NUTRITIONAL STATUS OF
CHILDREN
IN THE STATE OF KERALA
Dr. G.N.V.Brahmam
Scientist – ‘F’
Division of Community Studies,
National Institute of Nutrition, (I.C.M.R.)
Jamai-Osmania (P.O.), Hyderabad – 500 007.
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1
HEALTH AND NUTRITION
HEALTH
“… is a state of complete physical, mental,
and social well being and not merely
absence of disease or infirmity”
- - - WHO
NUTRITION
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“ … is a process of ingestion of food,
digestion, absorption, assimilation,
and utilization of various nutrients”
2
SIGNIFICANCE OF NUTRITION
 Normal Growth, development and functions
 Epidemiological data reveals strong association
between undernutrition and morbidity &
mortality.
 Chronic degenerative disorders such as,
- Coronary heart disease,
- Hypertension,
- Type 2 Diabetes,
- certain types of Cancers, etc.
are associated to diet and nutritional status
 Undernutrition in early Childhood is associated
with chronic degenerative disorders in later life
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3
SIGNIFICANCE OF NUTRITION (Contd.)
 Consumption of foods rich in dietary fiber, antioxidants is associated with reduced risk of
certain types of cancer.
 Obesity and overweight is also associated with
Increased risk of developing cancer of the
Breast, Colon, Endometrium, Gallbladder,
Oesophagus, Pancreas, Kidney, etc.
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4
MALNUTRITION
“ ….. a pathological state that results from
ingestion of one or more nutrients, either
in excess or deficient quantities over a
period of time.”
Undernutrition : Due to deficient intakes
Overnutrition : Due to excess intakes
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5
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
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6
DETERMINANTS OF NUTRITIONAL STATUS
Agro-climatic factors
Demographic factors
• Food production
• Land Ownership
• Type of land
• Rain fall
• Geographic conditions
• Agricultural techniques
• Use of hybrid seeds
• Use of fertilizers
• Population
• Family Size
• Urbanisation
H H FOOD
SECURITY
FOOD
INTAKE
Socio-cultural
factors
• Illiteracy
• Ignorance
• Taboos
• Lifestyles
NUTRITIONAL
STATUS
Environmental factors
• Environmental sanitation
• Personal hygiene
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• Safe
drinking water
Socio-economic
factors
• Religion
• Community
• Occupation
• Income
Physiological
factors
• Pregnancy
• Lactation
• Breast feeding
practices
• Infant & child
Feeding practices
Disasters
Drought/Floods
Wars
Availability of &
participation in
developmental
programmes
• PDS
• Rural Dev. Prog.
• Employment
generation prog.
Pathological Conditions
• Infections
• Diarrhoeas
• Resp. Infections
• Malaria
• Others
• Infestations
• Hook worms
• Round worms
• Giardiasis etc.,
7
HEALTH & ECONOMIC CONSEQUENCES
OF MALNUTRITION
 Increased Morbidities, cost of treatment
 Underdevelopment (Physical / Mental)
 Absenteeism, Reduced productivity, lowered
economic development
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8
INFECTION AND UNDERNUTRITION
….. a Vicious Cycle
INFECTION
Reduced
Food
intake/
absorption
Lowered
resistance/
Frequent
infections
Death
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UNDERNUTRITION
9
CAUSES OF DEATHS AMONG <5 YEAR CHILDREN
IN DEVELOPING COUNTRIES
Malaria *
8%
Others
29%
Measles *
5%
Diarrhoea
12%
Malnutrition*
60%
Perinatal
22%
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Pneumonia
20%
HIV/AIDS
4%
*
*
* Approximately
70% of all
childhood deaths
are associated
with one or more
of these five
conditions
10
Source: WHO 2002; Lancet-2003
Infant Mortality Rate (Per 1000 Live Births) in India
and South-east Asian Countries
100
44 (SRS-2011)
85
77
80
72
69
IMR
59
60
54
Source :
40
17
20
WHO/SEARO 2000
0
Pakistan
Bhutan
Nepal
India
Maldives Bangladesh SriLanka
* Source:
SRS-2011
11
Under-five Mortality Rate (Per 1000 Live Births) in South-east
Asian Countries & India
120
101
(55: SRS, 2011)
85
100
77
76
80
60
40
14
20
0
Pakistan
(2002)
India Bangladesh Nepal SriLanka
(2004)
(2000)
(2003-04)
(1999-2000)
* Source: SRS, 2011
12
IMR & UNDER-FIVE MORTALITY RATE : URBAN Vs RURAL
(Source: SRS – 2011)
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13
Maternal Mortality Ratio (Per 100,000 Live Births) in
India and South-east Asian Countries
212*
600
540
540
Source :
500
400
380
350
350
WHO/SEARO 2000
340
300
200
60
100
0
400
300
390
269 258
212
200
*
Registrar General of
India, SRS - 2011
100
0
178
148 145
134
104
97 81
14
Prevalence (%) of Low Birth Weight in India and South-east Asian
Countries
40
33
25
25
Source :
23
WHO/SEARO
20
2000
13
8
10
1
0
India
Bangladesh Nepal
Myanmar
Bhutan
Maldives Indnesia DPR Korea
30
25
25
Per cent
Per cent
30
30
20
16
17
19
19
21
22
22
23
23
22
15
10
* Source: NFHS 3
5
0
15
PERECNT CHILDREN (12-23 MONTHS) COMPLETELY IMMUNIZED
100
NFHS 1
NFHS 2
NFHS 3
INDIA
80
61
60
58
51
37
40
39
36
44
42
31
20
0
RURAL
URBAN
100
NFHS 1
KERALA
POOLED
NFHS 2
NFHS 3
85
88
78
80
60
80
75
69
54
56
54
40
20
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16
0
RURAL
URBAN
POOLED
INFANT & YOUNG CHILD
FEEDING PRACTICES
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17
Prevalence of Underweight among 6-59 months
children according to age* ( by IAP classification)
100
Kerala
States Pooled
80
P 60
e
r
c 40
e
n
t 20
59
57
43
41
57
61
40
46
36
27
0
6-12
Faulty BF
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12-24
24-36
36-48
48-60
Age (Months)
Faulty
Complementary
feeding
18
* By using Harvard Reference Values
INFANT AND YOUNG CHILD FEEDING PRACTICES (NFHS 3)
Percent
India
100
Rural
Urban
Pooled
92
96
94
Percent
80
60
56
54
55
57
56
56
40
Kerala
20
0
Early Initiation
of BF
Exclusive BF
Upto 6 months
19
Compl. Feeding
among 6- 9 months
Children
FOOD & NUTRIENT INTAKES
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20
Average Daily Consumption (per CU/day) of Foodstuffs
as % of RDA : Kerala Vs Other NNMB States Pooled
70
86
Kerala
States Pooled
58
Pulses
70
18
40
93
Other Vegetables
82
106
120
44
Milk & Milk Products
55
30
70
RDA
60
Sugar & Jaggery
47
0
20
40
60
80
100
120
140
% of RDA
KER
21
Source: NNMB Survey, 2005-06 ( 8 States) NNMB
Median Intake (per CU/Day) of Various Nutrients
(as % of RDA): Kerala Vs Other NNMB States Pooled
80
78
Protein
73
74
Energy
100
Calcium
Iron
15
Vitamin A
84
43
43
19
75
Thiamin
Kerala
States Pooled
92
36
Riboflavin
43
88
88
Niacin
RDA
47
50
Free Folic Acid
70
Vitamin C
70
0
20
40
60
80
100
Percent of RDA
KER
22
Source: NNMB Survey, 2005-06 ( 8 States) NNMB
Average Daily intake of Foodstuffs (as % RDA) among
1-6 Year Children : Kerala
58
Cereals & Millets
61
4-6 yr
22
Pulses
1-3 yr
43
5
Green Leafy Veg.
6
71
Other Veg.
83
130
Roots & Tubers
115
22
20
Milk & Milk Prod.
RDA
13
16
Fats & Oils
37
Sugar & Jaggery
35
0
20
40
60
80
100
120
140
Percent of RDA
KER
23
Source: NNMB Survey, 2005-06
Median Intake of Nutrients (as % RDA) by 1-6 year
Children : Kerala
73
Protein
90
49
Energy
57
37
Calcium
55
33
33
Iron
4-6 yr
1-3 yr
12
13
Vitamin A
50
Thiamin
56
29
30
Riboflavin
50
Niacin
RDA
64
53
Free Folic Acid
60
30
Vitamin C
33
0
20
40
60
80
100
Percent of RDA
KER
24
Source: NNMB Survey, 2005-06
Protein-Calorie inadequacy status of Children : Kerala
1-3 yr B+G
81
4-6 yr B+G
79
88
7-9 yr B+G
85
10-12 yr Boys
100
Girls
80
13-15 yr Boys
61
Girls
52
16-17 yr Boys
42
Girls
0
20
40
60
80
100
25
1-3 yr B+G
12
4-6 yr B+G
7-9 yr B+G
10
10-12 yr Boys
11
14
Girls
21
13-15 yr Boys
Protein inadequacy
12
Girls
31
16-17 yr Boys
29
Girls
KER
Calorie inadequacy
0
20
Source: NNMB Survey, 2005-06
40
60
80
100
25
DISTRIBUTION OF MICRONUTRIENT INTAKES IN 1-6 YEAR
CHILDREN IN KERALA - % RDI
100
90
80
% RDI
70
60
50
40
30
20
10
0
<50% RDA
50-70% RDA
>=70% RDA
Riboflavin
80
9
11
Vitamin A
94
2
4
Iron
80
12
8
F.F.Acid
41
26
33
KER
26
Source: NNMB Survey, 2005-06
Distribution (%) of Households According to Dietary
Energy Adequacy Status of Adults and Children In Kerala
DIETARY ENERGY
AGE GROUP
Pre-school
School Age
KER
Pooled
KER
Pooled
KER
Pooled
+
16.7
22.5
19.3
27.9
34.6
43.2
+
-
58.3
51.8
47.5
45. 4
34.3
27
+
-
+
0.5
0.5
0.3
0.6
1.6
1.4
+
-
-
3.1
3.8
3.3
3.6
2.8
2.8
-
+
+
0.5
2.0
2.0
3.0
0.3
5.7
-
+
-
12.5
10.6
18.7
10.3
11.9
8.6
-
-
+
0.5
1.3
0
0.6
0.7
1.3
-
-
-
7.8
7.5
9.7
8.6
7.2
10.0
81.8
73.7
78.4
67.9
62.8
48.4
Adult
Male
Adult
Female
Child
+
+
+
Child Inadequacy
KER
Adolescents
Source: NNMB Survey, 2005-06
27
FOOD & NUTRIENT INTAKES IN KERALA
. . . TIME TRENDS
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28
Average Intake of Foodstuffs (per CU/day) in
Kerala as % of RDI by Period of Survey (NNMB)
77
Cereals
69
70
43
45
Pulses
1996-97
2000-01
2005-06
58
25
GLV
13
18
88
O.Veg.
105
93
120
142
Roots & Tubers
Milk & M.P
Fats & Oils
30
44
45
40
55
RDA
87
Sugar & Jag.
57
0
KER
106
81
60
50
Percent
100
150
29
Median Intake of Nutrients (per CU/day) in Kerala
as % of RDI by Period of Survey (NNMB)
90
Proteins
1996-97
2000-01
2005-06
88
79
85
78
Energy
74
161
121
Calcium
99
28
46
41
Iron
0
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RDA
50
100
Percent
150
200
30
Median Intake of Nutrients (per CU/day) in Kerala
as % of RDI by Period of Survey (NNMB)
1996-97
2000-01
2005-06
28
Vitamin A
15
15
67
75
75
71
Thiamin
Riboflavin
43
36
RDA
73
87
88
Niacin
103
Vitamin C
73
70
128
47
47
F.Folic Acid
0
KER
50
100
Percent
150
200
31
ANTHROPOMETRIC
INDICATORS
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32
Prevalence (%) of Undernutrition Among 0-5 yr children
According to SD Classification (<Median - 2SD)
in Kerala*
50
Severe (<Median-3SD)
Moderate(Med-2SD to Med-3SD)
Total(<Median-2SD)
40
29
Percent
30
22
20
21
17
16
12
10
8
5
4
0
KER
Underweight
(Weight for age)
Source: NNMB Survey, 2005-06
Stunting
(Height for age)
Wasting
(Weight for Height)
* Using WHO Child Growth Standards
33
Prevalence (%) of Undernutrition among <5 yr Children – By State (2006)
By SD Classification
UNDERWEIGHT
KER
TN
KAR
WB
AP
MR
ORI
MP
GUJ
Pooled
STUNTING
22
Kerala
33
T.N.
39
40
41
45
20
30
40 50
Per cent
40
AP
42
ORI
50
MR
51
WB
53
MP
40
10
35
GUJ
46
46
46
0
29
59
Pooled
60
70
80
90 100
45
0
20
WASTING
KER
15
T.N
15
MR
17
KAR
17
AP
80
100
20
ORI
22
MP
24
GUJ
KER
40
60
Per cent
33
Pooled
20
0
10
20
30
40 50
Per cent
60
70
80
34
90 100
* Using WHO Child Growth Standards
Prevalence (%) of Undernutrition Among 1-5 yr children
According to SD Classification (<Median - 2SD) in Kerala
: By Age Group (Years)
1-3 Yr
P>0.05
3-5 Yr
40
Pooled
Percent
29
21
24
29 29
22
20
15
15 15
0
Underweight
Stunting
KER
Source: NNMB Survey, 2005-06 ( 8 States) NNMB
Wasting
35
* Using WHO Child Growth Standards
Percent
Prevalence (%) of Undernutrition Among <3 yr children
According to SD Classification (<Median - 2SD) in Kerala
: RURAL Vs URBAN (NFHS 3)
KER
Source: NFHS 3
36
* Using WHO Child Growth Standards
Prevalence (%) of Undernutrition Among 6-9 yr children
According to SD Classification*
Severe
Moderate
40
Total
Percent
24
21
20
7.6
8.6
3
1
0
Underweight
Stunting
KER
Source: NNMB Survey, 2005-06
37
* Using NCHS Reference Values
Prevalence (%) of Undernutrition Among Adolescent
children According to BMI (Age/Sex Centile values of
NHANES)
80
73
10-13 Yr
14-17 Yr
60
51
Percent
48
40
26
20
2
2
0
Undernourished
(BMI < 5th Centile)
KER
Source: NNMB Survey, 2005-06
Normal
(BMI 5th-85th Centile)
Overweight/Obese
(BMI >= 85th Centile)
38
Prevalence (%) of Overweight/Obesity among 6-15 yr urban children in Kochi City
[Overweight: BMI
85th
(Based on Age/Sex specific Centile values of BMI: WHO/CDC)
– 95th Centile; Obese: BMI: >=95th Centile; ; Overweight+ Obese: BMI >= 85th Centile]
Percent
P<0.028
Percent
P<0.005
GIRLS
Percent
BOYS
KER
P<0.005
39
Source: A.T.Cherian, Ind. Ped. 2012
Distribution (%) of Adult Men and Women According
to Nutritional Status by BMI
MEN
60
WOMEN
45.6
39.6
39.3
Percent
40
28.0
26.7
21.1
20
0
CED
(BMI < 18.5)
Normal
(BMI 18.5 - 23.0)
KER
Overweight/Obesity
(BMI > 23.0)
40
Source: NNMB Survey, 2005-06
MICRONUTRIENT
DEFICIENCIES
KER
41
KER
42
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
STATES
Dietary
Blood
Intake of
Vitamin A Vitamin
< 20 g/dL A < 50%
of RDA
Receipt of Massive Dose Vitamin A
No. of Doses
1 or 2
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
KER
43
Source:NNMB Tech. Rep. #23 - 2005
Distribution (%) of 1-5 year Children according to
Vitamin ‘A’ Status : By States
Blood Vitamin A < 20 g/dL
100
Dietary Vitamin A Intake < 50% of RDA
100
88
79
80
62
61
58
90
89
87
86
82
55 52
60
92
90
Per cent
62
Per cent
93
P > 0.05
49
40
81
78
80
70
20
60
d
ol
e
A
P
K
ER
K
Po
TN
AR
K
R
M
I
O
R
B
P
A
W
K
M
ER
P
0
R
A
M
R
M
P
TN
W
P
R
O
I
d
e
ol
o
P
100
80
P > 0.05
80
Receipt of Massive Dose
Vitamin A (1 or 2 Doses)
Per cent
57
60
52
52
51
55
51
49
39
40
20
E
K
d
oo
le
P
A
A
R
K
B
W
P
M
P
M
A
R
K
R
R
P
Source: NNMB-MND Survey, 2003 (8 States)
O
KER
I
0
44
Prevalence (%) of Anaemia Among Different Age, Sex and
Physiological Groups in Kerala
Mean
±SE
0.3
13.3
11.4
0.07
11.8
0.07
10.9
0.08
11.8
0.07
0
0.3
9.4
9.9
10.7
0.07
10.2
1.45
0.3
0.4
12.1
1.56
0.3
6.5
11.2
26.5
36.6
20.1
39
45
43.8
61
23.3
50.6
66.3
50.8
45.6
0
49.8
44.7
32.2
10.8
Pre-school
children
KER
Adol.
12-14 Yrs.
Normal
Adol.b
15-17 Yrs.
Mild
Source: NNMB-MND Survey, 2003 (8 States)
Preg.women Lact.women
> 6 months
Moderate
< 6 months
Severe
NPNL
Women
Column 5
Adult
Men
45
Distribution (%) of Target Beneficiaries according to
receipt of IFA tablets in Kerala
Particulars
Received IFA tablets
No. of tablets received
Pregnant
(n=144)
Percent
Lactating Children
(n=175) (n=117)
38.0
12.0
3.8
10 – 29
1.4
0.6
1.7
30 – 59
60 – 89
>= 90
10
8
18
4.6
0.6
6.3
0
0
1.7
Experienced side effects
5.5
4.8
0
KER
46
Source: NNMB-MND Survey : 8 States, 2003
Percent of Households consuming salt having adequate
Amount (>=15 ppm) of Iodine in Kerala
80
70
60
54.6
Per cent
49.9
50
40
29.7
31.3
29.4
30
25.6
24.4
23.3
20
10.1
10
0
WB
KER
KER
* By spot test
AP
MR
TN
STATES
KAR
ORI
MP
POOLED
47
Source: NNMB-MND Survey : 8 States, 2003
Challenges:

Despite the positive improvements in the
demographic, socio-economic and health sectors,
the dietary intakes of the rural communities
continues to be poor both in terms of quantity and
quality.

Dietary intake of energy is low and that of essential
micronutrients are grossly inadequate.

Infant and child feeding practices, especially during
the first 6 months, are sub-optimal

Prevalence of LBW is about 16%, and about 22% of
<5 year children are underweight and 30% are
stunted and 15% are wasted
States Pooled
48
Challenges (contd..):
• About 28% of the men and 21% of the women are
having CED.
• MNDs such as IDA and VAD continue to be of public
health significance and coverage of target groups
for IFA & Vit A distribution is low.
• About a third of men and 40% of women are having
overweight/obesity among adults known risk factors
for diet related chronic degenerative diseases such
as type 2 diabetes, hypertension and CHD.
• Nearly one half of adult population are found to be
having hypertension.
States Pooled
49
Possible Solutions:
•
Devise and implement appropriate IEC strategies to
improve the knowledge and practices among the
community, about infant and young child feeding.
•
Encourage the communities to include locally
available micronutrient rich foods such as green
leafy vegetables, and fruits in their regular diets
through Agri. / Horti. interventions.
•
Strengthening of on-going programmes to increase
the coverage of target beneficiaries for
Supplementary nutrition and distribution of folifer
tablets and massive dose vitamin A
States Pooled
50
Possible Solutions
(Contd..):
•
Fortification of foods with vitamins / minerals in
order to augment the micronutrient intakes of
the individuals.
•
Improving household food and nutrition security,
through socio-economic development
•
Institution of Nutrition Surveillance system and
MIS for effective monitoring and interventions
States Pooled
51
SUGGESTED STRATEGIES
 SHORT TERM
Strengthening supplementary nutrition Programmes, in
terms of quantity and type of Supplement and coverage
of target population and monitoring
Immunization, health care services
 MEDIUM TERM
Micronutrient fortification of staple foods and food
supplements under SNP
States Pooled
52
 LONG TERM
Development & implementation of State specific Nutrition
Policies and Programmes,
Strengthening Health & Nutrition education, especially
regarding:
- Infant & child feeding,
- Nutrition during adolescence, pregnancy and Lactation,
Dietary diversification, Bio-fortification of foods, promotion
of home gardening, through Krishi Vigyan Kendra (KVK),
Improving life-style practices
Environmental sanitation and personal Hygiene including safe
drinking water,
Programmes for Economic development, especially at grass
root level, through income generating activities, and
Population control.
States Pooled
53
KER
54