,.

C. Gopalan

Nutritional Status of India's ChildrenHas it Improved in Recent Years?

During the years that have elapsedsince her Independence, India has re­gistered impressive progress in manyfields of national activity - agriculture,industry and technology. How havethese remarkable developments beenreflected in the health and nutritionalstatus of her children? Since Human Re­sources Development is fortunately now

.being emphasised as the ultimate goalof the national development process, atthe highest levels of the Government,this question acquires relevance.

Child Mortality

Infant and child mortality rates areconventional indices of child-healthstatus. Since by and large, high infantand child mortality goes hand in handwith high prevalence of undernutrition,mortality trends are useful indicators.

The overall infant mortality rate (IMR)for the country declined from about 160in 1945 to 146 in 1960 and to 120 in1981. Child death rate (one to fouryears) declined from 26 in 1960 to 17 in1981. These figures apparently reflectsome improvement; but, in order to as­sess the adequacy and significance ofsuch improvement, we must take a lookat corresponding figures from some ofthe developing countries in ourneighbourhood (Table 1). Viewed in thiscontext, our performance thus far withrespect to reduction in infant and childmortality, in the country as a whole, may

not merit wild jubilation. Mortality trendsfrom a few States certainly reveal somebright spots (e.g. Kerala and Punjab);but these are swamped by the depres­sing picture presented by the populousHindi heartland. Clearly, if we have toachieve levels of IMR and child mortalityconsistent with our proclaimed goal of ."Health For All by 2000 A.D.", we haveto do a lot better in the next 15 yearsthan we have done during the last 40years.

Child Nutrition

, The outstanding manifestations of un­dernutrition in children are: (1) retarda­tion of growth and development; and(2) specific nutritional deficiency signs.Of the latter, protein-calorie malnutrition,vitamin A deficiency (nutritional blind­ness), iron-deficiency anaemia, andgoitre are the most important and wide­spread. We may now briefly examinesuch evidences as are available, to iden­tify trends, if any, with respect to theorder and severity of these manifesta­tions over the last few decades.

Table 1: Infant and Child Mortality Rates

Indicators IndiaSri LankaThailand

IMR1960

146701001981

1204350

Child Mortality 1960

26713

1981

1734

Growth and development: The twomajor national studies that provide valu­able data on growth and development ofchildren in the country, at two points oftime separated by nearly 20 years, are:(1) the ICMR study on "Growth andphysical development of Indian infantsand children (Technical report no 18),which started in 1956-57 and (2) the.Na­tional Nutrition Monitoring Bureau(NNMB) "Report for the year 1979".Both these studies have been carried

out under the leadership of the NationalInstitute of Nutrition by competent teamsusing standardised methodology, andmay therefore be considered as perhapsthe most authentic and .,.representativedata available. The sampling designsadopted in the two studies were notidentical. The first study covered a totalof 1,27,866 children between the agesof one and 21 years drawn from 11states of the country; the distribution ofthe subjects as between urban and ruralareas was in the ratio of 5:3. On theother hand, the NNMB studies, themajor part of which covered the ruralpopulation, provide data on children bet­ween birth to 19 years, over a six yearperiod (1974-79) drawn from 10 Statesof the country.

NNMB has also collected valuabledata on children from urban areas be­longing to different socio-economicgroups (NNMB Report onUrban Popula­tion - 1984). Despite differences withrespect to coverage and sampling de­sign, considering the large number ofpopulations covered by both studies, itis reasonable to assume that they hadboth largely succeeded in capturing rep­resentative samples of rural and urbanpopulations of the country. Comparisonof the rural NNMB data with the data onrural children gathered in the earlierstudy and comparison of the NNMB dataon the poor of urban slums with those of

the urban poor in the earlier study, couldtherefore be considered justifiable. In Fi­gures 1, 2, 3 and 4, such comparisonhas been attempted.

In Figures 1 and 2, the data on heightsof rural male and female children ob­tained in the ICMR study starting in1956-57 have been compared withthose of Kerala and Uttar Pradesh in theNNMB report of 1980. Since NNMB un­like the earlier ICMR study has pub­lished its data for the rural population foreach State covered by it separately (andnot for all States collectively) data on twoStates (Kerala and U.P) alone are in­cluded in the figures but the data fromother States covered in the NNMBstudies are either similar to the U.Pdataor lie between the UP and Kerala data.It will be seen that the years that hadelapsed between the two studies havemade practically no difference whatever

to the growth status of poor children whocontinue to exhibit the same order ofgrowth retardation (see standard in thefigure for comparison). In Figures 3 and4 it will be noticed that there is little dif­

ference with respect to weight for age ofchildren between the two studies. PoorIndian children whose weights for ageroughly corresponded to 75 percent to80 percent of the Harvard scale in thefirst study continued to exhibit the samedegree of growth retardation in th~ sec­ond study as well. In Table 2, data forheights of boys and girls of the so-calledclass VI (the poorest income groupwhich included urban slum children) inthe earlier ICMR study have been com­pared with those of boys and girls ofurban slums of the more recent NNMB

study. It will be seen that the growthstatus of urban slum children of today is,if anything, worse than that of the

poorest children in the country someyears ago. Comparison of the heights ofpoor Indian children in 1957 (K.S. Raoet. al. WHO Bulletin 20. 603. 1959) andin 1978 (NNMB) had also shown that thelatter were certainly no better (perhapsslightly worse off) than their counterpartstwenty years ago (C. Gopalan: 'Nutritionand Health Care '. Nutrition Foundation

of India Special Publication Series 1,1984. p.13).

In all developed countries of the worldduring their transitional stage of de­velopment among poor communities(and indeed even among affluent sec­tions of our own country) there has beena continuous and steady trend towardsincrease in heights and weights of chil­dren in successive generations (seculartrend). With improvement of socio­economic conditions and removal ofdietary constraints which inhibit growth

-_...----

Figure 1

Source: NNMB Report (7979)

and ICMR Technical Reportseries No. 18

10 11 12 13 14 15 16 17 16 19 20 21 22 23AGE (YEARS)

Figure 2

Mean Height of Indian Children(Female)

75

85

95

145

115

165

125

IV5

135

155

Source: NNMB Report (1979)

and /CMR Technical ReportSeries No. 18

~ Harvard 50th percentile

1-4.-"-1 ICMRRural(Repl. No. ,Sj~ U.P. Rural (NNMB)

~ Kerais Rural (NNMB)

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21

AGE (YEARS)

75

95

85

105

'"~ 135~>­~8 125~z"~ 115

145

165

Mean Heights of Indian Children(Male)

155

Figure 3 Figure 4

25

15

Mean Weights of Boys

~.,

1--'*--1I---1 Harvald (50th percent/Ie)

l--.---+---f ICMR rural ('956·57)

.....--- U,P. rural NNMB~-----IKera'a rural NNMB75

65

55

45

35

25

15

Mean Weight of GirlsI-+--*--t Harvard (50th percenlile}

~ ICMRrural(1956-57)

~ .~- •. -~ UP. rural NNMB

~.• -_ .. , Kerala rural NNM8

Source: NNMB Repor1 (1979)and leMR Technical ReportSeries no 18

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21AGE (YEARS)

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21AGE (YEARS)

Table 2: Comparison of Mean Heights and Weights of Children in Two Studies

1. ICMR (1956-57) Class VI Group

2. NNMB Urban Slum Study 1984.

Weights (kg.) Heights (ems.)Boys

GirlsBoysGirls2

222

13.0

12.512.412094592.693091.1176

16517.216.41133109.1111.8104.831.1

27031.2296143.4137.6141.9138.6

and development, the genetic potential

for growth finds increasing expression insuccessive generations. The seculartrend ceases once the genetic potentialhas found such full expression. This has

happened in all countries of Europe andNorth America. It has also happenedand is happening among children ofaffluent sections in India. However, as

our data show the poor children haveapparently remained where they were.Debates on 'poverty line' and how it has(or has not) moved up or down becomeirrelevant in the light of this direct evi­dence.

Recent intensive studies carried out

under the auspices of the Nutrition

Foundation of India among tribal popula­tions, rural communities and urban

slums in Madhya Pradesh and West

Bengal (to be published) indicate thatthe nutritional status of children in some

parts of the country may indeed be actu­

ally even worse than what is indicatedby the NNMB data.

Prevalence of'severe malnutrition' in children:

According to the conventional (widelyused) Gomez's classification, children

with weight for age less than 60 percentof the standard are considered 'severelymalnourished'. Applying this criterion,NNMB had computed that the percen­tage of 'severely malnourished children'between 1969 and 1975 ranged from

18.0 to 21.8 percent. Figures from 1976onwards show a 'lower percentage' (8.5percent or less). The abrupt "decline" inthe percentage of severely mal­nourished from 21.8 percent in 1975 to8.5 percent in 1976 and onwards wasunfortunately not due to a spectacularimprovement in the nutritional status ofchildren but due to the fact that NNMB

suddenly decided to switch over to a

lower standard of normalcy for the com­putation of severity of malnutrition. The

new NNMB standard chosen by NNMBon the basis of limited studies amongchildren in and around Hyderabad is sig­nificantly lower than the conventional in­

ternational standard (50th percentile ofHarvard standard). The 'decline' in 'se­vere malnutrition', under the cir­cumstances must be considered as a re­

sultant spurious artefact. However, withthe same new standard, the NNMB datashow decline in the prevalence of 'se­vere malnutrition' from 1976 onwards

without corresponding significant

Age

(yrs.)

4

713

change in the growth status of the chil­dren. This could mean a reduction in the

"tip of the iceberg" - an impact of nutri­tion intervention and relief programmedirected to the severely malnourishedchildren. However, a judgement as towhether even this is a true reductionmust wait. The NNMB studies are de­

signed as five-year cycles, the survey ofa given region being completed in fiveannual instalments, villages surveyed in

successive years not being the same.For this reason, comparison of data bet­ween five-year cycles will alone be reallyvalid.

Recent ongoing studies under the au­spices of the Nutrition Foundation ofIndia in Madhya Pradesh and West Ben­

gal (referred to earlier) among poor com­munities wherein the conventional stan­

dard has been employed, reveal a muchhigher incidence of 'severe malnutrition'in all locations under study.

Goitre: Earlier estimates had indi­

cated that the population exposed togoitre in the country may be about 120million. The emergence of new goitreendemic areas in recent years (e.g.Delhi was goitre-free 20 years ago andis now declared an endemic goitre reg­ion) suggests that the real figure maywell exceed 170 million. By 2000 AD.,the total population in the country thatwould need protection from goitre mayexceed 200 million. On the basis of the

somewhat low prevalence of frank cre­tinism and deaf-mutism in children in

goitre-endemic regions, we had earlierconcluded that only less than one to twopercent of children of goitrous motherswere vulnerable. Recent studies, how­

ever, indicate that learning disabilitiesand forms of mental retardation less

spectacular than frank cretinism are far

more widespread than we had imagined.Currently we have far more childrenafflicted with the effects of goitre in thecountry, not only in absolute terms (to beexpected because of the population in-

crease) but in relative terms as well (be­cause of the emergence of new goitre­endemic areas).

The technology for the prevention andcontrol of goitre (iodation of common

salt) is well-known and within our com­petence and resources. The NationalGoitre Control Programme was in fact in­itiated in the Second Five Year Plan.

The 'sad story' highlighting the shockinginefficiency with which the programmehad been implemented all these yearswas highlighted in an earlier issue of thisBulletin (C. Gopalan: The NationalGoitre Programme - A Sad Story, Bull.NFl 2.3. 1981). Detailed recommenda­tions for revamping the programme werealso made by the Foundation (NationalGoitre Control Programme - ScientificReport 1, 1983, Nutrition Foundation ofIndia). It is now being claimed that the

Programme has been since activised.Figures set out in Table 3, based on thelatest available official figures, will indi­cate the present trend.

We have to regretfully conclude thatwe have failed to make a significant denton the goitre problem during the last

30 years.

Nutritional blindness: Kerato-

malacia, arising primarily from vit­amin A deficiency and potentiated byprotein-calorie malnutrition, has beenthe major cause of nutritional blindness

in children, usually between one andthree years of age. We have at no timehad an accurate estimate of the preva­lence (or incidence) of keratomalacia inthe country, though the fairly large num­bers of cases of the disease seen in the

hospitals of the country - especially inthe southern and eastern parts indicatethat the disease is a major health prob­lem in the country. Unfortunately sinceour hospitals, and for that matter our

health services in general, reach lessthan 15 percent of our total populationand since proper records are maintained

only in a few hospitals in the country

Table 3: Extracts from Results of the Central Goitre Survey Team'

Place Baseline Survey

Year Prevalence %

Commencement Resurvey

of salt supply ---------Year Prevalence %

we have no convincing evidence that

that technology has been effectivelyapplied' to make a significant dent onthe problem of nutritional blindness

'Only such centres for which fairly recent figures are available have been included.

Table 4 . Some New Goitre Endemic Areas

Year of survey % Incidence

even estimates of hospital prevalenceare unreliable.

Field surveys do not bring out the trueincidence of keratomalacia because ofthe acuteness and short duration of the

disease and also because, as a study bythe National Institute of Nutrition

showed, a high percentage of poor chil­dren becoming blind from keratomalaciadie soon after, probably from neglect.Under the circumstances, the preva­lence of bitot spots, the less serious ocu­

lar manifestation of vitamin A deficiencyseen in older children in the community,has been taken to be a rough measureof the magnitude of the vitamin A defi­ciency problem (and therefore indirectlyof the keratomalacia problem) in thecommunity. The NNMB data do notshow evidence of any progressive de­

cline in the prevalence of bitot spots.

1982

6·14 yrs.

BoysGirls

96.3

97.798.7

66.3

52.963.8

609

61565.7

1·5 yrs.

Calcutta

HyderabadNew Delhi

Table 5: Percentage Prevalence of Anaemia inChildren'

The data in the two studies are not

strictly comparable, but the reasonableconclusion that appears justifiable is thatthe problem continues to be widespread.

'Report of ICMR Working Group, Am. Journ. Clin.Nutr1442.1982.

Iron-deficiency anaemia: It is nowwell recognised that iron-deficiencyanaemia is very much a problem of chil­dren as well, and not just of women in

the reproductive age period. A multi­centric study carried out under the au­spices of the Indian Council of MedicalResearch in 1965 (Report of WorkingParty 1977 IGMR Tech. Rep. No. 26)showed that as many as 62.8 percent ofchildren between one and three years of

age and 44.0 percent between three andfive years had haemoglobin level lessthan 10.8 g percent. The results of a col­laborative study carried out in 1982under the auspices of ICMR (Report of

Working Group - Am. Journ. Glin. Nutr.1442. 1982) are also available (Table 5).

Maternal nutritional status: No dis­cussion of the nutritional status of chil­

dren can ignore the important factor ofmaternal nutrition which determines the

course of intra-uterine development ofthe foetus, the birth weight of the infant,the lactation performance of the mother

and the further grow1h and developmentof the infant. Earlier reports have shownthat nearly a third of infants in the coun­try are of low birth weight (less than 2.5kg.), largely attributable to poor maternalstature, and undernutrition. An ongoingstudy of the ICMR, according to prelimi­nary reports, has failed to show any sig­nificant decline in this proportion of lowbirth weight infants. Such low birth

weight infants tend to grow along a sub­standard grow1h/development trajectoryto end up dS stunted adults. It had beenpointed out in an earlier issue of this Bul·letin (Gopalan C.: Maternal Health, Fertil·

45.8

26.8

28.7

345

64.5 (East)51.2 (West)

35.58

1981

1981

1979

1976

1982

1982

19631963

1964

1965

1964

1967

Cases of keratomalacia continue to be

seen in teaching hospitals with distress­

ing regularity though, as pointed out ear­lier, reliable statistics as to their numbersare either not available or forthcoming.

The National Institute of Nutrition had

developed a simple technology for thecontrol of nutritional blindness throughthe supply of just one teaspoonful(200000 IU) of vitamin A to childrenunder three years once in six months.This programme was included in theFourth Five Year Plan and adequatebudgetary provision for the supply of vit­amin A had been made. The programmehas been 'in operation' since 1970. Anevaluation of the results of the prog­

ramme (Vijayaraghavan, K. and PralhadRao, N. Nutr. Rep. Int. 25. 3. 1982)showed that in two-thirds of PrimaryHealth Centres, there was evidence of

some reduction in the prevalence of bitotspots. The authors list various factors re­

sponsible for "programme ineffect­iveness". The statistical basis underly­ing this evaluation exercise has howeverbeen challenged (K. Ramachandran,personal communication). Convincingevidence that in experimental (research)situations where vitamin A had been ad­

ministered with unfailing regularity tochildren under three years by teams ofworkers specially appointed for the pur­pose, the incidence of keratomalaciashows a decline, has been provided byother studies of the National Institute of

Nutrition (Vijayaraghavan, K. et. al. Lan­cet. July 21, 1984). We may, therefore,conclude that while we have a simple

and effective technology for the preven­tion and control of nutritional blindness,

93

38.0

34.5

40.3

35.8

209

1963

1969

1960

1960

1959

1959

Ropoor

Darjeeling

Champaran(East & West)

Sirmor

Mandi

Arunachal Pradesh

West Bengal

Bihar

Punjab

Himachal Pradesh

Maharashtra

Jalna

198335

Aurangabad

197335

Amravati

198346.16

Wardha

198354.92

Buldhana198449.53

Satara198529.29

GujaratBharuch

197731.7Valsad

198336.59

KeralaErnakulam

198444.47

Mizoram

197868.6

Sikklm

197637.82

ity Control and Child Nutrition 6. 1. 1985Bull N 7) that NNMB studies between1975-1979 had shown that 12 percent to25 percent of our women between 20 to

30 years of age in different States of thecountry have heights less than 145 cms.and 15 percent to 29 percent weightsless than 38 kg. - values considered tobe indicative of pregnancy risks includ­

ing low birth weights of offspring.ln addi­tion to the effect of such poor staturearising from malnutrition in their own

childhood, many of them also currentlysubsist on inadequate dietaries and areanaemic. A recent report covering diffe­rent parts of the country (Report ofWorking Group Am. Jour. CI in. Nut.1442. 1982) indicates continued highprevalence of such anaemias in women.There is apparently no evidence of sig­nificant improvement in maternal nutri­tional status over the last few decades.

Emerging problems: While on the onehand we have thus made no major ad­vances with respect to solving the oldnutrition problems "of the past", new

problems have emerged. The nutritionalproblems of children in our urban slumsare gathering in magnitude; increasingunhygienic use of commercial baby

foods in urban and peri urban areas bythe poor who have neither the resourcesto buy these foods in adequate amountsnor to use them hygienically is contribut­ing to the aggravation of the problem ofchild undernutrition. The salutary prac­tice of breast-feeding is being steadilyeroded to the detriment of the infant andchild.

In sum, it will be reasonable to con­

clude that there is no evidence of sig­nificant improvement in the nutritionalstatus of children of poor communities inthe country over the last few decades.

Concluding comments: During thelast three decades, we have had a highlysuccessful Green Revolution in the

country; unfortunately, the health/nutri­

tion revolution has hardly begun. Whatis worse, the enormity of the unfinishedtasks in the health and nutrition fields

has, as yet, not been adequately ap­preciated. The endless (diversionary)debates on the 'poverty line' and the tire­some search for alibis and fig leaveshave tended to obscure the fact that (1)by whatever reckoning, the problem ofundernutrition in our children and

women is massive, and continues to

progressively erode the quality of our

human resources, and (2) despite the

fact that our Constitution specifically laysdown nutritional upliftment of the peopleas a national objective in one of its Arti­cles, six Five Year Plans have failed to

make a significant dent on the problem.What makes this failure even more

pointed is the fact that our developmentprogrammes of the last few decadeshave actually greatly enhanced our po­tential ability and national capacity tocombat undernutrition. We produce

enough food for our growing population.No child in the country now need starve.

During the last few decades, Indianscientists have made valuable contribu­

tions towards better understanding ofthe nutritional problems facing the coun­try, and even more importantly towardstheir solution. Thus, elucidation of the

precise nature of the protein-calorie mal­nutrition problem and the explosion ofthe prevailing myth that its solution layin the distribution of expensive protein­concentrates; the development of a sim­ple practical procedure for combatingnutritional blindness; and the develop­ment of the technology for fortification ofcommon salt with iron were pioneeringcontributions of Indian scientists to the

world of nutrition science. Unfortunately,these contributions have found better

application and recognition outside thecountry than within.

If the new concern for "Human Re­

sources Development" is not to end upas an unfulfilled slogan, it must soon begiven positive content and direction.Much of the emphasis in recent procla­mations on the subject has been on

education and employment generation- undoubtedly the two areas of thehighest importance. Investments in edu­cation and employment generation prog­rammes cannot yield expected results in

a situation in which the learning ability ofchildren, and productivity, physicalstamina and employability of considera­

ble sections of our population are im­paired through chronic undernutrition.Specific time-bound actions for bringingabout sustained and durable improve­ment of the nutritional status of children

and women, must now become the

cornerstone of any meaningful futureprogramme for "Human Resources De­velopment".

We gratefully acknowledge the

matching grant provided by UNICEFfor this publication

FOUNDATIONNEWS

Project Advisory Committee Meet­ings: Advisory Committees of the Foun­dation connected with the followingthree projects met on November 26,

1985 at the World University Centre,Madras:

• Project on "Survey of Adequacy, Utili­sation and Impact of Health Inputs Pro­vided to Anganwadi Workers in ICDS".• Project on investigation of the possi­bility of improving lactation performanceof poor anaemic mothers, and growth/

development of their offspring throughan intensive programme of ironsupplementation.

• Project on investigation of growth anddevelopment of well-to-do (normal) In­dian girls during adolescence.

The Advisory Committee on the Pro­ject "Multicentric Study on Physical

Growth Characteristics of Affluent GroupPre-school Children" met on December22, 1985 at New Delhi.

Scientific Report-4 "Infant-feedingPractices with Special Reference tothe Use of Commercial Infant Foods":

Limited number of free copies of this re­port are available and will be supplied onrequest.

NUTRITIONNEWS

The 18th Annual Meeting of the Nutri­tion Society of India was held onNovember 27 and 28, 1985 at the World

University Centre, Madras, under thechairmanship of Dr. S. Varadarajan,

President of the Society. Over 300 dele­gates from various parts of the countryparticipated. Dr. K.T. Achaya deliveredthe Gopalan Oration on "Role of Fats inIndian Nutrition". The Institute of Child

Health, Madras, (Director Dr. B.A.Santhanakrishnan; Professor of Clinical

Nutrition of the Institute, Dr. S.Gnanasundaram, was responsible forthe successful organisation of the meet­ing.