld Health Organization (WHO),this figure declined to 0.04 per cent9,27.Data from the School of Tropical Medicine, Calcutta, once the hot-bed ofkeratomalacia, and from the Christian Medical College, Vellore27are alsosuggestive of a sharp reduction inthe documentation of keratomalacia(0 to 0.008 per cent in the late 1980s).A careful scrutiny of the hospital data
from Calcutta in fact suggests thatthe decline in the incidence ofkeratomalacia had started even before the massive dosage prophylaxisprogramme had been instituted27.
The changes in estimated prevalence of Bitot spots in preschool children from macro surveys aresummarised in Table 4. A marked
decline is evident, especially in theNNMB 'repeat survey5'. The slightapparent increase in later surveys29is probably related to the differentsampling areas which included therelatively poorly performing states ofUttar Pradesh and West Bengal. Interestingly and paradoxically, the overallprevalence of night blindness (1.1per cent) in this survey was lowerthan that of Bitot spots (1.9 per cent)in one to five year-old children29. Wideregional variations are apparent insome areas. A noteworthy observation was the absence of Bitot spots ininfants and children, even in the slums,in the surveys conducted in the 1990s.
Iron: Anaemia has been the mostcommon parameter employed to determine iron deficiency. Personal experiences of several paediatriciansand obstetricians allover the countryindicate a dramatic decline of severeanaemia with oedema in children andwomen (pregnant and non-pregnant).A limited comparison of studies conducted in similar areas on comparable age and physiological groupsat different time periods yielded twosuch series30-32.In Vadodra, there wasa significant (p=0.014) decline in theprevalence of anaemia (haemoglobin<11 g/dl) from 71 percent (n=500) to65 per cent (n=610) between 198284 and 1993-94 in urban low income
preschool children32. In pregnantwomen from Hyderabad, possibly fromdifferent settings3o,31 the prevalence
4
of anaemia (haemoglobin < 11 g/dl)significantly declined from 48.5 percent to 33.2 per cent. Estimates basedon ICMR evaluation in 1984-85 of theNational Nutritional Anaemia Prophylaxis Programme indicated that 88per cent of pregnant women wereanaemic with 47 per cent havinghaemoglobin values below 9 g/dI33.The latest estimates pertaining to theICMR multicentric field supplementation trial (published in 1992) on 1,968pregnant women lowered these estimates to 62 per cent and 17 per cent,respectively3'.
Iodine: In Delhi, the goitre prevalence rate in school children declined
from 55.2 in 198034 to 8.6 per cent in199635;the salt iodisation programmewas implemented in 1989. The routine surveys conducted by the Directorate General of Health Services36indicate a significant decline in totalgoitre prevalence rate in 17 out of 21districts from different states in whichrepeat information was available. Themagnitude of decline ranged from 6to 35 per cent (general values above30 per cent in the Himalayan regionand Uttar Pradesh) for repeat surveys performed six to 40 years later.Time series data revealed a markedreduction in the incidence of neonatal chemical hypothyroidism (NCH)in the highly endemic areas of UttarPradesh following salt iodisation37-38.
CONCLUDING COMMENTS
Recent trends with regard tonutritional status of women and children in India have been positive butmodest. The improvement has beenmarked with respect to the prevalence of 'severe malnutrition'. Evenwith respect to moderate undernutrition modest improvements inanthropometry and birth weights havebeen noticeable even amongst thepoor. These observations in poorwomen and children, despite a steepincrease in population and continuing social and economic inequalities,are heartening indications that, at longlast, India may be at the turning pointwith respect to nutrition.
The improvements though smallhave been achieved in the context of asubstantial decline in mortality. Mostmalnourished children who would havedied earlier are now being saved; andthis may be expected to swell the ranksof the 'moderate undernourished'.The fact that in spite of this, an
improvement in the overall averageshas been registered is heartening.
Reviewing the latest NNMB datain 1992, Gopalan39 had pointed outthat these data which revealed afavourable secular trend with regardto growth of women and children provide a glimmer of 'light at the end ofthe tunnel' and had suggested thatfuture survey results will be awaitedwith interest in order to decide if indeed, Indian children were now onthe march towards better nutrition.The present analysis shows that thismarch might well havebegun. Thoughthe beginnings are still small, theyprovide hope for the future of Indianwomen and children. The challengenow is to accelerate the pace of improvement.
There is yet another messagethat emerges from this analysis. Thenear total disappearance, within thelast four decades, of florid nutritionaldeficiency diseases which were oncemajor public health problems and theinitiation of a positive trend with respect to less severe forms of undernutrition have important practical implications. With the possible exception of iodine deficiency disorders,none of these changes can be credited to specific 'nutritional interventionprogrammes', but to all-round improvement in the economic, health and dietary status of poor communities.
Thus, no specific drug or vitamin was used to combat beri-beri orpellagra which were once rampantbut which have now disappeared. Norwas the present near disappearanceof kwashiorkor achieved through thesupply of 'protein-concentrates',strongly advocated by internationalagencies (before the 'protein fiasco').
This irrefutably argues for theconcept of an all-round, integrated,rather than a narrow (drug-based)approach towards combatingundernutrition.
The author is Professor and In-charge of theDivision of Clinical Epidemiology at the Departmentof Paediatrics, Maulana Azad Medical College, NewDelhi, India.
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