NUTRITIONAL STATUS OF THE COMMUNITIES IN THE RURAL AREAS - Current Scenario

Dr.G.N.V.Brahmam Dy. Director (Sr. Gr.), HoD,

Division of Community Studies,

National Institute of Nutrition, (I.C.M.R.)

Jamai-Osmania (P.O.),

Hyderabad – 500 007.

“Nutrition monitoring is the measurement of the changes over time in the nutritional status of a population or a specific group of

individuals” -- WHO, 1984Nutrition Monitoring is essential

- to assess the type, magnitude & distribution of

nutrition problems in the community,

- to evolve policies and to formulate & implement

programmes for the prevention and control of

malnutrition and

- to evaluate on-going nutrition programmes to

assess their impact and to initiate corrective

steps needed, if any.

NUTRITIONAL SURVEILLANCE

“ TO WATCH OVER NUTRTION IN ORDER TO MAKE

DECISIONS WHICH WILL LEAD TO IMPROVEMENT

IN NUTRITION IN POPULATIONS”. NUTRITIONAL

SURVEILLANCE METHODS PROVIDE REGULAR

INFORMATION ABOUT NUTRITION IN POPULATION;

THEY DRAW DATA FROM MOST SUITABLE

SOURCES THAT ARE ALREADY AVAILBLE,

INCLUDING SURVEYS AND ADMINISTATIVE DATA.

THE UNDERTAKING OF ADHOC INVESTIGATIONS

CAN ALSO BE INCLUDED IN NUTRITIONAL

SURVEILLANCE. FAO/WHO/UNICEF EXPERT COMMITTEE (1976) AND ELABORATED UPON BY MASON et al, 1984

HOUSEHOLD FOOD SECURITY:

Ability of the Household to access food which is culturally acceptable and adequate in terms of quality, quantity and safety for all members of the household throughout the year, in order to ensure active and healthy life

HOUSEHOLD FOOD INSECURITY:

Presently or potential inability to consume food which is adequate, having all the nutrients essential for a healthy and productive life.

NNMB was established in the year 1972, under the aegis of ICMR in the States of :

ANDHRA PRADESH

KARNATAKA

KERALA

TAMIL NADU

MAHARASHTRA

MADHYA PRADESH

ORISSA

UTTAR PRADESH

GUJARAT AND

WEST BENGAL

OBJECTIVES OF NNMB

To collect, on a continuous basis, on

representative segments of population in each of

the States, data on dietary pattern and nutritional

status by adopting standardized and uniform

procedures and techniques, and

To evaluate periodically, the ongoing national

nutrition programmes, to identify their strengths

and weaknesses and recommend appropriate

corrective measures.

ICMR

NIN - CRL

STEERING COMMITTEE

10 State Units

ORGANIZATION CHART OF NNMB

STAFF / UNIT

Medical OfficerNutritionistSocial WorkerField AttendantDriver

INVESTIGATIONS

Household demographic & socio-economic

particulars,

Dietary intakes of households / individuals,

Anthropometry viz., Heights, weights, MUAC &

Skinfold at Triceps,

Clinical examination for prevalence of signs of

nutritional deficiencies and

Village level information such as population,

agricultural production, nutritional & other

developmental programmes.

SAMPLING DESIGN

VILLAGES:

Sub-sample of NSSO sample frame of Consumer Expenditure survey carried out once in five years – to get better spatial distribution.

HOUSEHOLDS

Cluster sampling method

INDIVIDUALS

All individuals from the selected HHs.

Sub-sample by systematic random sampling procedure

SAMPLE SIZE

• Computed to arrive at State level estimates

HIGHLIGHTS OF NNMB SURVEYS

Coverage of rural, tribal & urban communities,

Repeat surveys in rural communities during 1975-

79, 88-90, and 96-97, covering same villages,

Repeat surveys among tribal communities during

1985-87 & 1998-99,

Study of physiologically vulnerable groups such

as adolescent girls, elderly etc.,

Assessment of MNDs such as IDA, VAD & IDD by

covering adequate sample sizes to arrive at State

level estimates, and

Evaluation National nutrition programmes

NUTRITIONAL STATUS OF THE RURAL POPULATIONS

NNMB Tech. Rep. #24, 2006

SOCIO ECONOMIC PROFILE OF HOUSEHOLDS (%)

21.9

11

3730.1

0

20

40

60

SC ST BC Others

COMMUNITY

22.3

61.9

15.8

0

20

40

60

Kutcha Semi-Pucca Pucca

TYPE OF HOUSE

49.1

31.7

8.8 10.4

0

20

40

60

No Land MarginalFarmers

SmallFarmers

LargeFarmers

LAND OWNERSHIP

15.3

28.223.6

32.9

0

20

40

60

Agri. Lab Other Lab Cultivators Others

OCCUPATION

SOCIO ECONOMIC PROFILE OF HOUSEHOLDS (Contd..)

29.0

34.4

15.6

21.0

0.0

10.0

20.0

30.0

40.0

50.0

<300 300-600 600-900 >=900

PER CAPITA INCOME / MONTH (%)

48

34.5

15.4

2.1

0

10

20

30

40

50

60

Illiterate 1-8 std. 9-12 std. College

FEMALE LITERACY (%)

27.4

75.572.1

0

20

40

60

80

Sanitary Latrine SeparateKitchen

Electrification

BASIC AMENITIES (%)

24

3539.1

1.1 0.80

10

20

30

40

50

OpenWell

TubeWell

Tap Pond Stream

SOURCE OF DRINKING WATER (%)

Average Daily Food Intake (% RDA) among 1-3 Year Children : By Gender

31

321918

26

31 232

21987

6917

1435

3680

74

0 50 100 150 200

Sugar & Jaggery

Fats & Oils

Milk & Milk Prod.

Roots & Tubers

Other Veg.

Green Leafy Veg.

Pulses

Cereals BoysGirls

Percent RDA

Average Daily Food Intake (% RDA) among 4-6 Year Children : By Gender

26

2630

3323

27166

181

87

8623

1954

5276

79

0 50 100 150 200

Sugar & Jaggery

Fats & Oils

Milk & Milk Prod.

Roots & Tubers

Other Veg.

Green Leafy Veg.

Pulses

Cereals BoysGirls

Percent RDA

Average intake of Food stuffs (as % of RDA) Among Adults (Sedentary): By Gender

5746

3560

5767

150138

95125

4518

8565

9995

0 20 40 60 80 100 120 140 160

Sugar & Jaggery

Fats & Oils

Milk & Milk Prod.

Roots & Tubers

Other Veg.

Green Leafy Veg.

Pulses

Cereals MenWomen

Percent of RDA

Median Intake of Nutrients (as % RDA) Among 1-3 year children : By gender

6058

3230

6156

4343

67

671414

3835

4040

5754 87

83

0 25 50 75 100 125

F.Folic Acid

Vitamin C

Niacin

Riboflavin

Thiamin

Vitamin A

Iron

Calcium

Energy

ProteinBoysGirls

Percent of RDA

Median Intake of Nutrients (as % RDA) Among 4-6 year children : By gender

6466

3637 65

683030

67

6716

173738

4952

5759 87

90

0 25 50 75 100 125

F.F.Acid

Vitamin C

Niacin

Riboflavin

Thiamin

Vitamin A

Iron

Calcium

Energy

ProteinBoysGirls

Percent of RDA

Median Intake of Nutrients (as % RDA) Among Adults (sedentary): By Gender

73

83 118

10155

50 122

10816

2038

5086

10597

889091

0 25 50 75 100 125

Vitamin C

Niacin

Riboflavin

Thiamin

Vitamin A

Iron

Calcium

Energy

Protein Men

Women

Percent of RDA

Distribution (%) of Children according to Protein - Calorie Adequacy

24.4

23.8

30.1

68.1

64.8

47.3

7.5

11.4

22.5

0 20 40 60

P+ C+

P+ C-

P- C-

1-3 Yrs

4-6 Yrs

7-9 Yrs

Distribution (%) of Adults according to Protein - Calorie Adequacy Status

80.0

67.9

11.8

22.4

7.2

9.4

1

0.3

0 20 40 60 80 100

P+ C+

P+ C-

P- C-

P- C+Men

Women

Distribution (%) of Households according to Protein - Calorie Adequacy Status

29.6

43.8

26.4

0.2

0 20 40

P+ C+

P+ C-

P- C-

P- C+

INTRAFAMILY DISTRIBUTION OF DIETARY ENERGY IN RURAL INDIA

Distribution (%) of Households According to Dietary Energy Adequacy Status of Adults Vs Children

DIETARY ENERGY INTAKE AGE GROUP

ADULTMALE

ADULTFEMALE CHILD

PRE-SCHOOL

SCHOOLAGE ADOLES-CENT

B G B G B G

+ + + 22.1 23.0 26.7 29.3 36.3 50.6

+ + - 51.0 52.6 44.9 45.9 32.7 21.3

+ - + 0.5 0.5 0.7 0.5 1.2 1.6

+ - - 4.0 3.6 3.9 3.3 3.1 2.5

- + + 2.0 2.1 3.3 2.7 4.4 7.0

- + - 11.3 9.9 10.7 9.9 10.1 6.9

- - + 1.4 1.1 0.7 0.5 1.3 1.3

- - - 7.7 7.2 9.1 8.0 10.8 9.1

+ : Adequate - : Inadequate ; 2 : 308.6 , p<0.001

ENERGY INADEQUACY 74.0 73.3 68.6 67.1 56.7 39.8

Source: NNMB- 2006

ANTHROPOMETRY

Distribution (%) of Pre-school children according to Gomez Classification – By Age Group

14.811.3 13

43.644.9

44.2

36.940.1

38.2

5.33.7 4.6

0

20

40

60

Normal Mild Moderate Severe

1-33-5Pooled

Per

cen

t

Distribution (%) of Pre-school children according to Gomez Classification - By Gender

13.3 12.8

43.9 44.5

38.2 38.2

4.6 4.5

0

20

40

Normal Mild Moderate Severe

BoysGirls

Per

cen

t

Prevalence of Undernutrition among <5 years children according to Weight for Age

(IAP classification)

39.9

56.458.7

57.4

56.8

61.0

20

40

60

80

6 12 24 36 48 60

Age (Months)

Per

Cen

t

Faulty BF Faulty Complementary feeding

Prevalence (%) of Undernutrition Among 1-5 yr Children According to SD Classification (<Median - 2SD)

: By Age Group

55 55 5551 52 52

1516 15

0

20

40

60

Underweight Stunting Wasting

1-3 yrs3-5 yrsPooled

Per

cen

t

Prevalence (%) of Undernutrition Among 1-5 yr children According to SD Classification (<Median - 2SD): By Gender

55 55

5053

1614

0

20

40

60

Underweight Stunting Wasting

BoysGirls

Per

cen

t

Distribution (%) of Adults by BMI Grades

3336

59

53

811

0

20

40

60

CED Normal Over Weight

Men

Women

Per

cen

t

57.1 52.0 53.1

0

20

40

60

SC BC Others

60.0 54.846

0

20

40

60

80

Kutcha SemiPucca

Pucca

59.855.8

47.3 46.5

0

20

40

60

80

<300 300-600 600-900 >=900

60.1

53.3

46.537.6

0

20

40

60

80

Illiterate 1-8 Std 9-12 Std College

PREVALENCE (%) OF UNDERWEIGHT (< Median - 2SD) BY SOCIO-ECONOMIC VARIABLES

BY COMMUNITY BY TYPE OF HOUSE)

BY MONTHLY PCI BY FEMALE LITERACY

P<0.001 P<0.001

P<0.001P<0.001

55.048.0 49.9

0

20

40

60

SC BC Others

55.1 52.3

41.1

0

20

40

60

80

Kutcha SemiPucca

Pucca

56.952

46.839.7

0

20

40

60

80

<300 300-600 600-900 >=900

PREVALENCE (%) OF STUNTING (< Median - 2SD) BY SOCIO-ECONOMIC VARIABLES

BY COMMUNITY BY TYPE OF HOUSE)

BY MONTHLY PCI BY FEMALE LITERACY

P<0.001 P<0.001

P<0.001P<0.001

57.250.3

41.133.3

0

20

40

60

80

Illiterate 1-8 Std 9-12 Std College

15.4 14.3 14

0

5

10

15

20

SC BC Others

16.414.9

12.4

0

5

10

15

20

Kutcha SemiPucca

Pucca

14.215.9 15.4

14.3

0

5

10

15

20

<300 300-600 600-900 >=900

PREVALENCE (%) OF WASTING (< Median - 2SD) BY SOCIO-ECONOMIC VARIABLES

BY COMMUNITY BY TYPE OF HOUSE)

BY MONTHLY PCI BY FEMALE LITERACY

NS

P<0.001NS 16.9

14.6

11.4

7.5

0

5

10

15

20

Illiterate 1-8 Std 9-12 Std College

NS

MICRO-NUTRIENT DEFICIENCIESNNMB-MND SURVEYS (Tech. Report #

23)

Pooled: 0.7

< 0.5 %

0.5 %

Kerala0

Tamil Nadu 0.5

Karnataka0.8

Andhra Pradesh 1.2

Maharashtra1.4

Madhya Pradesh1.2

Orissa0.3 West Bengal

0.6

Prevalence (%) of Bitot spots among1 - <5 year children

1.1

1.4

0.50.4

0

0.5

1

1.5

2

ST SC OBC OC

1.0

0.4

0

0.5

1

1.5

2

Illiterate Literate

1.2

0.9

0.60.5 0.4 0.3

0

0.5

1

1.5

2

Agl. Labout OtherLabour

Cultivators Artisans Service Business

0.6

0.90.7

0

0.5

1

1.5

2

<=4 5-7 >=8

Pe

r c

en

tP

er

ce

nt

Pe

r c

en

t

Pe

r c

en

t

Prevalence (%) of Bitot Spots in 1 - <5 Yrs. Children by Community

Prevalence (%) of Bitot Spots in 1 - <5 Yrs. Children by Occupation

Prevalence (%) of Bitot Spots in 1 - <5 Yrs. Children by Family Size

Prevalence (%) of Bitot Spots in 1 - <5 Yrs. Children by Female Literacy Status

Ag. Labour

Other Labour

Cultivators Artisans Service Business

Distribution (%) of 1- 5 Yr. Children with Blood Vit. A Levels of < 20 G/dL, Median Dietary Intake of Vit. A (as % RDA) and

Extent of Coverage for Suppl. of Massive Dose Vit. A – By State

STATESBlood

Vitamin A < 20 g/dL

Dietary Intake of Vitamin A < 50% of RDA

Receipt of Massive Dose Vitamin A

1 or 2

Doses

No. of Doses

One Two

Kerala 79.4 91.8 38.5 28.4 10.1

Tamil Nadu 48.8 81.9 50.6 20.2 30.4

Karnataka 52.1 90.4 56.6 42.1 14.5

AP 61.5 92.9 49.3 14.2 35.1

Maharashtra 54.7 88.8 52.1 29.4 22.7

MP 88.0 87.4 52.3 19.1 33.2

Orissa 57.7 77.5 80.0 38.8 41.2

West Bengal 61.2 80.6 50.6 46.8 3.8

Pooled 61.8 86.3 55.4 30.3 25.1

32.5 31.4 30.325.7 22.3 24.8

45.2

23.7

47 47.2

24.7

43.3 41.9

45.8

41.7

20.5 20.7

45.5

31.4 30.5

8.42.8 0.63.04.11.81.12.1

1-5 yr B+G 12-14 YrGirls.

15-17 Yr.Girls

Preg. W Lact. W NPNL. W Men

Normal Mild Moderate Severe

10.20.03

11.20.03

11.00.03

9.90.03

10.60.03

Mean ±SE

Prevalence (%) of Anaemia by Age, Gender & Physiological Groups

> 6 months < 6 months

10.71.99

12.62.09

Pooled: 3.9

< 5 %

> 5 %

Kerala0.6

Tamil Nadu 0

Karnataka1.9

Andhra Pradesh 3.8

Maharashtra12.2

Madhya Pradesh4.3

Orissa0.1

West Bengal

9.0

Prevalence (%) of IDD among 6 - <12 Year

Children

54.649.9

29.7 29.425.6 24.4

23.3

10.1

31.3

0

10

20

30

40

50

60

70

80

WB KER AP MR TN KAR ORI MP POOLED

Per cent of Households consuming salt having Per cent of Households consuming salt having adequateadequate

Amount (>=15 ppm) of IodineAmount (>=15 ppm) of Iodine

* By spot test

Per

cen

t

STATES

NUTRITIONAL STATUS - TIME TRENDS

Average Intake of Foodstuffs (per CU/day) as % of RDI by Period of Survey

8278

8290

40

3823

20

7068

808586

98

102110

0 50 100 150

O.Veg.

GLV

Pulses

Cereals

1975-771988-901996-972005-06

Percent

Average Intake of Foodstuffs (per CU/day) as % of RDI by Period of Survey (contd.)

4770

9777

706065

705557

6177

120

8882

112

0 50 100 150

Sug&J ag.

Fats&Oils

Milk&MP

Roots&Tub.

1975-771988-901996-972005-06

Percent

Average Intake of Nutrients (per CU/day) as % of RDI by Period of Survey

53 8997

108

110130

141

15276

879497

8290

97

103

0 50 100 150

Iron

Calcium

Energy

Protein 1975-791988-901996-972005-06

Percent

110100

9398

9279

8992

436464

57100

100108

12543

5047

41

0 50 100 150

Vitamin C

Niacin

Riboflavin

Thiamin

Vitamin A

1975-791988-901996-972005-06

Percent

Average Intake of Nutrients (per CU/day) as % of RDI by Period of Survey (Contd.)

Distribution (%) of Households According Dietary Energy Adequacy Status of Adults & Pre-school Child

-- Time Trends

31 31

2325

43

52

19

70 8

0

20

40

60

All Adequate AdultAdequate,Pre.sch.chiInadequate

All Inadequate

1975-801996-972005-06

%

Distribution (%) of Households According to Dietary Energy Adequacy Status of Adults Vs Children

DIETARY ENERGY INTAKE AGE GROUP

ADULTMALE

ADULTFEMALE CHILD

PRE-SCHOOL

SCHOOLAGE ADOLESCENT

75-79 2001 2006 2001 2006 2001 2006

+ + + 31.1 31.1 22.1 47.3 27.9 61.6 43.2

+ + - 21.4 42.9 51.8 27.4 45.4 13.2 27.0

+ - + 2.3 1.4 0.5 1.4 00.6 2.1 1.4

+ - - 6.5 4.2 3.8 2.2 3.6 1.4 2.8

- + + 3.8 2.9 2.0 4.7 3.0 7.3 5.7

- + - 8.4 9.3 10.6 8.8 10.3 6.2 8.6

- - + 3.4 1.0 1.3 1.2 0.6 2.2 1.3

- - - 19.1 7.2 7.5 7.0 8.6 6.0 10.0

+ : Adequate - : Inadequate ; 2 : 308.6 , p<0.001

ENERGY INADEQUACY 55.4 63.6 73.7 45.4 67.9 26.8 48.4

Source: NNMB- 2006

Distribution (%) of Households with Protein Calorie adequacy

73

80

84

78

30

48

53

58

0 50 100

Protein

Calorie

1975-79

1988-90

1996-97

2005-06

Percent

Distance Charts for Heights and Weights for Males and Females - Andhra Pradesh

Males

60

80

100

120

140

160

180

200

< 1

2 +

4 +

6 +

8 +

10 +

12 +

14 +

16 +

18 +

20-2

5

30-3

5

40-4

5

50-5

5

60 &

ab

ove

1975 - 19791988 - 19901996 - 19972005-06NCHS Std.

Females

60

80

100

120

140

160

180

200

< 1

2 +

4 +

6 +

8 +

10 +

12 +

14 +

16 +

18 +

20-2

5

30-3

5

40-4

5

50-5

5

60 &

ab

ove

1975 - 19791988 - 19901996 - 19972005-06NCHS Std.

Males

0

20

40

60

80

100

< 1

2 +

4 +

6 +

8 +

10 +

12 +

14 +

16 +

18 +

20-2

5

30-3

5

40-4

5

50-5

5

60 &

ab

ove

1975 - 19791988 - 19901996 - 19972005-06NCHS Std.

Females

0

20

40

60

80

100

< 1

2 +

4 +

6 +

8 +

10 +

12 +

14 +

16 +

18 +

20-2

5

30-3

5

40-4

5

50-5

5

60 &

ab

ove

1975 - 19791988 - 19901996 - 19972005-06NCHS Std.

Hei

gh

t (C

m)

Hei

gh

t (C

m)

Wei

gh

t (K

g)

Wei

gh

t (K

g)

Age (Yrs) Age (Yrs)

Age (Yrs) Age (Yrs)

Distribution (%) of Pre-school children (1-5 Yrs) According to Gomez Classification

6

10 913

32

3841

4448 44

44

38

15

96

5

0

10

20

30

40

50

60

Normal Mild Moderate Severe

1975-791988-901996-972005-06

Per

cen

t

Distribution (%) of Children by Undernutrition and Period of Survey

64

4955

67

60

52

21 23

15

0

20

40

60

80

Stunting Underweight Wasting

1990-91

2000-01

2005-06

Per

cen

t

UNDERNUTRITION (< Median - 2SD)

Distribution (%) of Adult Males according to BMI Grades by Period of Survey

56

4946

33

42

4850

59

2 34

8

0

20

40

60

CED Normal Over Weight

1975-79

1988-901996-97

2005-06

Per

cen

t

BMI <18.5 BMI:18.5 – 25.0 BMI: >=25.0

Distribution (%) of Adult Females according to BMI Grades by Period of Survey

52 4948

36

4547 46

53

3 46

11

0

20

40

60

CED Normal Over Weight

1975-79

1988-90

1996-97

2005-06

Per

cen

t

BMI <18.5 BMI:18.5 – 25.0 BMI: >=25.0

Prevalence (%) of Nutritional deficiency signs among Preschool Children

0.10.1

0.61.3

0.60.7

0.7

1.8

0.8

2.1

5.7

5.7

0 1 2 3 4 5 6 7

Marasmus

Bitot Spots

Ang.Stomat.

1975-79

1988-90

1996-97

2005-06

Percent

Dist-

ricts

NorthernNorth-

EasternEastern Central Southern

PREV. Current PREV. Current PREV. Current PREV. Current PREV. Current

1 41.6 10.4 65.8 5.4 35.2 22.9 44.0 3.4 54.0 12.4

2 41.2 9.6 40.2 4.6 33.2 23.1 36.6 14.5 64.4 11.5

3 27.4 8.5 26.5 8.4 64.3 40.1 40.9 14.5 28.0 9.3

4 44.7 17.2 68.6 4.8 20.9 21.9 35.0 8.2 32.9 9.5

5 45.7 14.4 68.6 5.2 37.8 26.7 55.6 10.2 32.1 7.7

6 30.0 6.9 50.2 8.6 37.8 23.7 41.8 16.2 41.1 7.2

7 52.3 20.6 25.9 5.0 21.6 21.8 22.0 9.2 21.0 12.8

8 24.5 19.3 25.9 6.5 30.3 39.6 13.7 9.9 44.4 11.2

Prevalence of Total Goitre (%) in Select Districts of Different Regions of the Country :[National IDD survey (40 districts) 2003