NUTRITION MONITORING AND SURVIELLANCE

Transcription

1 NUTRITION MONITORING AND SURVIELLANCE

2 Rationale for nutrition monitoring and surveillance India is a vast and varied country. There are huge differences in per capita income, purchasing power, availability of food items, dietary habits, lifestyle and nutritional status between and within states, among urban, rural and tribal population. There are large interstate differences in nutritional status as well as rate of nutrition transition. It is important to know what is happening where and initiate appropriate interventions

3 Rationale for nutrition monitoring and surveillance Nutrition monitoring and surveillance are of utmost importance, because India is undergoing rapid demographic, economic, social, educational, agricultural and health transition; all of these can modify dietary intake and nutritional status. It is imperative that the positive trends are identified and replicated and the negative trends are identified early and combated.

4 Nutrition Monitoring Collection and analysis of accurate data from large statistically representative sample of population, at regular intervals for the purpose of assessing the food and nutrition security of the population, time trends, and differences between sub groups of the population, in terms of access to food, expenditure on food, dietary intake, nutritional status and nutrition related health and disease risks. Inputs from nutrition monitoring is required for formulation of national nutrition policy, strategy and programmes and for brining about midcourse corrections in the programmes

5 Monitoring of food and nutrition security of the population should have the following components Food supply at national and state level- adequacy Accessibility and affordability to different segments barriers to equitable distribution Changes in food consumption patterns impact on nutritional status Nutritional status of the population- current status and time trends Differences in nutritional status of sub groups of the population Impact of current nutrition programmes Food safety

6 Surveillance Ongoing scrutiny, generally using methods distinguished by their practicability, uniformity and rapidity rather than complete accuracy. Main purpose of surveillance is to detect changes in trends or distribution of the problem in order to initiate investigation and control measure (Last ) Early detection of occurrence of adverse events at district or below district level and prompt institution of remedial measures to achieve preset goals, get precedence over completeness of and scientific accuracy of the data

7 Determinants of food and nutrition security Food security Nutrition security Nutrition security

8 National Nutrition Policy 1993 Envisaged building up of a regular monitoring and surveillance system and developing a reliable database in the country not only to assess the impact of ongoing nutrition and development programmes but also to serve as an early warning system for initiating prompt action.

9 Monitoring and Surveillance of Food and Nutrition Security Food security (National, state and vulnerable areas) Food production ( Min of Agriculture ) Access to food ( PDS, Food subsidy ) Affordability - Poverty ( NSSO, Planning Commission) Consumption Expenditure on food (NSSO ) Nutritional status ( vulnerable regions, groups, individuals) Dietary intake and nutritional status (NNMB,NFHS and DLHS)

10 Million Tonnes Pulse production stagnated; cost of pulses rose and pulses became un affordable to the poor Source: Reference5.3 Time trends in production of important food items Foodgrains Pulses Oilseeds Sugarcane Cereals Rice coarse cereals Population in million Food grain production kept pace with the population growth;rice and wheat production increased but coarse cereals production stagnated

11 Monitoring food intake and nutritional status NSSO surveys : monitor consumer expenditure including expenditure on food stuffs; from this data base, food consumption/ consumption unit (of different food stuffs and energy, protein and fat) is computed. Advantages: Nationally and state wise representative; robust sampling; provide time series data Disadvantages:Based on expenditure of the household on food stuffs; cannot provide data whether food procured was actually consumed by the family; does not give any information on intra-family distribution of food.

12 percent Figure 6.2: Time trends for % expenditure on various food items as share of total expenditure - NSSO 27th 32nd 38th 43rd 50th 55th 61st 27th 32nd 38th 43rd 50th 55th 61st Source: Reference 6.3 Urban Rural cereals & substitutes pulses & products milk & products edible oil egg, fish & meat vegetables fruits & nuts sugar beverages salt & spices non-food items Over years there has been decline in expenditure on food. This is mainly due to low cost of cereals The rise in non food expenditure is mainly due to higher expenditure in transport, housing, health and education

13 percent Quantity (Kg) Figure 6.5: % per capita expenditure on cereals to total expenditure (Rural) 27th 38th 43rd 50th 55th 61st Source: Reference 6.3 Rounds Low est income Middle income Highest income Figure 6.13: Quantity of Cereals (Kg) consumed amongst rural income classes Low est income Oct1972-Sept1973 Middle income July1999-June2000 Source: Reference 6.3 Highest income July1977-June1978 Though there has been is a reduction in expenditure on cereals, amount of cereal consumed has increased in the lower income. This is because of low cost of cereals especially subsidised grains through the PDS

14 Percent Quantity (kg) Figure 6.6: % per capita expenditure on pulses to total expenditure Oct1972- Sept73 Jan1983- Dec83 July1987- June88 July1993- June94 July1999- June2001 Low est income Middle income Highest income Source: Reference 6.3 Figure 6.18: Consumption of Pulses 0.8 (kg) -rural incom e classes Low est income Middle income Highest income Oct1972-Sept1973 July1999-June2000 July1977-June1978 Source: Reference 6.3 Consumption expenditure on pulses has increased in the lowest income group; but the amounts consumed has decreased due to high cost of pulses. Expenditure on pulses remained unchanged in middle and upper income groups, but there has been a steep decline in pulse consumption in these groups due to high cost of pulses

15 Value of consumption Value of consumption Figure 6.3: Consumption of foods ( in Rs) among urban income classes Figure 6.4: Consumption of foods (in Rs.) among rural income classes Low est income Cereals Milk & its products Sugar Vegetables Source: Ref 6.3 Middle income Higher income Pulses Egg, fish, meat Oil Highest income 0 Low est Income Middle Income Higher Income Highest Income Cereals Pulses Milk Meat, Fish, eggs Sugar Edible Oils Vegetables Source: Reference 6.3 Dietary diversity increases with increasing income

16 Kcal kcal Figure 5 Time trends in energy consumption Energy Rural Energy Urban Figure 6. Time trends in average per capita intake of energy by expenditure 3500 classes Rural Low er 30% Rural Middle 40% Rural Top 30% Urban Low er 30% Urban Middle 40% Urban Top 30% Over the last three decades there has been a slow but steady decline in energy intake in rural areas and a smaller decline in urban areas. Data from NNMB confirm this trend The energy intake of low income group (urban and rural ) has improved marginally. Energy intake of higher income groups has declined

17 gram grams Figure 7: Time trends in protein consumption Rural Urban 50 Figure 8: Time trends in fat consumption Fat Rural Fat Urban Data from NSSO and NNMB show that there has been a small decline in protein intake in rural areas. There is substantial increase in oil consumption both in urban and rural areas

18 There are large interstate differences in the amount of cereals, pulses, oil, animal products and vegetables consumed

19 Monitoring of dietary intake and nutritional status National Nutrition Monitoring Bureau (NNMB) Advantages NNMB provides data on dietary intake (by 24 hour dietary recall) and nutritional status (anthropometry and nutritional deficiencies) in 10 states of India (Kerala, Karnataka, Andhra, Tamil Nadu, Maharashtra, Orissa, Gujarat, Madhya Pradesh, West Bengal and Uttar Pradesh ) from NNMB is the only survey that provides data on time trends in intra-family distribution of food, dietary intake and nutritional status of individuals in the household over the last three decades. Problems : Does not cover the entire country. The sampling is not as robust as NSSO (though using NSSO sampling frames).

20 Mean Energy Consumption- NNMB 2000 Age groups Males Females Kcals RDA % RDA Kcals RDA % RDA Pre-school School Age Adolescents Adults The gap between RDA and the actual energy intake is greatest in preschool children and lowest in adults. Poor caring practices rather than poverty appear to be the major factor for low energy intake in children.

21 Dietary Adult Adult Preschool Intake Male Female Children Adequate Adequate Adequate Adequate Adequate Inadequate Inadequate Inadequate Inadequate Over years there has been an increase in the number of households where adults are getting adequate food but children are not; poor child feeding & caring practices rather than poverty is becoming the cause of under-nutrition in preschool

22 % % Figure: Trends in prevalence (%) of undernutrition in children Figure: Trends in prevalence (%) of severe undernutrtiion in children NNMB NFHS NNMB NFHS Underw eight Stunting Wasting Underw eight Stunting Wasting Over years there has been a decline in severe and moderate under nutrition (weight for age and height for age) but not in wasting (weight for height).

23 NFHS 1,2,3 Provide state level estimates of some major determinants of nutritional status (eg. sociodemographic profile, infant and young child feeding practices) and nutritional status of preschool children, women during reproductive age, and in NFHS 3 nutritional status of men also Advantages: Adequate sampling ; repeat surveys provide information on time trends Disadvantages : does not provide information on dietary intake or data on intrafamily differences in nutritional status

24 Figure : Demographic and socioeconomic variation in the prevalence of underweight, among children under 3, 1992/ /99 Source: HNP report 2005 Under weight rate varies with residence, caste and income. It is surprising that even among the children from high income group one third are under weight. Under weight rates in India are higher than that of subsaharan region but mortality and morbidity in Indian children are quite low. Mortality rates in children from Kerala are comparable to many European countries. This is termed as the South Asian Enigma

25 Kerala Tamil Nadu Punjab Orissa Uttar Pradesh Gujarat Nutritional Status of children by Income 35 Source: NFHS Low Medium High Under-nutrition rates among poor in Kerala are similar to under-nutrition rates among the rich in UP. Appropriate feeding and health care are critical for reduction in under-nutrition rates.

26 Figure: percentage of children age 0-71 m onths recieving services from an AWC < Not receiving supplementary food Any services Almost daily receving supplementary food Supplementary foods has not been accessed by majority of children among all age groups. 80 % of the children less than 12 months are not receiving supplementary foods, rest all other groups, the % varies from 70-80% % of the children irrespective of the age group are receiving any services from the AWC. 0nly 6% of the children < 12 months & 8% of children aged months are daily receiving supplementary food. Rest all the other age groups the % varies from 10-20%.

27 % Urban Figure: Mother receiving services from an AWC during pregnancy Rural No education <5y 5-7y 8-9y 10-11y Residence Mother's education No services Supplementary food Health check-ups NHE Majority of the mother s were not receiving services from an AWC during pregnancy, 83% & 76% of the mother s residing in urban & rural respectively were not receiving services from AWC. Only a small % of mother s i.e is 9% & 11% residing in urban & rural respectively were receiving NHE. The data did not vary much with respect to mother s education, however more % of mothers were receiving supplementary foods and health check ups whose education is between <5yr to 10 to 11yr than those who are =12

28 Orissa Chhatisgarh M izorum M adhya Pr. M aharashtra M eghalya Gujarat TamilNadu West Bengal Jharkhand Sikkim Nagaland Himachal Pr. Karnataka Goa India Uttranchal Kerala Andhra Pr. M anipur Assam Haryana Tripura Uttar Pr. Rajasthan J & K Arunachal Pr. Punjab Delhi Bihar Figure: Percentage of children 0-71 months receiving any services from an AWC There is a huge interstate difference in the % of children receiving services from AWC, Orissa and Chattisgarh has the highest % of children receiving services from AWC i.e 66 % & 65% respectively. While the lowest is in Punjab, Delhi & Bihar i.e 14%, 12% & 10% respectively Percentage

29 District level household survey Provides district level estimates of some major determinants of nutritional status (socio-demographic profile, infant and young child feeding practices) and nutritional status of preschool children and women during reproductive age Provides district level information on prevalence of anaemia in preschool children, adolescent girls and pregnant women If the nutrition component continues to be a part of DLHS, it can provide time trends in all these parameters at district level. Disadvantage : does not provide data on dietary intake

30 Gender difference in Undernutrition (DLHS2004) GIRLS BOYS %< -2SD %<-3SD If sex disaggregated standards (NCHS or WHO) are used for assessment of under-nutrition, there is no difference in the prevalence of under-nutrition between boys and girls.

31 % children with moderate and severe anaemia Nearly 80-90% of children are anaemic.about half have moderate or sever anaemia. Increase in intake of vegetables at home and in the anganwadi, increasing use of iron and iodine fortified salt in AW and at home will help in some reduction in anaemia, In addition screening at risk children (under weight, repeatedly ill children) and treating those whoa re anaemic will be required

32 Nutrition Surveillance systems The nutrition surveillance system (NSS) provides information on under/over nutrition, micronutrient deficiencies, their spatial distribution, causes, and changes in prevalence/incidence over time, the actions initiated to combat them and their impact

33 Nutrition Surveillance systems Though the National Nutrition Policy recommended the development and establishment of "nutritional surveillance of the country's population especially children and mothers in the country by the year 2000, the NSS is yet to be developed. Currently, there are two systems, which provide the essential core information that could be developed into a full-fledged nutrition surveillance Food Insecurity and Vulnerability Information and Mapping System (FIVIMS) under the Department of Food and Public Distribution. Monthly reporting system on nutritional status of preschool children in the ICDS programme

34 Food security The World Food Summit in 1996 defined food security as a situation in which all people, at all times, have access to sufficient, safe and nutritious food to meet their dietary needs and food preferences for an active and healthy life.

35 Food insecurity and vulnerablity information and monitoring system (FIVIMS) FIVIMS promotes better understanding of the characteristics and causes of food insecurity and vulnerability and contributes to improved policy and programme formulation, targeting, implementation and monitoring progress of interventions to reduce hunger and poverty at local, national, regional and global levels.

36 Objectives of FIVIMS Raise awareness about food security issues; Improve the quality of food security related data and analysis; Facilitate integration of complementary information; Promote better understanding of users' needs and better use of information; Improve access to information through networking and sharing.

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38 Major national surveys for monitoring nutritional status NNMB NFHS DLHS

39 At global level FIVIMS is coordinated by FAO; it promotes coordinated action among partner agencies in support of best practices in the development of national and regional food insecurity and vulnerability information and mapping systems to strengthen understanding of who the food insecure and vulnerable people are, how many, where and why people are food insecure or vulnerable. Better information and knowledge on the underlying causes must lead to targeted action to ensure eradication of extreme poverty and hunger. At the National Level Department of Public distribution system is the nodal agency for FIVIMS. The MSSRF in collaboration with the World Food Programme has brought out the food insecurity and vulnerability report and rural and urban Food Insecurity Atlas for India in 2003 and 2004

40 In order to analyse and document the sub-state patterns of food insecurity (which includes nutritional insecurity),world Food Programme (WFP) together with the Government of India and the Institute of Human Development is in the process of preparing state-wise 'Food Insecurity Atlases', taking districts as units of analyses. The states being taken up initially are Orissa, Madhya Pradesh, Jharkhand, Bihar and Chhattisgarh. The approach is to analyse food security in the accepted framework of availability, access and absorption. The atlases will be based on qualitative information as well as extensive analysis of secondary data (Census, NSSO, NFHS, DLHS).

41 Use of ICDS reporting for nutrition surveillance Both ICDS and the health functionaries regularly file monthly progress report on nutrition status. However, there are lacunae and delays in the collection, reporting, collation and analysis of data. Monthly progress reports are not utilised for district level monitoring and midcourse correction of ongoing programmes NIN, at the request of the Department of Women and Child Development, conducted a study in Andhra Pradesh for improving the monthly progress reports of the ICDS workers and improving monitoring of the ICDS programme at the district level.

42 Use of ICDS reporting for nutrition surveillance Data from the study indicated that it was possible to train and orient the ICDS functionaries to improve the quality and timeliness of the reporting. Analysis of the data and discussions on the implications of the reports with the functionaries facilitated the implementation of mid-course corrections and led to improved performance When data from the Andhra Pradesh study was used for Geographical Information System (GIS) mapping, it showed that the data generated by anganwadi workers are useful for monitoring the situation at the block/district levels and for building up, over time, a database for nutritional surveillance.

43 Use of ICDS reporting for nutrition surveillance Orissa had utilised `routine reporting of the ICDS workers for block-wise GIS mapping of the severe and moderate under-nutrition in the 0-6 years age groups. The GIS maps clearly brought out trends in undernutrition in different areas, different seasons and in different age groups. Meghalaya, Rajasthan, Maharashtra, Madhya Pradesh and Karnataka have initiated projects to improve nutrition monitoring, mapping and surveillance

44 Nutrition surveillance and response using ICDS reporting

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