,.
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.