integrated child development services (icds): an assessment
TRANSCRIPT
Integrated Child DevelopmentServices (ICDS): An Assessment
B.N. Tandon
ICDS was initiated in India in 1975,and has thus been operational for over17 years. It happens to be the largestsingle programme in the area of childdevelopment anywhere in the world. Itincludes services not only to children,but also to pregnant and lactating women.In this communication, an attempt willbe made to critically examine the experiences gained and to identify the majorachievements and shortcomings ofthisNational Programme during the yearsof its implementation.
The objectives of ICDS have beenstated in a number of official documents and reports1.lnthe ultimate analysis, the central objective is the reduction in child mortality and the achievement of optimal physical, mental andpsycho-social development of India'schildren. The programme, initially instituted in just 30 rural/tribal blocks andthree urban slums, had expanded tocover 2,460 rural/tribal blocks and 236urban slums by March 1992. Such expansion was undertaken in the light offeedback inputs received from periodicexternal evaluation and internal monitoring reports. These reports not onlyserved to highlight the achievementsand successes of the programme, butalso its shortcomings and deficiencies,from time to time2•
UNIQUE FEATURES
ICDS has some important andunique features which distinguish it fromseveral other national programmes.These can be enumerated as follows:
• It is a holistic approach to child development involving the active participation of the mothers.
• It serves the most underprivilegedcommunities of very backward and remote areas of the country.
• It delivers services at Anganwadis(AW: village centres) right at the doorsteps of the beneficiaries to ensuretheir maximum participation.
• It comprises three essential components, that is nutrition, primary healthcare and education, delivered asa CO!Tl-'
posite package of services to childrenand mothers.
• It utilises local women as honoraryvillage level workers for delivery of thepackage of services.
• It makes maximum use of the existing infrastructure of health, social welfare departments and voluntary organisations for the implementation, training, continued education, monitoring,motivation, supportive supervision, evaluation and research. Only minimal additional infrastructure had been created(Child Development Project Officers,Programme Officers and Mukhya Sevikas) specially forthe ICDS. The existingdepartments and institutions which havebeen used in different tasks in ICDSinclude: (a) the health infrastructure ofthe states from the Director of HealthServices down to the frontline Multipurpose Worker at the subcentres; (b) thefaculty of medical colleges throughoutthe country; (c) Indian Council of ChildWelfare and other voluntary organi-
sations; (d) National Institute of PublicCooperation and Child Development;(e) the faculty of Home Science colleges; and (f) eminent experts from thespecialities of health, nutrition, socialservices, education and child development. Medical academia drawn frommedical colleges in the country hadbeen involved in this effort, workingunder the direction of the Central Tech
nical Committee (CTCp.
• It works through a team approach,and members of the team include ad
ministrators, professionals in servicedepartments, academicians and voluntary workers.
• It has tried to promote the culture ofvoluntary work and output-related honoraria for social work.
• It has primarily used the nationalfunding mechanism with very little bilateral and international financial assistance. It is a truly Indian programme,conceived, formulated and implementedfor the country by the country.
ACHIEVEMENTS
The achievements of ICDS havebeen significant as indicated by evaluation and research studies. Till March1992, 784 evaluation and 140 research
CONTENTS
• Integrated Child DevelopmentServices (ICDS): An Assessment- B. N. Tandon 1
• REVIEWS AND COMMENTS:Efficacy of Megadose of Vitamin Aand Prevalence of Diabetesin Indians- C. Gopalan 6
studies had been carried out by thefaculty and students of the medical colleges, besides several investigations bythe National Institute of Public Cooperation and Child Development(NIPCCD), Home Science colleges,programme evaluation organisations ofthe Planning Commission and a fewvoluntary organisations. The results ofthese studies have been published injournals, books and monographs4.
Some salient conclusions ofthesestudies on the impact of ICDS can besummarised as follows:
Nutritional status of children
There is evidence of significantdecline in 'severe' and 'moderate' malnutrition in children. The former hadcome down in 1990 to 6.6 per cent andthe latter to 18.1 per cent from 20.5 percent and 28.9 per cent respectively in1976. As a result of this decline in 'severe' and 'moderate' protein-calorie undernutrition, the percentage of pre-schoolchildren belonging to the combinedgroups of 'Normal' and 'Grade-I nutrition' had increased from 50.6 per centin 1976 to 75.3 per cent in 19904.5.
Several aspects related to thedecline in undernutrition have been ex
amined. It has been noted that youngchildren belonging to special groups,namelytribals, scheduled castes, scheduled tribes and backward communities,had all shown beneficial impact of ICDSon their nutritional status5. Specialmulticentric research studies at different intervals during the 17 years ofICDS had confirmed that the nutritionalstatus of children in the ICDS projectareas was significantly better than thatof their counterparts in areas withoutthe benefit ofthe ICDS scheme6,7. Thusa study by the National Institute of Nutrition had recorded better nutrition status of children attending ICDS Anganwadis as compared to children of thesame village and similar socio-economicstatus not utilising the services of ICDS8.
There are multiple health and nutrition intervention factors in ICDS whichcould have contributed to the decline inprotein-calorie malnutrition. Food supplementation providing 300 calories and10-12 gm protein daily atthe Anganwadimust have been a major contributorycomponent1. Data show that the supplementary nutrition coverage to pre-schoolchildren in the ICDS areas had increasedfrom 25.6 per cent in 1976 to 65.7 percent in 19904,5.While the supplementary nutrition coverage in ICDS project
areas ranged from 61.1 per centto 76.3per cent, the coverage of pre-schoolchildren with supplementary feedingamounted to no more than 17.9 to 31.5per cent in those areas where ICDSwas not operational.
Anaemia and vitamin Adeficiency prophylaxis
Six-monthly mega dose administrations of vitamin A and the preventionof anaemia through the distribution ofiron and folic acid are the two importantnational nutrition intervention programmes now being implemented inthe country. However, it is agreed on allcounts that the implementation of theseprogrammes has been generally far fromsatisfactory. In this context, the significant improvement in the coverage ofchildren through both these programmesrecorded in the ICDS areas4 is noteworthy. Thus vitamin A distribution increasedfrom 15.0 per cent in 1976 to 45.6 percent in 19905; and iron and folic aciddistribution has increased from 17.3 percent to 46.9 per cent5.
Immunisation coverage
Immunisation coverage of children also had significantly increased inthe ICDS areas9,10.It will be recalled
that despite efforts in the past, immunisation coverage of village childrenhad remained well below the desiredtargets, and the Government had therefore to launch the UniversallmmunisationProgramme in 1985 over and above thealready ongoing activity of EPI. Thedata on the immunisation of children inICDS project areas, as assessed atperiodic intervals, provide a generallyencouraging picture.
Thus the immunisation coverage(BCG, DPT and polio - three doses) in1990 in ICDS project samples, had increased to 69.0 per cent, 67.6 per centand 67.7 per cent respectively from thebaseline of 21 per cent (1976), 4.9 percent (1976) and 13.7 per cent (1981)respectively5,11. In a recent study, dataon immunisation in ICDS projects werecompared with those on control children in non-ICDS areas. Significantly, ahigher coverage forthe BCG, DPT (threedoses), polio (three doses) and complete immunisation, was observed forchildren of one to two years in ICDSprojects. The success of immunisationin ICDS projects was noted for bothsexes, and included underprivilegedcommunities as well9. The AWW wasfound to be a very valuable functionary
for the promotion of the immunisatiordrive of the health and family welfaredepartment, and the credit for the better success of the immunisation programme in the ICDS area must largelygo to her.
Antenatal care
Mother-care through augmentedantenatal, perinatal and post-natal services has always been an integral partof ICDS. The coverage of pregnantwomen by antenatal services had showna significant improvement in ICDSprojects, as compared to non-I CDSareas. An increase from a baseline of19.5 per cent to 82.6 per cent has beennoted in areas covered by those ICDSprojects which had been operational formore then five years. Administration oftetanus toxoid (two doses) was alsonoted to be significantly higher in ICDS(68 per cent) compared to the control(non-ICDS - 40 per cent) group9,12.Individual investigators had also foundbetter nutritional status as measured byweight gain and haemoglobin levels ofpregnant women in the ICDS project13•A substantial decline in the proportionof low-birth-weight deliveries had alsobeen reported14.
The preference for home deliverycontinues to be high in rural populations, but significantly more womenutilised locally available trained personsfor their delivery in ICDS projects ascompared to the controls12.
It has been noted12 that lactatingwomen utilised the ICDS services forimproving their nutritional status (throughsupplementary nutrition and iron folicacid tablets), accepting family welfareadvice and enhancing their knowledge,attitude and practice for the better careof their children.
Health care of children
There has been evidence that
management of diarrhoea, respiratoryinfections and other minor ailments atthe village, and health centres had improved in ICDS areas4,15.Personal hygiene, and to a limited extent environmental hygiene, had also improvedthrough ICDS health education activity16. ICDS apparently also had facilitated family planning programmes insome areas17.
Child mortality
A decade after ICDS was instituted, evaluation studies suggested that
decline in infant and early childhoodmortality rates, observed in areas whereICDS was operational, was significantlygreater than the decline reported in thenational data of the Sample Registration Scheme4.18• Recentdata confirmedthese earlier findings and show lowerneonatal, infant and early childhoodmortality rates in ICDS-covered populations as compared to the overall national data19.2o•
Studies carried out at the NationalInstitute of Nutrition (NIN) suggest thatpsycho-social development of childrenattending the AW was better than ofthose who had not8. Further; schooldropout rates were lower and the educational performance better in childrenwho had attended the Anganwadiprogramme21•
FACTORS POSSIBLYCONTRIBUTING TO SUCCESS
Innovative and cost-effective approaches to the training of the functionaries at various levels, continued education, monitoring, evaluation and research have been the important factorscontributing to the success of ICDS.We will briefly discuss these below.
Training
Training for all the functionaries inthe areas pertaining to health and nutrition components of ICDS, was organisedthrough periodic courses conducted bythe paediatric and community medicinefaculty members of the medical colleges (honorary consultants) nearest tothe ICDS projects. The existing infrastructure facilities of the medical colleges were utilised to conduct this training22• The curriculum and the strategyfor training were periodically reviewedand revised by experts and consultantsat national and regional meetings. Theoutput and needs of the training programme were closely monitored by theCTC of ICDS.
The present strategy is to focus onshort introductory, and periodic refreshercourses, as these are cost-effective,cause minimum disruption in the activities of health and ICDS functionariesand are conducive to their maximalparticipation. The participation of theProgramme Officers, CDPOs and Supervisors is encouraged in each of thethree types of courses.
The training schedule is flexibleand consultants are free to make changesin the topics and the contents of the
training course, depending upon localneeds. So far, 1,761 training courseshave been held and 4,315 functionarieshave received training through honorary medical college consultants.
Evaluation and research
Evaluation and research studieswhich had generated data for assessment of ICDS were carried out by anumber of honorary consultants fromthe faculties of medical colleges. Theconsultants have been able to conductthe studies periodically at very low costbecause they were able to use the existing material and manpower resourcesof their own academic departments.Apart from being cost-effective fromthe point of view of the ICDS operation,this strategy has also served to enrichthe field experience of the medical college faculties.
It may be legitimately claimed thatfew other national programmes had enlisted the active involvement and participation of the academia of the medical colleges to the extent that ICDS hasdone. Subjects related to ICDS operation formed the basis of a large numberof MD/PhD theses and scientific publications from the country's medical colleges. It was through such a mutuallyrewarding cost-effective strategy ofexternal evaluation that valuable harddata on the programme could be gathered. This strategy has benefitted theprogramme, on the one hand, and, onthe other hand, has provided rich fieldexperience to medical students, contributing to their orientation in favour ofpublic health programmes. Nationalhealth programmes and health researchsystems have several lessons to learnfrom this valuable ICDS experience.
The data from the monthly progressreports for the field were assembled bythe CTC and monthly status reportswere regularly furnished to the Department of Women and Child Development. The procedure of monthly monitoring of reports by CTC was initiated asfar back as 1976, and has been continuously revised and improved in the lightof accumulated experience. Thus theICDS operation has, ever since its inception, enjoyed the benefit of a Technical Support and Monitoring Systemdeveloped and provided by CTC. In thisoperation, the medical academia of thecountry and the Government Department of Women and Child Welfare andCTC had throughout functioned in closeconcert and coordination.
3
CTC meetings have been heldregularly every quarter to review thetraining, evaluation and monitoring output, and to suggest appropriate steps toimprove performance. New approachesfortraining, continued education, evaluation, research, monitoring, etc, arealso discussed at these quarterly Central Technical Committee meetings.
SHORTCOMINGS
It is to be expected that a programme of the scale of ICDS, coveringan estimated population of 246 million,distributed over 2.5 lakh villages and225 pockets of urban slums in 25 statesand seven union territories, will encounter difficulties and shortcomings in management and implementation. The widevariations in the capabilities of programme implementation infrastructure,the relatively low priority to social-sector activities in National DevelopmentProgrammes, and the large proportionof honorary workers on whom ICDS isdependent, but over whom it has noeffective executive control, are factorswhich contributed to these shortcomings. The important shortcomings andremedial measures thereto that havebeen identified are mentioned below.
Lack of adequate decentralisation
Centralised planning of the programme had failed to fulfil the specialneeds of the difficult areas of northeastern,eastern and mountain regionsof the country. ICDS projects in theseregions showed low coverage of beneficiaries and poor impact of the services. Strengthening of the infrastructure and special location-specific strategies for management were subsequently attempted but with limited success. The important lesson from thisexperience is that it is necessary toinstitute decentralised planning for special and difficult regions of the countryand to adopt a flexible strategy whichpermits location-specific modifications.
Lack of adequate intrasectoralcoordination
The nodal department for the administration of ICDS is the Departmentof Women and Child Development (Central Government). Generally, atthe headquarters of the states it is the SocialWelfare Department that is the nodaldepartment. Health and Family Welfare is a key department whose programmes need to be coordinated withthe activities of the ICDS, since health
personnel at the field levels are directlyresponsible for the delivery of healthand nutrition services to the village community. Teamwork between the ICDSand the health staff, right from the village to the highest levels at the stateheadquarters is essential for success.Continuous efforts over the last fewyears have, no doubt, improved thecoordination between the two departments; but this is still much below thedesired level.
Conferences designed to promotesupportive supervision, monitoring andmotivation offunctionaries at the sector(group of 20 villages), project headquarters (community health centre), district headquarters and divisional andstate headquarters are conducted atregular intervals and are closely monitored by the Central Technical Committee of ICDS. The success rate for these"coordination conferences" is about
65 per cent.
Failure of team spirit has beenoften noted at places where senior officers have been unable to achieve adjustment and accommodation with theircounterparts of other departments. Apersuasive approach and moral pressure had b'een used to stimulate thecoordination between the functionariesat each level. Political pressure hadalso been applied in some instances. Anew experiment of a joint coordinationcommittee composed of official andnon-official persons has also been startedin the State of Orissa.
Failure to accord dignity andprestige to voluntary work
ICDS activities are highly dependent on honorary functionaries who include approximately 3,57,279 AWWs,block advisors, and consultants. Unfortunately, the honorary functionaries, specially AWWs, are often unable to getadequate rewards for their voluntarywork. Respect and appreciation are thetwo important rewards which must beoffered to honorary workers. Failure tocreate the culture where honorary workers feel proud of their jobs has resultedin demands for change-over to paidjobs as per labour laws.
If, as a result of this, ICDS becomes yet another purely governmental bureaucratic operation conductedby regular salaried employees, it wouldlose its unique character. Every effortshould be made to provide career opportunities to AWWs but it is not moneybutthe social prestige thatthe AWW is
able to earn that will be her real reward;and this alone will give her real emotional satisfaction. This reward can comeonly if there is a change in the attitude ofICDS staff towards the AWW. The latter must be treated not as a low-paidsubordinate in regular government employment, but as a respected honorarysocial worker from the community.
Disparities in incentives forhonorary work
Advisors and consultants are drawnfrom medical colleges and health departments in order to ensure cost-effective and competent technical expertise for ICDS implementation. A verymodest honorarium related to their work
is paid to this group of voluntary workers. These honoraria do not measureup to the sumptuous remuneration thatseveral bilateral and international programmes are able to offer to their consultants. National interest demands thata uniform system of financial assistance for honorary work in all nation.alprogrammes is insisted upon, irrespective of whether the programme is fundedby either national, bilateral or international sources.
Deficiencies in management andsupply logistics
The supply of material for services atthe AW is often interrupted, andis frequently of inferior quality. The logistics of supply of supplementary foodcan be cited as one example. There areindeed many difficulties in the matter ofensuring continuous supply of goodquality food at the AWWs which areoften located in remote and difficultareas. Intensive efforts to solve this
problem are required. The approachneeded may vary in different situations.The Department of Food must take theoverall responsibility in this regard anddevelop aproper system for decentralisedmanagement of timely and regular distribution of food supplements.
Inadequate emphasison antenatal care
Utilisation of ICDS services bypregnant women, lactating mothers andchildren below the age of three yearshas been relatively low as compared tothat by pre-school-age children. Sincepregnant women and infants are themost vulnerable groups, efforts have tobe made for their greater participationin AW activities. Since most pregnantwomen and mothers of infants are oc-
4
cupied with their family work, they areoften unable to come to AWs to avail ofhealth and nutrition services. Home visits by AWWs'to reach this group hadbeen stimulated; but these have notbeen very successful. The AWW, beinga part-time honorary functionary, is unable to find much time for repeatedhouse visits. It has been suggested thatat least one day a week may be specifically fixed for providing special servicesto pregnant, lactating mothers and infants. This suggestion is worth experimenting with, at least in some of theICDS projects.
Inadequate performance withrespect to health/nutrition education
Health/nutrition education activityhas been generally unsatisfactory inICDS.lndeed, most of our national healthprogrammes are weak in this regard.The AWW is able to do this job only toa limited extent due to her preoccupation with other activities at the AW.Attempts to involve Mukhya Sevikasand evolve a regular health and nutritioneducation activity have not really beenvery successful.
CTC is now considering the creation of a new cadre of honorary workers, that is, Junior Consultants from theyoung faculty of medical and HomeScience colleges and to give them theresponsibility for promoting health andnutrition education through the existinginfrastructure of ICDS and primary healthcentres. Here is an area where theservices of competent non-governmental organisations in the countrycould be enlisted.
Failure to promote effectivecommunity leadership and
participation
ICDS, despite its strong infrastructure of honorary workers, is still functioning as a "government scheme" andhas not become a "peoples' programme". Adequate information dissemination and interaction of officers ofthe programme with the local community is minimal in ICDS. The CTC plansto promote this activity through the proposed cadre of honorary Junior Consultants and NGOs.
THE FUTURE
The CTC has been improving itsown operational structure in order toprovide the best possible results. It hasdecided upon several changes in the
present system in the light of additionalinputs for child developments that havebeen made available through the WorldBank and UNICEF and new programmessuch as "Child Survival" and "SafeMotherhood" that have been started.The approach here is to avoid duplication of activities, prevent wastage oftime of functionaries and save unnecessary expenditure, by suitable alignment of these parallel efforts so thatthey converge to a common goal instead of functioning at crosspurposes.
To begin with, the CTC has introduced the subject of ICDS in all trainingprogrammes of medical and paramedical staff conducted through differentnew schemes. ICDS honorary consultants are actively involved in these training programmes. The CTC has changedits own thrust of training activity to thefrontline workers through district, blockand village level training programmes.Monitoring activity has also been modified by simplifying the monthly monitoring reports system from the PrimaryHealth Centre. Duplication of writingwork by AWWs has been reduced andwill soon be eliminated. The CTC hopesto evolve a monitoring system which willenable the functionaries in the field tofeel that they are working for "childdevelopment" rather than for a narrowisolated component of the operation.
The CTC also hopes to simulateefforts in the following directions:
• Establishment of a Federation of"Academic Associations and VoluntaryOrganisations for Child Development",including organisations such as Nutrition Foundation of India, Indian Academy of Paediatrics, Nutrition Society ofIndia, Indian Association of CommunityMedicine, Public Health Association ofIndia, Home Science Colleges Association and several voluntary organisations which, in one way or another,are contributing to child developmentactivities. It may be useful for theseorganisations to share their experiencesfrom time to time and evolve betterapproaches for their future activities.
• Development of effective "coordination groups" atthe state level, so thatnew programmes and ICDS activitiescan be properly coordinated in specificoperational areas.
• Introduction of a new programme ofhealth/nutrition education, communityparticipation, and information dissemination, through a system of honoraryjunior child development consultantsdrawn from the young faculty members
of Home Science and medical collegesand NGOs.
ICDS has been a valuable experience and it has made important contributions to child development in India. Ina democratic country, with wide variations with respect to needs, infrastructure and management, wide variationsin performance levels ranging from successes at one end to failures at theother, are to be expected. Professionals, administrators, and politicians haveobligations towards the children of thecountry and must continue to contributeto the effective implementation of ICDS.(CDS should also be able to absorbsuch additional inputs that may be madeavailable by international and bilateralagencies in order to expand and improve the quality of the programme,which should eventually cover almostthe entire country.
The author, former Dean and Professor of Gastroen
terology in AI/MS, New Delhi, is Chairman, TechnicalCommittee of ICDS, and has been associated with
ICDS since its very inception.
References
1. Integrated Child Development ServicesScheme (Revised), MinistrY of Social Welfare,
Government of India, New Delhi, July 1982.
2. Nutrition Foundation of India: IntegratedChild Development Services (ICDS). A studyof some aspects of the system, ScientificReport 7, Ed C Gopalan.
3. Tandon, B.N.: Participation of medical colleges in national health programme - An experiment in India. Bulletin of Nutrition Foundation of India, 1986, 7(3):1-3.
4. ICDS - evaluation and research, 1975-1988,
Central Technical Committee, Deptt of Women& Child Development, M/O. HRD, Govt ofIndia, New Delhi, 1990.
5. Integrated Child Development Services, Dataon health & nutrition parameters, ProjectwiseData Annual Survey - 1990-91, BiostatisticsCell (ICDS), Central Technical Committee, NewDelhi, 1992.
6. Patowary, A.C.: Comparative study of thenutritional status of children below six yearsof age in the ICDS and non-I CDS blocks ofKamrup District - MD Thesis, 1987, GauwahatiMedical College, Gauwahati, Assam.
7. Chopdar, A. et al: Nutritional status of
pre-school children at Subdega Tribal ICDSProject (Orissa). Indian Paedtr, 1979,46:87-91.
8. Annual Report 1990-91. National Instituteof Nutrition, Indian Council of Medical Re
search, Hyderabad.
9. Tandon, B.N. et al: Immunisation coveragein India for areas served by the IntegratedChild Development Services Programme. Bul-
5
letin of the World Health Organization, 1992,
70(4):461-465.
10. Tandon, B.N. et al: Immunisation in India:
Contribution of Integrated Child DevelopmentServices Scheme to Expanded Programme of
Immunisation. J Trap Paedtr, 1988,34:301-304.
11. Integrated Child Development Services
Projectwise data on health & nutrition parameters, Annual Survey, 1981-82. Central TechnicalCommittee (ICDS), New Delhi.
12. Integrated Child Development Services projectwise data on health & nutrition parameters, Annual Survey, 1988-89. Central TechnicalCommittee (ICDS), New Delhi.
13. Bhatnagar, S. et al: Effect of food supplement - early post-natal period on maternal
weight and infant growth. Indian J Med Res,1983, 77:366-72.
14. Lal, S. : Incidence of low birth weight inICDS and non-I CDS blocks of Rohtak Districtin rural areas - MD Thesis, 1987, Medical
College, Rohtak (Haryana).
15. Tandon, B.N. et al: Morbidity pattern and
cause specific mortality during infancy in ICDS
projects. J Trap Paedtr, 1987, 33:190-193.
16. National evaluation of Integrated Child
Development Services, National Institute ofPublic Cooperation and Child Development,New Delhi, 1992.
17. Training in integration of population educa
tion in ICDS. A study of its social impact byManju Jain: (unpublished); Research on ICDS:An overview, Volume 1(1975-85), NIPCCD,New Delhi, 1989.
18. Tandon, B.N. et al: Impact of IntegratedChild Development Services on infant mortalityrate in India. Lancet, 1984, ii:157.
19. A study of growth pattern in children andperinatal mortality and infant mortality in ICDSrural block - MD Thesis, S.C.B. Medical College, Cuttack, Orissa, 1990.
20. Infant mortality rate and its causes in tribalICDS blocks of Rajasthan - MD Thesis, R.N.T.Medical College, Udaipur, Rajasthan, 1990.
21. Vadhera, KK et al: A study of beneficial
impact of non-formal pre-school education component of ICDS on various psycho-social developmental parameters of children. CentralTechnical Committee, Deptt of Gastroenterol
ogy & HNU, All India Institute of MedicalSciences, New Delhi, 1990.
22. Monograph on integrated training on na
tional programmes for mother and child development, Central Technical Com'mittee on Health
& Nutrition, Deptt of Women & Child Development, Ministry of Welfare, Govt of India, NewDelhi, 1990.
We are grateful to UNICEF fora matching grant towards the
cost of this publication
REVIEWS AND COMMENTS
1. Efficacy of Megadose of Vitamin A2. Prevalence of Diabetes in Indians
C. Gopalan
1. Efficacy of Megadose ofVitamin A: The SudanHarvard Study
The results of the Sudan-Harvard
study recently published1, should serve,to some extent, to restore a properperspective to the debate on "vitamin Aand childhood mortality". The study highlights two important points:
• that massive doses of synthetic vitamin A do not bring about significantreduction in child mortality as is beingclaimed,
• that insome situations, massive dosesof vitamin A may even fail to exert asignificant beneficial effect on clinicalhypovitaminosis A.
The former finding is in line withthe observations reported by the Nationallnstitute of Nutrition, Hyderabad2•The latter observation, which is perhaps relatively more important, is inconsonance with earlier findings ofPereira-and Begum 3 from India. Apartfrom the possible reason for this finding, which were discussed in an earliercommunication 3, other possibilities alsoneed consideration.
It is known that the transport ofvitamin A to the target tissues is conditioned by the availability of carrier protein and zinc. The possibility of concurrent zinc deficiency in children with clinical hypovitaminosis A cannot be dismissed. There is suggestive evidenceof salination and alkalisation of soilsand of depletion of micronutrients (especially zinc) in soil and, consequently,in foods 5.6, in many hypovitaminosis Aendemic areas where populations subsist predominantly on cereal-based diets. It is even possible thatthe exhibitionof massive doses of vitamin A could,under these circumstances, aggravatezinc deficiency. However, this needs tobe investigated.
These considerations point to theadvisability of not playing around withsingle nutrients - and more especiallywith massive doses thereof, in populations which may be expected to sufferfrom multiple nutrient deficiencies. Thiscaution may be particularly relevant withrespect to hypovitaminosis A, in the
light of the growing knowledge of nutrient inter-relationships involved in vitamin A metabolism.
It will be a disservice to persuadedeveloping countries, whose health systems are already under great strainbecause of scarcity of material andmanpower resources, to resort to universal repeated administrations of massive doses of synthetic vitamin A to theirchildren as a "short-cut" to better childsurvival, on the basis of currently available questionable evidence.
The proposed expansion of theuse of periodic synthetic vitamin A massive dosage administration, to coverinfancy and children beyond three yearsof age, is wholly unnecessary and iIIadvised. And keratomalacia is not apublic health prol;>lem- at least in Asia.
Apart from the studies of West etal7 in Nepal which showed increasedrisk of mortality from respiratory diseases in vitamin A supplemented children, some recent studies also indicateincreased incidence of respiratory morbidity in vitamin A-supplemented groupsof children 8. Bhaskaram et af9 had alsoearlier shown significant reduction insecretory IgA after administration of100,000 or 200,000 IU vitamin A. It isregrettable that despite these evidences,attempts are being made to push supplementation vitamin A administration as
part of the EPI in poor countries of theworld. This would be clearly unethical inthe light of available knowledge.
The results of "meta analysis" ofdata from published studies have beenclaimed to justify the conclusion thatvitamin A mega doses bring down childmortality. The scientific validity of suchmeta analysis exercises may be questioned. The data for such meta analysishave been derived from studies of different designs and from different regions, and are of disparate quality, notall carrying the same weight. Moreover,since the majority of studies chosen foranalysis were those gathered by moreor less one and the same school, theanalysis must be considered "loaded"even to start with.
It would be highly risky to proposefar-reaching public health policies likely
to affect the lives of millions of childrenon the basis of exercises of such dubious validity. Children of developing countries are no expendable guinea pigs,even if they happen to be poor.
Even with respect to currently ongoing programmes of periodic massivevitamin A dose administration to children between the ages of one and threeyears in hyperendemic areas, it wouldbe wise to progressively phase themout within a reasonable time-frame, whilevigorous efforts towards the promotionof an adequate intake of locally available carotene-rich foods are mounted.
References
1. Herrera, M.G., Nestel, P., Amin, A.E., Fawzi,W.w., Mohamed, KA, Weld, Leisa: Vitamin
A supplementation and child survival. Lancet,1992,340:267-271.
2. Vijayaraghavan, K., Radhaiah, G., Prakasam,B.S., Sarma, K.V.R., Reddy, V.: Effect of massive dose vitamin A on morbidity and mortalityin Indian children. Lancet, 1990,336:1342-45.
3. Pereira, S.M., Begum, A.: American Journalof Clinical Nutrition, 1969, 22:858.
4. Gopalan, C.: Combating vitamin A deficiency- Need for a revised strategy. Prefatory chapter in "Recent Trends in Nutrition". The proceedings of the First International Symposiumof the Nutrition Foundation of India, Oxford
University Press 1992.
5. Bangladesh Agricultural Research Council:'Zinc in Nutrition'. Edited by Abdul Mannanand Abdur Rahim, 1988.
6. Micronutrients assessment at the countrylevel: An international study. FAD Soils Bulletin63, 1990, FAG, Rome.
7. West, K.P., Jr, Pokhrel, R.P., Katz, J. et al:Efficiency of vitamin A in pre-school childmortality in Nepal. Lancet, 1991, 338:67-71.
8. Kartasasmita, C.B., Rosmyum, 0., Soemntri,E.S.S., Deville, W., Demeds, M.: Vitamin A
and acute respiratory infections. Paediatr
Indones, Jan-Feb 1991, 31:(1-2) 41-49.
9. Bhaskaram, P. et al: Nutrition Research,
1989, 9:1017-25.
2. Prevalence of Diabetes inIndians:Urban-Rural Difference
Urban migration and rising affluence often tend to induce changes inthe traditional dietary patterns of populations. Prominent among such changesin Indian population groups are the following:
• Substitution of millets by rice or wheat,as the main staple;
Table: Age-adjusted prevalence (%) ofNIDDM in Indian populationsUrban
Rural
Men
WomenMenWomen
Madras2
8.47.92.61.6
Fiji Indians3
14.412.613.713.2
Mauritian Hindus4
11.99.0--
Southall Asians58.9 (Total)---
• Substitution of undermilled rice bythe more refined, highly-milled polishedvarieties; and
• Reduction of overall intake of complex carbohydrates (cereals) and increased intake of refined sugar and fat.
On the basis of available epidemiologic evidence, a recent WHO report1observes that such changes are "closelyrelated to the emergence of a range ofchronic diseases, including coronaryheart disease, cerebrovascular disease,various cancers, diabetes mellitus, gallstones, dental caries, gastro-intestinaldisorders and various bone and jointdiseases". The causal significance, ifany, of such an association betweenchanging dietary patterns and the emergence of some of the above diseases,however, has yet to be clearly established. Most of these diseases are ofmulti-factorial origin; and dietary excesses and errors could be just one ofthe contributory factors.
While there is considerable epidemiological evidence that changes inhabitual diets of populations induced byaffluence could partly contribute to theincreased prevalence of coronary heartdisease, evidence in this regard withrespect to diabetes is scarce.
The major questions that arisewith respect to diabetes are:
• What is the nature of the scientificevidence that points to the conclusionthat affluence arising as a part of developmental transition is, in fact, associated with an escalation of the prevalence of diabetes; and,
• In case the evidence of such anescalation does exist, what specifically,are the "ingredients" of developmentthat contribute to such escalation? Inparticular, what is the role, if any, ofchanges in dietary pattern induced byaffluence with respect to the prevalence of diabetes?
Answers to these questions are
obviously important for the institution ofmeaningful programmes of diabetes prevention and control.
The study in South India: In arecent study involving 900 urban and1,038 rural subjects in South India,Ramachandran et af2 found that theprevalence of non-insulin dependentdiabetes mellitus (NIDDM), using WHOcriteria and adjusted to the age of thepopulation, was 8.25 per cent in theurban and 2.4 per cent in the ruralpopulations. On the other hand, theage-adjusted prevalence of impairedglucose tolerance (IGT) was nearlysimilar in the urban and rural groups(8.7 per cent and 7.8 per cent respectively). The diagnosis of diabetes in thestudy was made if the "post-glucose"value (two hours after glucose administration) was ~ 11.1 mM, and IGT wasdiagnosed if the "post-glucose" valuewas~7.8mMbut<11.1 mM.
The urban population investigatedby Ramachandran et a/was apparentlymore affluent than the rural; while therural population was largely composedof agricultural labourers of the low-income group, the urban population included businessmen, traders, clerks,professionals and a small number of"manual labourers".
The authors argue that the highprevalence of IGT in both urban andrural populations, regardless of theirsocio-economic status, is possibly agenetic attribute of Indian populationsand is indicative of the high risk of thedevelopment of overt diabetes. Affluence and urban environment had apparently contributed to the expressionof this genetic trait resulting in a highprevalence rate in the urban group. Observations among Indian populations inFijP and Mauritius4 and among migrantIndian populations in Southall (UK)5 alsopoint to a high prevalence of diabetes inIndians (Table).
Unfortunately Ramachandran etaI's paper does not deal in detail with
the, actual com
position of the diets of the urban
and rural populations and diabetics. However, onthe basis of suchdata as are available from nationalsurveys, we maydraw some inferences. As wasmentioned earlier,
7
with increasing affluence there is a trendtowards decrease in the intake of com
plex carbohydrates, accompanied ~yincreased intake of free sugars. If millets are the staple cereal in the ruralsituation, urban migration often resultsin the substitution of millets by rice orwheat; in the case of populations thathad earlier subsisted on rice, there isincreasing preference for more polishedand refined varieties of the cereal inplace of the undermilled varieties.
The differences in fibre content asbetween a diet based on millets on theone hand, and one based on highlypolished rice on the other hand, couldbe substantial6• Polishing is also knownto remove important nutrients from thegrain. As a result, differences with respect to nutritive value as between ruraland urban diets largely based on staplecereals could be significant.
It may also be relevant to recall inthis connection the results of a studycarried out in India over three decades
ag07, in which the response of the bloodsugar levels to administration of different cereal diets containing identicalamounts of carbohydrates was investigated. Itwas found that the rise in bloodsugar levels following the administration of a millet meal (ragi - Eeusinecoracaia) was significantly less thanthat following the administration of arice meal.
The obesity factor: 8ivariateanalysis of the data of Ramachandranet aI's study, for the identification ofassociation, if any, of body-mass index(8MI), subscapular triceps ratio (STR)and waist-to-hip ratio (WHR), with prevalence of diabetes, revealed interestingdifferences between the urban and rural groups. While this association wassignificant in the case of urban men andwomen, it was not so with rural men; inthe case of rural women, only the association of 8MI with diabetes prevalencewas significant, while those with STRand WHR were not. We can only speculate on the reasons for this interestingdifference. This finding could justify thereasoning that it is not obesity per se butthe actual nature and composition ofthe diets that led to such obesity in theurban population, on the one hand, andthe rural population, on the other, thatmay be important.
High caloric diets predominantlybased on millets or unrefined undermilledrice could be less diabetogenic thanisocaloric, high caloric diets based onpolished rice and refined sugar even if
ration and a 'Plan of Action', which werediscussed in-depth and finally adoptedat the ICN in Rome.
The Declaration is largely a reaffirmation of the commitment of the participating governments to the early attainment of the goal of eradication ofundernutrition/malnutrition, andthe overall upliftment of the nutritional status oftheir populations. The 'Plan of Action'that was adopted outlines this majorobjective and the policy guidelines forits achievement, and indicates strategies and actions that could be pursuedfor this purpose.
The 'Plan of Action' adopted atthe conference concludes with the following statement with which few woulddisagree: 'ICN should be viewed as amilestone in the continuing process toeliminate hunger and malnutrition, especially in the developing countries, andat the same time to prevent the increased incidence of diet-related noncommunicable disease. The ICN preparatory process began in the countriesand to be effective, its follow-up mustnow be firmly anchored in national commitment and efforts to protect and promote the nutritional well-being of all.'
In the ultimate analysis, the truetest of the 'success' of the conferencewill lie in the follow-up action, especiallyat the country levels, which the conference is able to generate. The conference had made some recommendationfor follow-up both at the national andinternational levels.
References
turn of the century. Meaningful prevention/control programmes will call for moreinformation with respect to the precisenature of dietary excesses and errorscontributing 'to the escalation of diabetes in the urban situation. Studies ofthetype reported by Ramachandran et a/therefore need to be multiplied and intensified. Such studies should receivehigh priority in any future National Nutrition Research Agenda.
4. Ohlson, L.O., Larrson,B., Svadsudd,K.,Welin, L., Eriksson, H., Wilhelmsen, L.,Bjorntorp,P.,Tibblin,G.:Theinfluenceof bodyfat distributionon the incidenceof diabetesmellitus.13.5 yearsof follow-upof the participantsin thestudyof menbornin 1913. Diabetes,1985, 34:1055-58.
5. Mather,H.M.,Keen,H.: The Southalldiabetes survey:Prevalenceof knowndiabetesinAsians and Europeans.Br Med J, 1985,291 :1081-84.
3. Zimmet,P., Taylor,R., Ram,P.:Prevalenceof diabetesand impairedglucosetoleranceinthe biracialMelanesianand Indianpopulationof Fiji: A rural-urban comparison.Am. JEpidemiol, 1983, 118:673-88.
1. WHO Technical Report Series No 979,1990 (Diet, nutrition and the preventionofchronicdiseases:ReportofWHOStudyGroup).
2. Ramachandran, A., Dharmaraj, D.,Snehalatha,C., Viswanathan,M.: Prevalenceof glucoseintolerancein AsianIndians- urbanruraldifferenceand significanceof upperbodyadiposity.Diabetes Care, 1992, 15(10):1348-55.
both diets eventually result in the sameorder of obesity. However, in the presentstate of our knowledge and with thelimited data available, this far-reachinginference must remain a speculation.Clearly we need more data. Unlike inthe case of the South Indian subjectsinvestigated by Ramachandran et at,available reports do not indicate a significant difference in rates of the prevalence of diabetes as between urban andrural Indians of Fiji (see table). This waspossibly because rural Indians in Fiji,unlike rural Indians in India, "tend toconsume foods similar to those of theirurban counterparts - rice, wheatenroti, chapatfis, highly spiced vegetables,meat or fish ... "
Unlike in the case of Indians in Fiji,there was marked rural-urban difference in the prevalence of diabetes asbetween rural and urban Melanesiansof Fiji. "Rural Melanesians retain traditional food patterns, consuming kasava,taro, breadfruit, tropical fruits, meat andsea foods" -while inurban Melanasians"much of the food consumed is cannedmeat and fish, polished rice, flour, sugarand processed vegetables and fruits" 3
It is reasonable to assume that thelevel of habitual daily physical activityof the rural subjects was significantlyhigher than that of the urban population.This is an important aspect that willpossibly also need to be taken intoaccount in explaining the observed urban-rural difference in diabetes prevalence in India. Zimmet et af3 conclude 6. Gopalan,C.: Dietaryguidelinesfor affluentthat "factors other than obesity, such Indians.Bulletin of the Nutrition Foundation of
as differences in physical activity, diets, India, 1988, 9(3):1-4.
stress or other as yet undetermined 7. Gopalan,C., Ramachandran,M.K.: Effect The XXV Annual Meeting of Nutrifactors" ... could contribute to the rural- of differentcerealson bloodsugar levels.Ind tion Society of India was held at theurban difference in prevalence of dia- J Med Res, 1957, 45:255. National Institute of Nutrition, Hyderabetes among Melanesians in Fiji. ,----------------, bad, on December 18 and 19, 1992.
The highlights of the programme wereDiabetes-amajorhealthprob- NUTRITION the Gopalan Oration by Dr Michael C.
lem: It seems certain that one-third of NEWS Latham; the Srikantia Memorial Lec-India's population will be urban by 2000 ture by Dr B.S. Narasinga Rao; and twoAD. While it may be rash and injudi- ••••••••••••••• symposia, one on "Development pro-cious to extrapolate the data from fThe Internatl'onal Conference grammes or women and children andRamachandran et ars limited study to th . . t t 't' "
on Nutrition (ICN)"" ICN was an I'nter- elr Impac on nu n Ion , and the otherthe entire country, to arrive at an esti- "N h d
governmental conference, whl'ch took on ewer met 0 ologies in nutritionmate of possible actual numbers of h" Td. b . place at the FAO headquarters I'nRome researc. wo "Young Scientistsla etlcs in urban India by 2000 AD, the AdS . "t d between December 5 and 11, and was war sessions were organiseds u y at least shows that given the pre- h I
.1' attended by government delegates from were severa papers on different as-vallng trends, urban migration could t f 'c .. I over 150 countrl'es and a number of pec s 0 ommunlty' and 'Experimen-Imp y a nearly four-fold increase in the t I' ..
. d scientists. During the two yearsofprepa- a nutntlon were presented.magnltu e of the prevalence of diabe-tes in the country. This could be re- ration forthe conference, eight regional XIX Kamla Puri Sabharwal Me-f1ected in the rising prevalence of coro- meetings and two meetings of a spe- moria I Lecture on December 22,1992nary heart disease (CHD) as well, since cially designated Advisory Group of was given by Prof J.S. Bajaj, Memberdiabetes is a major risk factor in CHD. Experts had been held in orderto finalise Planning Commission, on "Nutrition and
the Agenda. A preparatory meeting at Health: An Interactive Independence"Diabetes could thus emerge as a the WHO Headquarters in Geneva in at Lady Irwin College. Dr C. Gopalan
leading public health problem by the August had brought out a Draft Decla- presided.Edited by Harvinder Kaur for the Nutrition Foundation of India, B·37 Gulmohar Parle Designed and produced by Media Workshop. Printed by Vashima Printers.