Nutritional Status Of Children And WomenIn India: Recent Trends

H.P.S. Sachdev

Over the past two decades,there has been a substantial andprogressive decline in infant andchild mortality rates in India1• Therehas also been a significant reduc­tion in the prevalence of florid nutri­tional deficiency disorders. It is there­fore important that increasing at­tention is now paid to the nutri­tional status of the survivors. Thealarming reports of some interna­tional agencies2 which have placedIndia at about the bottom-rung ofan arbitrary world development scale,have raised apprehensions that thenutritional status of women andchildren in India shows no signs ofimprovement. Recent trends withrespect to the nutritional status ofwomen and children in India havebeen analysed and evaluated, soas to address this issue.

This paper is based partially onpublished information but more im­portantly on non-indexed publicationsand reports, culled from several insti­tutions and individual scientists inthe country. The information on chang­ing trends gathered from these datais being presented here.

PROTEIN ENERGY NUTRITION

The most outstanding achieve­ment on the national nutrition frontduring the last four decades has beenthe virtual 'banishment' of acute largescale famines, of the type that usedto decimate sizable sections of thecountry's population with distressingregularity for centuries3.

The personal experiences ofpaediatricians throughout the coun­try indicate that in the past three de­cades there has been a significantdecline in severe protein energy mal­nutrition (classical kwashiorkor andextreme forms of marasmus) inhospitalised children. The decline hasbeen particularly dramatic in relationto classical kwashiorkor, which hasvirtually disappeared from numerousregions. This change in the spectrumhas been occasionally quantified4.

Reliable community-based data

generated by the National NutritionMonitoring Bureau (NNMB) from eightcentral and southern states (AndhraPradesh, Gujarat, Karnataka, Kerala,Madhya Pradesh, Maharashtra, Orissaand Tamil Nadu) also confirm a de­cline in clinical deficiency signs in pre­school children (one to five years old)from 1975-79 to 1988-90 in rural ar­eas5. The overall prevalence of marasmusdecreased from 1.3 to 0.6 per cent andkwashiorkor from 0.4 to 0.1 per cent.Amongst the 12,000 children evalu­ated in the 'repeat surveys', Gujaratshowed the highest prevalence of bothforms (1.1 per cent kwashiorkor and4.9 per cent marasmus), while in theother states their prevalence was below1 per cent. In the NNMB and NationalCouncil for Applied Economic Re­search (NCAER) linked survey con­ducted in 1994 in the same eightstates but in different sampled ar­eas6, among 1,828 preschool chil­dren the overall prevalences ofkwashiorkor and marasmus were 0.2and 0.4 per cent, respectively. In fact,

cases of kwashiorkor were seen onlyin Madhya Pradesh, where the preva­lence was about 1.4 per cent. Fortu­nately, a similar declining trend wasdocumented in the under-privilegedurban slums? of these six states (citiesincluded Ahmedabad, Bangalore,Bhubaneswar, Cuttack, Hyderabad,Nagpur and Trivandrum). The overallprevalence of marasmus diminishedfrom 3.7 per cent in 1975-79 (n=519)to 0.2 per cent in 1993-94 (n=334).No case of kwashiorkor was observed.

LOW BIRTH WEIGHTS

It is generally believed that therehave been no differences in the re­ported mean birth weights and theproportion of newborns with LBW (lowbirth weight8; <2,500 g) in the threedecades between the late 1960s andthe late 1980S8,9. These inferenceswere based on a comparison of datafrom disparate settings at various timepoints. Given the expected marginalmagnitude of change in birth weightin two to three decades in a nation

CONTENTS• Nutritional Status Of

Children

And Women In India: Recent Trends

1

- H.P.S. Sachdev •Iodine Deficiency Diseases

In India

6

• Nutrition News

7

- N. Kochupillai• Foundation News

8

• Universal Salt lodisationProgramme (USI) In India -Progress And Achievements

8I- S. Vir

TABLE 2Changes in Prevalence (%) of MalnutritionSurvey

MalnutritionNNMB5NNMB5NNMB6NFHS19

Index1975-791988-9019941992-93 *

(n=6,428)(n=13,422)(n=1,832)(n=25,578)

Weight-far-age(underweight)<2SD

77.568.663.653.4<3 SD (severe)

38.026.624.720.6

Height-far-age(stunting) 52.0

<2SD 78.665.163.0<3 SD (severe)

53.336.835.828.9

Weight-far-height(wasting)<2SD

18.119.916.717.5<3 SD (severe)

2.9.2.42.63.2

* For weight-for-age assessment only. The sample size for the other two indices was

lower.

TABLE 1Trends in Intrauterine Growth

Ref

Area SettingComparison Period Observed Changes(Mean gap in yr)

WeightGestationIUGC

10

Rourkela Industrial1963 & 1986MBW +74gNANA(Orissa)

Hospital(23) LBW -34 vs 25%11

Delhi Hospital1969 & 1989NATerm +*0(Poor)

(20)13

Delhi Hospital1973-74&1985-87NANA+(Better-off) (12.5) 14

North Arcot(Tamil Nadu)

Rural1969-73 & 1989-93MBW+78gM+0.7W+p(20)

LBW -27 vs 16%PT -21 vs 16%Urban

1969-73 & 1989-93MBW+52gM+0.8W+p(20)

LBW -19 vs 11%PT -20 vs 15%15

Veil ore Hospital1969 & 1994MBW+126gMe+0.3WNA(25)

LBW -27 vs 15%PT -14 vs 10%16

Mumbai Hospital1988 & 19.95LBW -60 vs 38%0NA(Poor)

(8)17

Delhi Hospital1986 & 199600NA(Poor)

(11)

+: significant increase; + p: significant at some gestations; -: significant decline; 0: no

significant change; IUGC: Intrauterine Growth Curves; M: Mean; Me: Median; MBW:Mean Birth Weight; NA: Not Available; Ref: Reference number; W: Gestation in weeks; *Calculated by comparison with earlier study values cited in reference 12.

commencing epidemiologic transition,these inferences from such a researchdesign are not surprising. It would,however, be more valid to analysedata from the same area at differenttime points.

In analyses of this nature (Table1), a positive time trend for birth weightis evident in most hospital-based dataand the solitary community study. The

mean magnitude of improvement ismarginal (52 to 126g). However, thishas resulted in a greater reduction ofLBW prevalence (by 8 to 12 per cent).These calculated mean improvementsin birth weight are probably under­estimates since concomitant changesin other important associates havebeen ignored. With time, the meanbirth order has also decreased andcorrection for this factor alone'5 en-

2

hanced the magnitude of change inthe community study (rural and ur­ban areas combined) from 70g to1DOg (first-borns have lower weightsthan later births). The absence of atime trend in the two Delhi hospitalsmay be related to the relatively shortgap in one report17 and the fact thatthese institutions primarily cater tothe underprivileged population in whomthe transition is expected to com­mence last of all. In one of thesestudies11, the higher percentage ofterm births could be regarded as thebeginning, since term new-borns havethe best intrauterine growth as a group.

The small improvement in birthweight is probably contributed to byan increase in both the overall gesta­tion period and an increase in birthweight at different gestation periods(intrauterine growth curves).

GROWTH OF CHILDREN

In developing countries, anthropometry,despite its inherent limitations, stillremains the most practical tool forassessing the nutritional status ofchildren in the community. In thiscontext, there have been several smallscale surveys but the data from thesemay not be representative ofthe countryas a whole. The two major nationalsurveys which provide data related tonutrition and cover large segments ofIndia's population are:• the periodic surveys carried out bythe NNMB5.7.18of the National Insti­tute of Nutrition, Hyderabad, and• the recent National Family HealthSurvey (NFHS) initiated by the Minis­try of Health and Family Welfare, Gov­ernment of India19.

It is important to be aware ofseveral factors, notably the samplingframework, which can potentially in­fluence the estimates of malnutritionprevalence from these surveys20.

Table 2 compares the estimatedprevalence of various indices of mal­nutrition in these surveys as per thecurrent international recommendationand nomenclature. A distinct improve­ment in the prevalence of underweightand"stunting (including in the severecategory, namely, below 3 SD) is evi­dent from the NNMB data at an aver­age rate of 1 per cent per annum. TheNFHS19estimates were still lower thanthe NNMB-NCAER6 prevalences atcomparable time periods. This couldbe partly related to differences insampling design, areas surveyed (whole

FIGURE 2: Secular Trend in Weights of Women

4237

interest in the Indian setting, has alsobeen analysed. A positive trend in allthese anthropometric parameters isevident at virtually all the ages ex­amined (statistically significant atmost points) with each successivesurvey recording higher mean val­ues than the preceding one. How­ever, the differences in height (Fig­ure 1) between the NNMB 1988-90and NNMB 1994 surveys were neg­ligible at several ages.

The positive time trends in heightin the 'repeat surveys' (1988-90) weremore marked in the age group 12 to14 years (mean differences between1.7 to 3.0 cm) than later (mean differ­ences between 0.3 to 1.4 cm). Themean increase in adult stature be­tween 1975-79 and 1988-90 was cal­culated to be 1.2 cm26. The quantumof difference (marginal) in height maybe related to the relatively short inter­observation period (average 12 years)

for documenting seculartrends in this parameter.The usual differences inmean weight ranged from0.7 to 2.2 kg between the1975-79 to 1994 surveys andthe corresponding figuresfor mean triceps fat foldthickness were 1.5 to 2.5mm. These differences toowere not striking for an av­erage inter-observationperiod of 17 years, but theydo represent the initiationof a positive nutritional trend

3211 22 27

AGE IN Co)lPLETID YEARS

• NNMB(1975-79) [J Nl'MB (198'·90) [J NNMB(1994)

FIGURE 3: Trend in Fat Fold of Women

The time trends in NNMB

data5,6,18for height, weight andtriceps fat fold thickness in fe­males between the ages of 12 to47 years are depicted in Figures1-3. The adolescent age group(12 to 18 years), of particular

TABLE 3Trends in Body Mass Index in Adult Women

Survey (values in %)

Body MassNNMB5NNMB5NNMB6NNMB7

SlumIndex1975-791988-9019941993-94

Definition(value)(n=6,428)(n=13,422)(n=1,832)(n= 1 ,319)

Chronic Energy Deficiency Third

«16) 12.711.310.49.5Second

(16-17)13.212.911.29.2First (17-18.5)25.925.125.518.0All «18.5)51.849.347.136.7Normal

(18.5-25)

44.846.646.351.7Obese

(>25)

3.44.16.611.6

* Body Mass Index (BMI) is defined as weight (kg) / height2(m).The percentages for NNMB surveys 1975-79 and 1988-90 for the various categorieswere taken from reference 26.The percentages for different categories for BMI < 18.5 for NNMB survey 1994 wererecalculated from the total adult sample.

for all the states) on heights, weightsand body mass index over the periodshows a definite improvement. Theaverage values of measurements, ingeneral, for almost all the age groupsin both sexes show an increase; heightincrements tended to be more in chil­dren, with weight increments morevisible in adults and adolescents. State­wise data clearly indicate that the

heights of children and adoles­cents, and weights of adults andadolescents in the state of Keralaand, to some extent, in Maha­rashtra and Gujarat were dis­tinctly better as compared tothe 1970s9.

42

"T

R 13I

CEPII

F

0L07

(mm)

42

,12

o

37

373227

o

32

22

o

17

17

AGE IN COMPLETED YE..\RS

• NNMB (1975·79) 0 NNMB (1988·90) I!J NNMB (1994)

22 27 32

AGE 11';COMPLETED YEARS

.NNMB(1975·79) CNNMB(1988·90) I:INNMB(1994)

'55

13012

so

M45E

AN ..,W EI

35G HT 30

(kg) "12

FIGURE 1: Secular Trend in Heights of Women

NUTRITION OF WOMEN

country versus eight states and ur­ban plus rural versus rural) and theage groups analysed (zero to fouryears versus one to five years).

Fortunately, a similar overalldeclining trend was also documentedin the underprivileged urban slums?of six states between the periods 1975­79 and 1993-94 for weight-far-age(Gomez classification based on Na­tional Centre for Health Statisticsreference).

It must be noted that there isvirtually no change in the profile ofwasting in this period and the NNMBand NFHS estimates are also identi­cal (Table 2), indicating thereby thatthe improvement in the weight-for­age index is predominantly due to anincrease in the height.

A few studies have attempted toquantify the secular trends in heightby comparison of mothers and daugh­ters8,21·25.No positive trend was dis­cerned in women from poor socio­economic strata8,23.25whereas a sig­nificant increase, even up to a meanvalue of 5 cm18, was documented inwell-to-do communities21,22.

An analysis of the NNMB 're­peat survey5' aggregate data (pooled

TABLE 4Changes in Prevalence of Bltot Spots in PreschoolersSurvey

PeriodPrevalence (%)

leMR 1977 (28)

1965-694,2NNMB 1975-79 (5)

1975-791.8NNMB 1988-90 (5)

1988-900.7

NNMB 1992-93 (29)1992-931.9*

NNMB 1994 (6)

19941.1

NNMB Slum (7)1993-940.9 to 2.5%*

* This rural survey included two additional states (Uttar Pradesh and West Bengal) than

earlier NNMB surveys.* Bitot spots documented in only three of six cities surveyed.Figures within parentheses are references.

in the relatively poor rural population.A similar analysis was not feasible forthe urban poor as the published re­porF did not provide comparative fig­ures for this purpose.

Body Mass Index (BMI): BMI isbeing increasingly used as a mea­sure of nutritional adequacy in adultsand is considered to be a better indi­cator of chronic energy deficiency(CED)9. The time trends in BMI ofadult women from the NNMB data aresummarised in Table 3. A distinctshift of the distribution to the right isevident in the rural population. Inter­estingly, the underprivileged urbanslum population had the best values.However, even now CEO is prevalentin 37-47 per cent of the women withthe severe variety being documentedin 10 per cent. Obesity is also nowbeginning to emerge (7 to 12 per cent).

MICRONUTRIENTS

Vitamin A: Since preschool chil­dren bear the brunt of the deficiency,nationally representative surveys haveprimarily focussed on this age group.A nationwide survey conducted bythe ICMR during 1971-74 showed that2 per cent cases of blindness wereattributable to corneal disease caused

by vitamin A deficiency9. In the sub­sequent (1985) national survey of blind­ness, carried out under the auspicesof the Government of India and theWorld Health Organization (WHO),this figure declined to 0.04 per cent9,27.Data from the School of Tropical Medi­cine, Calcutta, once the hot-bed ofkeratomalacia, and from the Chris­tian Medical College, Vellore27are alsosuggestive of a sharp reduction inthe documentation of keratomalacia(0 to 0.008 per cent in the late 1980s).A careful scrutiny of the hospital data

from Calcutta in fact suggests thatthe decline in the incidence ofkeratomalacia had started even be­fore the massive dosage prophylaxisprogramme had been instituted27.

The changes in estimated preva­lence of Bitot spots in preschool chil­dren from macro surveys aresummarised in Table 4. A marked

decline is evident, especially in theNNMB 'repeat survey5'. The slightapparent increase in later surveys29is probably related to the differentsampling areas which included therelatively poorly performing states ofUttar Pradesh and West Bengal. In­terestingly and paradoxically, the overallprevalence of night blindness (1.1per cent) in this survey was lowerthan that of Bitot spots (1.9 per cent)in one to five year-old children29. Wideregional variations are apparent insome areas. A noteworthy observa­tion was the absence of Bitot spots ininfants and children, even in the slums,in the surveys conducted in the 1990s.

Iron: Anaemia has been the mostcommon parameter employed to de­termine iron deficiency. Personal ex­periences of several paediatriciansand obstetricians allover the countryindicate a dramatic decline of severeanaemia with oedema in children andwomen (pregnant and non-pregnant).A limited comparison of studies con­ducted in similar areas on compa­rable age and physiological groupsat different time periods yielded twosuch series30-32.In Vadodra, there wasa significant (p=0.014) decline in theprevalence of anaemia (haemoglobin<11 g/dl) from 71 percent (n=500) to65 per cent (n=610) between 1982­84 and 1993-94 in urban low income

preschool children32. In pregnantwomen from Hyderabad, possibly fromdifferent settings3o,31 the prevalence

4

of anaemia (haemoglobin < 11 g/dl)significantly declined from 48.5 percent to 33.2 per cent. Estimates basedon ICMR evaluation in 1984-85 of theNational Nutritional Anaemia Prophy­laxis Programme indicated that 88per cent of pregnant women wereanaemic with 47 per cent havinghaemoglobin values below 9 g/dI33.The latest estimates pertaining to theICMR multicentric field supplementa­tion trial (published in 1992) on 1,968pregnant women lowered these esti­mates to 62 per cent and 17 per cent,respectively3'.

Iodine: In Delhi, the goitre preva­lence rate in school children declined

from 55.2 in 198034 to 8.6 per cent in199635;the salt iodisation programmewas implemented in 1989. The rou­tine surveys conducted by the Direc­torate General of Health Services36indicate a significant decline in totalgoitre prevalence rate in 17 out of 21districts from different states in whichrepeat information was available. Themagnitude of decline ranged from 6to 35 per cent (general values above30 per cent in the Himalayan regionand Uttar Pradesh) for repeat sur­veys performed six to 40 years later.Time series data revealed a markedreduction in the incidence of neona­tal chemical hypothyroidism (NCH)in the highly endemic areas of UttarPradesh following salt iodisation37-38.

CONCLUDING COMMENTS

Recent trends with regard tonutritional status of women and chil­dren in India have been positive butmodest. The improvement has beenmarked with respect to the preva­lence of 'severe malnutrition'. Evenwith respect to moderate undernutri­tion modest improvements inanthropometry and birth weights havebeen noticeable even amongst thepoor. These observations in poorwomen and children, despite a steepincrease in population and continu­ing social and economic inequalities,are heartening indications that, at longlast, India may be at the turning pointwith respect to nutrition.

The improvements though smallhave been achieved in the context of asubstantial decline in mortality. Mostmalnourished children who would havedied earlier are now being saved; andthis may be expected to swell the ranksof the 'moderate undernourished'.The fact that in spite of this, an

improvement in the overall averageshas been registered is heartening.

Reviewing the latest NNMB datain 1992, Gopalan39 had pointed outthat these data which revealed afavourable secular trend with regardto growth of women and children pro­vide a glimmer of 'light at the end ofthe tunnel' and had suggested thatfuture survey results will be awaitedwith interest in order to decide if in­deed, Indian children were now onthe march towards better nutrition.The present analysis shows that thismarch might well havebegun. Thoughthe beginnings are still small, theyprovide hope for the future of Indianwomen and children. The challengenow is to accelerate the pace of im­provement.

There is yet another messagethat emerges from this analysis. Thenear total disappearance, within thelast four decades, of florid nutritionaldeficiency diseases which were oncemajor public health problems and theinitiation of a positive trend with re­spect to less severe forms of under­nutrition have important practical im­plications. With the possible excep­tion of iodine deficiency disorders,none of these changes can be cred­ited to specific 'nutritional interventionprogrammes', but to all-round improve­ment in the economic, health and di­etary status of poor communities.

Thus, no specific drug or vita­min was used to combat beri-beri orpellagra which were once rampantbut which have now disappeared. Norwas the present near disappearanceof kwashiorkor achieved through thesupply of 'protein-concentrates',strongly advocated by internationalagencies (before the 'protein fiasco').

This irrefutably argues for theconcept of an all-round, integrated,rather than a narrow (drug-based)approach towards combatingundernutrition.

The author is Professor and In-charge of theDivision of Clinical Epidemiology at the Departmentof Paediatrics, Maulana Azad Medical College, NewDelhi, India.

References

1. Puri, R.K. and Sachdev, H.P.S.: Secular trendsand determinants of under five mortality compo­nents in India: Implications for child survival strat­egies. Report submitted to the Ministry of Healthand Family Welfare under USAID Child SurvivalProgrammes, September 1991.

2. Investigating in Health. World DevelopmentReport, 1993. Oxford University Press, New York.

3. Gopalan, C.: The changing profile of undernu­trition in India. NFl Bull, 12(1): 1-5, 1991.

4. Bhattacharya, AX, Chattopadhyay, P.S., RoyPaladhi P.K., Ganguli, S. and Bhattacharyya, N.:Kwashiorkor and marasmus: Changing hospitalincidence ofsyndromic presentation (1957-88).IndianPediatr, 27: 1191-1198, 1990.

5. National Nutrition Monitoring Bureau. Reportof Repeat Surveys (1988-90). National Institute ofNutrition, Hyderabad, 1991.

6. Nutritional Status of Rural Population: Reportof NNMB Surveys. National Nutrition MonitoringBureau, National Institute of Nutrition, Hyderabad,1996.

7. Report of urban survey - slums (1993-94).National Nutrition Monitoring Bureau, National In­stitute of Nutrition, Hyderabad, 1994.

8. Srikantia, S.G.: Pattern of growth and develop­ment of Indian girls and body size of adult Indianwomen. In: Women and Nutrition in India. Eds:Gopalan, C. and Kaur, S., NFl Special PublicationSeries 5; 108-152, 1989.

9. Reddy, V., Shekar, M., Rao, P. and Gillespie,S.: Nutrition in India. National Institute of Nutrition,Hyderabad, 1992.

10. Satpathy, R., Das, D.B., Bhuyan, B.K., Pant,K.C. and Santhanam, S.: Secular trend in birth

weight in an industrial hospital in India. Ann TropPediatr, 10: 21-25, 1990.

11. Man Mohan, Shiv Prasad, S.R., Chellani, H.K.and Kapani, V.: Intrauterine growth curves in NorthIndian babies: Weight, length, head circumferenceand ponderal index. Indian Pediatr, 27: 43-51,1990.

12. Bhargava, S.K., Sachdev, H.S.P., Iyer, P.U.and Ramji, S.: Current status of infant growth mea­surements in the prenatal period in India. ActaPediatrScand, 319 (Suppl): 103-110, 1985.

13. Singhal, P.K., Paul, V.K., Deorori, A.K., Singh,M. and Sundaram, K.R.: Changing trends in intrau­terine growth curves. Indian Pediatr, 28: 281-283,1991.

14. Trends in intrauterine growth of single live bornsduring 1969-73 and 1989-93 among rural and urbancommunities of North Arcot, AmbedkarDistrict, TamilNadu, India. Longitudinal Studies in growth anddevelopment, Monograph No 21, Department ofBiostatistics, Christian Medical College, Vellore.

15. Mathai, M.: Changes in health status and birthweight in Vellore over 25 years (1969-1994). Paperpresented at aworkshop on 'Health in Transition' inNorway, (personal communication) May 1995.

16. Fernandez, A.R.: Change in birth weight andgestation patterns in Sion, Mumbai. Personal com­munication, 1996.

17. Ramji, S.: Changes in birth weight and gestationpatterns in Delhi. Personal communication, 1997.

18. National Nutrition Monitoring Bureau. Reportfor the year 1979. National Institute of Nutrition,Hyderabad,1980.

19. National Family Health Survey: MCH and Fam­ily Planning -India, 1992-93. International Institutefor Population Sciences, Mumbai, 269-287,1995.

20. Sachdev, H.P.S.: Assessing child malnutrition:Some basic issues. NFl Bull, 16(4): 1-5, 1995.

21. Kapoor, S., Kapoor AX, Bhalla R. and Singh,I.P.: Parent offspring correlation for body measure­ments and subcutaneous fat distribution. HumanBioi, 57: 141-150, 1985.

5

22. Visweswara Rao, K., Balakrishna, N., andShatrugna, v.: Secular trends in height of well-to­do adults and the associated factors.Man India, 73:267-273, 1993.

23. Shatrugna, V. and Viswesvara Rao, K.: Secu­lar trends in the heights of women from the urbanpoor community. Ann Human Bioi, 14: 375-377,1987.

24. Secular changes in heights of daughters ascompared to their mothers. NIN, Hyderabad, An­nual Report 1986-87.

25. Studies on adolescent girls. National Instituteof Nutrition, Hyderabad, Annual Report 1987-88.

26. Reddy, V., Pralhad Rao, N., Gowrinath Sastry,J. and Kashinath, K.: Nutrition trends in India.National Institute of Nutrition, Hyderabad, 1993.

27. Gopalan, C.: Nutrition research in South EastAsia: The emerging agenda for the future. WorldHealth Organization - Regional Office for SouthEast Asia, 1994.

28. Studies on preschool children. Report of theworking group of the Indian Council of MedicalResearch, New Delhi. ICMR Technical Report SeriesNumber 26, 1997.

29. Vijayaraghavan, K., Brahman, G.N.V., Reddy,G. and Reddy, V.: Linking periodic dosing of vita­min A with universal immunisation programme ­An evaluation. National Institute of Nutrition,Hyderabad, 1996.

30. Prema, K., Neelakumari, S. and Ramalakshmi,B.A.: Anaemia and adverse obstetric outcome.NutrRep Int, 23: 637-648, 1981.

31. Field supplementation trial in pregnant womenwith 60 mg, 120 mg and 180 mg of iron with 500~cgof folic acid. Indian Council of Medical Research,Task Force Study. New Delhi, ICMR, 1992.

32. Seshadri, S.: Change in prevalence of anaemiain urban low income preschool children in Vadodra.Personal communication, 1997.

33. Evaluation of National Nutritional Anaemia Pro­phylaxis Programme. Indian Council of MedicalResearch, New Delhi, 1989.

34. Pandav, C.S., Kochupillai, N., Karmarkar, M.G.,Ramachandran, K., Gopinath, P.G. and Nath, L.M.:Endemic goitre in Delhi. Indian J Med Res, 72: 81­82, 1980.

35. Kapil, U., Saxena, N., Ramachandran, S., Balamu­rugan, A., Nayar, D. and Prakash, S.: Assessmentof iodine deficiency disorders using the clusterapproach in the National Capital Territory of Delhi.Indian Pediatr, 33: 1013-1017, 1996.

36. Unpublished reports of the All India GoitrePrevalence Surveys conducted by the DirectorateGeneral of Health Services, Ministry of Health andFamily Welfare, Government of India, 1956-1996.

37. Kochupillai, N.: Neonatal chemical hypothyroi­dism of nutritional origin: A major public healthproblem that impairs growth in developing coun­tries. In: Recent Trends in Nutrition, 181-193. Ed:Gopalan, C., Oxford University Press, Delhi, 1993.

38. Kochupillai, N.: Micronutrient deficiency andhuman health and development. Srikantia Memo­rial Lecture at the XXIX Annual Meeting of theNutrition Society of India, November 21-22, 1996,Hyderabad (unpublished data).

39. Gopalan, C.: Light at the end of the tunnel?Reviews and Comments.NFI Bull, 13 (1): 7-8, 1992.