THE BANYAN TREE: VOLUME II : BRINGING CHANGE - APPROPRIATE NUTRITION : ITS ROLE IN HEALTH

( By Editor : Carol Huss )

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1-Distribution of Malnutrition in India

Examination of national Nutrition Monitoring Bureau (NNMB) data, ICDS (Integrated Child Development Scheme) and other data reveal briefly the following features about nutrition.

  1. Taking average nutritional status of households, severe malnutrition is more prevalent in the eastern states, and in UP, MP and Kerala (See for instance Table 9A for Rural Bihar).
  2. The nutritional status of scheduled castes and tribes was substantially lower than the recommended minimum in most states. In particular, the intakes of scheduled casts in Kerala, Maharashtra, Tamil Nadu ,MP and UP and tribes in MP, Gujarat and West Bengal were alarmingly low. (See for instance Table 9B where this comes out clearly). The figures for Karnataka which has a high poverty ratio and for Kerala whose low average in a spite of a supposed high standrs of health, remains a puzzle. Kerala's very poor agricultural performance and the very high free market retail price(40% higher than the all India price of rice) are possible explanations. Also considering the fact. that the decline in poverty ratio was lowest among SC and ST groups, their nutrition probably has not much improved since 1980-81.
    1. The incidence of acute malnutrition is definitely high among children, especially in the age group 0-3 years in almost all states, it being higher in tribal tracts. (See Table 9C and 9D). In a number of states, the percentage of children with adequate caloric protein intakes were much lower than the corresponding percentage for households, Children of Scheduled Castes and Tribes in all cases where data was available, suffer from a high incidence of malnutrition.
    2. ICRISAT data for extremely backward arid zone (for 1976) confirms the incidence of seven malnutrition among children in the age group 1-3 among all classes, with incidence of energy deficiencyhigher among children of landless laboureres and small farmers.1
    3. Others have tried to show the prevalence of malnourished children of Scheduled Castes and Tribes groups to be higher in districts that are less developed (irrigation ratio was found associated associated inversely with malnutrition).2
    4. Table 9E on 'Summary Nutritional Status by Age in Bihar Villages' shows that nearly half of the children aged less than 54 months suffered from a nutritional deficiency, the figure being 78% for 6-18 months group. On the average only 53.5% of all households was normal.
  3. Although resaerch and scholarly data is not very conclusive, there is field experience of several activists to suggest that there is a gender discrimination in food intake against very young girls, not only in North India (which the research data tends to agree),but elsewhere too. There is general gender discrimination with respect to providing quality of life to all women, either it be health care when sick or education or sharing of drudgery. However, it should be noted that the NNMB data does indicate higher incidence of protein-energy malnutritionamong especially the school children, even though caloric inadequacy is comparatively lower among girls. Table 9F also indicates that during the period 1975-80, both males and females suffered to the extent from caloric inadequacy (calorie intake two standard derivations or more below the average). Infact,Table 9F shows figures slightly less for females.
Table 9A
Summary Nutritional Status of Households in Rural Bihar by Social Class (% Distribution)*


ClassNormalWastedStuntedAcuteN
Agricultutral Labour 43.731.015.110.2270
Agricultural Labour tied45.628.614.511.3103
Poor- Middle peasant 57.627.99.35.273
Middle peasant75.417.14.92.090
Big Peasant57.331.18.33.3243
Landlord70.620.68.40.3164
Non-Agricultural ----------
No Activity45.231.411.811.649
All53.528.411.36.8992

* The norms used by the authors for defining "normal", "stunted", etc. are as follows:
Weight for age
over 85%over 85%"normal"
less than 85%over 85%"stunted"
over 85%less than 85%"wasted"
less than 85%less than 85%"acute"
Source : P.H Prased et. al "The Pattern of Poverty in Bihar" (World Employment Programme Research), Working Paper No. 152.

Table 9B
Stage-wise calorie intake (Kcal/cu) 1975-80
Average (Rural) by Social Class


Calorie Intake Of Schedule Castes as a percent of Calorie Intake Of Schedule Tribes as a percent of
StatesState AverageState AverageRecommended Daily Allowance (2400)State AverageRecommended Daily Allowance (2400)
Karnataka283786.6102.4SS --
Andhra Pradesh251796.3101.0SS--
Orissa 232494.191.096.393.3
Tamil Nadu229288.784.7SS-
Maharashtra228685.681.598.193.5
West Bengal 222798.791.592.285.5
Gujarat 221198.090.392.485.1
Madhya Pradesh216092.583.389.480.5
Uttar Pradesh212397.286.0SS-
Kerala194294.167.4SS-
SS : Small Sample
Source : Computed from disaggregated NNMB data.

Nutritional Problems in India

The major nutritional problem in India is therefore PCM or protein calorie malnutrition, especially among most vulnerable groups like children, pregnant women, lower income groups and population living in tribal tracts. The term PCM implies the problem of malnutrition is one of primarily calorie or energy intake deficiency, the protein deficiency being secondary, since in Indian conditions, the dietary sources of proteins and calories are the same, an adequate qota of calories will expectedly take care of an adequate proteinin the diet.
The other major nutritional deficiency diseases are Vitamin A deficiency, goitreand iron deficiency anemia. In certain parts of India fluorosis is also a problem due to the presence of excessive amounts of fluoride in drinking water. Pellagra, caused due to niacin or nicotinic acid deficiency is prevalent in populations whose staple diet is maize. Pellagra has also been reported in jowar caters, although there is no niacin defiency in this millet

Table 9C
Percentage of Malnourished (Gr. III + IV) Children in ICD Projects by Caste Status, 1981*


AverageScheduled CastesScheduled Tribes
0-36 months0-72 months0-36 months0-72 months0-36 months0-72 months
Andhra Pradesh 9.68.610.48.39.97.5
Bihar31.831.739.540.9--
Gujarat 7.36.26.03.911.7-
Haryana4.63.5---
Himachal Pradesh5.34.37.09.3-
Karnataka8.88.310.18.55.02.5
Kerala7.77.811.010.217.515.6
Madhya Pradesh----24.312.7
Maharashtra15.813.316.714.823.720.7
Orissa16.713.019.016.8-
Punjab 8.68.213.912.3-
Rajasthan8.28.717.312.18.17.6
Tamil Nadu8.16.410.17.1-
Uttar Pradesh13.110.517.113.216.313.4
West Bengal19.917.326.521.317.012.1
* ICDS authorities follow the Indian Academy of Paediatrics (IAP) classification, as shown below :
  • <50% weight for age : Grade IV malnutrition
  • 51-60% weight for age : Grade III malnutrition
  • 61-70% weight for age : Grade II malnutrition
  • 71-80% weight for age : Grade I malnutrition
  • >80% Normal

Source : Compiled from Child in India. A Statistical Profile, Ministry of Welfare, Government of India


Table 9D
Percentage of Malnourished (Gr. III + IV) children * (0-36) months of Scheduled Castes and Tribes in Rural/Urban/Tribal ICDS Projects, 1981 (%)


StateAverageRural@ Tribal#Urban$
Andhra Pradesh9.611.010.810.3
Himachal Pradesh5.38.112.426.3
Maharashtra15.827.314.316.4
Uttar Pradesh13.130.813.920.8
West Bengal19.916.233.8
  • * IAP classification (defined in footnote to Table 9C).
  • @ and $ Children of Scheduled Castes
  • # Children of Scheduled Tribes

Source : Compiled from Child in India. A Statistical Profile. Ministry of Welfare, Government of India.


Table 9E
Summary Nutritional Status by Age (% Distribution) in Bihar Villages*


AgeNormal Wasted Stunted AcuteN
6 Months but less than 1822.842.522.811.941
19 Months but less than 5436.733.119.310.9248
54 Months but less than 11452.531.09.96.6419
114 Months or more76.317.93.72.2 279
All53.528.411.36.8992
* For definitions of "normal", "wasted", etc., see footnote to Table 9A
Source : P.N. Prasad, et al., "The Pattern of Poverty in Bihar" (World Employment Programme Research) Working Paper No. 152.

Table 9F
Calorie Inadequacy* Among Adult Males and Females
(Perecent of Population)


1975-19791980
StatesMalesFemalesMalesFemalesMalesFemales
Kerala 60.850.960.654.681.858.5
Madhya Pradesh48.428.863.355.0--
West Bengal45.738.453.154.635.330.4
Orissa42.624.039.622.139.320.3
Maharashtra40.327.944.036.9--
Uttar Pradesh36.732.228.829.538.425.8
Andhra Pradesh35.618.522.97.735.124.1
Gujarat 35.227.324.217.229.320.9
Tamil Nadu34.825.415.716.741.436.1
Karnataka18.810.419.87.911.010.3
* Intake two standard deviations or more below the mean
Source : NNMB data, as reported in Kamala S. Jaya Rao, "Undernutrition Among Adult Indian Males", NFI Bulletin, July 1984.

Lathyrism is especially prevalent in MP, Bihar, UP, etc. among landless labourers and poor farm workers , who are usually the victims and who often get Khesari Dal as a form of wages. The pulse itself is rich in protein. Harmful effects of this pulse are produced if a diet in 2-4 months contains more than 40 percent of Khesari Dal. The disease manifests itself in the form of paraplegia with most victims crippled for the rest of their lives. Khesari is often used for adulteration of other pulses, which is one more vested interest to ensure its cultivation. Soaking of Khesari in hot water to detoxify it is not feasible because of fuel shortage. Studies of the University of Dhaka have shown that boiling the seeds withwater five times did not detoxify it. The only solution seems to be banits cultivation in MP, Bihar and West Bengal as has been done in other states.

Also in India there are a host of other mineral and vitamin deficiency diseases, other deficiency anemias, like folic acid, vitamin B12 and B6 deficiency anemias, and problems caused by food toxicants like epidemic dropsy(adulteration of usually mustard oil with argemone seed oil), alfatoxicosis (due to consumption of ground nut flour becoming now common for the school children' diets- that has been contaminated by a paricularly toxic fungal growth in groundnutseeds). An epidemic of Veno-Occlusive disease (VOD) of liver hit Surguja district in Eastern MP in 1973 and again in 1975. VOD is apparently caused contamination of seeds of Crotalaria mana with Gondli millet. Guinea worm infestation of water is also a major problem as also a whole host of problems affecting nutrition that are caused by unclean drinking water, chief of which are diarrhoea and intestinal parasitic infestation (including hookworms) that promote chronic blood loss and in turn aggravate iron deficiency.

Table 9G
Average Intake of Food- stuffs (g/cu/day)* in Different Urban Groups


Income GroupMiddle ClassSlum DwellersRCI(Sedentary)RDI (Moderate)
Cereals and Millets316416460520
Pulses57334050
Leafy Vegetables21114040
Other Vegetables113406070
Roots and Tubers82705060
Nuts and Oil Seeds219----
Fruits12426----
Fish1210----
Other Fresh Foods199----
Milk42442150200
Fats and Oils46134045
Sugar and Jaggery434203055
*Grams per consumption unit per day
NNMB Reprot on Urban Population (1975-79), published 1984, NIN

Table 9H
Average Weights and Heights of Adults (20-25 years) in Different Urban Groups


MalesFemales
Income GroupHeight (cms)Weight (Kgs) Height (cms) Weight (Kgs)
Middle class166.450.4154.646.8
Slum–dwellers 161.446.6150.141.7
Source : NNMB Report on Urban Population (1975-79), published 1984, NIN.

Dietary Patterns of the Affluent

As Indian populations, move up in social scale, important changes that appear to take place are:

  1. Substitution of 'coarse' grains like millets for more 'prestigious' cereals like wheat and rice. There is also a progressive increase in use of polished varities of rice. The total substitution of millet by rice or wheat would decrease fibre content in diet by about 50% (See Table 10 on 'Fibre Content of Indian Foods').
  2. Increase in intake of vegetable oils and ghee with often vanaspati (hydrogenated fat) replacing, vegetable oils.
  3. Increase in intake of sugar.
  4. General increase in calorie intake not related to sedentary nature of occupations.
  5. Increased intake of pulses, vegtables andmilk--thismay be conasidered beneficial.
  6. More consumption of market processed and commercialised foods, some of which include junk foods high in calories,fats,salt and sugar--all condusive to heart disease and strokes. The upper five is also the more exposed to international (read Western) dietary tastes and therefore exposed to wider junk food choice.

The affluent group of Indians has had prevalence of economy heart disease (CHD) comparable to the affluent in the first world, with prealence of type II diabetes, there to five times that of similar groups in West. Indian who beome affluent appear to be particularly genetically prone to diabetes and CHD, especially when devoid of dietary discipline. Fat intake (in the form of ghee, vanaspati, edible oils) in Indians is particularly bizarre withe the 5% of population consuming 40% of the available fat. Achaya has shown that practically every Indian diet consists of some fat--as 'invisible fat'.2 Using more recent information available on total lipids in food materials, especiallly, rice, wheat and other cereals, and the average rural dietary data for 1980,the intake of invisible fat was shown to be 20 to 50 gms a day, averaging 29.0 gms. Large coconut intakes in Kerala and Tamil Nadu led to high levels of invisible fat in these states. Staples (tapioca being included in this category in Kerala) contributed to the bulk of the invisible fat (31-88%; average 68%) and milk and pulses an average of 11.4% and 2.4% respectively. Total fat intakes, both visible and invisible made an average contribution of 14.7% in 10 states of India.

Table 10
Fibre Content of Indian Foods


Millets
Bajra (Penniseum typhoideum) 20.4 g %
Jower (Sorghum vulgare)14.2 g%
Maize (Zea mays)6.8g%
Ragi (Elensine coracana)18.6g%
Wheat
Wholemeal (100%)9.6g%
Refined 3.0g%
Rice
Raw (brown)5 to 8 g%
Polished2.4 g%
Chemical Nature of Cereal Fibre
Non-Celluloid polysaccharide48.9 - 61.5%
Celluloid31.8 - 32.7%
Liguin6.7 - 18.4%
Estimated Total Fibre Contents of Average Indian Cereal-based Dietaries
Wheat based57.7 g/day/person
Rice based33.2 g/day/person
Millet based90.0 g/day/person
Source : R.D. Sharma, National Institute of Nutrition, Personal Communication. Quoted in Gopalan, op. cit.

The upshot of these findings is that even poor Indian diets are reasonably adequate in fat. For the affluent sections, intakes of edible fat of the order observed are wholly unnecessary if not dangerous.

A related point to be noted is that the fashion among the affluent to go in for safflower oil and sunflower oil, based on their reported superiority due to high content of polyunsaturated fatty acids(PUFA), instead of traditioal vegetable oils like groundnut, may actually be misplaced. These never oils contain 70% of linoleic acid (an essential fatty acid) as compared to 30% linoleic acid for groundnut and sesameoils. Excess linoleic acid could lower blood cholesterol--a feature desirable for coronary heart disease pone populations. Excess linolec acid is also suspected to lead to certain types of tumors and suppressionof immune response.

< Dietary Guidelines for the Affluent

Lest dietary guidlines for the affluent be thought of as an irrelevance,one should remember that even at 5% (let us assume only 5% have affluent characteristics described above) of the totalpopulation of India, they constitute about 40 million, which is a big number of people at nutritional risk, not to speak of the economic costs of keeping this 5% healthy.
Dietary guidelines are just that,merely guidelines for nutritional discipline. They may not solve all health problems of the affluent but could certainly help minimise the nutritionally related risk factors in, for instance CHD or diabetes. These guidelines2 should form part of school curricula in especially upper class schools.

  1. Overall energy intake should be restricted to levels commensurate to the sedentary occupations of the affluent, so that obesity is avoided.
  2. Highly refined and polished cereals should be avoided in preference to under-milled cereals.
  3. Green leafy vegetables (a source not only of carotenbe bu also of linoleic acid derivatives) should be included at least in levels recommended byICMR.
  4. Edible fat intake need not exceed 40 gms and total fat intake should be limited to levels at which fat will provide no more than 20% of total energy. The use of ghee, clarified butter, a prized item in the Indian culinary system should be restricted for occasions and should not be a regular daily feature.
  5. The intake of sugar and sweets should be restricted.
  6. High salt intake should be avoided. In house-holds in some parts of the country, diets contain unnecessarily high levels of salt, spices and condiments. High salt intake certain certainly serves no useful nutritional purpose and is generally best avoided, and especially by those prone to hypertension.

Dietary Guidelines for the Poor

The Indian Council for Medical Research (ICMR) makes periodic recommendations on desirable diets for Indian populatuions . Considering the fact that at least one-third of the households in India are not able to afford even the minimum nutritional requirements (these households spend 80% of their income on food), the ICMR felt that its Recommended Diet Intake (RDI) should also have practical suggestions as to how the recommended nutrient allowance could be procured from low-cost diets. The model least cost diets per day that are 'balanced' are shown in Tables 11 and 11B. In rcommending diets for poor Indian Groups, the ICMR has been guided by the following considerations:

  1. Diets recommended should be least expensive and confirm to traditional and cultural practices as closely as possible.
  2. Energy derived from cereals need not exceed 75% of the total energy requirement.
  3. Pulse (legum) intake should be suh that the ratio of cereal protein to pulse protein does not exceed 5:1.
    This would imply that pulse intake should be atleast around 9% to 10% of the cereal intake.The diet should provide for a minimal milk intake of 150 ml. These recommendations regarding intake of pulses and milk were designed to improe the protein quality of the predominantly cereal-based diet, usually devoid of animal protein to minimal acceptable levels.
  4. About 150g of vegetables (leafy and other vegetables) should be provided. These were considered as levels which will not unduly increase the bulk of the cooked food-a major consideration in all diets that are heavily cereal-based.
  5. Energy derived from fat and oil need not exceed 15% of total calories . This takes into consideration the fact that cereal diets already provide invisible ats at levels of about 10% of total energy.
  6. Energy drived from refined carbohydrates (sugar or jaggery) need not exceed 5% of total calories.

In reality as already seen from Table 11A and 11B actual intakes are far lower than RDI.

Table 11A
'Balanced Diet's Recommended by ICMR on the Basis of RDI

Adult MenAdult WomenChildrenBoysGirls
Food ItemsSedentaryModerate WorkHeavy WorkSedentaryModerate WorkHeavy Work1-3 years4-6 years10-12 years10-12 years
Cereals460520 670410440575175270420380
Pulses40506040455035354545
Leafy Vegetables4040401001005040505050
Other Vegetables607080404010020305050
Roots and tubers50608050506010203030
Milk150200250100150200300250250250
Oil and fat40456520254015254035
Sugar or Jaggery30355520204030404545
* Grams per day for each category
Source : Recommended Dietary Inta kes for Indains, ICMR, 1984

Table 11B
Average Intake of Nutrients (cu/day) in Different Urban Groups


Middle ClassSlum-dwellersRecommended Intake
(ICMR-1981)
Protein (g)73.153.455.0
Calories (Kcal)260320082400(sedentary)
2500(moderate)
Calcium (mg)1121492400-500
Iron (mg)27.324.924.0
Vitamin A Retinol (?g)881248750
Thiamine (mg)1.471.271.20
Riboflavin (mg)1.520.811.40
Niacin (mg)15.314.616.0
Vitamin C (mg)934040
Source : NNMB Report on Urban Population (1975-79), published 1984, NIN.

Additional messages that need to be got across with respect to children are:

  1. Breastfood as long as possible.
  2. Introduce semi-solids from 6 months.
  3. Feed young children 3 to 6 times a day.
  4. Do not reduce food in illness.
  5. Use available health services, immunise your child. Keep the family and surroundings clean even as you drink clean water.
  6. Do not ignore mother's health and food needs during pregnancy and lactation. Most mothers in India being anaemic require appropriate iron-folic acid supplements.(See also Table 11C and box).
Table 11C
Additional Allowances During Pregnancy and Lactation


Food ItemsPregnancyCalories
(K Cal)
LactationCalories
(K Cal)
Cereals 35g11860g203
Pulses 15g5230g105
Milk100g83100g83
Fat----10g90
Sugar10g4010g40
Total--293--521
Source : RDI, ICMR (1981)

A Good Diet for Pregnancy and Lactation

During pregnancy and lactation a woman needs more food and a greeater vcariety of food. More food is the first and most important thing. Diets based on cereals are generally good, but the woman needs more of them. She should eat one-fourth more food than she was eating before she became pregnant (25% extra) Find out how much she was eating before. Divide that into 4 portions. Tell her, or better show her, how much one of these portions is. This is the extra food she should eat, not only in pegnancy, but right through lactation.

Pregnant and nursing mothers should eat for two persons

A variety of foods will supply most of the nutrients a pregnant woman needs. These are listed below:
The cereal which are suitable for her diet include wheat, maize, sorghum, rice, and millet.
It is better not to use refined or polished cereals because the nutritious part of the cereals is lost during such processing. Parboiled rice is more nutritious than polished white rice.
Similarly, brown wheat flour (whole flour) is better than white refined flour. In some countries casava, Yams, plantains, and potatoes are used in place of cereals.
Legumes or pulses are valuable, particularly for those cannot afford animal food or who do not eat them. The legumes include peas, beans, lentils, etc.
Vegetables, especially dark green leafy and coloured ones, such as tomatoes and carrots, supply special nutrients. Other vegetables and fruits are also useful.
Edible oils, butter, and sugar or molasses and their derivaties make food more tasty. They also supply energy in a concentrated form.
Animal foods are valuable but not essential. Do not emphasize meat, eggs, fish, etc. in group teaching, if such foods are beyond the means of the community.

Source: Guidelines for Training Community Health Workers in Nuttrition. 2nd Edn. WHO.(Geneva,1986).


Guidelines for other Major Nutritional Problems

  1. Iron-deficiency anemia: Usually responds well by iron salts like ferrous sulphate tablets. These are very low cost, much cheaper than iron tonics and vitamin preparations.
    Iron is found in green leafy vegetables (Palak, amaranth, drum stick leaves, coriander, etc.) ragi and . dried fruits. The average Indian diet provides as high as 30 gm iron daily. However, the simultaneous presence of phytate and tannins inhibit iron absorption. There is also low level of calcium and ascorbic acid (vitamin C)--a factor that could augment net bioavailability of iron.
    Mass strategies that have been suggested are prophylatic administration of iron and folic acid to women and children in poor communities as part of routine PHC services through MCH centres and schools.
  2. Vitamin A Deficiency : Vitamin S as retinol is mostly drived from beta-carotene. Absorption of beta-carotene from carrots and papayas has been shown to be good when diets have even low fat content.
    Intake of green leafy vegeables are recommended by ICMR in its model least-cost blanced diets for adults would provide 600mg of retinol dilay and 300 mg daily for the pre-school children (about 40 gms of green leafy vegetables). Usually many of the foods rich in iron are also rich in retinol. Thus intake of greens will help in both vitamin A and iron deficiency. It is an irony that green leafy vegetables, though comparatively inexpensive, are as people go up the social scale, not considered 'prestige food'. The colostrum, usually not given to the child by many mothers on accounts of certain beliefs, is rich in vitamin A. Other strategies for combatting vitamin A deficiency, especially in cases of repeated infections and despite recommended intake of green leafy vegetables (and at present low levels of knowledge about bioavailability of retinol from various varieties of greens), is prophylactic administra tion of massive doses of vitamin A ( 2 lacs IC once in 6 months) for children under 3 years.
  3. Goitre/Iodine Deficiency : Studies need to be made as to how new goitre-endemic areas emerge. It has been sugested that the Green Revolution type technology could have induced iodine deficiency in soils and foods that are grown in such soils. But for the present, strategies to combat goitre seem to be universal iodisation of common salt and banning of unfortified salt. There are of course many logistical problems about universal iodisaion of salt.
  4. Fluorosis: Simple techonologies for defluoridation or drinking water with the upper limit for flouride set at 1 PPM. Strategies for lowering fluoride content found to be extent of 10 mg/kg in staple food items like rice, corn, wheat, cabbage, potatoes, etc. are yet to be clearly thought about.
  5. Lathyrism : No other alternative, but banning of cultivation of Khesari dal is the most appropriate and just policy.

There are dietary guidelines that have been formulated for a host of other deficiency problems but the above to be the major ones. Particular guidelines will have to be worked out considering location specific conditions.

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