Nutritional Status of Preschool Children in Kerala: The … · 2017-07-27 · Kerala: The Problem and Possible ... Th e s pecific objectives of the study are; ... concentrated 10

* Associate Professor and Head, Department of Applied Economics, Kannur University. E-mail:[email protected]

** Assistant Professor, Department of Economics, Zamorin’s Guruvayoorapan college, Kozhikode.E-mail: [email protected]

Nutritional Status of Preschool Children inKerala: The Problem and Possible

Interventions

K. GANGADHARAN* & K. P. VIPINCHANDRAN**

INTRODUCTION

The convincing performance of Kerala in achieving demographictransition, in spite of low economic development, has received Globalattention. The overall status of Kerala state with regard to the health aswell as social status is of developed countries. Significant advanceshave taken place in health and healthcare services over the past decadelike low birth rate and death rate along with higher female lifeexpectancy, low infant mortality and low maternal mortality rate, highliteracy rate and better women’s status, narrow negligible gap betweenrural and urban, wide immunization coverage and lower levels ofdisability etc. The major factors contributing to such a unique situationare a wide network of health infrastructure and manpower, policies ofsuccessive state government and other social factors like women’seducation, general health awareness and clean health habits of thepeople (Panikar and Soman 1984; Soman 1992; Kannan et al., 1991;Navaneetham and Thankappan 1999). Researchers and social scientistshave revealed that even in the face of adverse economic conditionssome international communities have registered impressive health gain.China, Cuba, Costa Rica, Sri Lanka are examples of such countries andKerala state in India if taken separately also had quite a commendablerecord in the health sector in the past few decades (Table 1).

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Table 1Demographic, Socio-Economic and Health Profile of Kerala State and India

Sl. No. Item Kerala India

1 Total population (Census 2001) (in million) 31.84 1028.612 Decadal Growth (Census 2001) (%) 9.43 21.543 Crude Birth Rate (SRS 2007) 14.7 23.14 Crude Death Rate (SRS 2007) 6.8 7.45 Total Fertility Rate (SRS 2007) 1.7 2.76 Infant Mortality Rate (SRS 2007) 13 557 Maternal Mortality Ratio (SRS 2004 -2006) 95 2548 Sex Ratio (Census 2001) 1058 9339 Population below Poverty line (%) 12.72 26.10

10 Scheduled Caste population (in million) 3.12 166.6411 Scheduled Tribe population (in million) 0.36 84.3312 Female Literacy Rate (Census 2001) (%) 87.8 53.7

Source: Census, 2001 and SRS, 2007.

The important challenges of the present health scenario in Keralaare decreasing allocation to public health sector, degenerating publichealth system, graying population, high rate of anaemia amongchildren, unregulated private sector leading to inequality and increasein cost of health care, the uncontrolled growth of the private sector,escalation of health care cost and marginalization of poor, re-emergingepidemics. The morbidity rate is now all time high, malnutrition andundernutrition alarming, various types of capitalist diseases arepredominant, calorie intake going down and infant mortality has startedrising. The growth of private hospitals and clinics has not reduced thehealth care cost but has rather accentuated it in Kerala. The cartelscreated by doctors and private run hospitals are able to create a situationof collusive oligopolistic health market where prices are high and sticky.This type of ratchet inflation is working in full swing in the healthmarket in less developed countries, particularly in India, where thehealth care services are controlled mainly by the private sector(B. N. Ghosh, 2009). The health care system in Kerala is moving througha very dangerous path (Thankappan 2007; Ekbal 2006).

Certain disturbing trends have emerged in Child development inrecent years, The health indicators of Kerala are higher, compared toother states in India; the NFHS-3 reveals that the situation of child healthand nutrition status is alarming picture and also much needs to be doneto improve the health of women and children especially among dalits,

NUTRITIONAL STATUS OF PRESCHOOL CHILDREN IN KERALA: / 65

marginalized and deprived sections of the community. By consideringthe sound human development base that existed in Kerala for the lastfew decades the present nutritional picture is not attractive comparedto the rest of the country except for a slight decrease in the severelymalnourished children.

Objectives: The specific objectives of the study are;1. to examine the rural-urban comparison and recent trends of

prevalence of malnutrition in India and Kerala.2. to examine the proximate causes of child malnutrition in Kerala

and explain its association.3. to suggest the possible interventions to combat malnutrition

among preschool children in Kerala.

SOURCES OF DATA AND MEASUREMENT OF NUTRITIONALSTATUS

The three rounds of National Family Health Surveys (NFHS) during1992-1993, 1998-1999 and 2005-06 have provided nationallyrepresentative anthropometric indices in the case of India. This hasmade it possible to examine the health and nutritional status of childrenin Kerala, in relation to a range of demographic, socio-economic andhousehold backgrounds. This present study is based on the recent datafrom NFHS-III, DLHS-RCH, India 2002-04 and NNMB data, 2002.

Anthropometry is widely recognized as one of the useful techniquesto assess the growth and nutritional status of an individual orpopulation (Jelliffe and Jelliffe, 1989; Rao et al., 1986). It reflects bothhealth and nutrition and predicts performance, health and survival.Three indices of nutritional status were calculated for children: height-for-age, weight-for-height, and weight-for-age. The height-for-age indexexamines linear growth retardation and is an indicator of chronicundernutrition. The weight-for height index compares body mass tobody length. This index reflects acute undernutrition. Weight-for-ageis a composite measure of both chronic and acute undernutrition.Undernourished children on the weight-for-age index are referred toas ‘underweight’ on the height-for-age index as ‘stunted’ and on theweight-for-height index as ‘wasted’. The measurements on these threeindices are compared with the international reference population asrecommended by WHO. The weights and heights of 1-5 year childrenwere compared with those of National Centre for Health Statistics(NCHS) standards for grading their nutritional status according to

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Gomez Classification, Indian Academy of Pediatrics (IAP) classificationand Standard Deviation (SD) Classification as described below:

Gomez Classification

Table 2Gomez Classification of Nutritional Status

Weight-for-age(% of NCHS standard) Nutritional Grade

>_ 90 Normal

75-89.9 Grade I ( Mild undernutrition)

60- 74.9 Grade II (Moderate undernutrition

< 60 Grade III (Severe undernutrition)

The NNMB has been using Gomez classification since 1975 to assessthe nutritional status of preschool children.

IAP Classification

Table 3IAP Classification of Nutritional Status

Weight-for-age(% of Harvard standard) Nutritional Grade Type of Undernutrition

>_ 80 Normal Normal

70- 79.9 Grade I Mild

60- 69.9 Grade II Moderate

50- 59.9 Grade III Severe

< 50 Grade IV Very severe

The distribution of 6-59 months children according to IAPclassification is given to help comparison with ICDS data.

STANDARD DEVIATION (SD) CLASSIFICATION

The World Health Organization recommends the use of SD classificationto categorize the children into different grades of nutritional status.The percent distribution of preschool children according to underweight(weight for age), stunting (height for age) and wasting (weight forheight) was computed using NCHS reference values, as given below.


Table 4Standard deviation Classification of Nutritional status

SD Classification Weight-for-age Height-for-age Weight-for-height

>_ Median Normal Normal Normal< Median to Median

– 1 SD< Median – 1 SD to

Median –2 SD

< Median –2 SD to Moderate Moderate ModerateMedian –3 SD undernutrition stunting wasting

< Median – 3 SD Severe Severe Severeundernutrition stunting wasting

TRENDS AND PATTERNS OF CHILD NUTRITIONAL STATUS

(i) Rural-Urban comparison of prevalence of malnutrition

All developing countries in the world are undergoing socio-economicand nutrition transition; in the last decade pace of nutrition transitionin India has undergone acceleration. Malnourished children areconcentrated 10 per cent in Indian villages which account for almost30 per cent of all underweight children. Three national health surveysare used for the comparison of rural-urban difference, Table 5 indicatesthe prevalence of stunting, underweight and wasting among preschoolchildren in India and Kerala over the period from 1992-93 to 2005-06.In the case of Kerala, child stunting is to be concerned, where aggregateprevalence is lowest in the country as a whole and also the rural-urbandifference is marginal (– 0.2), it suggest that a lower prevalence for ruralKerala compared to urban Kerala. At all India level, the prevalence ofstunting shows gradual decline from 52.0 per cent in 1992-93 to38.4 per cent in 2005-06. The absolute rural-urban difference also comesdown 9.6 percent in 2005-06 against 12.9 per cent in 1998-99. In thecase of wasting among preschool children, the rise is highest for Keralafrom 11.1 per cent to 16.1 per cent for the period of 1992-1993, 1998-1999and 2005-06. Rural-urban disparity is also higher for Kerala in 2005-06.

All India picture reveals that increase in prevalence of wasting inthe country both at aggregate level as well as rural-urban separately. Inthe case of rural children, the finding is very disturbing. In India andmost of the Indian states there is an increase in ‘rural-urban disparity’in wasting. Underweight and wasting among preschool children mayoccur due to diseases like diarrhoea and infections which reduce theabsorption capacity from the body of preschool children and also cause

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Tab

le 5

Pre

vale

nce

of

Stu

nti

ng,

Un

der

wei

ght a

nd

Was

tin

g am

ong

Pre

sch

ool C

hil

dre

n in

In

dia

an

dK

eral

a ov

er 1

992-

93 to

200

5-06

: A R

ura

l-U

rban

Com

par

ison

Pre

vale

nce

of S

tunt

ing

(Hei

ght-

for-

Age

)

NFH

S-1

(199

2-93

)N

FHS-

II (

1998

-99)

NFH

S-II

I (2

005-

06)

Rur

al-

Rur

al-

Rur

al-

Rur

al-

Rur

al-

Rur

al-

urba

nur

ban

urba

nur

ban

urba

nur

ban

Tot

alU

rban

Rur

alga

pra

tio

Tot

alU

rban

Rur

aldi

ffere

nce

gap

Tot

alU

rban

Rur

aldi

ffere

nce

gap

Ker

ala

27.4

21.5

29.6

8.1

1.37

721

.918

.522

.74.

21.

227

21.1

21.3

21.1

– 0.2

0.99

1In

dia

52.0

44.8

54.1

9.3

1.20

845

.535

.648

.512

.91.

362

38.4

31.1

40.7

9.6

1.30

9

Pre

vale

nce

of U

nder

wei

ght

(Wei

ght-

for-

Age

)

Ker

ala

28.5

22.9

30.6

7.7

1.33

626

.922

.428

.05.

61.

250

28.8

22.5

31.9

9.4

1.41

8In

dia

57.5

55.9

45.2

– 10.7

0.80

947

.038

.449

.111

.01.

292

45.9

36.4

49.0

12.6

1.34

6

Pre

vale

nce

of W

asti

ng (

Wei

ght-

for-

Hei

ght)

Ker

ala

11.6

012

.011

.50

– 0.50

0.96

11.1

010

.90

11.2

00.

301.

0316

.10

10.1

019

.10

9.0

1.89

Ind

ia17

.50

15.8

18.0

02.

201.

1415

.50

13.1

016

.20

3.10

1.24

19.1

016

.90

19.8

02.

901.

17

Sour

ce:

Nat

ion

al a

nd S

tate

lev

el r

epor

ts f

rom

NFH

S-I,

NFH

S-II

and

NFH

S-II

I.


severe depletion of nutrients, which cumulates in the process ofreducing weight. Since malnourished children are concentrated in ruralhinterlands, the future studies have to be focused on these areas.

(ii) Child Nutritional Status of Kerala

Malnutrition is a major problem in India which account for 46 per centof India’s children under the age of three are underweight and highestpercentages of undernourished children in the world (NFHS-3). Thoughthe Health indicators of Kerala are higher, compared to other states inIndia, the situation of nutrition in critical sectors and areas of populationdoes not portray a rosy picture. There is widespread prevalence ofmalnutrition in the form of underweight, low birth weight, wasting,stunting, anaemia, and other manifestations of micro-nutrientdeficiencies among different age groups of the population as a whole.In the same way, children’s nutritional status in Kerala has worsenedin the seven years since NFHS-2 based on two of the three nutritionalstatus measures. Children and adults are vulnerable to malnutritionbecause of low dietary intakes, infectious diseases, lack of appropriatecare and inequitable distribution of food within the household. ThoughKerala is successfully implementing all nutrition oriented programmesand related programmes of housing, sanitation and potable drinkingwater, the state could not achieve the nutritional level of best performingcountries. Table 6 indicates that large disparities in district wise analysisof selected child health indicators in Kerala.

Table 6Selected Health Indictors in Different Districts in Kerala-2005

Complete Institutional CompleteDistrict ANC delivery immunization % LBW IMR

Thiruvanthapuram 72 99.5 81.6 11 12Kollam 90 99.0 90.6 12 8Pathanamthitta 85 99.4 91.4 18 8Alappuzha 93 100.0 97.4 12 8Kottayam 92 99.4 79.1 16 14Idukki 82 93.3 90.8 15 20Ernakulam 90 99.4 93.4 18 12Thrissur 89 99.2 90.5 13 9Palakkad 86 93.4 75.1 16 12Malappuram 79 88.0 59.8 17 10Kozhikode 93 98.9 90.9 17 14Wayanad 90 97.8 82.3 30 22Kannur 90 99.4 84.7 15 14Kasaragod 75 96.7 87.4 15 10

Source: Human Development Report-Kerala, 2005.

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Around 21 per cent of children in Kerala under the age of five arestunted, or too short for their age, which indicates that they have beenundernourished for sometime. 16 per cent of children are wasted, ortoo thin for their height, which may result from inadequate recent foodintake or a recent illness. 29 per cent are underweight, which takes intoaccount both chronic and acute undernutrition. Overall, girls and boysare about equally undernourished and undernutrition is substantiallyhigher in rural areas than in urban areas in the State.

Table 7Child Health and Nutrition Indicators-Kerala and India

Kerala IndiaIndicators (2005-06) (2005-06)

Differential in Mortality (Per 1000 live births)Neonatal Mortality (NNM) 11.5 39.0Postnatal Mortality (PNM) 3.8 18.0Infant Mortality (IMR) 15.3 57.0Child Mortality (CMR) 1.0 18.4Under-five Mortality (U5MR) 16.3 74.3

Nutritional status of children (%)Stunted 21.0 39.0Wasted 16.0 19.0Underweight 29.0 46.0Anaemia status 55.7 79.2Vaccination coverage 75.0 44.0

Utilization of ICDS services (%)Children age 0-71 months who received any services 30.8 32.9Received food supplements 24.7 26.3Received immunization 9.0 20.0Received health check-ups 17.6 15.8Went for early childhood care/preschool 30.7 22.8

Source: NFHS-3, 2005-06.

Anaemia is a major health problem in Kerala, especially childrenand women population. Anaemia can result in maternal mortality,diminished physical and mental capacity, increased morbidity frominfectious diseases, perinatal mortality, premature delivery, low birthweight, and (in children) impaired cognitive performance, motordevelopment and scholastic achievement. Anaemia is considerablyhigher in rural areas than in urban areas, for children of women withno education, for disadvantaged groups and for children in householdsin the lower wealth quintiles. The prevalence of Children’s anaemiastatus is closely linked with the anaemia status of the mother.


The ICDS programme provides nutrition and health services forchildren under age six years and pregnant or breastfeeding women aswell as early childhood care or preschool activities for children age3-5 years. These services are provided through community-basedanganwadi centres. The recent health statistics of Kerala tell a gloomynarrative of degenerating public health system especially the percentageof fully vaccinated children in the age group 12-23 months came downfrom 80 per cent in 1998-99 (NFHS-2) to 75 per cent in 2005-06 (NFHS-3).The proportion of anaemic women in the age group of 15-49 years hasalso increased from 22.7 per cent to 32.3 per cent and that of underweight children from 27 per cent to 29 per cent during the same period.Infant mortality in the state which reached 10 per 1000 live births inthe mid 1990s has increased to 14 as per the latest SRS data (M.A. Oomen2008; Kabir and Krishnan, 1996; Kunhikannan and Aravindan, 2000).

(iii) Nutritional Status of Preschool Children in Kerala: Evidencefrom NNMB

During 2000-2001, the National Nutrition Monitoring Bureau (NNMB)carried out survey in a sub-sample of NSSO 54th round on Consumerexpenditure in the states of Andhra Pradesh, Gujarat, Karnataka, Kerala,Madhya Pradesh, Maharashtra, Orissa, Tamilnadu and West Bengal,to assess diet and nutritional status of individuals and prevalence ofmorbidity in the rural populations. Based on the above measurementsof nutritional status, these data sets were used for the analysis of thenutritional status of preschool children in Kerala.

Gomez Classification: Sex wise Classification

Table 8Distribution (%) of 1-5 Years Children by Nutritional Status in

Kerala – (Weight-for-Age) Gomez Classification

Nutrition Grades (NCHS Standards)

Sex N Normal Mild Moderate Severe

Boys 191 17.3 55.0 26.2 1.6Girls 184 24.5 45.7 27.7 2.2Pooled 375 20.8 50.4 26.9 1.9

Source: Diet and Nutritional status of rural population, National institute ofNutrition, 2002.

The distribution of body weights of preschool children accordingto Gomez classification is presented in Table 8. Children with moderate

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and severe grade undernutrition are considered as ‘at risk’ group frompublic health point of view. The proportion of ‘at risk’ male childrenwas 26.2 per cent and 1.6 per cent. In the case of female children, theproportion of ‘at risk’ was 27.7 percent and 2.2 per cent. Slightdifferentials were observed in the nutritional status of preschoolchildren in Kerala.

Age Wise Classification

Table 9Nutritional Status (Weight-for-Age) – Gomez Classification

According to Age


Age (years) N Normal Mild Moderate Severe

1-3 211 24.2 46.4 27.5 1.93-5 164 16.5 55.5 26.2 1.8

Pooled 375 20.8 50.4 26.9 1.9


The distribution of body weights of preschool children on the basisof age-wise, according to Gomez classification is presented in Table 9.Children with moderate and severe grade undernutrition are consideredas ‘at risk’ group from public health point of view. The proportion of‘at risk’ 1-3 age group children were 27.5 per cent and 1.9 per cent. Inthe case of 3-5 children, the proportion of ‘at risk’ was 26.2 per centand 1.8 per cent.

IAP Classification

Table 10Distribution (%) of 6-60 Months Children According to IAP Classification

Nutrition Grades

Age(months) N Normal Grade I Grade II Grade III Grade IV

6-12 58 79.3 17.2 1.7 1.7 0.012-24 123 54.5 33.3 10.6 1.6 0.024-36 88 65.9 21.6 10.2 1.1 1.136-48 108 59.3 30.6 10.2 0.0 0.048-60 56 55.4 35.7 8.9 0.0 0.0Pooled 433 61.4 28.4 9.0 0.9 0.2



Table 10 presents the percentage of 6-60 months children accordingto IAP Classification. Children with grade III and grade IVundernutrition are considered as ‘at risk’ group. The proportion of ‘atrisk’ 6-12 months age group children was 1.7 per cent and in the caseof 12-24 months age group children, the proportion of ‘at risk’ was1.6 per cent. In the age group 24-36 months, the proportion of ‘at risk’was 1.1 per cent and 1.1 per cent respectively with grade III and grade IVof nutrition grades respectively.

SD Classification

The distribution of 1-5 year children according to weight-for-age(underweight), height-for-age (stunting), and weight-for-height(wasting) by SD classification using NCHS standards.

Weight-for-Age

In the case of boys, the proportion of children with underweight(< median – 2 SD) was about 33.5 per cent, while that of severeunderweight (< median – 3 SD) was 6.8 per cent and also female childrenwith moderate underweight was about 31.5 per cent and severeunderweight was 8.7 per cent. The proportion of severe grade ofunderweight was observed to be marginally higher among the girls.

Table 11Distribution (%) of 1-5 Years Children According Weight-for-Age

Standard Deviation (SD) Classification


Sex N < Median – 3 SD – 3 SD to – 2 SD – 2 SD to – 1 SD – 1 SD to Median



Height-for-Age

In the case of boys, the extent of stunting (< median – 2 SD) amongpreschool children was 18.8 per cent, while that of severely stunted(< median – 3 SD) was 25.1 per cent and also female children withmoderate stunting was about 21.7 per cent and severe underweightwas 21.2 per cent.

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Table 12Distribution (%) of 1-5 Years Children According to Height-for-Age

Standard Deviation (SD) Classification





Weight-for-Height

Table 13 indicates the weight-for-height, about 6.3 per cent of malechildren and 7.1 per cent female children were wasted (< median – 2 SD).Slightly sex differential were observed in the prevalence of wasting.

Table 13Weight-for-Height of Preschool Children





PROXIMATE CAUSES OF CHILD MALNUTRITION

Children in rural areas are more likely to be undernourished, but evenin urban areas, 22 per cent of children suffer from chronic undernutrition.Boys are slightly more likely to be undernourished according to eachof these three measures than girls. Children’s nutritional status in Keralahas improved slightly since NFHS-2 by some measures but not by allmeasures. Anaemia is a major health problem in Kerala, especiallyamong women and children.

Breastfeeding improves the nutritional status of young children andit reduces morbidity and mortality. Breast milk not only providesimportant nutrients but also protects the child against infection. Thetiming and type of supplementary foods introduced in an infant’s dietalso have significant effects on the child’s nutritional status. An importantcorrelate of child nutritional status is nutrient intake, which in turn


depends on the nature and duration of feeding (including breastfeeding)practices. Feeding practices are especially critical during the first fewdays and months of an infant’s life, since growth is faster and protectionagainst illnesses and infections are most needed during this crucial period.Ideally, a baby should be put to the mother’s breast immediately afterbirth. The Government of India recommends that initiation ofbreastfeeding should begin immediately after child birth, preferablywithin one hour (Ministry of Women and Child Development, 2006).WHO offers three recommendations for infant and young child feeding(IYCF) practices for children 6-23 months old, continued breastfeedingor feeding with appropriate calcium-rich foods if not breastfed; feedingsolid or semi-solid food for a minimum number of times per dayaccording to age and breastfeeding status; and foods from a minimumnumber of food groups per day according to breastfeeding status.

For a large number of Indian children, malnutrition begins veryearly in life when they are born with low birth weight. If children bornwith a weight of less than 2.5 kg they are at significantly greater risk ofsubsequent malnutrition than children whose birth weight is above2.5 kgs. Nationally, about 22 per cent of births classify as low birthweights, with wide variations across states. Even in Kerala, theproportion of low birth weights is as high as 18 per cent. Low birthweight in turn is determined by a number of factors but importantamong them is maternal nutrition. Malnourished or low-weightmothers are more likely to give birth to low-weight babies, whichimplies that children of low-weight mothers are more likely to bemalnourished than children of heavier mothers.

In Kerala, there has been a decrease in full vaccination coveragefrom 80 per cent in NFHS-2 to 75 per cent in NFHS-3. The decline infull immunization coverage has been accompanied by a decrease inthe coverage of almost all vaccines. The nutritional supplementationhas played a major significant role in determining the overall nutritionalstatus of the children in Kerala. The ICDS programme provides nutritionand health services for children under age six years and pregnant orbreastfeeding women, as well as preschool activities for children in theage group of 3-5 years. These services are provided through community-based anganwadi centres.

Research shows that waiting at least three years between childrenreduces the risk of infant mortality. The infant mortality rate in Keralahas been steadily decreasing over time. Infant mortality is currentlyestimated at 15 deaths before the age of one year per 1,000 live births,down from the NFHS-2 estimate of 16 deaths and the NFHS-1 estimate

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of 24. Under-five mortality in Kerala is 16 deaths per 1,000. Kerala,along with Goa, has the lowest infant mortality rate of any state in thecountry. In Kerala, the infant mortality rate for boys is higher than forgirls. Access to safe drinking water and sanitation can improve childnutrition by reducing a child’s exposure to water and vector bornediseases. Likewise, access to electricity can also improve nutritionalstatus by improving the hygiene, cooking and health practices in thehousehold and in the community. Rural roads enable easier access tomarkets and health workers and thereby better information to childnutrition-improving information.

THE THREE ‘A’ APPROACH TO COMBAT MALNUTRITION

Malnutrition can be combated using the three ‘A’ approach – awareness,access and affordability.

Awareness

Awareness has to be created not only in the community, but also amongthe providers – politicians, bureaucrats, NGOs, and medical andagricultural professionals. Innovative methods of creating awarenessin the community are needed. The media and school education canplay an important role. The NRHM emphasizes the need to provideuniversal access to equitable and affordable health care that isaccountable and responsive to the poor and marginalized people inthe rural areas, especially children and women. National NutritionMission has been set up in 2003, with the basic objective of addressingthe problem of malnutrition in a holistic manner.

Access and Affordability

Most of the Indian states including Kerala have special nutritionprogrammes which improve access to food and nutrition among thevulnerable groups. These include: (i) supplementary feedingprogrammes for vulnerable groups, (ii) distribution of micronutrientslike iron, folic acid and vitamin A and (iii) food fortification. Globalstudies have shown that supplementary feeding programmes make animpact on child nutrition, only if a strong educational component formothers is built into it. Food fortification is more cost-effective thandistribution of micronutrient tablets. Ultimately, effort has to be madeto enable the community to feed itself. The targeted public distributionsystem (PDS) can go a long way in meeting the food needs of the poor.Apart from cereals, PDS should also include millets, pulses, oil and if


possible some vegetables, fruits, and animal products (milk, eggs, fishpowder) to ensure dietary diversification.

Access to a balanced and diverse diet to ensure food and nutritionsecurity at the household and individual levels can be greatly improvedby decentralized production of a variety of foods (cereals, millets,pulses, vegetables, fruits and animal products) at the block or villagelevel. Such people-centric planning can increase household nutritionsecurity and not just national food security, and also generate livelihood,particularly for women. It has been found that within a household,diet of preschool children is deficient compared to that of adults,suggesting that it is not just affordability, but also the knowledge of achild’s nutritional needs and feeding.

NEED FOR PARADIGM SHIFT

There is need for paradigm shift in objectives from: Child survival to child health. Food security to nutrition security (household and individual) Literacy to education and skill development for women. Focus only on pregnant and lactating women to lifecycle

approach, including girl children, adolescents and elderlypeople and

Aid to empowerment through livelihood security for women.Problem of undernutrition amongst preschool children needs to be

addressed through comprehensive, preventive, promotive and curativemeasures. The community needs to be educated about environmentalsanitation and personnel hygiene and also proper child rearing, breastfeeding and weaning practices, especially in the context of changinglife style of the rural people in Kerala. A comprehensive child survivalprogramme with supplementary feeding, growth and developmentmonitoring and early detection and prompt treatment during illnessneeds to be devised and implemented ensuring communityparticipation. The government needs to spend more money on qualitynutritional programs in order to improve the state of malnutrition andtherefore health services, education for females and poverty.

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Facility Survey Under Reproductive and Child Health Project(DLHS-3, 2007-08), District Fact Sheet-Kasaragod, International Institute ofPopulation Studies, Mumbai and Ministry of Health and Family Welfare,Government of India, New Delhi.

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DLHS-RCH-3 Survey, Government of India, (2008), District Level Household andFacility Survey Under Reproductive and Child Health Project(DLHS-3, 2007-08), State Fact Sheet-Kerala, International Institute ofPopulation Studies, Mumbai and Ministry of Health and Family Welfare,Government of India, New Delhi.

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Gangadharan K., (2009), Health Services in Kerala: Features, Problems and Policies,in B. N. Ghosh, and Padmaja D. Namboodiri, (Eds), The Economy of Kerala,Yesterday, Today and Tomorrow, Serials Publications, New Delhi.

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Government of India, (2001), Census of India.Government of India, (2006), Ministry of Women and Child Development.

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