Nutritional interventions through primary health care: impact of the ICDS projects in India

In 1975 the Government of India initiated an integrated approach for the delivery of health care as well as nutrition and education services for deprived populations at the village level and in urban slums through centres, each of which was run by a local part-time female worker (anganwadi) who was paid an honorarium and had a helper. This national programme, known as the Integrated Child Development Services (ICDS), began with 33 projects but, by March 1986, had expanded to 1611 projects covering 23% of the country's population and representing about 50% of the population in the socioeconomically backward areas. The ICDS can therefore be considered to function as a primary health care programme for preschool children (under 6 years old), pregnant women, and lactating mothers. The present study investigated the impact on the nutritional status of the target population after 3-5 years and after 8 years of ICDS interventions, compared with the nutritional status of non-ICDS (control) groups. The results showed that the ICDS nutrition intervention programmes achieved better coverage of the target population and led to a significant decline in malnutrition among preschool children in the ICDS population, compared with the non-ICDS groups that received nutrition, health care and education through separate programmes. This example may lead other developing countries to introduce integrated programmes with certain modifications to suit local conditions. International agencies and national governments should strive to bring about the integration of nutritional services with primary health care and development programmes for children because of the good results in terms of child survival and child development.     

Study of impact of nutrition & health day strategy on the coverage rates of supplementary nutrition and health interventions among the ICDS beneficiaries in a rural block of Madhya Pradesh

To study the trends of beneficiary coverage (pregnant and lactating women and children less than two years of age) for utilization of supplementary nutrition and health services in a rural block before and after the launch of a strategy to converge Health & Integrated Child Development Services (ICDS) on a single day christened "Nutrition and Health Day" (NHD). It is a before and after intervention design in rural ICDS block Amarwada in district Chhindwada. As a part of intervention, NHD were organised on which convergent services of Health & ICDS were made available to the beneficiaries. On the weekly NHDs, uncooked supplementary nutrition for the week was distributed to pregnant and lactating mothers and children under two. The Health worker visited the Anganwadi Centre (AWC) and immunized children and pregnant women, distributed IFA, Vitamin A and provided health and nutrition education. The study assessed the impact of these interventions on the coverage rates of the services. Study was conducted between May 97 and March 98. The routine monitoring reports of the ICDS and Health System of the state government were used as study tools. The study sample comprised of AWC beneficiaries in the project area. The total population of the block was 89,476. Participation in the supplementary nutrition program (SNP) increased two to three folds in all categories of the target population. Immunization and Vitamin A coverage levels for children also showed an increase of about 3 and 5-8 times from baseline status respectively in a year's time. Among pregnant women, Tetanus Toxoid (TT) and Iron and Folic Acid (IFA) utilization rates have also shown two and five fold increase respectively.     

Integrated training of health functionaries in ICDS scheme

India's Integrated Child Development Services (ICDS) was first implemented in October 1975, in 33 experimental blocks and expanded to include 2499 projects by March 1991. ICDS is multisectoral and coordinated at the village, block, district, state, and central government levels. Program responsibility is vested in the women and child development department at the center level and at a variety of different departments at the state level (social welfare, rural development, tribal welfare, or health and family welfare departments). The target population is children under 6 years of age and lactating women aged 15-44 years. Program objectives include improving the nutritional and health status of children aged 0-6 years; providing a foundation for proper psychological, physical, and social development of children; reducing the incidence of mortality, morbidity, malnutrition and school dropouts; effectively coordinating policy and implementation among relevant departments; and enhancing mothers' capabilities to provide for the normal health and nutritional needs of their children. "Anganwadi" workers at the local level and supportive personnel from health departments administer services, which include the following: supplementary nutrition, immunization, health checkups, referral services, treatment of minor illnesses, nutrition and health education for women, preschool education for children aged 3-6 years, and cooperation with improvement in supportive service such as water supply and sanitation.     

Toddler diets in the U.K.: deficiencies and imbalances. 1. Risk of micronutrient deficiencies

The toddler diet in the U.K. changed considerably during the 25 years between the last two national dietary surveys, and these and other reports suggest that the nutritional intake of many toddlers does not comply with national recommendations. This is a concern for parents and health care workers because both deficiencies and excesses in nutrition are associated with increased risk of diseases, such as iron deficiency anaemia, rickets, dental caries and diseases related to obesity. Paradoxically, a decrease in energy intake has been accompanied by a rise in obesity, while a parallel fall in vitamin and mineral intake has been seen in tandem with an increase in diseases associated with nutritional deficiency. Establishing good dietary habi in early childhood is therefore important for short-term health. Dietary patterns at this time may be crucial to later behaviour and, if carried through to adulthood, may affect long-term health. In particular, deficiencies of micronutrients such as iron, zinc and vitamin D are a cause for con cern. Childhood diseases such as rickets, which affects bone development and was thought to have been eradicated, have re-emerged in recent years and the prevalence of iron deficiency anaemia has increased, particularly among migrant populations among migrant populations. Part 1 of this review considers the relationship between current toddler diet and micronutrient deficiencies, focusing on the impact of deficiency on both short- and longterm health. In Part 2 (to be published in Journal of Family Health Care 2007; 17[6]), the authors will consider effects on health of nutritional imbalance resulting from overconsumption of energy and nutrients.     

Community-level micronutrient fortification of a food supplement in India: a controlled trial in preschool children aged 36-66 mo

BACKGROUND: Children participating in the Integrated Child Development Service (ICDS) in India have high rates of iron and vitamin A deficiency. OBJECTIVE: The objective was to assess the efficacy of a premix fortified with iron and vitamin A and added at the community level to prepared khichdi, a rice and dal mixture, in increasing iron and vitamin A stores and decreasing the prevalence of iron deficiency, anemia, and vitamin A deficiency. DESIGN: This cluster, randomized, double-blind, controlled trial was initiated in 30 Anganwadi centers (daycare centers) in West Bengal state, India. Children aged 36-66 mo (n = 516) attending village-based ICDS centers were randomly assigned to receive either a fortified or a nonfortified premix for 24 wk. Blood was drawn at 0 and 24 wk by venipuncture for the measurement of hemoglobin, serum ferritin, and serum retinol. RESULTS: The change in the hemoglobin concentration of anemic children was significantly different between fortified and nonfortified khichdi groups (P < 0.001). Prevalence rates of anemia, iron deficiency, and iron deficiency anemia were significantly lower after 24 wk in the fortified-khichdi group than in the nonfortified-khichdi group (P < 0.001). There were no significant differences in serum retinol concentrations or in the prevalence of vitamin A deficiency between the fortified- and nonfortified-khichdi groups. CONCLUSION: A premix fortified with iron, vitamin A, and folic acid and added to supplementary food at the community level can be effective at increasing iron stores and reducing the prevalence of iron deficiency and anemia.     

Impact of ICDS on health and nutritional status of children

The Integrated Child Development Services (ICDS) in India comprises health, nutrition, and education human resource development in 1745 rural, 716 tribal, and 235 urban projects in about 45% of community development blocks of the country. Research studies have found that in ICDS areas there were fewer children suffering from Grades S II and IV malnutrition compared with non ICDS areas and the percentage of normal children has increased. 6.8% of children aged 0-3 years and 4.0% of children aged 3-6 years in ICDS areas were in Grades III and IV of malnutrition. The ICDS treatment for malnutrition is administration of 16-20 gm of protein and about 600 calories and monitoring monthly; there are 13.9 million children presently receiving supplementary nutrition in the ICDS program. The nutrition program in general aims to provide health and nutrition inputs to expectant mothers throughout the gestation period in order to prevent low birth weight babies; the nutrition supplement distribution has improved, but chronic malnutrition among pregnant mothers persists. The ICDS program provides regular health checkups, immunization, detection of malnutrition, treatment of diarrhea, and deworming of and for children. These services have contributed to improved health among children in ICDS areas. The infant mortality rate (IMR) of 71.3/1000 live births in 1992 in ICDS areas was found to be lower than national estimates in 1989. In ICDS projects more than 3 years old, IMR was found to be 84.5; further decline in IMR in 1990 were found in projects older than 5 years. Morbidity and mortality have been fund to be higher in non-ICDS areas, and declines have been observed in ICDS areas. The incidence of vaccine preventable diseases was not found to have declined in ICDS areas, in spite of increased immunization. ICDS provides anganwadi community workers (AWWs) and services through a network of Primary Health Centers and subcenters, which are not optimally used. However, when compared with non-ICDS areas, prenatal services are used by 71.9% of the pregnant population compared with 40% in a non-ICDS control group. In 1992, there was 90% coverage of children aged 0-6 years with health check ups; this level of usage may be due to the availability of medicine kits through AWWs. ICDS provides potential for enhancing the survival of children.     

Assessment of community contribution to the ICDS scheme in district Agra: a case study

This study was conducted to assess community contribution to the Integrated Child Development Services (ICDS) program, which promotes mother and child health in the Agra district, Uttar Pradesh, India. Three rural ICDS projects in the district were selected, out of which a total of 74 Anganwadi centers (AWCs) were chosen for the study. The Anganwadi workers (AWWs) were interviewed through a semi-structured questionnaire to assess the community?s contribution during the previous 6 months. Results revealed that about 68% of AWWs had been able to receive assistance in bringing the children to the AWC. 53.3% had received free accommodation for AWC, and 42.6% had obtained assistance in implementation of health activities. Only 4% and 12% of the AWWs reported community assistance in the preparation and distribution of nutritional supplements, respectively. There had been no contribution received in terms of raw food for supplementary nutrition and fuel for cooking. The study concludes that rural area free accommodation for the AWC and community assistance in bringing children to the AWC were the most common forms of community contribution to the ICDS program.     

Strategies for nutritional improvement

India has achieved self-sufficiency in the production of food grains, yet the production of milk, legumes, vegetables, oils and fats, eggs, and meat is far short of the needs of the population. The Indian diet predominantly comprises cereals, and the diets of expectant and nursing mothers as well as children are grossly deficient in protective foods. Serious nutritional inadequacies have resulted in low birth weight, retarded growth, and nutritional deficiencies (protein energy malnutrition in preschool children, vitamin A deficiency, iron deficiency in women of reproductive age, and iodine deficiency disorders among neonates and schoolchildren). General malnutrition is prevalent in 25% of the rural and 20% of the urban population. Deficiency symptoms of vitamin B complex and vitamin C are also not uncommon. 37% of the population of India lives below the poverty limit, the literacy rate is only 52.1% (39.4% for women), safe drinking water is scarce, nutritional ignorance is rampant, there is a lack of personal hygiene, and poor sanitation all account for malnutrition. A number of government and nongovernmental organizations' programs have attempted to raise the level of nutrition and the standard of living of the people. Some of them include the integrated child development services, special nutritional program, national vitamin A deficiency prophylaxis program, national anemia prophylaxis program, national goiter control program, midday meal program, special class feeding programs, universal immunization program, nutritional and health education through the mass media as well as the observance of world food day and world health day. The national health policy gives high priority to the promotion of family planning, the provision of primary health care, and the acceleration of welfare programs for women and children. As a result of policies and programs of health and nutrition, the infant, child, and maternal mortality rates have declined and life expectancy at birth has risen.     

Participation of pregnant and lactating mothers in ICDS programme in rural area

In the Integrated Child Development Services (ICDS) project Chiri in India, interviews with 363 pregnant and lactating mothers and an examination of household records were conducted to learn the extent of their participation in the ICDS Programme activities and to identify obstacles to under- or non-utilization of these services. 62% of the women were currently involved in the ICDS Programme. 23.7% had never used ICDS services. The most frequented services were supplementary nutrition (97.3%), tetanus toxoid prophylaxis (89.3%), and iron and folic acid prophylaxis (87.1%). 62.8% of the women participating in the supplementary nutrition program participated more than 20 days/month. Since tetanus toxoid prophylaxis and iron and folic acid prophylaxis occurred one day/month with high participation, the workers could have used this day for group meetings, individual counseling, discussions, and demonstration, but the opportunity was missed for prenatal care, contraception, growth monitoring, and health and nutrition activities. 89.8% of women participating in the supplementary nutrition program took the food home to share with family members. Participation rates were less than 50% for organized radio listening (9.3%), Mahila Swasthya Sangh meetings (20.4%), birth spacing (40.4%), health and nutrition education (40.4%), family planning (46.2%), and prenatal care (47.4%). The major reasons for never using ICDS services were: could not spare time (53.5%) and working outside the household for long hours (50%). 15% were never approached by an anganwadi worker and were therefore not aware of ICDS services or the workers did not have an encouraging attitude. Other possible contributing factors to under- or non-utilization were high illiteracy (61%) and insufficient awareness of ICDS services among heads of households (94.9%).     

Nutritional anaemia--a major controllable public health problem.

Nutritional anaemia, due chiefly to iron deficiency, is widely prevalent in many parts of the world. There is increasing evidence that even mild anaemia affects health and reduces productivity and that a high prevalence of anaemia has profound socioeconomic consequences. The pathogenesis of nutritional anaemia is now reasonably well understood. Measures avilable for combating it include: therapeutic supplementation for accessible population groups with a high prevalence of anaemia, such as pregnant women and schoolchildren; iron fortification of one or more widely consumed foodstuffs; management of those conditions, such as hookworm infestation, that increase requirements for haemopoietic nutrients; and education of the public, and of all categories of health personnel, regarding the importance of anaemia and the ways of controlling it. Experience has shown that there is no simple solution to the problem and in each area where iron deficiency anaemia is prevalent it will probably be necessary to develop and combine many or all of these measures. In each community it will be necessary to introduce these measures so that their effectiveness can first be studied in a pilot trial. When this has been successfully completed it should be followed by a field trial under realistic conditions, and only when this has proved successful should a regional or national programme be introduced. However, the problem is complex and it is only by sustained effort of all concerned that it will prove possible to develop adequate public health control of nutritional anaemia.     

Iron, folate, and vitamin B 12 nutrition in pregnancy: a study of 1000 women from southern India

As part of a WHO collaborative programme the prevalence of anaemia was studied and the serum concentrations of iron, folate, and vitamin B₁₂ were measured in 1 000 pregnant women from southern India. The results of the study show a high prevalence of anaemia, resulting from iron and folate deficiency with iron deficiency predominating. Interrelationships between these nutrients and their effect on pregnancy and the fetus were investigated. The results indicate that, in comparison with populations in developed countries, there was a high prevalence of iron and vitamin B₁₂ deficiency in the community, but the state of folate nutrition was similar to that found elsewhere.     

我国营养学事业发展的辉煌成就

新中国成立70年,尤其是改革开放40年以来,在国家政策及措施的带动下,我国营养学事业发展迅速,在营养缺乏病防治、营养改善行动、慢性非传染性疾病改善计划、营养学研究及知识普及等方面成绩显著。随着国家重视营养工作的加强,营养科学技术的快速发展,一大批营养新技术、新方法的广泛应用必将极大地促进和提高了人类的健康水平。     

High Prevalence of Stunting and Anaemia Is Associated with Multiple Micronutrient Deficiencies in School Children of Small-Scale Farmers from Chamwino and Kilosa Districts,Tanzania

Inadequate macro- and micronutrient nutrition and its consequences, such as anaemia, iron and vitamin deficiency, and growth retardation, could particularly affect children of small-scale farmers. In the present cross-sectional study, 666 school children aged 5–10 years from villages of Chamwino and Kilosa districts were studied for associations between nutritional and micronutrient status and dietary intake. The overall prevalence of stunting, underweight, and overweight was 28.1, 14.4, and 5%, while that of anaemia and deficiency of iron (ID), vitamin A (VAD), and zinc (ZnD) was 42.9, 29.3, 24.9, and 26.4%, respectively. Dietary recalls (24h) revealed that, except of iron (74%), only small proportions of children reached the recommended daily micronutrient intakes: 4% for zinc, 19% for vitamin A, and 14–46% for B vitamins. Stunting was highly associated with wasting in both districts and with VAD in Chamwino. Anaemia was predicted by ID, VAD, and ZnD in Chamwino and by elevated infection markers, C-reactive protein (CRP) and α-1 glycoprotein (AGP), in Kilosa. Overall, elevated CRP and/or AGP increased the risk while higher serum carotenoids indicating a diet of more fruit and vegetables reduced the risk of VAD. The significantly lower prevalence of anaemia and ID in Chamwino was related to higher iron and vitamin A intake and the consumption of mainly bulrush millet with dark green leafy vegetables compared to maize or rice with legumes in Kilosa. Nutrition and hygiene education integrated with home and school garden programmes could reduce the multiple burdens of anaemia; micronutrient deficiencies and infections; and, in the long term, the prevalence of stunting.     

Diet quality and nutritional status of rural adolescent girl beneficiaries of ICDS in north India

This study assessed the diet quality and nutritional status of beneficiaries of Adolescent Girl scheme, a national programme targeted towards their nutrition/health needs. 209 girls (aged 11-21 years) from six rural blocks - Delhi (Alipur, Kanjhawala and Mehrauli), Haryana (Madhosinghana), Rajasthan (Deeg) and Uttar Pradesh (Fatehpur Sikri) comprised the sample. Weight and height were measured and dietary intake data were gathered by one day 24 Hour Recall coupled with Food Frequency approach. Incidence of thinness ('BMI for age' <5th percentile) and stunting ('height for age' <3rd percentile) was 30.6% and 29.7%. The subjects followed a two-meal pattern and their diets were monotonous and cereal-based. 49.3% of them were found to have energy intake less than 75% of RDA while a substantial proportion of them had inadequate nutrient intake (NAR <0.66) with respect to most of the micronutrients especially iron (84.7%), folic acid (79.4%) and vitamin A (73.2%). The mean daily intake of milk and milk products, pulses, green leafy vegetables, other vegetables and fruits was grossly inadequate meeting only 47%, 36%, 26%, 34% and 3% of the suggested allowances; that of fats/oils and roots/tubers was somewhat adequate meeting 65% and 72% of the allowances while the intake of cereals and sugar was almost adequate revealing a deficit of only 7% and 3%. The study reveals not only a high incidence of under-nutrition but also an inadequate energy/micronutrient intake among the beneficiaries of Adolescent Girl scheme. Therefore, sustained efforts are needed to strengthen the scheme for improving its field-level implementation.     

The challenge to eliminate micronutrient malnutrition

OBJECTIVE: This paper takes a public health approach to examine briefly: (i) the global magnitude and consequences of deficiencies of iodine, vitamin A and iron; (ii) the intervention options for addressing the deficiencies and associated critical issues; (iii) roles of the main 'players' involved; (iv) current programs and results. METHOD: Analysis of the literature, especially that coming from the UN agencies; distillation of experience from the recently completed OMNI Project, and involvement in relevant international meetings. RESULTS: More than one in three individuals throughout the world are at risk of the health and development consequences of iron, vitamin A and/or iodine deficiencies. There has been a 40% decline in the prevalence of vitamin A deficiency over the last 10 years. More than 60% of all salt is now fortified with iodine. CONCLUSIONS: Significant progress has been made, particularly with the iodine deficiency disorders and vitamin A deficiency. Little apparent progress has been made with iron deficiency anaemia. IMPLICATIONS: National governments, UN multilateral agencies, international consultative groups, bilateral agencies, global and national non-governmental organisations, and increasingly, the private sector need to work together in looking for innovative approaches, especially for iron, increasing awareness of the broader social and public health nutrition context, and supporting increased international funding.     

Introduction of red palm oil into the 'ready to eat' used supplementary feeding programme through ICDS

Children attending the anganwadi centres were fed with Ready to eat (RTE) food containing 2g of Red Palm Oil (RPO). Daily children's attendance, their participation in the feeding programme, quantity of food supplement consumed were recorded. Heights, weights, clinical signs of vitamin A deficiency and morbidity pattern of the beneficiary children were assessed. There was increase in attendance of the children in the feeding programme after introduction of RPO. Quantity of the food supplement consumed by the children also increased. An improvement in the nutritional grades of children was observed. Signs of vitamin A deficiency were absent. Anganwadi teachers, helpers and parents accepted the inclusion of RPO in the supplementary feeding programme.     

Anaemia and iron deficiency anaemia among young adolescent girls from the peri urban coastal area of Indonesia

Anaemia due to iron deficiency is still a widespread problem. Among adolescent girls, it will bring negative consequences on growth, school performance, morbidity and reproductive performance. This cross sectional study aimed to identify the different nutritional and iron status characteristics of young adolescent girls 10-12 years old with iron deficiency anaemia and anaemia without iron deficiency in the rural coastal area of Indonesia. Anaemic girls (N =133) were recruited out of 1358 girls from 34 elementary schools. Haemoglobin, serum ferritin, serum transferrin receptor and zinc protophorphyrin were determined for iron status, whilst weight and height were measured for their nutritional status. General characteristics and dietary intake were assessed through interview. Out of 133 anaemic subjects, 29 (21.8%) suffered from iron deficiency anaemia, which was not significantly related to age and menarche. About 50% were underweight and stunted indicating the presence of acute and chronic malnutrition. The proportion of thinness was significantly higher (P < 0.05) among subjects who suffered from iron deficiency anaemia (51.7% vs. 29.8%). Furthermore, thin subjects had a 5 fold higher risk of suffering from iron deficiency anaemia (P< 0.05) than non-thin subjects (OR: 5.1; 95%CI 1.34-19.00). Further study was recommended to explore other factors associated with anaemia and iron deficiency anaemia, such as the thalassemia trait and vitamin A deficiency. The current iron-folate supplementation program for pregnant women should be expanded to adolescent girls.     

Monitoring and continuing education system of ICDS Programme in Hooghly District, West Bengal

The functioning of "Monitoring and Continuing Education System" of ICDS Programme in Hooghly District was studied through record analysis and individual interviews of Anganwadi Workers (AWW). No Sector Adviser was entrusted the task of monitoring and continuing education activities in 15 out of 17 sectors, supervisors and Health Workers were present in 88.0% and 29.4% sector meetings respectively. The sector meetings were not usually held on fixed dates. Visits of Anganwadi centres (AWC) by Health Workers, Supervisors and Child Development Project Officers (CDPO) were very infrequent and no joint visit was made. Only 11.8% Anganwadi Workers were exposed to continuing education sessions. There was gross under reporting of pregnant mothers and live births. Need of all-round improvement of functioning of 'Monitoring and Continuing Education System' of ICDS Programme is well felt.     

Micronutrient status of primary school girls in rural and urban areas of South Vietnam

Dietary habits, especially micronutrient intake, and nutritional status of Vietnamese primary school girls were investigated in a cross-sectional survey. We interviewed 284 girls aged 7 to 9 years old, randomly selected from three rural (N=148) and two urban (N=136) primary schools. Dietary data were calculated from the results of 24-h recall interviews over three consecutive days. The dietary micronutrient pattern of the rural group showed deficiency of iron, calcium, phosphorus, potassium, magnesium, beta-carotene, vitamin A and vitamin C. On the contrary, adequate consumption of these elements, except low beta-carotene, was observed in the urban group. Despite a low prevalence of anaemia, the prevalence of rural children with iron deficiency was close to the level regarded as being a public health problem. In contrast, 7.7% of urban children were found to have excessive iron status. Children with exhausted retinol stores (7.1%) requiring immediate retinol supplementation were only found in the rural group. Furthermore, the prevalence of children with marginal retinol stores in both the rural (35.7%) and urban (21.4%) groups was above the level of being a public health problem (20%). In both groups, more than 50% and 20% of children showed beta-carotene and tocopherol levels in the range of severe deficiency, respectively. Thus, nutritional education to improve the dietary habits of the two groups is necessary for Vietnamese primary school children.     

Immunization coverage in India for areas served by the Integrated Child Development Services programme. The Integrated Child Development Services Consultants.

The Integrated Child Development Services (ICDS) programme was launched by the Indian government in October 1975 to provide a package of health, nutrition and informal educational services to mothers and children. In 1988 we studied the impact of ICDS on the immunization coverage of children aged 12-24 months and of mothers of infants in 19 rural, 8 tribal, and 9 urban ICDS projects that had been operational for more than 5 years. Complete coverage with BCG, diphtheria-pertussis-tetanus (DPT) and poliomyelitis vaccines was recorded for 65%, 63%, and 64% of children, respectively, in the ICDS population. By comparison, the coverage in the non-ICDS group was only 22% for BCG, 28% for DPT, and 27% for poliomyelitis. Complete immunization with tetanus toxoid was recorded for 68% of the mothers in the ICDS group and for 40% in the non-ICDS group. Coverage was greater in the urban and lower in the tribal projects. Scheduled castes, scheduled tribes, backward communities, and minorities (groups that have a high priority for social services) had immunization coverages in ICDS projects that were similar to those of higher castes.