(The Gist of Kurukshetra) NUTRITION: A PUBLIC HEALTH PRIORITY [JANUARY-2020]

NUTRITION: A PUBLIC HEALTH PRIORITY

Introduction:

In the month of September, one would have heard and read a lot about ‘POSHAN Mah, and nutrition.
The aim of this article is to enhance the understanding of 'nutrition' and learn its importance, while also discussing some related aspects of nutrition and healthy eating.

What is Nutrition? What do we know about nutrition?

The definition given by the British Nutrition Foundation is: 'the study of nutrients in food, how the body uses nutrients and the relationship between diet, health and disease.'
The other more comprehensive definition is -'nutrition is the intake of food, considered in relation to the body's dietary needs.
The important aspect to note here is the 'intake of food in relation to the body's dietary needs'. This implies that as the body's needs change, so should the diet i.e. a lifecycle approach should ideally cater to dietary needs of each stage.
For example, nutrition needs of a child vary from that of an adolescent and those of an adult working person may vary from that of a geriatric individual. Good nutrition, an adequate, well balanced diet combined with regular physical activity, is considered to be a cornerstone of good health. Poor nutrition can lead to reduced immunity, increased susceptibility to disease, impaired physical and mental development, and reduced productivity.
This brings us to the next set of words which are results of improper nutrition, and termed as malnutrition. Malnutrition comprises both undernutrition and overnutrition and they both lead to their own set of disease conditions.

Measuring under-nutrition:

In the realm of public health, we consider three terms which are the standards to measure under-nutrition i.e. stunting, wasting and under-weight; while overnutrition is measured by incidence of overweight, obesity, and diet-related Non-Communicable Diseases (NCDs) comprising of heart disease, stroke, diabetes and cancer.
A stunted child is one whose height is lower than the standard height for the given age of child. Stunting is the result of long-term nutritional deprivation and often results in delayed mental development, poor school performance and reduced intellectual capacity. Also, women of short stature are at greater risk for obstetric complications because of a smaller pelvis. Further, small women are at greater risk of delivering an infant with low birth weight, contributing to the inter-generational cycle of malnutrition, as infants of low birth weight or retarded intra-uterine growth tend be smaller as adults.
Wasting is defined as a condition where the weight of the child is lower than the standard weight for the given height. Wasting in children is a symptom of acute under-nutrition, usually as a consequence of insufficient food intake or a high incidence of infectious diseases, especially diarrhoea. Wasting in turn impairs the functioning of the immune system and can lead to increased severity, duration of and susceptibility to infectious diseases and an increased risk for death.
On the other hand, underweight is a condition where the weight is lower than the standard weight for the given age of the child. Evidence has shown that children who are even mildly underweight have an increased risk of mortality and severely underweight children are at a greater risk of the same.
A child is considered to be overweight when the weight is higher than the standard weight for the given age of the child. Childhood obesity is associated with a higher probability of obesity in adulthood, which can lead to a variety of disabilities and diseases, such as diabetes and cardiovascular diseases.
The risks for most NCDs resulting from obesity depend partly on the age of onset and the duration of obesity. Obese children and adolescents are likely to suffer from both short-term and long-term health consequences, the most significant being, cardiovascular diseases (mainly heart disease and stroke), diabetes, musculoskeletal disorders (especially osteoarthritis) and cancers of the endometrium, breast and colon.
Child growth is internationally recognized as an important indicator of the nutritional status and health in populations; the above-mentioned indicators are a direct measure of the same and subsequently, essential for our discussion here.

Nutrition Status:

Globally, 15.08 crore children under five years are stunted and 5.05 crore are wasted, as stated by the Global Nutrition Report 2018. In India, 4.66 crore children are stunted, and 2.55 crore are wasted.
Also, India figures among the set of countries that have more than 10 lakh overweight children. Overall, of the 141countries analysed in the report, 88 per cent (124 countries) experience more than one form of malnutrition. The developmental, economic, social and medical impacts of the global burden of malnutrition are serious and lasting, for individuals, their families, communities and for the countries that suffer from loss of productivity and therefore lower growth.
To understand the malnutrition status in India, let us look at the figure below, which gives a succinct snapshot of the same. The critical issue that can be deducted from the figure is that even though little improvement can be observed from National Family Health Survey (NFHS)-3 to NFHS-4, the improvement is not on course to meet all nine global nutrition targets. Another important fact that comes through, is that more than 50 per cent of our children and adolescent women are anemic.

Initiatives by Government:

As has been mentioned above, minor improvements have been observed between NFHS-3 and NFHS-4, which implies that the policies and initiatives of the Government are in the right direction and making an impact.
The determinants of health comprise various factors across the socio-economic, cultural and behavioural realms. In the past few years, significant work has been done on several key determinants of nutrition. The Swachh Bharat Mission focuses on creating Open Defecation Free (ODF) communities; this has significantly contributed to reduced incidences of diarrhea and gut infections amongst children. The Pradhan Mantri Matru Vandana Yojana provides support to pregnant women and lactating mothers and also encourages health seeking behaviour and immunisation.
Mission Indradhanush, which targets the left out and missed out children and pregnant women for immunisation, is aimed on increasing the rates of complete immunisation of women and children. Mothers Absolute Affection (MAA), the exclusive breastfeeding initiative, is focused on increasing rates of exclusive breast feeding to reduce infection amongst children up to the age of 6 months.
For children, adolescents and pregnant women, to manage nutrition issues, MoFIFW also implements the Intensified Diarrhoea Control Fortnight (ICDF) programme, National Deworming Day (NDD) programme and the Pradhan Mantri Surakshit Matritva Abhiyaan (PMSMA). In September 2017, the cost norms for providing supplementary nutrition through anganwadis to pregnant women and lactating mothers, children and adolescent girls were revised and linked with the food price index.
However, these are all individual and independent programmes run by separate Ministries and work has been carried out in silos. International experience has shown that converging initiatives such as these, with focus on areas with high malnourishment, accelerates the rate of reduction of malnourishment; and this was the genesis of the National Nutrition Mission (NNM). On the occasion of International Women's Day 2018, Prime Minister Shri Narendra Modi launched the NNM.

The 6X6X6 AMB strategy:

Provision of supervised biweekly iron folic acid (IFA) supplementation by the ASHAfor all under five children;
Weekly IFA supplementation for 5-10 years old children;
Annual/biannual deworming (children and adolescents); Point of care testing (POCT) and treatment for in-school adolescents and pregnant women using newer technologies; Establishing institutional mechanisms for advanced research in anaemia;
Addressing non-nutritional causes of anaemia; and Setting a comprehensive communication strategy including mass/mid media/social media communication material (radio and TV spots, posters, job-aids, interpersonal communication (IPC) material, etc).

Conclusion:

Nutrition is certainly a policy issue going beyond women and children alone, as the country has moved away from the selective emphasis of the MDGs to the more comprehensive SDGs. The increasing burden of communicable diseases as well as over-nutrition, are leading to complex policy challenges: for example, diabetes and hypertension prevalence are higher among men than women, although more women are overweight/obese.
The focus is on enhancing awareness around nutrition and healthy eating practices, and to make a shift to a healthy lifestyle too. Hence, while government policies and programmes are converging and taking steps to manage malnutrition, the most important factor affecting positive change will be behaviour change of the population, where individuals and communities make informed choices regarding their nutrition needs and the food they eat, and also changing to a healthy lifestyle which strongly compounds the benefits of healthy eating. As the tagline of POSHAN Abhiyaan states: Sahi Poshan Desh Roshan— a healthy population is the foundation rock of a healthy and productive nation.