(GIST OF YOJANA) Creating Mass Movement to Address Malnutrition [MAY-2018]

(GIST OF YOJANA) Creating Mass Movement to Address Malnutrition


Creating Mass Movement to Address Malnutrition

It is a known fact that undernutrition is an outcome of not one but multiple detrimental factors. These factors play their role in helping sustain this continuous burden of undernutrition leading to our inability to achieve our desired human resources potential, generation after another. In order to achieve its true potential and play the role as a global super power India will need to focus on eradication of malnutrition so as to ensure that the coming generations are healthy, enabling higher intellectual potential, leading to enhanced work productivity. This one factor will enable us to connect the dots between schemes like Make in India, Digital India, Skill India and grow to our desired potential as a Nation.
On March 8, 2018; the Prime Minister launched POSHAN Abhiyaan – PM’s Overarching Scheme for Holistic Nourishment from Jhunjhunu in Rajasthan. The programme through use of technology, a targeted approach and convergence strives to reduce the level of stunning, under-nutrition, anemia and low birth weight in children, as also, focus on adolescent girls, pregnant women and lactating mothers, thus holistically addressing malnutrition. The programme aims to ensure service delivery and interventions by use of technology, behavioral change through convergence and lays-down specific targets to be achieved across different monitoring parameters over the next few years. To ensure a holistic approach, all 36 States/UTs and districts will be covered in a phased manner i.e. 315 districts in 2017-18, 235 districts in 2018-19 and remaining districts in 2019-20. More than 10 crore people will be benefitted by this programme. Never before has nutrition got so much prominence at the highest level in the country.

Different Ministries/Departments at the Centre and States/UTs deal with varied interventions required for reduction of malnutrition in a stand-alone manner. States/UTs being the highest implementing agency for all such schemes, it is pertinent to achieve synergy of all interventions to effectively target malnutrition. POSHAN will provide the required convergence platform for all such schemes and thus augment a synergized approach toward Nutrition. Convergence at centre is being achieved through formation of the National Council for Nutrition and the Executive Committee for POSHAN Abhiyaan. Both these draw members from all the stakeholders of the Abhiyaan. Similarly, the convergence action plan at state, district and block level define the implementation and monitoring mechanisms for the Abhiyaan. The very high speed network (VHSN) day provides the convergence platform at village level, for participation of all frontline functionaries.

The problem of malnutrition is inter-generational and is dependent on multiple factors which, inter-alia, include optimal Infant & Young Child Feeding (IYCF) practices, Immunization, Institutional Delivery, Early Childhood Development, Food Fortification, Deworming, access to safe drinking water and proper sanitation (WASH), Dietary diversification, and other related factors. Therefore, to address the problem of stunting, under-weight and wasting, especially in children, there is a need to take-up sustained efforts requiring multi-pronged approach and bring grass-root synergy and convergence.
Ministry of Women and Child Development is the nodal Ministry for anchoring overall implementation; as described above, the vision is for all these Ministries to work together for addressing undernutrition. Never before has so many programmes been pulled together for addressing undernutrition at national level in India. The Prime Minister Office will review the progress every six months and similar review is expected at state level; and this process will be augmented by nutrition specific review in every district by the District Magistrate on a quarterly basis every 10‘” January, April, July and October. As the National Family Health Survey (NFHS-4) highlights that inter-state and inter-district variability for undernutrition is very high, so every state/district needs to develop its Convergence Action Plan which includes their specific constraints and bottlenecks and what can they address in short, mid or long term. It is very important that we put all the necessary processes in place before we start expecting miraculous changes in the undernutrition burden across the country. This Abhiyaan is going to be linked with incentives for the front line workers like Anganwadi workers for better service delivery, for the team based incentives for Anganwadi workers, ASHA and ANM for achieving targets together; and for early achiever states and UTs. For the non-performing states/UTs/ districts/ blocks/ Anganwadi centers there would be focused support and hand holding to make them start performing better.

Thus, the POSHAN Abhiyaan is to bring all of us together, put accountability and responsibilities on all stakeholders, to help the Country accomplish its desired potential in terms of its demographic dividend of 130 Crore human resource.

Food to Nutrition Security

Since 1947, achieving food security has been a major goal of our country. This was because the Bengal Famine created awareness of the need for paying priority attention to the elimination of hunger. Our Food Security Act 2013 specially mentions the need for nutritional security (An Act to provide for food and nutritional security in human life cycle approach, by ensuring access to adequate quantity of quality food at affordable prices to people to live a life with dignity and for matters connected there with or incidental there to).
In 1986, both in my lecture at FAO and in a book on “Global Aspects of Food Production” I stressed the need for a change in emphasis from food security to nutrition security. I also defined nutrition security as “physical economic and social access to balanced diet, clean drinking water, sanitation and primary healthcare”. Further I stressed the need for a food based approach to nutrition security and not a drug based one. Now after 30 years, the concept of nutrition security is gaining ground. MSSRF is planning to demonstrate how agriculture, health and nutrition can enter into a symbiotic relationship. In the area of nutrition security, it is important to look at food adequacy, protein deficiency and deficiency of micronutrients like iron, iodine, zinc, vitamin A etc. The Farming System for Nutrition (FSN) developed by me provides a methodology for achieving such symbiotic linkages. Above all, a global grid of genetic gardens of Biofortified plants will be an important tool for fighting hidden hunger.

National Nutrition Week

It will be worthwhile to spend National Nutrition Week and other such events in generating awareness of the implications of malnutrition particularly with reference to brain development in the child. As an action programme, it will be useful to launch a National Grid of Genetic Garden of Biofortitifed Plants. It will help us to provide agriculture remedies to major nutrition problems particularly affecting the poor. These events provide a great opportunity to launch a programme for the nutritional well being of our population.

Making National Nutrition Mission a Success

Government has approved a National Nutrition Mission with a three year budget of Rs. 9,000 crore. This is government’s response to the widespread malnutrition resulting in children with impaired cognitive abilities. The Nutrition Mission to be successful should be designed on a mission mode with symbiotic interaction among components and with a Mission Director who has the requisite authority coupled with accountability. Earlier Missions were not successful because the concept of the Mission was not fully operationalised. For example the Nutrition Mission should have the following interactive components to make it a success:

Overcoming undemutn'tion through the effective use of the provisions of the Food Security Act and also taking advantage of the enlarged food basket which includes millets in addition to rice and wheat.
Assuring enough protein intake through increased pulses production and increased consumption of milk and poultry products.
Overcoming the hidden hunger caused by micronutrient malnutrition through the establishment of genetic gardens of biofortified plants.
Ensuring food quality and safety through steps for the adoption of improved post-harvest management.

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National Nutrition Mission

On the occasion of the International Women’s Day on March 8, 2018 the Prime Minister launched a pan India National Nutrition Mission covering all the 640 districts of the country. To achieve the goals of the National Nutrition Mission, the following five areas need concurrent attention.

1. Overcoming calorie deficiency through the effective use of the provisions of the National Food Security Act 2013
2. Overcoming protein hunger through the increased production and consumption of pulses and milk and poultry products.
3. Overcoming hidden hunger caused by micro nutrient deficiency through the establishment of genetic gardens of biofortiiied plants and promoting a Farming System for Nutrition programme.
4. Ensuring the availability of clean drinking water, sanitation and primary health care.
5. Developing a cadre of Community Hunger Fighters who are well versed with the art and science of malnutrition eradication.

If all the above five areas are attended to concurrently, we can achieve the goal of the National Nutrition Mission.


Ref: Swaminathan, M.S. and S.K. Sinha (1985). Global aspects of Food Production. Tycooly International Publishing Company, Dublin.

Role of Health Services in Nutrition

When India became independent, the country faced two major nutritional problems: a threat of famine and the resultant acute starvation due to low food production and the lack of an appropriate food distribution system. The other was chronic under-nutrition due to poverty, food insecurity and inadequate food intake. Famine and starvation hit the headlines because they were acute, localised, caused profound suffering and fatalities. But chronic low food intake was a widespread silent problem leading to under-nutrition, ill health and many more deaths than starvation. Mutually reinfor cing adverse consequences of under-nutrition and ill health resulted in high morbidity and mortality in all age groups and the longevity at birth was only 35 years. Recognising that optimal health and nutrition were essential for human development and human resources were the engines driving national development, Article 47 of the Constitution of India states “the State shall regard raising the level of nutrition and standard of living of its people and improvement in public health among its primary duties”. The country adopted multi-sectoral, multi-pronged strategies to improve the nutritional and health status of the population. Successive Five-Year Plans documented the policies, strategies and intervention programme, provided the needed funds and laid down targets to be achieved in the defined time frame. Progress was monitored through the national surveys.

A decline of under-nutrition

Pre-school children were recognized as the vulnerable group prone to under-nutrition and ill health. Under-nutrition in pre-school children renders them susceptible to infections; infections aggravate under-nutrition and micro-nutrient deficiencies. Severe or repeated infections in under-nourished children if left untreated could result in death. Therefore high priority was accorded to reducing under-nutrition in pre-school children. Data from surveys carried out by the National Nutrition Monitoring Bureau (NNMB) indicated that despite poor coverage under ICDS, there has been a slow but steady reduction in the prevalence of under nutrition in pre-school children. Data from NFHS 2, 3, and 4 showed similar trends between 1990 and 2015 (Figure 3). During this period there was sustained a reduction in infant mortality rate (IMR) and under-five mortality rate (USMR) (Figure 4). Infections were the major causes of USMR; the steady decline in USMR between 1970 and 2015 was due to substantial improvement in access to health services for immunization and treatment of infections in under-five children. Prevention and treatment of infections reduced energy loss due to infection and prevented deterioration in nutritional status. Thus, improved access to healthcare played an important role in achieving a steady reduction in the under-nutrition rates in pre-school children in the last four decades.

Optimal nutrition in childhood

Indian children are short and underweight right from birth. As birth weight is a major determinant of growth, low birth weight children grow along a lower trajectory of growth during infancy, childhood and adolescence. As a result, nearly half of the children are classified as stunted and underweight. Height, weight and BMI are three parameters widely used for assessing nutritional status. Of the three, BMI Body Mass Index which is the indicator of current energy adequacy has long been accepted as the indicator for assessment of nutritional status in adults. However, WHO standards for BMI-for-age for children became available only in 2006 (0-5 years) and 2007 (5-18 years). Analysis of data from NFHS 4 using WHO standards showed that if BMI for age is used as the criterion for under nutrition only 18.4 per cent of the under five children were under nourished and 2.6 per cent were over-nourished.

Elimination of blindness

During the 1960s poverty, household food insecurity and hunger were widespread among poorer segments of the population. Dietary intake of all nutrients was low and moderate and severe under-nutrition in young children were common. Poor green and yellow vegetable intake led to widespread vitamin A deficiency. Prevalence of respiratory infection and measles was high in young children living in overcrowded households. The primary health care infrastructure for treating infections was poor in urban areas and non-existent in rural areas. Untreated severe infections, especially measles, in the already severely under nourished young children, led to keratomalacia; those who survived the infections were often left with nutritional blindness. Studies carried out by the National Institute of Nutrition showed that massive dose Vitamin A (200,000 units) administered once in six months to children between one and three year s of age.

Universal salt iodization

Iodine deficiency disorders (IDD) have been recognized as a public health problem in India since the 1920s. Unlike other mirco-nutrient deficiencies, iodine deficiency disorders are due to deficiency of iodine in water, soil and foodstuffs and affect all socio-economic groups living in defined geographic areas. IDD during pregnancy was associated with high abortion and foetal wastage rates; some infants born to these mothers suffered from cretinism and mental retardation. In adults, IDD include hypothyroidism and goitre. Universal use of iodised salt is a simple, inexpensive method of preventing iodine deficiency disorders.

Take this into account National Iodine Deficiency Disorders Control Programme (NIDDCP) was initiated in 1992 with the goal that all salt for the human consumption will be iodised to ensure universal household access to iodised salt. However, over the next fifteen years, the household access to adequately iodised salt remained below 50 per cent. This was partly because persons living in coastal states with a low prevalence of IDD were not aware of the health benefits of the use of iodised salt and bought ~ and used cheaper non-iodised salt. In 2007 mandatory fortification of all salt for human consumption with iodine was notified. Concurrently, an awareness campaign on health benefits of the use of iodised salt was mounted through all media of communication. These initiatives paid rich dividends. Data from the NHS 4 showed that in 2015, over 90 per cent of the households accessed and sed iodised salt. Universal salt iodization programme is an example of a nutrition programme not only achieving nutritional goals but also preventing mental retardation in children and IDD related health problems in adults.

Dual nutrition and health burden

Over the last three decades, there has been increasing mechanization of the transport, occupation and household work related activities. As a result, there has been a steep reduction in the physical activity and majority of Indian have become sedentary. There has been some reduction in food intake but this was not commensurate with the reduction in physical activity. As a result, there has been a progressive rise in over nutrition. The data from surveys carried out by the NNMB had shown that there has been a progressive increase in the over-nutrition rates both in men and in women in the last four decades. The increase in over nutrition rates was steeper between the mid-nineties and 2012 (Figure 6 and Figure 7). Over-nutrition rates in women were higher than over nutrition rates in men. Data from NFHS 4 showed that with increasing age, over-nutrition rates increased. Women ignore such weight gain and do not seek any nutrition or health advice and incur the risk of with obesity, it is essential to screen men and women for over-nutrition and proyide appropriate health and nutrition counseling nourished persons.
Health education message (through all media of communication) that at least 30 minutes of sustainable discretionary physical activity (such as walking) per day is essential for optimal nutrition and health may go a long way in halting the rise in over nutrition and NCD rates in adults.


India’s health system was built up with focus on early detection and effective treatment of under-nutrition, infections and maternal child health problems. Most of these health problems are symptomatic and acute. Ill persons do access health care and under-nutrition and infections can be readily treated. Over years utilization of health care had improved and this led to sustained reduction in under nutrition, ill health and mortality rates.

Once the assessment is done appropriate advice should be given depending upon their nutritional status: Normally nourished persons protect their current lifestyles and provide support for continued normal nutrition and health status those who are under-or-over nourished and are at risk of health / problems provide counseling regarding appropriate food intake and physical activity, if required provide nutritional supplementation and monitor for improvement; those with illness-identify nutritional problems, provide appropriate health and nutrition therapy to restore normal health and nutrition and monitor response. Nutritionists and physicians have to play a critical role in combating the dual nutrition and disease burden by appropriate nutrition and lifestyle counseling and nutrition and health N care. Promoting synergy between T health and nutrition services will * enable the country to successfully face the nutrition challenges and achieve rapid improvement in health and nutritional status of the population.

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