S.8. Srikantia

The National Nutrition Monitoring Bureau

Information on prevailing patterns ofdietary intakes and current nutritionalstatus of representative populationgroups in the country is necessary forthe formulation and implementation ofmeaningful national health and nutritionpolicies. In order to derive such informa­tion, numerous diet and nutrition surveyshad been carried out in the country dur­ing the last few decades. Most of thesesurveys had been undertaken in earlieryears by the nutrition sections of thePublic Health Directorates of differentstates. The results of these studies were

annually compiled and published by theNational Institute of Nutrition (and in ear­lier years its precursor, the Nutrition Re­search Laboratories). On the basis ofthe data gathered from these surveys,the National Institute of Nutrition hadalso published a diet atlas and a nutritionatlas both of which had attracted wide

attention on the part of scientists, policy­makers and planners in the country.

However, the major weakness in theabove efforts was that the results of sur­

veys carried out in different locations bydifferent agencies were not alwaysstrictly comparable. Sampling designswere not strictly standardised. It becameobvious that in order to derive scientifi­cally valid and authentic data, whichwould provide a reliable picture of thenational situation with respect to dietaryintakes and nutritional status, the accu­racy of the. data as well as their com­parability had to be ensured. It was inrecognition of this that in 1972 the thenDirector of the National Institute of Nutri­tion (Dr. C. Gopalan) conceived the ideaof setting up the Nation~ NutritionMonitoring Bureau as an integral part of

the National Institute of Nutrition.The Bureau began its activities with

nine peripheral units - one in each ofthe following states - Andhra Pradesh,Gujarat, Karnataka, Kerala, MadhyaPradesh, Maharashtra, Tamil Nadu,Uttar Pradesh and West Bengal. Fiveyears later, Orissa jOined the Bureau asits 10th unit.

The NNMB thus has two clear and

major objectives:• To collect on a continuing basis,

analyse and report on dietary intakesand nutritional status of representativesegments of the population in each ofthe states, employing standardised anduniform procedures and techniques, and

• To periodically evaluate on-goingnational nutrition programmes to identifythe strengths and weaknesses and re­commend mid-course corrections whencalled for.

The NNMB has been functioning forwell over a decade (now nearly 16years). An attempt has been made hereto evaluate its contributions.

Some Unique Features Of NNMBData Collection

The representativeness of the samplecovered by the study is ensured by arigorous multistage sampling procedure,by which every village in a state has aneven opportunity to be included. Districtsare stratified into one of four develop­mental categories and in each of the fourcategories, one third to one sixth thenumber are selected each year for sur­vey. All districts in the state would thusbe covered within a three to six yearperiod, 'depellding upon the size of the

state. The selection of households in

each district is so made that the percen!of rural population covered in each dis­trict conforms to the ratio of rural to totalpopulation of that district. Selection 01

villages is made after categorising the'Tinto small, medium and large, dep ,dirupon the population, and then b' ..Jsir,random numbers. Depending ur .. thvillage population, 5, 10 or 20 '0IJ!)eholds are included in the stud~ Th(selection of households is made by If

survey team after it visits the village, S(as to ensure that different socio­economic and occupational categoriesare represented.

This sampling frame was evolvedafter in-depth discussions with Dr. C.R.Rao - the then Director of the IndianStatistical Institute, Calcutta, and cur­rently National Professor.

In the urban areas, the capital city ofthe state is included, for reasons of con­venience of operation, and apart fromthe low, middle and high income groups,one slum and one big industrial concernin the city are covered. Clearly, theseare not representative samples of eitherthe urban, slum or industrial labourpopulations (National Nutrition Monitor­ing Bureau - Plan of Operation, NIN1971).

Data on food consumption at thehousehold level are obtained through di­rect weighing of all raw foods used bythe family, on three consecutive days. Atthe individual level information on in­takes is obtained by the 24 hour oral re­call method. Thus data are collected notonly on total family food consumptionbut also on intra-familial food distribu­

tion. This helps in cross-checking thevalidity of the data generated on totalfamily food consumption.

Since data on socio-economic factors,dietary intakes, and nutritional status ­both anthropometric and clinical - areall obtained from the same households,it would be possible to inter-relate them

in terms of cause and effect.

In each state, all data are collected bya team consisting of a medical officerand a nutritionist, who are speciallytrained at NIN.

Standardised techniques are usedboth for diet surveys and anthropometricmeasurements, thus ensuring uniformityof methodology, to the extent possible. Itneeds to be recognised that despiteusing the best and most appropriatesampling methods, true representative­ness can never be ensured. Similarly,the inherent limitations in the best dietsurvey methods pose problems of in­terpretation and a three-day weighmentmethod or a 24-hour recall method can­not be projected as being truly valid forlonger periods. Give'nthese limitations, itwould be fair to say that the data gener­ated and reported by the NNMB areperhaps the most authentic that are av­ailable in our country today. They can beused with confidence not only for inter­regional comparisons, but also for com­parisons across time.

Contributions Of The NNMB

Coverage: Since its inception in1972, till the end of 1984, the Bureauhas covered a total of 39,129 house­holds for diet surveys and 243,536 indi­viduals for assessment for nutritionalstatus, in rural areas. In urban areas cor­responding figures are 8,207 and32,500. The Bureau has published itsfindings in a series of reports brought outannually. Data have been presented notonly for the state as a whole, but alsoseparately for each of the districts co­vered.

Apart from this regular annual datacollection, the Bureau has also carriedout two special studies. In 1983-84, anNNMB-NSSO linked study, to relate theexpenditure-pattern to dietary consump­tion was done, while in 1985-86 specialtribal groups in the Integrated Tribal De­velopment Project Areas were com­prehensively studied. The reports ofthese studies are not as yet available.

Programme evaluation: The NNMBhas evaluated the following nutritionprogrammes and published the findingsas special reports.

• Vitamin A prophylaxisprogramme 1977-78

• Applied NutritionProgramme 1977-78

• India Population Project,Karnataka 1979

• Special NutritionProgramme 1979-80

• World Food-assistedFeeding Programme 1981-82

• National Anaemia

Prophylaxis Programme(Report not yet published) 1986-87

The coverage of both households andindividuals in the Survey looks large andimpressive, as does the fact that everymajor nutrition programme, except theNational Goitre Programme has beensystematically and objectively evaluatedfor its impact, on at least one occasion.The numbers when viewed in the con­text of the country's vast population maylook small and may give one the impres­sion that the larger numbers shouldhave been covered - particularly in thesmall villages. But considering themeticulous sampling system employed,the figures are not inadequate to drawvalid conclusions.

The original plan of completing datacollection from each state within a periodof three to six years has not beenachieved; nor has the NNMB been ableto revisit a single area which it had ear­lier covered, to examine directly, thechanges which might have taken placeas a result of the various developmentaland nutrition inputs. Though this activityhad been originally envisaged, it wouldappear that several factors, includingsome administrative difficulties, hadcontributed to this situation.

Scientific Data Generated

It is not the intention here to go into allthe data generated by the NNMB, but tohighlight some of these, which are ofpractical importance. Detailed informa­tion may be obtained from the Bureau'sAnnual Reports, published by the NIN.

Intake of food and nutrients and

magnitude of adequacy/inadequacy:(i) Because of the data generated by theNNMB, it is now possible to provide in­formation on the mean intakes of foodand nutrients of households and indi­viduals and also to provide quantitativeestimates of the proportion of familiesand subjects in rural India, whose nut­rient needs are not met (mean - 2SD ofthe recommended allowances are usedas cut-off levels). The wide variationsbetween states have become clearer thanbefore as a result of valid comparisonswhich can be made, between regions.

(ii) Data on nutrient intakes havehelped to place on a very firm scientificfooting the observation that the primary

limiting nutrient in the diets of even thepoorest segments of rural India isenergy and not protein - a finding ofenormous practical importance firstmade by Gopalan and co-workers sev­eral years ago. This situation is true of allthe states in the country.

(iii) Data on the intrafamilial distribu­tion of food has shown that a higherproportion of preschool children get lessthan their physiological needs, as com­pared to adults - again a finding com­mon to all the states studied.

(iv) Contrary to the widely prevalentbelief that in situations where a house­

hold has insufficient food, the man getsa higher share than does the woman,the NNMB data show that there is no

such discrimination. Proportion of menand women who have calorie inadequ­acy is similar. Similarly, contrary topopular belief, there is no gender biasagainst girls (Kamala S. Jaya Rao: NFlBulletinVol.5, No.3, 1984).

(v) The NNMB data have made it pos­sible to relate factors such as land hold­ing status, occupation, income and fam­ily status (whether joint or nuclear) toadequacy of food and nutrient intake(Nutrition News, NIN Vol. 3, No.2,1982).

(vi) The data have also indicated thatthe measurement of the consumption ofjust one food item - cereals - can beused as a proxy for total energy intake tomake rapid, approximate estimates ofchanging trends in calorie consumption.

Nutritional status: (i) As with foodand nutrient intakes, the NNMB datahave made it possible to provide quan­titative estimates of the growth status ofpreschool children - a measure widelyused as a proxy for nutritional status.The types of anthropometric measure­ments recorded have made it possible toclassify children according to gradesand types of malnutrition, as also tomake inter-state comparisons.

(ii) The simultaneous recording ofspecific clinical nutritional deficiencysigns, has not only provided informationon the prevalence rates of deficiencydiseases, but also to relate growthstatus to clinical deficiency signs.

(iii) Anthropometric measurements ofadult men and women in rural India wasscanty. The NNMB has provided thismuch needed data The widely held im­

pression that rural women are more un­dernourished than are men is not borneout by these data (Kamala S. Jaya Rao,NFl Bulletin Vol. 5, No.3, 1984).

(iv) The expected socio-economic

gradient in nutrient intake has been con­firmed. The energy and protein inta.kesof urban slum dwellers are no way dIffe­rent from those of the rural landlesslabourers (Kamala S. Jaya Rao, N~IBulletin Vol. 6 No.4, 1985). The nutn­tional status of even the urban middle in­come groups is far from satisfactory(Kamala S. Jaya Rao, NFl Bulletin Vol.7, No.1, 1986). .

(v) The nutritional status of rural girlsof preschool age has been found to beessentially similar to that of correspond­ing boys, indicating that there is no gen­der bias in nutrition care (Gopalan, NFlBulletin Vol. 8 No.4, 1987).

(vi) Data generated by the NNMBhave raised a host of issues related tothe interrelationship between nutrient in­take on the one hand and body size onthe other, as well as the importance ofnon-nutritional factors in determiningnutritional status (Gopalan, NFl BulletinVol. 5 ,No.1, 1984; Vol. 6, No.4, 1985).

Programme evaluation: The evalua­tion reports published by the NNMBhave helped in identifying the correctivesteps which need to be taken, with re­spect to the Vitamin A ProphylaxesProgramme, the SNP and the WorldFood-assisted Feeding Programme. Italso identified the basic weaknesses inthe Applied Nutrition Programme - theineffective education component.

Changes in the food and nutrilion- situation over time: (i) The Bureauhas found that there is a changing pat­tern in the types of food grains beingconsumed. The consumption of cereals- wheat and rice - show an upwardtrend, while that of millets, jowar, bajra,ragi, and maize show a downward trend.The mean consumption of vegetables,fruits, milk, oils and fats and sugar haveremained essentially unchanged.

(ii) According to the NNMB, over thelast decade there have been changesboth in the mean calorie intake of ruralIndian households and in the prevalenceof severe forms of growth retardationamong preschool children, at the mac­rolevel (aggregated data). The Bureau'sconclusion that "during the period from1975 to 1980, there has been an in­crease in average calorie consumptionlevels of rural populations at the house­hold level" and that "the average intakeof calories in the lowest income groups(less than Re. 1 per person per day)show a definite increasing trend" (Nutri­tion News, Vol. 7, Nos. 2 and 5, 1986)have come in for sharp criticism (K.

Ramachandran, NFl Bulletin, Vo1.8, No.1, 1987) This criticism has been ~a~edon consideration of both the statisticalmethodology employed and on the ob­servation that the pattern of coverage ofhouseholds according to income .overtime had changed - in favour of higherincome. (The mean increment in calorieintake between 1975 and 1980 has b~enaround 100 calories per consumptionunit.)

The NNMB, however, argues that thevalidity of some of the statistical pointsmade by Ramachandran is debatable. Italso points out that the per capita dataare derived depending mainly on occu­

pation and that when intakes of separateoccupational groups are looked at, thetrend of increasing calorie consumptionwould be evident, the largest increasebeing in the landless labour group. How­ever, NNMB's data in the years sub­sequent to 1980 indicate that the earliertrend of increasing calorie consumptionclaimed by it had been reversed. Thissignificance which the NNMB has at­tached to marginal variations perhapsneeds to be reassessed.

(iii) The NNMB has indicated that theirdata on the nutritional status of rural In­dian preschool children show a generaltendency to improve from 1976 to 1980,based on the observation that the prop­ortion of children with severe grades ofmalnutrition has fallen from 8.5 percentin 1976 to around five percent in lateryears. A look at the earlier NNMB re­ports shows that there was a suddendrop in this value from over 21 percent in1975 to 8.5 percent in 1976. It needs tobe emphasised that this sensational de­cline was due to the switching over to adifferent standard of normalcy - from theHarvard to the Hyderabad standard. Thelatter was evolved on the basis of inves­

tigation of a relatively small sample ofchildren belonging to well-to-do familiesin Hyderabad. The validity of the use ofthis standard has been questioned onthe basis of the finding that when thisstandard is used, more boys than girls inrural India show greater degrees ofgrowth retardation! This may lead one toan erroneous conclusion that boys,rather than girls are discriminatedagainst (C. Gopalan, NFl Bull. Vo1.8,No.4, 1987). It has also been pointed outthat despite the NNMB's finding aboutthe lower prevalence of severe growthretardation, the mean values for heightsand weights of rural Indian children hadchanged little over the years (Gopalan,NFl Bull. Vol. 7, No.1, 1986).

The need for caution and circumspec-

tion in the interpretation of valuab~edatahardly needs emphasis. It may mdeedbe prudent on the part of NNM.Bin fu~ureto have in-depth in-house discussionson tentative conclusions and have them

critically examined by its own exp.ertgroup before such co~clu~ion~, ~hlchcould carry wide practical Implications,are publicised. This will avoid unneces­sary confusion and criticism.

It needs to be emphasised here thatthe criticisms considered above pertainto interpretations of some data; the relia­bility of the data themselves gathered byNNMB meticulously has not been

questioned. The criticism of interpreta­tions should not be allowed to obscureor belittle the solid achievements. Thepoint to remember is that the data beinggenerated by NNMB are about ~heon!yreliable and authentic data available mthe country today regarding dietary in­takes and nutritional status of represen­tative population groups in some parts ofthe country. There can also be no doubtabout the great potential value of thesedata.

Some Limitations Of The NNMB And

Suggestions To Remedy Them

The contributions of the NNMB are

quite impressive. But for it to express itsfull potential and play the important roleexpected of it, it is necessary to correctsome deficiencies.

• An obvious and serious weakness.of the Bureau relates to its incompletecoverage of the country. Its activities arelimited to just 10 states. Some of themost prosperous and developed states- Punjab and Haryana - and none ofthe North-Eastern states are covered,

thus raising the valid objection that cur­rent data are not applicable to the coun­try as a whole. This situation needs to bequickly corrected.

• The Bureau's inability to completedata collection within the time frame

originally conceived is also a seriouslimitation. Apart from the data becoming'outdated' to some extent, the validity ofpooling of yearly data to arrive at thestate position may become question­able. The category into which a districtwas placed may change since develop­ment is a dynamic process and theBureau may do well to look into whetherthe original indices employed shouldcontinue. To achieve time-bound cover­age, expansion of staff and associatedfacilities must be seriously considered.

• Most data-collecting bodies makeuse of but a small fraction of what is col-