‘nutrition challenges confronting developing india’
TRANSCRIPT
‘NUTRITION CHALLENGES CONFRONTING DEVELOPING
INDIA’
Dr Kramadhati Venkata RameshwarSarma, M.D.
Scientist ‘F’ (Retd.) National Inst. of Nutrition(ICMR) Hyderabad. India 500007
Michigan Epidemiology Conference 2012Michigan Public Health Association
30 March 2012
Basic National Demographic IndicatorsParameter 1951 1994 2001 2011Population (millions) 361 904 1027 1210
Av. Annual Gr Rate 1.25 2.2 1.95
% Urban Population NA 26.1 27,8 31.2
Crude Birth Rate 39.9 28.7 25.8 19.8
Crude Death Rate 27.4 9.3 8.5 6.0
Total Fertility Rate 5.96 3.5 2.9 2.2
Infant Mort. Rate 148 74 68 58
Sex Ratio 946 NA 933 940
Source: Census India
Consumption Pattern across different classes in India
HOUSEHOLD NUTRIENT INTAKES
Macro Nutrients
78
118
79
85
48
98
91
92
51
131
87
90
0 20 40 60 80 100 120 140
Iron (mg)
Calcium (mg)
Energy (Kcal)
Protein (g)
PER CENT
RuralTribalUrban Slums
Micro Nutrients
0
105
55
87
46
164
120
64
100
63
156
102
71
104
51
0 50 100 150 200
Folic acid (µg)
Vitamin C (mg)
Riboflavin (mg)
Thaimin (mg)
Vitamin A (µg)
PER CENT
RuralTribalUrban Slums
Poverty Ratios in Urban and Rural India
Government Expenditure on Social Sector as % of GDP
The Development Paradox• The paradox is that while India now in the front ranks of fast growing global economies, with a vibrant economic growth rate of around 7 %, nearly 30 % of the global burden of child deaths is borne by India.
• Economic growth is, at best, a slow and undependable way of eliminating child under‐nutrition.
• While income poverty in India is reduced to 26 % ‐underweight prevalence in children under three years remains at 50% (NFHS‐3; 2005‐06).
• India’s economy is growing rapidly. Yet it has a large number of poor and a modest level of human development.
Life Expectancy at Birth in India
MAJOR NUTRITION DEFICIENCY DISEASES
PROTEIN ENERGY MALNUTRITION (PEM)
VITAMIN ‘A’ DEFICIENCY DISORDERS (VADD)
NUTRITIONAL ANEMIAS (Esp. IDA)
IODINE DEFICIENCY DISORDERS (IDD)
RISING NON COMMUNICABLE DISEASESKRAMADHATI SARMA, Scientist ‘F’ (Retd.) National Institute of Nutrition(ICMR), Hyderabad.
Vulnerable groups of the population
1. Children < 5 years of age
2. Pregnant women
3. Lactating women
4. Adolescent girls
5. Elderly persons
6. Socially deprived communities
1. Children < 5 years of age
2. Pregnant women
3. Lactating women
4. Adolescent girls
5. Elderly persons
6. Socially deprived communities
KRAMADHATI SARMA, Scientist ‘F’ (Retd.) National Institute of Nutrition(ICMR), Hyderabad.KRAMADHATI SARMA, Scientist ‘F’ (Retd.) National Institute of Nutrition(ICMR), Hyderabad.
“Raising the level of Nutrition,Standard of Living and Improvementof Public Health are the primaryduties of the states.”
-Article 47 of the Indian Constitution
DETERMINANTS OF MALNUTRITION
MATERNAL MALNUTRITION
START WITH A HANDICAP(LBW)
FAULTY CHILDFEEDING PRACTICES
DIETARY INADEQUACY
FREQUENT INFECTIONS
LOW PURCHASING POWER
LARGE FAMILIES
HIGH FEMALE ILLITERACY
TABOOS AND SUPERSTITIONS
INFANTS WITH LOW BIRTH WEIGHT(%)
The prevalence of low birth weight continues to be about 30% for last three decades. Low birth weight babies are more likely to die because of neonatal infections and under nutrition.
Malnutrition contributes to 60% of the 10 million deaths globally that occur everyyear among children under five years of age. I
Pelletier, D.L., E.A. Frongillo, Jr., D.G. Schroeder, and J.P. Habicht. 1994. Journal of Nutrition 124 (10 Suppl.): 2106S‐2122S.
EXTENT OF MALNUTRITION Almost half of children under age five years (48 percent) are
chronically malnourished. Acute malnutrition, as evidenced by wasting, results in a child
being too thin for his or her height. One out of every five children in India under age five years is wasted.
Forty‐three percent of children under age five years are underweight for their age. Underweight status is a composite index of chronic or acute malnutrition. Underweight is often used as a basic indicator of the status of a population’s health.
The percentage of children under age five years who are underweight is almost 20 times as high in India as would be expected in a healthy, well‐nourished population
Chronic Energy Deficiency in adults is 39% in females and 37% in males (NNMB2002).
PER CENT DISTRIBUTION OF CHILDREN GOMEZ CLASSIFICATION (18 STATES/Uts)
Severe12.2%
Mild37.1%
Normal21.2%
Moderate29.5%
Severe12.8%
Mild37.3%
Normal23.0%
Moderate27.0%
MALE FEMALE
Dr. RAMESHWAR SARMA, Deputy Director, National Institute of Nutrition, Hyderabad.Dr. RAMESHWAR SARMA, Deputy Director, National Institute of Nutrition, Hyderabad.Dr. RAMESHWAR SARMA, Deputy Director, National Institute of Nutrition, Hyderabad.Dr. RAMESHWAR SARMA, Deputy Director, National Institute of Nutrition, Hyderabad.
IRON DEFICIENCY ANEMIA (IDA)
• Iron Deficiency Anemia prevalence continues to be high particularly among the high risk groups like children under 5 years, adolescent girls, pregnant and lactating women.
• About 68‐78 per cent of these population groups suffer from anemia (NNMB 2003).
VITAMIN ‘A’ DEFICIENCY (VAD)
• Continues to be a problem of public health significance among pre‐school children with prevalence of Bitot’s spots more than WHO cut off level of 0.5%.
• The stagnant prevalence of vitamin A deficiency (Bitot’s Spots) ranging from 0.7% to 1.1% during the period 1988‐90 to 2003 requires a comprehensive approach for its prevention and control.
IODINE DEFICIENCY DISORDERS (IDD)
• No state in India is free from Iodine Deficiency Disorders.
• The total goiter rate (TGR) in 260 districts out of 321 districts surveyed is reported to be more than 10%, a prevalence more than the WHO recommended cut off level of 5%, indicating endemicity of IDD.
NUTRITION SCENARIO
ACHIEVEMENTS:• Florid Nutritional Deficiency Syndromes like Pellagra, Beri‐beri, Scurvy, Kwashiorkar have disappeared.
• Famines do not visit any more.• Severe malnutrition among preschoolers has reduced appreciably and nutritional status of adults has improved significantly.
NUTRITION SCENARIO‐2
The Challenge:• High Malnutrition Levels particularly in Women and Children
• Under‐nutrition affecting productivity• Micronutrient Malnutrition• Emerging diet related diseases,• High Mortality Rates‐IMR, U5MR and MMR• Inadequate Access to Health Care, Immunization etc
Infant and young child feeding practices• According to NFHS‐3, only one quarter of children are breastfed
within the first hour of birth and slightly more than half are breastfed within one day of birth though breast feeding is universal (98%).
• Exclusive breast feeding is limited to 46% in infants under six months of age and drops to only 28 percent by age 4‐5 months.
• One‐third of infants under two months of age are not being exclusively breastfed.
• Some are weaned before one year and weaning accelerates beyond 1 yr. More than one‐fifth of 18‐23 months are not being breastfed at all.
• Complementary foods are commenced at too young an age for many and almost one‐fifth of children age 4‐5 months are given complementary food, contrary to recommendations.
FEEDING PRACTICES IN INFANTS UNDER SIXMONTHS
AGE AND MALNUTRITION
• Age wise distribution of prevalence of underweight in children reveals that malnutrition peaks during the first two years of life.
• From 11.9% prevalence among 0‐6 month old infants, it reaches 58.5% in 12‐23 months old children.
• This steep rise in malnutrition during the first two years is mainly due to poor infant feeding practices.
MATERNAL MORTALITY• Maternal mortality continues to be high in India. Maternal
Mortality Ratio is estimated to be at 440 per 100,000 live births
• The main causes are depicted in the graph below and include severe bleeding, infection, unsafe abortion and eclampsia. More than 20 percent of maternal deaths are caused by diseases such as malaria, anemia, TB, and HIV/AIDS that are aggravated by pregnancy.
• Adolescents are at increased risk of dying during pregnancy and childbirth. They are twice as likely to die as women in their twenties, and teens younger than 15 are five times as likely to die of complications.
• The chances of survival are greatly increased by availability and access to health care, especially, emergency obstetrical care.
IMR and MMR in India
Source :
Chronic Energy Deficiency (BMI < 18.5) in adults is 36% in females and 33% in males (NNMB 2005-06).
Source :
Physiological Group n Normal
Anaemia
Mild Moderate Severe Total
1-<5 Yrs Children 3186 32.5 23.7 41.7 2.1 67.5
12-14 Yrs Adolescent Girls 3188 31.4 47.0 20.5 1.1 68.6
15-17 Yrs Adolescent Girls 3214 30.3 47.2 20.7 1.8 69.7
Prgnant women 2890 25.7 24.7 45.5 4.1 74.3
Lactating women 3099 22.3 43.3 31.4 3.0 77.7
PREVALENCE (%) OF ANAEMIA IN DIFFERENT PHYSIOLOGICAL GROUPS PREVALENCE (%) OF ANAEMIA IN DIFFERENT PHYSIOLOGICAL GROUPS
Source: NNMB 2002‐2003
Special Nutrition Program (SNP) Balwadi supplementary Nutrition Program Tamil Nadu Integrated Nutrition Project (TINP) National Prophylaxis Program for prevention/control of
Nutritional Anemia Mid Day Meal Program National prophylaxis Program for control of Vitamin
A deficiency (Blindness) National Control program for IDD National Diarrheal Diseases Control Program Integrated Child Development Service Scheme (ICDS)
National Nutritional Programs (NNP)
MONITORING OF NUTRITION SITUATION
Nutritional Surveillance of the country’s population The nodal Dept. must involve NIN / NNMB, NFHS, Central
Health and Education Bureau, Home Science & Medical colleges & NGOs.
There should be a mechanism to utilize the services ofFood & Nutrition Board by the Health Dept. to manage National Nutrition Programs efficiently.
The NNMB should be strengthened and expanded toall the States (current coverage in 10 states representing¾ths of country’s population).
NUTRITION SURVEILLANCE SYSTEM
Nutritional StatusGrowth falteringNutr. Def.Enrolment, Att.Suppl. FeedingMorbidityMortalityORTARIVit.AIFAImmunisationPre-school Edn.
HH
INTER HH INTER- AWC INTER SECTOR INTER PROJECT INTER DT. INTER DT> ®ION
V A R I A T I O N
SPATIAL DISTRIBUTION
ICDS & HEALTH
COMMUNITYFormal &InformalGroup Leaders
} +
ICDSAWW SUPERVISOR CDPO DPO RD
COMM
HEALTH
ANC Check upSafe deliveryReferralPost natal checkNew born careBirth weightSpacingColostrum feedingExclusive B FCompl. feedingEligible couples� of RTI / STDAdolescent Girls
As a part of NNP, NIN has developedNutrition SurveillanceSystem in Andhra Pradeshand extended the same to other states of India
Dr. RAMESHWAR SARMA, Deputy Director, National Institute of Nutrition, Hyderabad.
Integrated Child Development Services Scheme (ICDS)
The program was initiated in 1975. Implementing Agency is DWCD, GOI. ICDS presently covers almost all Community
Development Blocks (>5000 CDBs i.e. almost entire country).
Under this program, the package of services are: Supplementary Nutrition Immunization Health Check up for minor ailments Referral Services Non-formal Pre-school Education Nutrition & Health Education (NHE)
Lacunae and bottle-necks in NNP Lack of regular super vision, monitoring and mid course
corrections for the project Irregular supply of foods and consumable items. Lack of transport facilities Lack of money to handle the contingency expenditures. No regional flexibility in adopting to suitable menus for
different socio-cultural communities. No proper storage facilities for storage of food
supplements. lack of government buildings for AWCs and other
institutions
Suggestions and Recommendations.. Try to solve the above said bottle necks in the programs. Since soc-econ (SE) factors play a significant positive
role in improving the NS, a comprehensive strategy including SE reconstruction should be undertaken.
Enrolment of women working groups(WWG), increase their participation in Intervention and Developmental Programs.
Social marketing & qualitative techniques be used for formative research involving progressive members of Women Working Groups as agents of change.
Nutrition Surveillance System developed by NIN should be used to serve as inbuilt evaluation system. This would identify at risk areas/groups and suggest appropriate mid course corrections.
