NATIONAL NUTRITION MONITORING BUREAU

NATIONAL INSTITUTE OF NUTRITION Indian Council of Medical Research HYDERABAD - 500 007. INDIA 2000

Nutrition monitoring is the measurement of the changes over time in the nutritional status of a population or a specific group of individuals WHO, 1984

The paucity of reliable and comparable data from all parts of the country is a definite obstacle towards a realistic and disaggregated problem definition. This calls for a national-wide monitoring system. To achieve this, it is necessary to restructure and strengthen the existing National Nutrition Monitoring Bureau (NNMB) and to develop a mechanism for generating nation-wide disaggregated data National Nutrition Policy, Govt. of India, 1993

Undernutrition continues to be a widespread problem in India, despite significant improvement in food production and advancement in science during the last fifty years, since Indian independence. The National and the State governments have been implementing a number of poverty alleviation programmes for the overall socioeconomic development of the community and several nutrition programmes to mitigate the sufferings of the vast multitudes of the population at risk. The Government of Indias National Nutrition Policy, apart from setting nutrition goals to control and prevent malnutrition in the country, recommended that a national nutrition surveillance system should be developed. For the purpose of deciding policies and to formulate programmes to control and prevent malnutrition, it is essential to assess What? Where? How? and Why? of the nutrition problems in the country. Monitoring of the nutritional status of population, therefore, becomes an important aspect of any nutrition programmes to assess the impact of these massive inputs and to determine the direction in which the communitys nutrition is progressing, so as to initiate appropriate corrective actions. The Indian Council of Medical Research (ICMR), hence, established National Nutrition Monitoring Bureau (NNMB) in the year 1972, with a Central Reference Laboratory at the National Institute of Nutrition, Hyderabad. To start with, the bureau was established in the States of Andhra Pradesh, Gujarat, Karnataka, Kerala, Madhya Pradesh, Maharashtra, Orissa, Tamil Nadu, Uttar Pradesh 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 adopting standardized and uniform procedures and techniques, and

To periodically evaluate the ongoing national nutrition programmes, to identify their strengths and weaknesses and to recommend appropriate corrective measures.

ORGANIZATION Separate teams of research investigators, who are either Medical graduates or postgraduates in Nutrition/ Sociology, collect information on diet and nutritional status of population. All the members of the team are given intensive training in the methods of data collection, analysis and interpretation. Each state has also been provided with a vehicle for field survey.
ORGANIZATION

ICMR

STEERING COMMITTEE

NIN-CRL
Medical Officer Nutritionist 10 State Units Social Worker Field Attendant Driver

COLLABORATION WITH STATES The NNMB was envisaged, at the outset, as a collaborative exercise between the Indian Council of Medical Research and the respective State governments. The team has, therefore, been put under the administrative control of the State Nutrition Officer. The team gets necessary cooperation from the local staff and is provided with adequate facilities so that it could complete the survey as per schedule. However, in the States of Andhra Pradesh, Madhya pradesh, Orissa and Uttar Pradesh, the NNMB units are attached to the ICMR Institutes/Regional Centers. DATA Well-trained investigators, in each state, collect information on dietary pattern and nutritional status of population in rural, tribal or urban areas on a representative sample, by adopting prescribed

standard procedures and using accurate equipment. The details of data collected are indicated below

Household demographic and socioeconomic status, Dietary intake of individuals and households, Nutritional anthropometry on all the available members of the households, Village level information on population, agricultural production, nutrition and other developmental programmes.

UNIQUE FEATURES OF NNMB

NNMB is not a routine data collecting organization. It has several special features The unique features are : Organization of repeat surveys in 1988-90 and 1996-97, in the same villages in all the States that were surveyed during 1975-79, to assess time trends in diet and nutritional situation. NNMB generates data periodically on diet and nutritional status of socially vulnerable groups of population like the tribals living in the integrated tribal development project areas, and the population at-risk physiologically like elderly population and adolescents. NNMB is the only organization involved in continuous collection of data on actual intakes of families, and individuals belonging to different physiological and age groups, in different states Assessment of intra-family distribution of foods and nutrients

Perhaps, one of the advantages of the bureau is availability of expertise of the NIN to carry out detailed analysis of the data to provide policy directions. SAMPLING The NNMB, in the beginning, adopted the sampling design, developed in consultation with Prof. C.R.Rao, a world-renowned statistician. Since 1990, to obtain better spatial distribution and representativeness, a subsample of NSSO sample is covered.

AP

GUJ

KAR.

KER.

MP .

MAH.

ORI.

T.N.

U.P.

W.B

States

16 Strata 5 Villages

Households Nutrition Assessment : 20 Dietary Assessment : 10 TOTAL COVERAGE/STATE Nutrition Assessment : 1600 Dietary Assessment : 800

For the purpose, the sampling frame of the National Sample Survey Organization (NSSO) f or its Consumer Expenditure Surveys is used. In each state, 80 villages are covered from 16 strata (districts) in three subrounds. The strata are so selected that all are represented in each subround so as to take care of any seasonal variations.

COVERAGE
The cumulative coverage by the NNMB, so far, is indicated below: Type of Area Rural Tribal Urban Slums Other Urban Groups Total

CUMULATIVE COVERAGE
Household Diet Survey 29,514 Not done 1,633 2,379 33,526 Individual Diet Survey 27,289 46,347 2,087 3,628 79,351 Nutrition Assessment 3,79,062 1,32,416 13,699 24,080 5,49,302

SALIENT SCIENTIFIC OBSERVATIONS Food and Nutrient intakes

About 30% of households consume less than 70% of energy requirements. The diets of children under the age of 5 years of age are more inadequate than those of adults and are well below the recommended dietary allowances.

Woefully inadequate consumption of protective foods like pulses, green leafy vegetables, and milk & milk products.

Dietary micronutrient deficiency, particularly with respect to vitamin A and iron, is wide spread. About 80% of the individuals consume diets, which provide less than half of the RDA for these micronutrients.

INTRA-FAMILY DISTRIBUTION OF DIETARY ENERGY : PERCENT Intra-family distribution of foods and nutrients reveals HOUSEHOLDS ACCORDING TO ADEQUACY STATUS OF ADULTS Vs that preschool children get less than their physiological needs PRESCHOOL CHILD as compared to adult males and females.

ADULT INADEQUA C Y C HILD ADEQUAC Y 10%

A DULT + C HILD A DEQUA C Y 31%

ADULT ADEQUA C Y C HILD INADEQUA C Y 25%

ADULT +C HILD INADEQUAC Y 34%

Nutritional Status of Population

About a half of the children are underweight and about 40% are stunted. The prevalence of underweight and stunting is considerably high even among adolescents About a half of the adults and elderly suffer from chronic energy deficiency as measured by body mass index (< 18.5) There is no gender bias with respect to nutritional status of females.
DISTRIBUTION (%) OF PRESCHOOL CHILDREN ACCORDING TO WEIGHT FOR AGE BY SEX

SEVER E 5.8%

NOR MA L 8.8%

SEVER E 5.8%

NOR M A L 8.8%

SEVERE 5.8%
MODER AT E 44.8%

NORMAL 8.8%
M ILD 40.6%

SEVERE 6.7%
M ODER A TE 44.8%

NORMAL 9.1%
M ILD 40.6%

MODERAT E 44.8%

BOYS

MILD 40.6%

GIRLS MODERAT E 43.6%

MILD 40.6%

About a quarter of the adolescent girls are married before the age of 18 years and among them about 25% are at risk of maternal problems due to their short stature (<145cm). Nutritional status of tribals is worse than their rural counterparts. TIME TRENDS Repeat surveys, in the same villages surveyed about 20-25 years back, indicate improvement in the intakes of energy & protein in all the age groups of individuals.
DISTRIBUTION (%) OF 1-6 YEAR CHILDREN WITH NUTRIENT INTAKES BELOW 70% OF RDI 100 90 80 70 60 50 40 30 20 10 0 86.3 1975-79 61.2 54.6 1996-97 46.7 27.3 11.1 49.3 87.8 71.6 71.4

Percent

Energy

Protein

Vit.A Nutrients

Iron

Ribo.

DISTRIBUTION (%) OF ADULT FEMALES WITH NUTRIENT INTAKES BELOW 70% OF RDI 100 90 80 70 60 50 40 30 20 10 0 1975-79 1996-97 87.9 82 60.3 49.5 25.6 10 13.4 4.8 Protein Vit.A Nutrients Iron Ribo. 50.1 37.5

Percent

Energy

The extent of undernutrition and stunting declined during the past two decades.
DISTRIBUTIO N (%) O F PRE-SC HO O L C HILDREN AC C O RDING TO SD C LASSIFIC ATIO N (<MEDIAN-2SD) AND PERIO D O F SURVEY

100 90 80 70 60 50 40 30 20 10 0

76.5 62.5

78.6 57.7

1975 - 79 1996 - 97

Percent

18.1

18.5

Wt.for Age

Ht. For Age NUTRITION GRADES

Wt. for Ht.

There was reduction in the prevalence of nutritional deficiency signs over time.
CHANGES IN PREVALECE (%) OF NUTRITIONAL DEFICIENCY SIGNS IN RURAL PRE-SCHOOL CHILDREN

7 6 5 Percent 4 3 2 1 0

1975 - 79 1996 - 97

5.7

1.7 0.2

1.8 0.7

2.1

PEM

Bitot spots

Angular stomatitis

Nutritional Deficiency signs

Secular trends in linear growth of adolescents were observed.

DISTANCE CHART FOR HEIGHT ADOLESCENTS

180 170
Height (Cms)

BOYS

160 150 140 130 120 10 11 12 13 14

Age (Yrs)
1975-79 1996-97 NCHS

15

16

17

DIS TANCE CHART FOR HEIGHT ADOLES CENTS

180 170
Height (Cms)

GIRLS

160 150 140 130 120 10 11 12 13

Age (Yrs)
1975-79 1996-97 NCHS

14

15

16

17

There was reduction in the extent of chronic energy deficiency in adults as compared to those studied in 1975-79.
PER CENT PREVALENCE OF CED AMONG ADULTS BY PERIOD OF SURVEY 70 60 50 Percent 40 30 20 10 0 Male Female
55.6 45.5 1975 - 79 1996 - 97 51.8 44.8

USERS OF NNMB DATA The State governments, the Planning Commission, Department of Women and Child Development (nodal agency for nutrition), UNICEF, WHO, FAO, Home Science college involved in Food and Nutrition, international agencies like CARE and voluntary organizations such as Nutrition Foundation of India make use of the data generated by the NNMB. The bureau published regularly the reports of all its annual surveys, a compilation of 25 years of work of NNMB, reports on the nutritional status of Indian adolescents, elderly population and a report on the dietary intakes of individuals of different age and physiological groups. Two Ph.D. theses have also been published.

EVALUATIION OF ONGOING PROGRAMMES

In fulfillment of its second objective, the Bureau undertook process and impact evaluation of the following nutritional programmes. Sl. No. Nutrition Programmes evaluated Applied Nutrition Programme Vitamin A prophylaxis programme India Population Project (Rural) Supplementary Nutrition Programmes (Urban) World Food Programme assisted Supplementary Nutrition Programme Period States concerned Kerala, Uttar Pradesh, Maharashtra, Orissa, Himachal Pradesh & Manipur Andhra Pradesh, Gujarat, Karnataka, Kerala, Orissa, Rajasthan and West Bengal Karnataka Karnataka Bihar, Gujarat, Kerala, Madhya Pradesh, Maharashtra, Orissa, Rajasthan, Uttar Pradesh and West Bengal Andhra Pradesh, Gujarat, Karnataka, Kerala, Orissa and Tamil Nadu

1.

1977-78

2. 3. 4.

1977-78 1979 1980-81

5.

1981-82

6.

Mid-Day Meal Programme

1991-93

These studies have focused on the corrective steps, which can be communicated to the implementing agencies so as to improve their functional effectiveness.

PUBLICATIONS BASED ON NNMB WORK 1. Pralhad Rao,N. Surveillance of growth and development during childhood, Baroda J. Nutr. 1982, 9, 348-352. 2. Ramnath, T. Vijayaraghavan, K., Swaminathan, M.C. Cerealmillet intake as an indicator of calorie adequacy. Nutr. Rep. Int. 1983, 27 (4), 671-680. 3. Jaya Rao, K.S. Undernutrition among adult Indian males, NFI Bulletin, 1984, vol.5 (3), 1-6. 4. Kullah, K.M., Ramnath, T. Nutritional status of the aged in rural areas of Andhra Pradesh. Ind. J. Nutr. Dietet. 1985, 22, 3303336. 5. Brahmam, G.N.V., Ramnath, T., Sastry, J.G., Vijayaraghavan, K. and Rao, N.P. Diet and nutrition status of urban population, Nutrition News, NIN, Hyderabad, March 1985, Vol. 6, No.2. 6. Murthy, P.S.N., Ramnath, T., Vijayaraghavan, K., Pralhad Rao, N. Nutritional profile of joint and nuclear families in rural Andhra Pradesh. J. Family Welfare, 1985, 32: 80-87. 7. Kamala S.Jaya Rao. Urban Nutrition in India 1, NFI Bulletin, vol.6, (4), October 1985, 5-7. 8. Kamala S.Jaya Rao Urban Nutrition in India 2, NFI Bulletin, vol.7, (1), January 1986. 9. Pralhad Rao, N. Information system for Monitoring Nutrition Status of children in Monitoring Survival and Development of the Young Child, by Dr.A.B.Bose, 1986, NIPCCD, New Delhi. 10. N.P.Rao, J.G.Sastry. Changes in diet and nutrition profile in 10 States in India. Nutrition News, NIN, Hyderabad, March 1986, vol. 7, No.2. 11. K.T.Achaya. Fat intake in India. NFI Bulletin, 1986, vol. 7 (2) 17. 12. Pralhad Rao, N., Ramnath, T., Sastry, J.G. Diet and nutrition in urban areas, Proc. Nutr. Soc. India, 1986, 32, 1-9. 13. Pralhad Rao, N., Sastry, J.G. Monitoring Nutrient intakes in India. Ind. J.Ped. 54, 1987, 495-501.

14. K. Ramachandran. Food consumption in rural Indian households Has it increased in recent years? NFI Bulletin, 1987, Vol. 8 (1), 1-3. 15. Pralhad Rao, N., Hanumantha Rao, D. and Narasinga Rao, B.S. (1987). Drought and Nutrition, Nutrition News, 8 (7), 1-4. 16. Pralhad Rao, N., Hanumantha Rao, D. and Narasinga Rao, B.S. (1988). Drought and Nutrition, ICMR Bulletin 18 (7). 17. C.Gopalan, National Nutrition Monitoring Bureau its importance to nutrition research and National Planning, NFI Bulletin, 1989, Vol. 9 (2), 4-6. 18. C.Gopalan, Consumption of edible oils in India the present picture. NFI Bulletin, 1988, Vol. 9 (2), 6-8. 19. S.G.Srikantia. The National Nutrition Monitoring Bureau, NFI Bulletin, 1988, Vol. 9, (2), 1-4. 20. Brahmam, G.N.V., Sastry, J.G., Pralhad Rao, N. Intra family distribution of dietary energy an Indian Experience. Ecol. Foods Nutr. 1988, 22, 125-130. 21. Pralhad Rao, N. Diet and Nutrition during drought an Indian experience. Disasters, 1989, 13, 61-72. 22. Sastry, J.G., Vijayaraghavan, K., Pralhad Rao, N. Indian preschool children A profile of stunting and wasting. J. Trop. Ped. 1989, 35,22-25. 23. N.P.Rao, Sastry, J.G., Nadamuni Naidu, A., Vinodini Reddy. Trends in Nutrition NNMB surveys, Nutrition News, NIN, Hyderabad, May, 1991, Vol. 12, No.3 24. K.Vijayaraghavan, National Nutrition Monitoring Bureau, Swasth Hind, 1992, XXXVI: 241-43. 25. Ramnath, T., Vijayaraghavan, K., Pralhad Rao, N. Nutritional Anthropometry Validation of cut-off points. J. Trop. Ped. 1993, 39: 200-204. 26. Naidu, A.N. and Pralhad Rao, N. Body Mass Index: a measure of the nutritional status in Indian populations. European Jour. of Clin. Nutr. 1994, 48, Suppl. 3, 5131-5140. 27. Grace Maria Antony, Visweswara Rao K and Balakrishna N. Suitability of HDI for assessing health and nutritional status.

Economic and Political Weekly, August 2001; XXXVI: pp 29762979. 28. K. Venkaiah, K. Damayanthi, M. Uma Nayak and K.Vijayaraghavan,. Diet and nutritional status of rural adolescents in India. European Journal of clinical nutrition 2002; 56: pp 1119-1125. 29. Vijayaraghavan, K., Surya Prakasam, B and Laxmaiah, A. Intra Family Distribution of Dietary Energy in Rural India and Time trends Food and Nutrition Bulletin. 2002; 23: pp 390394 30. Arlappa, N., Balakrishna, N., Sharad Kumar, Brahmam, G.N.V., andVijayaraghavan, K. Diet & Nutritional Status of the Rural Elderly in India. J. Nutr. For the Elderly, Vol.22, (4) 2003 (in Press).