Transcript Slide 1

Nutrition Related Public Health
Problems In Women
Dual nutrition & disease burden in women
Under- nutrition
Prevalence of under-nutrition and micronutrient
deficiencies are high in adolescent girls, pregnant
and lactating women
Adverse
consequences
of
macro
and
micronutrient under nutrition in women affect
not only the mother but also her offspring
Over-nutrition
Data from NFHS and NNMB surveys indicate
that over-nutrition in women is emerging as a
public health problem especially in urban areas
Over-nutrition is associated with increased risk
of non-communicable diseases
This presentation will review
Nutritionally vulnerable periods in woman’s
life
Effect of maternal under-nutrition on mother
child dyad
Anaemia and its adverse effects
Magnitude of undernutrition in women
Nutritionally vulnerable periods
in woman’s life
Effect of pregnancy on nutritional status
Weight (kg) MUAC(cm) FFT (mm)
NPNL
42.3
22.5
10.5
1st trimester
41.5
22.2
9.6
2nd trimester
44.6
22.1
9.7
3rd trimester
46
21.7
9.2
Women from poor households subsist on 161800kcal/day; there is no increase in dietary
intake during pregnancy.
Mean weight gain during pregnancy is 5-7 kg.
There is a reduction in FFT indicating that there
is mobilisation of fat.
There is no increase in dietary intake during
lactation.
There is reduction in body weight and FFT
during first year of lactation suggesting that there
is mobilisation of fat to meet the energy needs.
Body weight improves after 12 months
Factors predisposing to
maternal under-nutrition
NFHS-2
151.6
151.4
151.2
151
150.8
150.6
150.4
150.2
150
15
14.5
14
13.5
13
12.5
12
11.5
11
15-19
M ean height (cm)
%women <145 cm
20-24
25-29
%height<145
Height(cms)
Age and height
30-34
Age
Many adolescent girls have not completed their
physical growth
If pregnancy occurs in early teens, there will be
no further linear growth
Women
who
had
severe/moderate
undernutrition in childhood are shorter and
lighter in adult life.
Birthweight is lower in women who are short
or having poor weight gain during pregnancy.
Body
weight
Weight of pregnant women who concieved during
lactation
55
50
45
40
35
Not lactating
<= 12
13-24
Durationof lactation
>24
Pregnancy in lactating women imposes
additional nutritional needs; the impact is
greater if inter-pregnancy interval is short.
If dietary intake remains low, there is
deterioration in maternal nutritional status
and poor maternal weight gain
Weight(kg)
Effect of work in and out of home
46
44
42
40
38
WW
WW-working women
HW Housewife
HW
NPNL
WW
HW
Pregnant
WW
HW
Lactating
Working at home and out side home imposes
additional energy needs; if not met there is
reduction in bodyweight
Effect of maternal nutrition on
birth weight
Birth w eight in relation to m aternal BMI
3200
60
50
40
30
20
10
0
3000
2800
2600
2400
2200
< 16
16-17
17-18.5
18.5-20
20-25
> 25
BMI (Kg/m2)
Mean Birth Weight (g)
Prevalence of LBW (%)
Source: Tenth Five Year Plan, GOI, 2002
Maternal under-nutrition is associated with
increased risk of low birth weight.
birth weight (kg)
Effect of conception during lactation on birth w eight
of infants
2.9
2.8
2.7
2.6
2.5
2.4
< 12
13-24
>24
monthspregnant womwn who were lactating
pregnant
Mean birth weight is lower if IPI is less than
12 months.
Mean birth weight in all groups is lower if
conception has occurred in lactating women
Effect of maternal nutrition on outcome of pregnancy
Height
(Cms.)
Weight
(Kg.)
Hb
(g/dl)
Abortion
rate %
Birthwt.
(Kg.)
%LBW
Low
Income
151.5
45.7
10.9
12
2.70
33
Middle
Income
156.3
49.9
11.1
8
2.90
20
High
Income
156.3
56.2
12.4
6
3.13
15
Poor pregnancy outcome in low income groups is partly
due undernutrition/ anaemia and partly due to poor ANC.
To sum up
Pregnancy and lactation impose additional
nutritional demands; they can be met through
lifestyle “adaptations”
in well nourished
women
Situations associated with deterioration in
maternal
nutrition
and
reproductive
performance are:
Pregnancy in undernourished adolescent girls
Pregnancy in young adolescent girls
Pregnancy in lactating women
Pregnancy within two years of last delivery
Dual stress of work at and outside home
Interventions to improve maternal nutrition
All pregnant and lactating women should be
weighed
Pregnant women with bodyweight less than 45
kg are identified and given 6 kg food grains
every month for the remaining period in
pregnancy
Lactating women with bodyweight less than 40
kg are identified and given 6 kg food grains
every month for the remaining period of
lactation upto one year
Quantity (Kg)
Pattern of consumption of different cereals
(Kg) NSSO
12.0
10.0
8.0
6.0
4.0
2.0
0.0
11.3
10.5
8.3
3.4 2.4
Low est
incom e
4.8
1.4
All classes
Oct1972-Sept1973
Rice+Wheat
Low est
incom e
1.4
All classes
July1999-June2000
Coarse cereals
Percentage Distribution of MPCE(NSSO 2001)
1 20. 0
Percentage
1 00. 0
80. 0
60. 0
40. 0
20. 0
0. 0
Oc t1 9 7 2 -Se pt1 9 7 3
Jul y1 999-
Jul y1 977-June 1 978 Jan1 983-De c 1 983
Jul y1 987-June 88
Jul y1 993-June 94
June 2000
Ye ars
Cereals
Other food stuffs
Intoxicants
Pulses
Beverages
Other Non food stuffs
Figure-1
PER CAPITA NET AVAILABILITY O F
FO O DGRAINS
Grams
600
400
200
0
Cereals
1951
Source: NNMB
Pulses
1971
T otal
Foodgrains
1996
Average daily Per capita dietary intake
Calorie
Protein
Fat
Rural
Urban
Rural
Urban
Rural
Urban
1972-73
2266
2107
62
56
24
36
1983
2221
2089
62
57
27
37
1993-94
2153
2071
60.2
57.2
31.4
42
1999-2000
2149
2156
59.1
58.5
36.1
49.6
Source: NSSO
Average Per Capita Calorie Intake by Expenditure Classes
Expenditure
Classes
Rural
Urban
197273
197778
199394
197273
197778
199394
Lower
30%
1504
1630
1678
1579
1701
1682
Middle
40%
2170
2296
2119
2154
2438
2111
Top 30%
3161
3190
2672
2572
2979
2405
Steps to improve household Nutrition security
Increase production and availability of cereals,
pulses and vegetables
 Reduce post harvest losses by appropriate
processing .
Make vegetables available at affordable cost
through out the year to urban and rural
population
More efficient targeting through TPDS
Provide coarse grains, pulses and iodised salt to
BPL families through TPDS
Improve purchasing power by appropriate
programmes including food for work programmes
Anaemia and its adverse consequences
Prevalence of anaemia Source: WHO
Global Developed Developing
Children<5 yrs 43
Children > 5yrs 37
Men
18
Women
35
Pregnant
59
Women
12
7
3
11
14
51
46
26
47
51
India
Urban Rural
60
70
50
60
35
45
50
60
65
75
About one third of the global population (over 2 billion
persons) are anaemic.
Anaemia is the most common nutritional deficiency
disorder in the world.
Prevalence of anaemia is higher in developing countries
Prevalence of anaemia in India is very high in all groups of
the population.
ANAEMIA IN PREGNANCY ASIAN COUNTRIES
90
80
70
60
I
N
D
I
A
50
40
30
20
10
B
A
N
G
L
A
D
E
S
H
C
H
I
N
A
I
N
D
O
N
E
S
I
A
M
A
L
A
Y
S
I
A
M
Y
A
N
M
A
R
N
E
P
A
L
0
Bangladesh
India
Malay sia
Nepal
P
A
K
I
S
T
A
N
P
H
I
L
I
P
P
I
N
E
S
Philippines
S
R
I
L
A
N
K
A
S
P
O
R
E
T
H
A
I
L
A
N
D
Srilanka
WHO 1992
Prevalence of anaemia is high in South Asia. Even
among South Asian countries prevalence of anaemia
in pregnancy is highest in India.
Source: NNMB 2003
Among the southern states, prevalence of anaemia in
pregnancy is lower in Kerala and Tamil Nadu - ? due to better
access to health care.
India’s share in global maternal deaths
INDIA
It is estimated that globally there are over 5 lakh maternal
deaths every year.
There are about 1 to 1.2 lakh maternal deaths in India every
year.
India with 16% global population accounts for 20-25% of all
maternal deaths in the world.
CAUS ES OF MATERNAL MORTALITY
T oxemia
8%
Others
8%
Hemorrhage
30%
Obst. Lab
10%
Abortion
9%
Sepsis
16%
Anemia
19%
SRS-1998
Anaemia continues to be a major cause of maternal deaths
Prevalence of anaemia in children, adolescent
girls and pregnant w omen from 3 surveys
100
80
60
40
20
0
NNMB
ICMR
DLHS NNMB ICMR
Pregnant w omen
Normal
DLHS NNMB DLHS
Adolescent girls
Mild
Moderate
Source NNMB
Children
Severe
Majority of children, adolescents, adult men & women are
anaemic.
Anaemia antedates pregnancy & gets aggravated during
pregnancy. Maternal anaemia results in poor iron stores in
foetus.
Prevalence of anaemia in children is high because of poor
iron stores, low iron content of breast milk and
complementary foods.
There is thus an intergenerational self-perpetuating vicious
cycle of anaemia in all age groups.
Prevalence of Anaem ia (%){DLHS 2003}
Percentage
100%
80%
60%
40%
20%
0%
preschool
children
adolescent girls
pregnant w omen
Group
severe
moderate
mild
no anaemia
Anaemia is a major problem right from
childhood; it worsens during adolescence in girls
Advent of pregnancy further aggravates anaemia
Anaemia in pregnant women
(Age between 15 - 44 years)
3
TOTAL
36
51.4
2
URBAN
36
52.9
3
RURAL
36
50.9
Mild
Moderate
Severe
Over the last five decades there has not been any
reduction in prevalence of anaemia; even in 2003
(DLHS) over 90% of pregnant women are anaemic
Prevalence of anaemia in adolescent girls & pregnant
women by education & standard of living index
80
60
40
20
Education
Education
High
Medium
Low
>10yrs
0-9 yrs
Illiterate
High
Standard of living
index
Adolescent girls
Source: Ref 7.11.1.6
Medium
Low
>10yrs
0-9 yrs
Illiterate
0
Standard of living
index
Pregnant women
Severe Moderate
Prevalence of anaemia is high even in high income
groups and among well educated pregnant women.
Time trends in intake of iron, folic acid and vitamin C in rural
and urban areas (c/day) – (NNMB)
Nutrients
NNMB
Rural
Urban
197579
1988-90 1996-97 2000-01 2004-05 1975-79 1993-94
Iron (mg)
30.2
28.4
24.9
17.5
14.8
24.9
18.96
Vit C
37
37
40
51
44
40
42
Folic
acid
*
*
153
62
52.3
*
*
Dietary intake of iron and folate are less than 50% of RDA.
Bioavailability of iron from phytate and fibre rich Indian diets
is only 3 -5%.
Time trends in intake of iron (mg / day) in different groups
Age group
1975-79
1996-97
2000-01
2004-05
B
19
20
12.2
12
G
18
19
12.1
11.5
B
21
21
15.4
13.3
G
20
21
12.9
13
B
25
26
16.7
16.4
G
22
22
15.3
13.4
26
27
17.5
19.6
21
22
17.1
13.8
Pregnant
20
23
14
14
Lactating
23
23
14.6
14.7
10-12
13-15
16-17
Adult men
Adult women
Iron intake is low in all age groups and does not increase in
pregnancy; there has been no increase in iron intake over 3
decades.
Prevalence of Iron deficiency anemia in South Asia%
Country
Children Women
< 5 years 15-49 years
Pregnant
women
Maternal deaths
from anemia
Afghanistan
61
36
55
-
-
Bhutan
65
55
81
74
68
2600
<100
India
75
51
87
22000
Nepal
65
62
63
760
Bangladesh
South Asia
Region Total
25,560
World Total
50,000
About half the deaths from anaemia in the world
occur in South Asian countries. India accounts for
over 80% of deaths due to anaemia in South Asia.
Consequences of anaemia in pregnancy
8-11 g/dL: easy fatigability, poor work capacity
5-7.9 g/dL: impaired immune function, increased
morbidity due to infections
<5 g/dL: compensated stage: increased morbidity
and maternal mortality due to inability to withstand
even small amount of bleeding during pregnancy
/delivery and increased risk of infections
<5 g/dL: decompensated stage: about 1/3rd develop
severe congestive cardiac failure and many with
congestive
failure
succumb
either
during
pregnancy or during labour
There is 8 to 10 fold increase in  MMR when the
Hb is <5 g%.
Effect of maternal hemoglobin level on birth weight and
perinatal mortality ( Prema 1982)
Effects on
Hemoglobin (g/dL)
<5
Mean birth weight(g) 2,400
5-7.9
2,530
8-10.9
2,660
11.0
2,710
Perinatal mortality
(rate/1000 live births)
174
76
55
Number
500
312
362
1015
1456
Maternal anaemia is associated with poor intrauterine
growth and increased risk of preterm births resulting in
increase low birth weight rates.
This in turn results in higher perinatal morbidity and
mortality, higher IMR and poor growth trajectory in infancy,
childhood and adolescence.
A doubling of low birth weight rate and 2 to 3 fold increase
in the perinatal mortality rates is seen when the Hb is <8 g%.
Immune status of anaemic pregnant women
There is a fall in T and B cell count when maternal
Hb is below 11g/dL.
The fall in T and B cell counts are significant when
Hb is <8g/dL.
There
is
no
alterations
in
lymphocyte
transformation or in cell mediated immunity.
Prevalence of morbidity due to infections including
asymptomatic bacteriuria is higher in anaemic
pregnant women.
Higher morbidity rates might contribute to the
higher low birth-weight rates in anaemic pregnant
women.
Interventions to prevent/ treat anaemia
Counseling to improve dietary diversity/ double
fortified salt if available
Screen all pregnant women as early in pregnancy
as possible
If not anaemic IFA tablets through out pregnancy
to prevent anaemia
If anaemic oral or IM iron depending upon the
severity of anaemia and period of pregnancy
Programmes for prevention and management of
anaemia in pregnancy
India was the first developing country to take up a National
Nutritional Anaemia Prophylaxis Programme to prevent
anaemia among pregnant women and children in 1973.
At that time AN care coverage under rural primary health
care was very low and there was no provision for screening
pregnant women for anaemia. Therefore an attempt was
made to identify all pregnant women and give them 100
tablets containing 60mg of iron & 500μg of folic acid.
In hospital settings, screening for anaemia and iron-folate
therapy in appropriate doses and route of administration for
the prevention and management of anaemia have been
incorporated as an essential component of antenatal care.
Management of anaemia in pregnancy
Obstetric text books in India provided country
specific protocols for management of anaemia,
based on studies carried out in the country.
Hb < 5 g/dL
Constitute 5- 10% of anaemic women,
Admission and intensive care preferably in
secondary or tertiary care institutions to ensure
maternal and fetal salvage.
Hb 5 to 7.9g/dL
Constitute 10 to 20% of anaemic women,
Screen for systemic/obstetric problems and
infections,
If she has no other systemic or obstetric
problems give her parenteral iron (IV or IM).
Total Dose IV Iron (TDI) therapy
Safety and efficacy of Intravenous total dose iron
therapy was proved by trials undertaken by Dr
Menon.
Subsequently IV total dose iron therapy was used
in several hospitals in Chennai and elsewhere.
Advantage: Only two day hospital admission
Disadvantage: On rare occasions anaphylactic
reaction occurred; even in the tertiary care
hospitals it was not possible to save all women who
had anaphylactic reaction.
In view of this TDI was given up and intramuscular
iron therapy was preferred.
IM iron therapy
IRON DEXTRAN - Following initial successful trials by Dr.
Menon, Dr. Bhatt and others, IM iron dextran injections were
widely used in hospital settings often on out-patient basis;
about 1/3rd develop fever arthralgia or myalgia.
IRON SORBITOL COMPLEX: Initial trials by Dr. Menon
showed promising results but it was not so widely used
because 1/3rd of the drug gets excreted in urine and higher
dose of elemental iron is required.
Side effects are mild: nausea, giddiness.
Effect of IM iron dextran on Hb & birth weight (Prema 1982)
Group
No.
No.
Hb < 8g/dl untreated
443
2530 + 651
IM iron from 20 weeks
76
2890 + 428
IM iron from 28 weeks
105
2734 + 416
None of the women who received 1gm of IM iron dextran had
Hb less than 11g/dl at delivery.
Problems in implementation of anaemia
prevention and control programmes
Antenatal Care
(Household Surveys 1998-99)
120
98.1
100
87.8
88.1
79.1
70.4
80
57
60
40
46.7
48.7
30.9
30.1
27.727.7
26.3
20
17
9.5
9.2
0
Bihar
U.P
Any ANC
Abd. Checkup
Haryana
W eight Taken
IFA
T. Nadu
BP Checkup
DLHS 1 (1998-99) showed that pregnant women were not
being screened for anaemia and given appropriate therapy.
All pregnant women who were given antenatal check up were
given tablets containing iron (100mg) and folic acid 500 μg.
Most women in poorly performing states did not come for
antenatal check up. Many of those who came, did not get IFA
through out pregnancy. Majority did not consume even the
tablets that they got.
Proportion of pregnant women who receive IFA tablets is
not high even among well-performing states like Tamil Nadu,
Kerala and Maharashtra.
Many of those who received IFA did not receive 100 tablets.
Many of those who received did not take the tablets
regularly.
Hb in Pregnant women taking Iron Supplementation (ICMR
2000)
No of tablets ingested
Hb (g/dL)
No.
Mean
S.D
1-15
16-30
310
251
8.8
9.2
1.7
1.5
31-60
61-90
196
99
9.3
9.2
1.8
1.6
>90
Total who had IFA
74
930
9.1
9.1
2.1
2.2
B.Not known
C.Not had IFA
16
3829
9.1
9.1
2.6
3.8
A+B+C
4775
9.1
3.590 tablets
ICMR study confirmed
that most women
received
without Hb screening. Many did not take tablets regularly.
Even among small number of women who took over 90
tablets rise in Hb was low and many continued to be anaemic.
IM iron therapy
IM iron therapy mainly iron dextran was used in
some medical colleges and rarely at district
hospitals. It never reached primary health care
level.
There were problems in ensuring continuous
supply of drugs even at medical colleges.
Some women found it difficult to come to OPD
daily for ten days for IM injections.
Though women who were counseled agreed to IM
therapy, those who developed trouble some side
effects like arthralgia wanted to discontinue;
convincing them to continue was difficult.
New initiatives in the Tenth Plan – NRHM
New Initiatives in the Tenth Plan
Emphasis on screening all pregnant women for anaemia
& providing appropriate treatment depending upon Hb
levels.
Anaemia prophylaxis For women who are not anaemic
one tablet of iron 100mg & 500 μg folic acid once a day
would be sufficient to prevent any deterioration in Hb
levels.
Oral iron therapy for mild anaemia Majority of anaemic
pregnant women have mild anaemia. Oral iron folate
therapy (one tablet of iron 100mg and 500 μg twice a
day) regularly should be able to improve their Hb.
IM iron therapy for moderate anaemia One-fifth of
pregnant women have moderate anaemia. They should
get IM iron therapy.
Hospitalisation and intensive care for those with severe
anaemia.
Components of antenatal care
DLHS -2
Breast examination
17.4
49.8
Abdominal examination
42.1
Blood pressure checked
43.8
Blood tests
41.4
Weight measured
Urine tests
42.2
Internal examination
27.6
Height measured
Sonogram/Ultrasound
20.4
16.4
DLHS 2 (2006) showed that there was some
improvement in coverage and content of antenatal
care. About 40% women had blood examination –
which might include Hb estimation.
Iron & Folic Acid Supplementation
in pregnancy
DLHS – 2
Two or More
18%
IFA Per Day
No IFA
38%
During Entire Pregnancy
35.3
20
Received but
not consumed
5%
One IFA
39%
Less than 100
IFA
100+ IFA
DLHS 2 also showed that there has been some improvement in %
of pregnant women receiving IFA tablets. There has been a
significant reduction in the % of women who received but did not
consume the tablets. These data suggest that if all pregnant
women are screened for anaemia and provided appropriate
therapy it might be possible to achieve substantial reduction in
prevalence of anaemia in pregnancy.
Challenges in the Eleventh Plan period
Challenges in anaemia prevention & control
programmes
Majority of Indians are anaemic,
Over 3/4th of pregnant women are anaemic,
There has not been any decline in the prevalence
of anaemia or its adverse consequences on mother
child dyad over the last six decades.
Opportunities in the Eleventh Plan period
Strategy for prevention of anaemia in pregnancy
health and nutrition education to improve over all
dietary intakes and promote consumption of iron
and folate-rich foodstuffs - possible through NRHM’s
Health and Nutrition Days,
dietary diversification and inclusion of iron folate
rich foods as well as food items that promote iron
absorption - possible with proper linkages with
National Horticultural Mission,
introduction of iron and iodine-fortified salt
universally to improve iron intake - possible with NIN
technology,
Opportunity:
Affordable & sustainable interventions to improve
iron and folate intake of the entire family and
prevent anaemia are readily available.
Strategy for prevention of anaemia in pregnancy
focus on Hb estimation for detection and treatment of
anemia in adolescent school girls as a part of school health
check – possible through school health system.
focus on Hb estimation in girls/women who are married, for
detection and treatment of anemia prior to pregnancy - can
be attempted through coordination with AWW.
screening all pregnant women for anemia - Possible using
filter paper blood collection for Hb estimation by
cyanmethaemoglobin technique
providing one tablet of IFA to prevent any fall in Hb levels in
non-anaemic pregnant women - possible through NRHM.
Opportunity:
All these interventions are feasible & affordable for the
individual and health system. With universal coverage and
monitored supplementation it is possible to ensure that nonanaemic women do not become anaemic.
Strategy for detection & management of anaemia
in pregnancy
Diagnosis of anaemia by a gold standard time tested method of
estimating Hb eg cyanmethaemoglobin possible by upgrading
equipment in hospitals and urban health facilities
iron folate oral medication at the maximum tolerable dose
throughout pregnancy for women with Hb between 8 –10.9g/dL –
possible through convergence between AWW and ANM,
IM iron therapy for women with Hb between 5 and 7.9 g/dL if
they do not have any obstetric or systemic complication - possible
with urban & rural PHCs taking the major responsibility,
hospital admission and intensive personalised care for
women with haemoglobin less than 5 g/dl - possible with
referral to tertiary care centres using emergency transport
funds and ASHA,
screening and effective management of obstetric and
systemic problems in anaemic pregnant women - possible
in hospitals,
improvement in health education to the community to
promote utilisation of available care - possible through
AWW, ASHA, ANM and local self government
representatives.
Opportunity:
All these interventions are feasible & affordable for the
individual and health system.
Opportunities for prevention, detection and
appropriate management of anemia
in pregnant women
Delhi currently has the necessary infrastructure,
manpower, technology and funds for this task;
Indians are rational and responsive; people’s
institutions are in place for providing the necessary
community support;
Prevention, detection and appropriate management
of anemia in pregnant women and preventing the
adverse consequences of anaemia on the mother
child dyad is feasible under NRHM and its urban
counterpart.
Delhi should take this opportunity to showcase how
it can cope with a major challenge effectively.
Time trends in dietary intake and
nutritional status
Figure 1: Time trends in energy intake
percent energy
2500
2000
1500
1000
500
0
100
1975- 1996- 2000- 2004199579
97
01
05
96
NNMB
INP
Male
Female source: NNM B & INP report
8.9
13.9
80.3
75.5
10.8
10.6
1979
2001
80
60
40
20
0
Protein
Carbohydrate
Fat
Over years there has been decline in cereal and pulse
intake; some increase in fat intake;
Over all energy intake has declined both in urban and rural
areas; micronutrient intake is low
Inspite of increase in fat intake fat supplies less than 15% of
energy
Time trends in mean heights in rural
/urban women
Height (cms)
190
170
150
130
110
90
Source: NNMB Reports
70
NCHS
1975-79
1988-90
1996-97
55-60
35-44
16+
18-24
Age (years)
14+
12+
10+
8+
6+
4+
2+
0+
50
2000-01
Increase in height over three decades is less than 4 cms;
children and women are shorter as compared to NCHS
norms
Time trends in mean weights in rural and
urban women
60
60
50
Weight (Kg)
40
30
20
40
30
20
Age (years)
NCHS
1975-79
1988-90
1996-97
2000-01
55-60
35-44
18-24
16+
14+
12+
8+
6+
4+
10+
55-60
35-44
18-24
16+
14+
12+
10+
8+
6+
4+
2+
0+
0
0
2+
10
10
0+
Weight (Kg)
50
Age (years)
Source: NNMB Reports
NCHS
1975-80
1993-94
Increment in weight over three decades is higher than
increment in height .
Urban women weigh more than the rural women even
though their height is similar
20
15
10
Age (years)
Age (years)
NCHS
1975-79
1988-90
1996-97
2000-01
NCHS
1975-80
1993-94
Over years there has been an increase in fat fold
thickness in all age groups; increase in fat fold
thickness is more in urban women
The increment in body weight in women is
mainly due to increment in fat
55-60
35-44
18-24
16+
14+
12+
10+
8+
6+
4+
0
2+
5
0+
Tricep skinfold (mm)
55-60
35-44
18-24
16+
14+
12+
10+
8+
Source: NNMB Reports
6+
4+
2+
18
16
14
12
10
8
6
4
2
0
0+
Tricep Skinfold (mm)
Time trends in mean triceps fatfold
thickness in rural & urban women
60
50
40
30
20
10
0
Figure: Trends in nutritional status of adult
w om en
%
%
Figure: Trends in nutritional status of adult
m en
‘75-79
‘89-90
‘96-97
‘00-01
NNMB
BMI <18.5
04-05
60
50
40
30
20
10
0
‘75-79 ‘89-90 ‘96-97 ‘00-01 04-05
NNMB
BMI >25
BMI <18.5
199899
NFHS
BMI >25
Over the last three decades there has been a slow
but steady decline in undernutrition both in women
and men
Since mid nineties there has been a some increase
in overnutrition rates even in rural women .
In 2005 prevalence of both under and over nutrition
in women are higher than men
Even among poorer segments of population,
there is a progressive reduction in undernutrition and progressive increase in overnutrition with increasing age
Prevalence of overnutrition is higher among women
belonging to urban areas and from families with high
income
Figure 3: Nutritional Status of Women NFHS-3
50
45
40
35
30
25
20
15
10
5
0
Bihar
Jharkhand
Chhatisgarh
Orissa
Madhya
West
Assam
Tripura
Uttar
Rajasthan
India
Mahrashtra
Gujurat
Karnataka
Andhra
Haryana
Uttranchal
Himachal
Tamilnadu
Jammu &
Goa
Nagaland
Arunachal
Mizoram
Manipur
Meghalaya
Punjab
Kerala
Delhi
Sikkim
%< 18.5 Kg/m2
%>25.0 Kg/ m2
There are huge interstate differences in prevalence
of both under and over-nutrition
By and large states with low under-nutrition rates
had high over-nutrition and vice versa
In most states with high over-nutrition rates have
high longevity; they may face high NCD risk
Changes in body weight in HIG
Groups
30-39
40-49
50-59
Weight
(Kg)
BMI
59
64
69
Energy
Intake
24.8
26.4
28.6
Energy
expenditu
re
2134
2056
2264
2191
2195
2146
Source : Wasuda and Siddhu
Even in women from high income group, the
energy intake is less than ICMR RDA.
Energy expenditure is lower than intake by
about 75- 100Kcal
This positive energy balance leads to a
progressive increase in body weight over
decades
Health consequences of over-nutrition
Prevalence (age-std) of diabetes and IGT in the
urban population in India
16
14
percent
12
10
8
6
4
2
0
Diabetes P revalence (%)
Total
Men
IGT P revalence (%)
Women
Source: National Urban Diabetes Survey , 2001
Prevalence of diabetes and impaired glucose
tolerance in women is high – especially in
urban areas
Over decades there has been a steep increase
in hypertension, especially in urban areas
Prevalence rates in women are as high as in
men
Prevalence of IHD
prevalence/1000
200
150
URBAN MEN
URBAN WOMEN
RURAL MEN
100
RURAL WOMEN
50
0
20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59
60+
Age
Coronary heart disease is more common in urban
men and women
IHD is as common in women as in men
Summary and conclusions
Over the last three decades there has been a
decline in household expenditure on food,
cereal and energy intake.
Unlike the earlier era poverty and poor access
to food are not the major determinants of
low dietary intake
Nutrition education and better utilization of
health and nutrition care can result in rapid
improvement in dietary intake and nutritional
status
Under-nutrition in infancy, childhood and
adolescence predisposes to under-nutrition
and over nutrition in adult life
Prevalence of maternal under-nutrition is high
especially in states/areas where access to
nutrition and health care is low
Maternal under-nutrition is associated with
higher morbidity due to infections. Infections
aggravate undernutrition
Over decades there has been no decline in
anaemia
Anaemia is present from infancy and
childhood;
gets
aggravated
during
adolescence in girls and is perpetuated by
pregnancy
Anaemia is responsible for substantial
increase in maternal morbidity & mortality
Maternal under-nutrition and anaemia are
major factors responsible for low birth
weight
Inspite of reduction in energy intake there has
been an increase in over-nutrition
Reduction in physical activity is the major
factor responsible for emerging problem of
over nutrition
Over-nutrition
predisposes
hypertension and CHD
to
diabetes,
In India prevalence of diabetes, hypertension,
& CHD is high; prevalence rates in women are
comparable to those in men
Effective behavioral change communication
promoting healthy life styles will enable India
to combat over-nutrition and its adverse
consequences