HIDDEN HUNGER IN RURAL KERALA: AN EXPLORATIVE STUDY OF THRISSUR

Dr RAJEEV.C .BHARATHAN@

Introduction Under nutrition continues to be the most serious health problem in South Asia which has the second highest concentration of such people after Sub Saharan Africa. Although the proportion of undernourished people has declined from 26 percent to 22, the absolute number has gone up from 290 million to 2981. Out of this 298 million, an overwhelming majority (212 million) live in India.2. The level of child under-nutrition in India is second only to Bangladesh and is worse than Sub Saharan Africa .The third National Family Health Survey clearly reveals that about forty six percent of rural children in India under the age of three are suffering from under-nutrition3. This implies that children in the age group of 0-6 are suffering from micronutrient deficiency that may have disastrous consequences on their brain development. In effect, their ability to pursue education beyond primary level will be seriously impaired. They can add to the increasing number of manual labor force as they cannot complete their high school education. In this context, the study attempts to explore the prevalence of nutrition deficiency in rural Kerala, a State projected to be well advanced in human development indicators 4.
1

See Table 9.12 (p194) of Human Development Report in South Asia, 2007, Oxford University Press, Karachi, Pakistan. 2 See table 9.13 as above
3

See National Family Health Survey-3 (2005-06) in the website< http://www.nfhsindia.org > accessed on 20-1009. Also see Ghosh S.Kilaru and Ganapathy S( 2002) : Nutrition Education and infant growth in Rural Indian infants, Journal of Indian Medical Association, Vol 100, 483-90
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A plethora of studies have indicated this high status of Keralas achievements. See for instance Richard W.Frank and BH Chasin (1989), John Ratcliff (1978), Jeffrey R (1992) KP Kannan and V.M Pillai (2004).

However, one has to concede that these high social indicators of development were the cascading effects of several popular policies initiated by the Princely states of Kochi and Thiruvithamkore and in some cases the British efforts to educate the low castes in Malabar. Many socio-economic and religious reforms were adopted by the rulers in response to Public action (P.K.M .Tharakan, 2005). Conceptual Frame work and Review of Literature Undernutrition is poor nourishment of the body due to inadequate quantity of nutritious food intake resulting in low nutrient consumption. It is not due to the lack of food articles but owing to the deficiency in intake of micro nutrients. This is not the raw(open) hunger that is felt when the need arises to fill the belly every five hours or so. It can be termed as hidden hunger because the need for the vitamins or minerals like iron, iodine, calcium is not translated in to pangs of hunger. There fore this requirement is not even noticed by the child or her parents .It can be detected only by the behavioral changes in the child when these are manifested as deficiency diseases like night blindness, goiter, scurvy and pellagra. Under-nutrition can be broadly classified in to the following three groups: a. Protein calorie malnutrition(PCM) Children below the age of six suffer from this condition. This may be either due to lack of proteins/ carbohydrates or imbalance between the two. This disease has far reaching consequences. The mental retardation caused by it is irreversible even if the child is well nourished in the later years. b. Vitamin deficiency diseases Deficiency of different vitamins leads to various diseases like night blindness (A) beriberi (B), Scurvy (C) and rickets (D). c. Mineral deficiency diseases.

If children do not get sufficient quantities of minerals like iron and iodine, it leads to mineral deficiency diseases like anemia and goiter respectively5. From the above, it is obvious that under nutrition in children, especially in the age group of 0-6 has serious consequences. It may lead to impaired brain development which may adversely affect the progress of society as a whole6. It is widely prevalent in India because of the inadequate access of large section of Indians to nutritious food. Undernourished children are generally underweight and do not have adequate subcutaneous tissues and exhibit the symptoms of vitamin deficiency and anemia. They can become mentally retarded and show little interest in studies or the external world. If under nutrition is prolonged, the children lacks adequate resistance to infection and therefore are more susceptible to diseases. In brief one can argue that their mortality rate is very high. Studies conducted by Neuroscientists have shown that malnutrition endured during certain sensitive periods in early development would produce irreversible brain damage possibly resulting in mental retardation and impairment in brain functions (David A Levitsky and Barbara J Strupp (1995). Under nutrition in early childhood have serious, long-term consequences because it impedes motor, sensory, cognitive, social and emotional development. They are less likely to perform well in school and more likely to grow into undernourished adults, at greater risk of disease and early death (Guesry PR et al, 2003; Deolaikar Anil 2005). Under nutrition produces a variety of minimal brain dysfunction-type syndromes, including attentional processes and learning disabilities. It often produces distributed, nonfocal brain pathology. Iodine deficiency constitutes one of the most common preventable causes of

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See Sundararaman, Economic and Political Weekly, 2006:3675. For more details on the effects of under nutrition on brain development of infants see David A Levitsky and Barbara Strupp (1995), Arbaugh MJ et al (1998) and Guesery PR et al (2003).

mental deficiency in the world. Iodine deficiency causes cretinism, deaf mutism and cerebral palsy by altering neuronal and dendritic growth. Copper deficiency during development leads to smaller, shorter and narrower cell nuclei in the infrapyramidal and suprapyramidal arms of the dentate gyrus and smaller cell nuclei in region CA3 of the hippocampus. All alterations in the groups fed low-copper diets are consistent with slowed cell nuclear maturation. The findings indicate that copper is required for maturation of the dentate gyrus and hippocampus. Arachidonic acid is deposited in large amounts in the nonmyelin membranes of the developing CNS. Inadequate supplies of fatty acids during CNS development are of concern because of possible long-term changes in learning ability and reduced visual function. Prenatal protein under nutrition produces differential morphological changes on CA3 pyramidal cells. Significant decreases occur in the somal size, length of apical dendrites, apical and basal dendritic branching and spine density. Thus, prenatal protein malnutrition affects normal development and produces long-term effects on CA3 pyramidal cells. Arbaugh M.J et al
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argues that three widely prevalent nutritional deficiencies

(protein-energy, iron, and iodine) can be recognized to be having the potential for permanent adverse effects on learning and behavior. Supplementation with adequate protein and calories during the first two years of life improves the cognitive performance of poorly nourished children, and the benefits may be even more robust years later when the children become adolescents and young adults. Iron deficiency is the most common global nutritional problem; among the earliest functions to be affected are those associated with the brain enzymes involved in cognition and behavior. The effects of iron deficiency during infancy appear to be irreversible. At older ages iron deficiency is intellectually and educationally

Arbaugh MJ et al (1998) Malnutrition, brain development, learning, and behavior, Nutrition Research,

Volume 18, Number 2, 1998, pp. 351-379(29) Elsevier

disadvantageous independently of ethnicity and of physical and social environment. Nutritional deficiencies are also potential contributors to impaired cognition in the elderly. Michael Gragnolatia et al (2006) 8 have found that the prevalence of child under nutrition in India was among the highest in the world, nearly double that of Sub Saharan Africa. It also notes that nutritional inequalities across different states, socio economic and demographic groups are large- and in general ,are increasing .The study argues that ICDS programme in the country has failed to reach the children under three years old the age window during which nutrition interventions can have the most effect. Despite, the reported high rates of economic growth and food production in the state of Punjab, a higher proportion of preschool children were consuming diets, which are inadequate with respect to energy, fat, iron, riboflavin, vitamin A and vitamin C. The prevalence of under nutrition was high as was found in other states (Laxmaiah A et al, 2002). As to the question of relationship between income poverty and under nutrition, Radhakrishna and Ravi (2004) argue that under nutrition would persist even when the poverty level is brought down to zero. Although one of the major causes for under nutrition is inadequate nutritious food intake, it is influenced by other factors too. The availability of health services and access to them, the availability of care for the child and the pregnant women, the quality of that care, whether acceptable hygiene practices are followed or not are important contributing factors. Under nutrition in South Asia and India The trends of undernourished in the South Asian countries can be observed from table 1.Bangladesh has the highest share of undernourished population (30). In absolute numbers, India has about 214 million accounting for 20 percent of the total population. Nepal has the highest percent of stunted children (51%) though the share of undernourished in the total
8

Michael Gragnolatia et al (2006) Indias undernourished children: A Call for Reform and Action, HNP Discussion Paper, World Bank, Washington.

population was only 17.This only shows that majority of children are not provided with micronutrients required for their brain development. TABLE 1 Share of undernourished persons in South Asia Countries No of under Proportion undernourished 30(1) 20(4) 17(5) 23(2) 22(3) of % of under five

nourished) Bangladesh India Nepal Pakistan Sri Lanka 2001-03 43(millions) 214 4 35 4

children

suffering

stunting 1996-2005 43(3) 46(2) 51(1) 37(4) 14(5)

Source: Table 9.13 and 9.14 from HDR of South Asia, 2007

Around one-third of all adult women are underweight. Inadequate care of women and girls, especially during pregnancy, results in low- birth weight babies. Nearly 30 per cent of all newborns have a low birth weight, making them vulnerable to further malnutrition and disease. Vitamin and mineral deficiencies also affect childrens survival and development. Anemia affects 74 per cent of children under the age of three, more than 90 per cent of adolescent girls and 50 per cent of women. Iodine deficiency, which reduces learning capacity by up to 13 per cent, is widespread because fewer than half of all households use iodized salt.

TABLE 2 Incidence of undernutrition in India States Poverty ratio Under nutrition Inadequate food

2004-05 AP Assam Bihar Gujarat HP Karnataka Kerala MP WB All India 15.8 19.7 41.4 16.8 10.0 25.0 15.0 38.3 24.7 27.5

Below 3 years 2005-06 36.5 40.4 58.4 47.4 36.2 41.1 28.8 60.3 43.5 45.9

2004-05 0.5 5.0 2.7 0.2 0.0 0.2 2.3 1.6 9.0 1.9

Source: GOI, (2009) Economic Survey 2008-09, Table 10.4 (Page 263) Table 2 shows clearly that MP has the highest share (60.3) of children under 3 as under nourished in the country. Bihar with 58.4 percent trails just behind. Over all, India has about 46 percent of undernourished 3 years old children .This is very alarming as this sizable share will not be able to utilize their physical and brain power to contribute to the development of the country. From table 3, we can observe that in all parameters of undernourishment, Kerala shows a lower share than India. However it should be noted that even in a state which has been leading in human development indicators for the last few decades, the levels of undernourishment has not declined much during the period 1993-2006 9.The data reveals that the share of stunted has remained stagnant in all the three survey periods. In the case of the shares of underweight and anemic children, there is a marginal decline from the 1993 level. It is surprising that Kerala which has experienced a phenomenal decline in the poverty rates from around 58 in 1973-74 to 15(2004-05)10 could not reduce child under nutrition substantially. Table 3 Share of undernourished children under 3 years, 2005-06 Parameters Stunted
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Kerala 21.1

India 38.4

10

See the three NFHS Report 1(1993-94) ,2(1998-99) and 3 (2005-06) for Kerala Economic survey 2008-09

Wasted 16.1 19.1 Under weight 28.8 45.9 Anemic 55.7 79.2 Source: NFHS 3 Key Findings report, India and Kerala. Table 4 Under nutrition among children (aged 1-5) Years All India Kerala MP Karnataka 1975-79 61.5 56.8 61.3 64.3 1991-92 56.2 35.6 NA 62.8 2000-01 47.7 28.8 63.9 47.7 Notes: Undernutrition estimates are based on the Gomez classification of Children based on weight for age Sources: 1. National Nutrition Monitoring Bureau (1999), Diet Nutrition status of rural population, Technical Report 18; 2 National Nutrition Monitoring Bureau (2002), Diet Nutrition status of rural population, Technical Report 18 From the table 4, it is clear that undernutrition among children in Kerala has fallen much faster than national level during the 1975-2001.However it is distressing to note that even after five years from 2001, the level of under nutrient children remained stubbornly the same(See NFHS-3 data for 2005-06 level). Exploratory survey A research survey was conducted in the seven schools of Puthur Panchayath of Thrissur District, Kerala in September 2006. Out of the total students surveyed (2143) One hundred and sixty eight were found suffering from Learning disabilities (LD) (7.9%). A second tier survey was conducted to find out the causes of high proportion of learning disabilities in this socio-economically backward region. It was found that more than fifty eight percent of students with LD were SC/ST. This result is very alarming because the share of SC/ST children in the total school children was around twenty percent. I t is only logical to argue that though the overall human development in the state is very high, certain outlier class like the SC/ST has not benefited much from the overall development of the region. 8

TABLE 5 Incidence of Learning disability in Puthur Panchayath Schools Total Students no in of No of students No of students Percent the participated in identified with of the survey 3 535 361 329 338 249 236 195 2143 LD 4 31 23 26 27 21 22 18 168 students with LD 1 A B C D E F G TOTAL 2 576 387 342 354 253 249 214 2375 5 5.8 6.4 7.9 7.9 8.4 9.3 9.2 7.9

Seven Schools

Source: Field survey From table 5, it is clear that more than ninety percent of students participated in the surveys. It can also be observed that there are differences (from 5.8 % to 9.2%) in the incidence of LD in the seven schools. However the average incidence is around eight percent which is very close to the national average. TABLE 6 Social compositions of students surveyed Schools A B C D E F G Total General 205 158 152 196 131 133 101 1076 OBC/OEC 132 117 113 76 69 56 53 616 SC/ST 98 86 64 66 49 47 41 451 (21.1) Total 435 361 329 338 249 236 195 2143 (100)

( 50.2) (28.7) Source: Field survey

Table 6 reveals the social composition of the surveyed students. Socially disadvantaged groups like OBC/OEC and SC/ST account for almost fifty percent of the student population.

TABLE 7 Social compositions of LD students Groups General OBC/OEC SC/ST Total Total students 1196 416 451 2143 Students Percentage

with LD 44 3.7 26 6.3 98 21.7 168 7.9 Source: Field survey

From table 7, it can be observed that the incidence of LD is the least (3.7%)in the general category and the highest in SC/ST Students(21.7%).Out of the total LD students, the share of the SC/ST students are alarmingly high at 58.3 percent . The implication of this result is that the hidden hunger (micronutrient deficiency) of the SC/ST children may have been the primary cause of their under achievement in school performance due to poor cognitive development. This is an issue which has to be explored further by conducting more broad based scientific surveys utilizing the services of Nutrition scientists, Pediatricians and special educators. Policy Prescriptions In the midst of spectacular economic achievements, high rate of nutrition deprivation among Indias children remains a matter of national shame 11. Indian State has seriously neglected the nutrition problem of pre-school children in the past decades. Though Integrated Child Development Scheme (ICDS) was started early, it failed to cater to the needs of poor children, particularly in the age bracket of 0-3 years. Most studies have pointed out that this age is very critical as it is during this particular time, brain development of infants take place. Therefore, any deficiency in nutrition during this period may stunt the brain development of the child which naturally makes her unable to study properly12.

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See Hulshof Karin (2009) in which it is reported that Indias PM recently referred to undernutrition as a matter of national shame. 12 See the recommendations of Working Group on Children under Six (Planning Commission) submitted in 2007.But the pertinent question is how far these are implemented in the country even after three years.

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Specifically the following steps may be adopted to reduce the hidden hunger (micro nutritional deficiencies) of the poor children/lactating mothers in India: * Promote the breast feeding habits to children up to 24 months * Improve high nutritious food availability by supplying them at subsidized prices * Provide fortified cereals and supplementary foods to targeted population * Encourage farmers to cultivate fortified cereals and pulses through the active participation of Agricultural research and extension services. This is a long term strategy to reach the undernourished population in the relatively rural and remote areas. Acknowledgement (I am greatly indebted to Dr PT Sasi, Clinical Psychologist, Dr P.S.Krishnamoorthy, Pediatrician for helping me with technical information and Mytri Samagata, Executive Director of the Foundation for Social Health for motivating me to undertake this research as a part of School Mental Health Programme of the Foundation for Social Health. I am also grateful to Sreekumar Chandran, Keerthy, Asha Kalliyath and Anita Natarajan for providing logistical support.). @ Dr Rajeev C.Bharathan hails from the Indian State of Kerala and has over twenty five years of teaching and research experience. His major interests are in Development and Health Economics. His research papers on Poverty, Rural development and health inequality are published in National and international journals. He is also a Health activist working closely with the Foundation for Social Health, an NGO dedicated to help children with learning disabilities and ADHD. He can be contacted at {rajeevcb@gmail.com}

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REFERENCES Aarti Thakur et al(2008) Health and Nutritional Status of Women and Children from Female Headed Households , Department of Food Science and Nutrition, S.N.D.T Womens University, Mumbai, India,(Accessed from esocial sciences Research paper series from www.esocialsciences.com/ on 5 July 2010). Arbaugh MJ et al (1998) Malnutrition, brain development, learning, and behavior, Nutrition Research, Volume 18, Number 2, 1998, pp. 351-379(29) ,London, Elsevier . Arlappa,N et al (2008)Clinical and Sub-clinical Vitamin A deficiency among rural Preschool children of Maharashtra ,India in Annual Human Biology,2008 ,606 Biswas, K. Bose & A. Mukhopadhyay (2009) High prevalence of stunting among Integrated Child Development Services (ICDS) Scheme Children aged 1-5 years of Chapra Block, Nadia District, West Bengal, India, The Internet Journal of Biological Anthropology. 2009 Volume 3 Number 2 [Accessed on 5 July 2010] Cravioto, J. Delicardie, E.R.; Birch H.G (1966) Nutrition, Growth, and Neurointegrative development: An experimental and ecological study. Pediatrics. Supplement No. 2, Part II. 38, pp319-325 David A Levitsky and Barbara J Strupp (1995) Journal of Nutrition, 12, 5, pp 2212-20.

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Gal Reddy et al (2006) Diet and nutritional status of rural pre-school children in the state of Orissa, Journal of Human Ecology, 19, p205. Ghosh S.Kilaru and Ganapathy S(2002) Nutrition Education and infant growth in Rural Indian infants, Journal of Indian Medical Association, Vol 100,pp 483-90. Gopalan C (1973) Effect of Calorie supplementation in growth of undernourished children, American Journal of Clinical Nutrition, 26, pp563-6. Guesry PR et al (2003) Nutrition and brain development of the infants, Acta Pediatric, Supplement 2003, 442.pp1-36 Hulshof Karin (2009) Child undernutrition in India is a Human rights issue, The Hindu, December 10, pp9. International Institute for Population Sciences (2008) National Family Health Survey (NFHS3) National Fact Sheet/Fact Sheet Kerala (Provisional Data) Kannan K.P and Vijay Mohan Pillai (2004) Development as a Right to Freedom: An Interpretation of the Kerala Model, Working Paper no 361, Centre for Development Studies, Trivandrum, India. Laxmaiah A et al (2002) Diet and nutritional status of rural Pre-school children in Punjab, Indian Paediatrics, 39, pp331-8 Mahbub ul Haq Human Development Centre (2008) Human Development in South Asia, 2007, Karachi, Oxford University Press. Michael Gragnolatia et al (2006) Indias undernourished children: A Call for Reform and Action, HNP Discussion Paper, Washington, World Bank. National Nutrition Monitoring Bureau (1999,), Diet Nutrition status of rural population, Technical report 18, National Institute of Nutrition, Hyderabad. National Nutrition Monitoring Bureau (2002), Diet Nutrition status of rural population, Technical report 21, National Institute of Nutrition, Hyderabad.

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Radhakrishna R and C Ravi (2004) Malnutrition in India: Trends and determinants Economic and Political Weekly, Vol 34, 7(February 14-20) pp671-76. -----------------(2006)Chronic poverty and malnutrition in India: Incidence and determinants in A.K Mehta and A Shepherd (eds)Chronic Poverty and Development Policy, New Delhi,Sage Publications. ------------------------(2008)Economic well- being and Deprivation in India in Jayaram N and Deshpande R.S(Eds)Footprints of Development and Change pp385-413, New Delhi, Academic Foundation, Sharma Dinesh (2001) Alternative strategies for eradicating Hidden hunger in India, The Lancet Sinha, Sachidanand (2005), Reaching out to undernourished children: Social inequalities and Policy Prescriptions, Journal of Health and Development 1 (3-4) Tizard. J ((1974) Early malnutrition, growth and mental development in man, British Medical Journal 30, pp169-174.

Working Group on Children under Six (Planning Commission) Strategies for children under six, Economic and Political Weekly, Dec 29, 2007, pp87-101

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