(The Gist of Kurukshetra) HEALTH AND NUTRITION OVERVIEW AND THE WAY FORWARD [JANUARY-2020]

HEALTH AND NUTRITION OVERVIEW AND THE WAY FORWARD

Introduction:

The inter-linkage between health and nutrition has been recognized since ages. Good nutritional status ensures that individuals can fight disease-causing agents, stay healthy, be productive to society and contribute to overall development.Under-nutrition in children, especially in fetuses during pregnancy and up to 2 years of age, can take away upto 15 IQ points.

Overview by World View:

A study by the World Bank has estimated that the annual cost of malnutrition in India is at least US$ 10 billion and is driven by loss of productivity, illness and premature deaths. Alongside, illnesses in an otherwise 'normal weight' person can lead to under-nutrition, which can spiral into a vicious cycle. Clearly, the challenge of nutrition is multi-layered. It is not the under-nutrition only, the over-nutrition (obesity), 'protein hunger' and 'hidden hunger' (or micronutrient deficiencies) in otherwise normal weight persons are the other dimensions. The terminology of malnutrition is commonly used to capture the under and over nutrition and the related challenges. However, in a particular setting, burden was predominately of one type of malnutrition. It is being recognized that in many settings and countries, both under and over-nutrition are increasing as an emerging challenge, described as 'Double Burden of Malnutrition (DBM). The DBM co-exist in many settings and affects the health outcomes and survival of the population. While under-nutrition continues to be a major and pressing challenge in India, the issue of overnutrition is also real. Therefore, it is time that India also shifts attention on holistic approach of targeting malnutrition with focus and appropriate strategies to tackle DBM.

Under Nutrition as Persistent Challenge:

India had poor health and nutritional indicators at the time of independence in 1947. Around the 1950s, the life expectancy in India was 32 years (which has increased to 68 years in 2017). The infant mortality rate (IMR) was nearly 200 per 1,000 live births and maternal mortality ratio (MMR) around 2,000 per 100,000 live births. The IMR in India in 2017 was 33/1,000 live births and MMR was 130 per 100,000 LB during the period of 2014-16. Over these years, through targeted interventions, the proportion of population living below poverty line has declined and even the food production and availability has drastically increased.
However, the nutritional status of population has not witnessed the commensurate decline. India has had a high rate of under-nourished population, with marginal improvement in the situation in the last 25 years. The prevalence of underweight, stunted and wasted is higher in rural than urban populations.
The progress on other parameters of the nutritional status such as level of anemia in population groups and birth-weight of newborns is also slow. Recognizing the challenge, India had a series of initiatives and programmes since independence which focused on improving nutritional status of the population.

Diseases Linked to Under-nutrition:

The nutritional status of an individual affects his/her health status and outcomes A a poorly nourished person has weak immunity and an immune defence system. An undernourished individual, including those with micronutrient deficiency, are at higher risk of majority of infectious diseases including tuberculosis, viral and all other infections. An underweight and under-nourished child is at higher risk of diarrhea and pneumonia. The chances of recovery in such children are slower.
They are more likely to become under-nourished after such a disease spell. While the poor nutrition affects the health outcomes in all population sub-groups, it is the women in reproductive age and newborn and children, who are most commonly and adversely affected. Public health science has generated evidence that it is a vicious cycle of under-nutrition which starts at the time of pregnancy (in mother's womb) and continues to affect the newborn for the rest of the life and for many generations.
Understandably, the initiatives to tackle under-nutrition are targeted/focused/prioritized for women in reproductive age groups, children and adolescent girls. There are emerging evidence that under-nourished and under-weight children are at higher risk of non-communicable diseases such as cardio vascular strokes and diabetes in adult age.

Initiatives to Improve Nutritional Status:

The efforts to tackle under-nutrition in India have been partially successful so far and recent and new attempts are being made to accelerate the progress. The Govt of India had launched National Nutrition Strategy in Aug 2017 and then National Nutrition Mission (NNM) in March 2018.
NNM aimed at 2-3 per cent annual reduction in the rate of low birth-weight, stunting, undernourishment and anaemia amongst women. NNM is now being implemented as POSHAN Abhiyaan, under Ministry of Women and Child Development, aiming for Kuposhan Mukt Bharat (Malnutrition free India) by year 2022. The programme aims at reducing levels of underweight, stunted, low birthweight and anaemia in population. As part of this POSHAN Abhiyaan, nutrition is proposed to be a Jan Aandolan or mass movement and the month of September has been designated as POSHAN Mah.
In addition, Pradhan Mantri Matru Vandan Yojana (also known as Maternity Benefit Scheme) was announced in late 2016 and launched in 2017, aims to provide financial assistance to pregnant women for the first pregnancy and ensure good nutritional status. There is renewed attention on reducing prevalence of anaemia through Anaemia Mukt Bharat. There are a number of complementary initiatives under different ministries to focus on improved nutritional status though approaches such as Eat Healthy and Fit India initiative. The Aspirational District programme also has nutritional status as a performance indicator.

Discussion:

Health and nutrition (and education) contribute to human capital formation, and the growth and development of a nation. The malnutrition results in making people prone to various adverse health outcomes, as described in earlier section. Especially the first 1000 days of children (Nutritional status in 270 days of nine months in pregnancy and 730 days of first two years of a child's life are very crucial for health and childhood development related outcomes for rest of life). Much of the development of the brain happens either in pregnancy or first two years of life. Therefore, the poor nutrition affects the newborn for rest of life and not only physical but brain development and other social milestones as well. This is increasingly being understood and realized and a compelling reason for taking urgent actions.
The intergenerational effects of malnutrition can be devastating not only for affected families, but also the national productivity, growth and development. Poor maternal nutrition in pregnancy results in low birth weight, which in turn results in risk of poor growth, infections and low educational outcomes and development deficit and more prone to cardiovascular diseases and diabetes in adulthood. The adverse effect of pregnant woman's (mother's) nutritional status carries with the child for rest of the life but on the next generations as well through epigenetic effects. This situation clearly demands that interventions to tackle under-nutrition in India are implemented in life cycle approach from nutritional status of women in reproductive age, pregnant women, breastfeeding and complementary feeding. In this process, the societal dimension of nutrition i.e., maternal literacy, women empowerment & prevention of child marriage etc. also need to be given due attention and interventions.
The need for sustaining the multi-sectoral engagement for better health & nutritional outcomes are being recognized. The nutritional status is inter-play of at least three broad factors; dietary intake contributes to 45-50 per cent, poor maternal health results in low birth-weight which accounts for another 25 per cent and illnesses amongst children such as diarrhoea for another 25-30 per cent of under-nutrition. Thus, there is a need for targeted interventions for reducing the proportion of low birth weight babies, which constitute nearly 30 percent of total newborns in India.
Overweight and obesity are other and increasingly recognized spectrum of malnutrition. These were earlier reported from affluent and urban populations and are now slowly extending to poor and rural counterparts as well. There are nutritional deficiencies in people who are otherwise overweight as their diet may be rich in calories but deficient in specific micronutrients. Even in 'normal body weight' people, there is a high level of body fat and reduced muscle mass indicating a nutritional imbalance that places such individuals at increased risk of obesity related diseases. No wonder we see many faces of malnutrition in our population.
Under-nutrition is not only cause but effect as well. Enteric infections such as diarrhea and typhoid are more common in children who are under-nourished. As well as a healthy child who gets such infections can become under-nourished afterwards. Therefore, to tackle under-nutrition, there is a need to improve water and sanitation. Similarly, the problem of stunting cannot be solved by increased access to nutritious food, it requires better housing and improved water and sanitation.

Way Forward:

There has been some progress on improving the nutritional status of the population in India. However, India of 2020 needs to do more than what has been done in the past.

A few suggestions are as follows, not necessarily in same order:

Integrated health and nutrition initiatives with closer collaboration of health, Worsen and child development and education departments. This has already started to happen through three As of AWW, ASHA and ANM (Anganwadi workers; Accredited Social Health Activists and Auxiliary Nurse Midwife) as of now but require improved performance of these mechanisms. The nutrition programme run under ICDS and school mid-day meal scheme of education department and care of mothers and children under health departments need to be interlinked with better collaboration and coordination. It will be important to share the data, have joint analysis and action plans.
Diversification of supply of food under government programmes including more nutritious items such as millets, eggs, milk, soybean and nutrient rich fresh foods. Mass fortification of rice, wheat, salt, edible oils and salts, with essential minerals and vitamins like iodine, iron, zinc and vitamin A and D should be optimally used. The inclusion of pulses and edible oil in Public Distribution System (PDS) as well as National Food Security Act (NFSA) has been proposed by many experts. Similarly, there is a need to increase protein and micronutrient content in mid-day meals and ICDS food.
Regular monitoring on real time basis: Comprehensive National Nutrition survey (CNNS 2016-18) is the most recent survey on nutritional status of Indian population. The NFHS-5 data collection has been completed and an analysed report is expected to be available soon. It will be imperative that analyzed data is made available and used to inform policy decision making. The delay in the availability of analyzed data, delay the interventions. There is a felt need for improved real time data recording and reporting systems with data flow in two directions. This is possible with the use of digital technology.
Promote 'Nutrition Garden' concept: Ministry of Human Resource Development has brought the concept of school 'nutrition garden' encouraging eco-club of students to help them identify fruits and vegetables best suited for topography, soil and climate. These gardens are intended to give students lifelong skills to identify fruits and vegetables for their plates. This clearly has the potential to improve the nutritional status of the population.
Focus on 'behavioural change' for improved nutrition: The major challenge in bringing the sustained behavioural changes are related to a continuum of 4A of awareness, assessment, analysis and action. The awareness is raised through AAAM: ASHA, AWW, ANM and Mothers. However, a balanced approach of going beyond awareness and focus on analysis of information and actions needs to be strengthened.
Attention on 'dietary diversification' and focus on healthy diet: The dietary diversity with balanced nutrients is the key to growth and good health across the life course. The skewed agricultural priorities due to production of cash crops, marketing tactics, food processing has resulted in the sacrifice of nutrient rich balanced diet by many people. With diet diversification in the spotlight, My Plate for the day' publication of The National Institute of Nutrition (NIN), India has highlighted that the fruits and vegetables should share nearly 50 per cent of an individual’s food plate. The Expert Committee of the Indian Council of Medical Research (ICMR), New Delhi has recommended that every adult should consume at least 500 g of vegetables in a day, which should include 100 grams of green leafy vegetables; 200g each of other vegetables and the roots and tubers. In addition, everyday per person 100 gram of fresh fruits should be consumed regularly. These guidelines should be widely promoted.
Establish more cold chain storage capacity for food items across the country: It has been recognized that while India produces a lot of fresh fruits and vegetables, a significant amount is wasted during sorting/ grading, transport, storage in godowns or processing units, or with wholesalers and retailers. Therefore, establishing more cold chain stores especially in rural India can contribute to less wastage and improved availability and thus improved nutrition for Indian population.
Promote local production of fruits and vegetables in rural India: Contrary to common belief, the cost of fruits and vegetables in rural areas is higher than urban as the transportation cost is also factored in. Therefore, the production and consumption of locally available all kinds of vegetables, fruits including seasonal fruits in rural areas need to be promoted. As most of the government organizations in India such as Anganwadi centres, government primary and high schools and panchayat office have space around their buildings, the area can be utilized to grow locally consumed green leafy vegetables, roots & tubers and locally available fruits.
Educate people on health benefits of consumption of fruits and vegetables along with training in community or kitchen gardening or terrace gardening. The school and college teachers and students should be involved in the process. Training and a capacity building of both teachers and students on healthy diets should be prioritised. The younger generation should be trained in healthy diets. Junk the 'junk food' should be promoted to school students and ban on unhealthy food in school and college canteens should be actively promoted.
Link the overall nutrition and healthier lifestyle: The schools could be suitable platforms to call parents of children and educate them about healthy nutrition and lifestyle. The awareness about nutrition should be linked to a healthy lifestyle to prevent noncommunicable disease risk factors and adopt physical activity, healthy diet, no smoking and moderate or no use of alcohol. Schools/colleges should regularly invite nutritionists and health experts to deliver talks to parents and family members of students.
Engage elected representatives and civil society members in making healthy India: The nutritional outcomes of society will be dependent upon how political leaders, elected representatives contribute in making nutrition ‘Jan Andolan' and improved nutritional outcomes in India.

Conclusion:

The Double Burden of Malnutrition (DBM) is a nutritional reality for many countries including India. The period of 2016-25 is the United Nations (UN) decade of nutrition, and only six years are left. The target for sustainable development goals is 2030, which has nearly a decade to achieve. Only three years are left to achieve the targets set up under the National Nutrition Mission (NNM) of India.
Clearly, there has to be an urgency to accelerate interventions. While till now efforts and initiatives have been focused on priority challenge of under-nutrition, the policy makers and programme managers in India, both at national and state level, need to be mindful of new nutritional reality. It is time to consider new approaches to reduce under-nutrition and obesity at the same time. The focused attention and tailor-made strategies for specifically vulnerable population groups such as women in reproductive age group, children and all rural residents would be needed. It would also require stronger collaboration and coordination between multiple departments, improved data collection and analysis for action and sustaining the political commitment and public attention on tackling nutrition challenges in India.