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4.3 Food and Nutrition Security

Nutrition in infancy and early childhood (0-5 years)

4.3.123 Preschool children (defined as aged 1-5 years by NNMB) constitute the most nutritionally vulnerable segment of the population and their nutritional status is considered to be a sensitive indicator of community health and nutrition. The prevalence of underweight, wasting and stunting among children as determined by anthropometric measurements as shown in Fig.21.

4.3.124 Over the last two decades there has been some improvement in energy intake and substantial reduction in moderate and severe undernutrition in preschool children (Fig.22).

Though there has not been any change in the intake of green leafy vegetables and other vegetables, there has been substantial decline in prevalence of nutritional deficiency signs (Fig.23). There are still substantial interstate differences in nutritional status and nutritional deficiency signs; however, over the last two decades there has been substantial reduction in severe grades of undernutrition and severe grades of nutritional deficiency signs in all the major States.

4.3.125 Available data on weight for age among under five children is given in Fig.24. At birth about one-third of all neonates are under weight (less than 2.5 Kg). In the first six months the percentage of undernourished infants comes down (15.6%). This is mainly because of the practice of universal breast-feeding, which has been protected and promoted. However, there is a progressive increase in the percentage of children who are under weight in the 6-11 months and 12-23 month’s age group (Fig.24). This is due to two major problems:

1. too early (before 6 months) or too late (beyond 6 months) introduction of supplements to breast fed infants (Fig.25)
2. high morbidity rates due to infection in this age group.

4.3.126 During the Ninth Plan efforts will be made to ensure nutrition education for timely and appropriate supplement introduction is given through all media of communication. The 6-24 month child can take only small quantity of supplements (50-60 Kcal) at any given time. It is therefore essential that the child is fed 4 - 5 times a day in order to meet the requirements of supplements to breast milk in this age group. The support of the family, neighbours and community are all essential for ensuring that infant does receive the care and attention that it needs to consume food needed for growth and development. Employers, women's group, the community and Panchayati raj institutions have to provide conducive environment and enabling provision to women to achieve this objective. Prevention of infection through promotion of environmental sanitation and provision of safe drinking water, early detection and prompt treatment of infection by health workers envisaged as a part of the RCH package are some of the other interventions to improve nutritional status,.

4.3.127 Data from NNMB surveys and repeat surveys indicates that over years there has been a decline in the percentage of 1-5 year old children with moderate and severe degrees of undernutrition (Fig.26). During this period there has been a decline in clinical deficiency signs also (Fig.23). This is partly due to some increase in the dietary intake and partly due to improved health care for infection. This encouraging trend should be further accelerated through coordinated efforts of all concerned sectors especially DWCD and Dept. of Family Welfare.

4.3.128 There are substantial interstate differences in childhood undernutrition. Kerala and Tamil Nadu have achieved substantial reduction in undernutrition inspite of relatively low per capita income, expenditure on food and food consumption. Maharashtra has shown the steepest decline in undernutrition among States even though food intake has not changed substantially. Madhya Pradesh continues to have high unaltered prevalence of under nutrition in under five children (Fig.27).

4.3.129 These data emphasize importance of health inputs in reducing infection related deterioration in nutritional status. During Ninth Plan additional assistance is being provided to poorly performing States for bridging critical gaps in primary health care; optimal utilisation of these and effectively targetted food supplementation are expected to result in substantial improvement in health and nutritional status of under 5 children.

Children in the 5-14 age group:

4.3.130 Both the severity and magnitude of undernutrition are less in 5-14 age group than that in early childhood. The mid day meal programmes and the school health programme are ongoing nutrition and health intervention in this age group; howerver both quality and coverage are often suboptimal. In addition the non-school going children who are more at risk of nutrition and health problems are not covered. During the Ninth Plan the Education Dept. will intensify efforts to ensure universal enrollment and improved retention at school. The midday meal programme will continue; there will be efforts to weigh all children and identify those suffering from moderate and severe undernutrition and ensure that they benefit from the ongoing midday meal programme. School health check up and nutrition education will receive the attention that they deserve.

Emerging nutritional problem:

Adolescent Nutrition

Geriatric Nutrition

Overeating and obesity

4.3.133 During the last two decades there has been a major alteration in life styles and activity pattern among all segments of population. With the ready availability of cooking gas, piped water supply, labour saving gadgets and ready transport, there had been a substantial reduction in the physical activity pattern and energy expenditure especially in middle and upper income group. However, the dietary intake has not undergone any reduction; in fact ready availability of fast foods, ice creams and other energy rich food items at affordable costs have resulted in increased consumption of these by all members of the family. All these have lead to increasing energy intake over and above the requirement and consequent obesity in these segments of population (Figure - 19). Nutrition and health education to convince the population about restricting food intake and increasing exercise so that energy balance is maintained will be taken up during the Ninth Plan.

4.3.134 Operational strategy during the Ninth Plan to improve health and nutritional status of vulnerable segments includes

1. Pregnant and lactating women - screening to identify women with weight below 40 Kgs. and ensuring that they/ their preschool children receive food supplements through Integrated Child Development Services Scheme (ICDS); adequate antenatal, intrapartum and neonatal care.
2. 0-6 months infants - Nutrition education for (a) early initiation of lactation (b) protection and promotion of universal breast feeding (c) exclusive breast feeding for the first six months (unless there is specific reason supplementation should not be introduced) (d) immunisation, growth monitoring and health care.
3. Well planned nutrition education carried out through all channels of communication to ensure that the infants and children in the critical 6-24 months period, do a) continue to get breastfed; b) get appropriate cereal-pulse-vegetable based supplement fed to them at least 3-4 times a day- appropriate help in ensuring this through family/community/work place support; c) immunisation and health care for all children.
4. Ensure that children in the 0-5 age group are screened, by weighment; children with moderate and severe undernutrition get double quantity supplements through ICDS; screen all 0-5 children for nutrition and health problems and provide appropriate intervention.
5. Screen primary school children and ensure that those with moderate and severe chronic energy deficiency do receive the mid-day meal/ or their families get the cereals through TPDS.
6. Monitor for improvement in the identified undernourished infants, children and mothers; if there is no improvement, refer to physician for identification and treatment of factors that might be responsible for lack of improvement;
7. Nutrition education on how dietary needs of different members of the family vary and how they can all is met by minor modifications in the family meals. Intensive health education for improving the life style of the population coupled with active screening and management of the health problems associated with obesity.

Micronutrient deficiencies

Anaemia

4.3.135 Anaemia is the most wide spread yet most neglected Micronutrient deficiency disorder in India. Iron and folic acid deficiency due to inadequate intake of green leafy vegetables and other iron folate rich foodstuffs is the most common cause of anaemia. Poor bioavailability of iron from the phytate, fibre rich Indian diet aggravates the situation. Anaemia affects all age groups of population from all strata of the society. Pregnant women and pre-school children are the worst affected (Fig.28). Anaemia is associated with reduction in work capacity and increased susceptibility to infection. Association between anaemia and low birth weight are well documented. Details of the ongoing interventions for prevention and management of anaemia their impact and proposed Ninth Plan intervention is described in Chapter on Family Welfare.

4.3.136 Operational strategy for the Ninth Plan for pregnant women:

a) Screening of all pregnant women using a reliable method of hemoglobin estimation for detection of anaemia, b) oral iron folate prophylactic therapy for all non-anaemic pregnant women (Hb > 11 g/dl), c) iron folate oral medication at the maximum tolerable dose throughout pregnancy for women with Hb between 8 and 11 g/dl, d) parenteral iron therapy for women with Hb between 5 and 8 g/dl if they do not have any obstetric or systemic complication, e) hospital admission and intensive personalised care for women with Hb < 5 g/dl, f) screening and effective management of obstetric and systemic problems in all anemic pregnant women

1. Fortification of common foods with iron to increase dietary intake of iron and improve hemoglobin status of the entire population including children, adolescent girls and women prior to pregnancy.
2. Health and nutrition education to improve consumption of iron and folate rich foodstuffs such as green leafy vegetables,
3. Horticultural interventions to improve availability of green leafy vegetables in urban and rural areas at affordable costs throughout the year.

Vitamin A deficiency

4.3.138 In the fifties pediatricians in major hospitals in most States reported that blindness due to Vit A deficiency is a public health problem. Vitamin A deficiency in childhood is mainly due to inadequate dietary intake of Vit. A. Increased requirement of the Vit. A due to repeated infection aggravated the magnitude and severity of the deficiency. The association between measles, severe PEM and keratomalacia and high fatality in such cases was reported by many paediatricians. Prevalence of night blindness and Bitot's spot in pre-school children ranged between 5% and 10% in most States. Blindness due to Vitamin A deficiency was one of the major causes of blindness in children below 5 years. In view of the serious nature of the problem of blindness due to Vitamin A deficiency it was felt that urgent remedial measures in the form of specific nutrient supplementation covering the entire population of susceptible children should be undertaken. In 1970 the National Prophylaxis Programme against Nutritional Blindness was initiated as a Centrally Sponsored Scheme (CSS). Under this CSS, all children between ages of one and five years were to be administered 200,000 I.U of Vitamin A orally once in six months. Details of the ongoing intervention for prevention of Vitamin A deficiency and proposed Ninth Plan intervention is described in Chapter on Family Welfare.

Iodine deficiency disorders

4.3.139 Iodine deficiency disorders (IDD) have been recognised as a public health problem in India since mid-twenties.

4.3.140 The National Goitre Control Programme was initiated in 1962 as a 100% Centrally funded Central sector programme with the aim of conducting goitre survey, supplying good quality iodised salt to areas having high IDD, health education and resurvey after five years. The programme was renamed as the National Iodine Deficiency Disorder Control Programme in 1992. Details of the ongoing intervention for control of Iodine Deficiency Disorders and proposed Ninth Plan intervention is described in Chapter on Health.

Health nutrition interactions:

4.3.141 It is well recognised that the pregnant and lactating women from one of the most vulnerable segments of the population from nutritional point of view; the ill effects of maternal undernutrition affect not only of the mother but also her offspring. Adverse nutrition and health consequences of "too early, too close, too many and too late" pregnancies on the mother child dyad were recognised early in our country and contraceptive care was recognised as an indirect effective intervention to improve maternal and child nutrition. Research studies during the sixties and seventies documented the magnitude and health hazards associated with chronic energy deficiency iron, folate, iodine and vit. A deficiency. National programmes to combat these were drawn up and are being implemented. Yet another important indirect cause of undernutrition continues to be infections. Pediatricians still grapple with the vicious cycle of severe CED and infection; obstetricians and pediatricians continue to tackle the increased morbidity in anaemic women and children. With the advent of HIV epidemic in India in the eighties, it is inevitable that over the next decade there will be an increase in the severe undernutrition associated with AIDS in all the age groups.

Malnutrition and Mortality among Adults

4.3.142 Both undernutrition and obesity are associated with higher risk of morbidity and mortality. A longitudinal study conducted by the NIN showed a good correlation between the nutritional status of adults (as measured by BMI) and mortality during the subsequent 10-year period (1979-1989) (Fig. 29). Clinical data from India has unequivocally demonstrated the increased risk of non-communicable disease especially cardiovascular disease and diabetes and the higher mortality risk in obese individuals. Association between low birth weight and perinatal and infant mortality and growth faltering and high-risk childhood mortality are well documented.

4.3.143 Association between severe grades of anaemia and high perinatal and maternal mortality has been well documented. Anaemia is one of the leading causes of maternal mortality in  India. Mortality rates are higher in children with moderate and severe grades of under nutrition. Vicious self-perpetuating cycle of undernutrition increasing susceptibility to infection and infection aggravating undernutrition often ends in death. HIV/AIDS is a new addition to the existing infections that causes undernutrition and result in death.

4.3.144 The Health sector programmes during the Ninth Plan are aimed at combating both problems of undernutrition and overnutrition. The Reproductive and Child Health initiative and the Health Sector programmes strive for early detection and treatment of both undernutrition and infections especially in preschool children and women. Food supplementation especially if they are targetted to undernourished individual could reduce morbidity. During Ninth Plan, integrated health and nutritional intervention will be taken up with appropriate intersectoral coordination to ensure rapid decline in undernutrition, morbidity and mortality.

Intersectoral coordination between health and ICDS functionaries

4.3.145 Over the last decade there has been substantial improvement in the collaboration between the AWWs and ANMs. The AWW have assisted the ANMs in immunisation and undertaking antenatal check ups. The ANM has been providing the micronutrient supplements as and when required. However the collaboration has not resulted in the improvement in the quality of screening for undernutrition, monitoring the improvement following supplementation, identification and management of at risk women and children. The quality of nutrition and health education has also not improved substantially. It is imperative that the ANM and the AWW are given orientation and training in nutrition and health problems, ongoing intervention programme in both the sectors, appropriate messages for nutrition and health education, so that they can function more effectively. This area will receive due attention during the Ninth Plan because increasingly improving nutritional status will depend on the synergistic effect of food supplements, infection management and fertility regulation. Effective antenatal care and targetting food supplements to women below 40 kg

will hold the key to reduction in low birth weight; breast feeding, growth monitoring and infection treatment will be needed for improving health and nutritional status of the under fives and reducing under five mortality.

4.3.146 Intersectoral coordination at and below the district level especially at the village level holds the key to improvement of health and nutritional status of the population within the available resources. It is essential that improving awareness regarding environmental sanitation and safe drinking water are done in settings which have access to both these. Therefore, the drinking water and sanitation programmes both in urban and rural area should provide these facilities on high priority to Panchayat, anganwadi, primary school and primary health care institutions. Nutrition and health education forms a part of school curriculum. If these are taught in real life situation they will have more impact. Utilising the time for "Socially useful productive work" in school for students and teachers' participation once in a month in health and nutrition check up, growth monitoring, immunisation activities at the Anganwadi would not only improve children's knowledge and promote child to child care but also assist the hard pressed ANM and Anganwadi worker to complete their activities and keep the records meticulously.

4.3.147 Mahila Swasth Sangh and PRI members can assist in identifying pregnant and lactating women weighing below 40 Kg. and infants and children showing growth faltering and ensuring that these persons/families have access to food supplementation in the ICDS on priority basis. The agricultural workers and PRI members can ensure that green leafy vegetables, herbs and condiments are grown in the village land and supplied to anganwadi on a regular basis so that food supplements do have vitamin and minerals and are also more palatable.

Monitoring of ICDS Programme:

4.3.148 Effective monitoring and midcourse corrections are essential for successful implementation of the intervention programmes; this is even more critical in programmes like ICDS that requires good intersectoral coordination for achievement of the goals. Evaluation of ICDS carried out by both Nutrition Foundation of India (NFI) and National Institute of Public Cooperation and Child Development (NIPCCD) have suggested that there is a need for improved monitoring of the implementation of the programme.

4.3.149 Both ICDS and the health functionaries regularly file monthly progress report, which are collated and reported. However the existing monitoring systems are functioning suboptimally. There are lacunae at the levels of collection, reporting and collation. There are delays in analysis and reporting. The reports of the health and family welfare programme by the respective workers, and the Monthly progress reports sent by the ICDS workers are not utilised for district level monitoring and midcourse correction of the ongoing programmes. Currently there are efforts to improve these and also ensure effective utilisation of the available district data for area specific micro planning and monitoring.

4.3.150 At the request of the Dept. of Women and Child Development the National Institute of Nutrition has carried out a study in Andhra Pradesh for improving the monthly progress reports of the ICDS workers and improve monitoring of ICDS programme at district level. The data from the study indicated that it was possible to train and orient the ICDS functionaries to improve the quality and timeliness of the reporting; analysis of the data and discussions on the implications of the reports with the functionaries facilitated the implementation of midcourse corrections and led to improvement in performance. Careful monitoring of the data on prevalence of undernutrition in under five children will also be the first step towards building up of a nutrition surveillance and response system at the critical district level.

4.3.151 Under the Reproductive and Child Health initiatives the ANMs are to identify, and refer `at risk' undernourished women and children. Collaboration between the ANM and the AWW at the village level would improve implementation and monitoring of both health and nutrition programmes. During the Ninth Plan period attempts will be made to improve the monitoring not only regarding the coverage but also quality of services such as the identification of the `at risk' individuals, ensuring that they do take supplements, assessing the response to food supplements and if they are not improving, referring them to the PHC for examination and management.

Monitoring Nutritional Status of the Population

4.3.152 India is a vast and varied country. There are large differences in per capita income, availability of the food stuffs, purchasing power, dietary habits, habitual consumption of food stuffs, health and nutritional status between different States in the country. In all States there are substantial urban-rural and inter-district variation in the above indices. The tribal population differs considerably from the non-tribal population residing in the same district.

4.3.153 Sound, reliable data on the factors modifying dietary intake and nutritional status of the population in States/ districts are essential for policy makers, programme managers and monitoring agencies to carry out appropriate decentralized planning, policy and programme formulation which keeps in focus both the National goals and the local needs. Ready availability of data on process and impact indicators and continuous monitoring is vital for midcourse correction of ongoing programmes.

4.3.155 In 1972 the National Nutrition Monitoring Bureau was set up by the Indian Council of Medical Research to:

1. Collect the data on dietary intake, and nutritional status on a continuous basis from different states and
2. Evaluate the ongoing national nutrition programmes, identify their strengths and weaknesses and recommend midcourse corrections to improve their effectiveness.

4.3.156 The National Nutrition Monitoring Bureau (NNMB) has been undertaking surveys on dietary intake (household and individual) and nutritional status of the population on a continuing basis since 1972 in nine major States (Andhra Pradesh, Gujarat, Karnataka, Kerala, Madhya Pradesh, Maharashtra, Tamil Nadu, Uttar Pradesh, West Bengal); Orissa has been included in 1977.

4.3.157 The National Nutrition Policy envisages that the Nutrition monitoring will be extended throughout the country and the Central Reference Laboratory of NNMB situated in National Institute of Nutrition will assist the Deptt. Of Women and Child Development in this process.

4.3.158 India is currently undergoing demographic, economic, social, educational, agricultural and health transition. These factors individually and collectively can bring about substantial alteration in health and nutritional status of the population. Several programmes have been initiated to combat these problems. In this context it becomes imperative that the existing mechanisms for monitoring and midcourse corrections are further strengthened, streamlined and utilized effectively.

4.3.159 Currently, the agricultural production (Deptt. of Agriculture), economic indices including expenditure on food (NSSO), demographic and health indices (SRS) are monitored on an yearly basis throughout the country. NSSO surveys on consumer expenditure provides information on expenditure on food and quantity of food consumption at household level. But NSSO does not provide information on intrafamilial distribution of food in the household. NNMB carries out nutrition surveys, monitors dietary intake including intrafamilial distribution of food and assessment of nutritional status but this is done only in ten states. There is at present no mechanism for continuous monitoring of nutritional status in the rest of the States.

4.3.160 During the Ninth Plan efforts will be made to extend Nutritional Monitoring on yearly basis throughout the country. Appropriate agencies/ institutions, which could undertake nutritional survey with good quality control and ensure rapid, cost effective coverage will be identified in States, which have not been covered as yet. The sampling frame may be modified and improved through coordination with NSSO. The Central Reference Laboratory of NNMB will continue to be the focal point for training of personnel and quality control. Mechanisms for data collection, analysis and reporting will be strengthened so that updated information is available on yearly basis which could be utilised for planning intervention, monitoring of progress of ongoing interventions and effecting midcourse correction.

Research:

4.3.161 India is one of the pioneers in Nutrition research not only in the Asian region but also in the world. Several research institutions and Universities are carrying out the research studies with assistance from Ministries and research funding agencies such as ICAR, ICMR, CSIR, DBT and DST. Basic, clinical, applied and operational research studies carried out in the country have identified major nutritional problems in the country, their aetiology, appropriate remedial and preventive measures to tackle the problem and the modalities of effectively operationalising the intervention programme at the regional and national level. Initially the focus of research was on deficiency diseases and chronic energy deficiency - health hazards associated with them, methods for detection, treatment and prevention. It is noteworthy that the major intervention programmes such as food supplementation programmes, anaemia prophylaxis programme, massive dose vit A supplementation programme have all been initiated on the basis of research work carried out in the country. During the last two decades responding to the changing spectrum of nutrition related disorders, research studies on food and drug toxins and nutritional risk factors associated with noncommunicable diseases have been initiated.

4.3.162 During the Ninth Plan period basic, clinical, applied operational and socio - behavioral research in Nutrition will continue to receive priority attention so that the country can effectively and rapidly tackle the nutritional and associated health problems. Net working of the research institutions and universities carrying out research studies in Nutrition will be attempted, so that there is no unnecessary duplication of efforts and the available resources are fully utilised.

1. Research studies on major micronutrient deficiencies with special emphasis on prevention, speedy control, and effective management
2. Changing nutrition- fertility and nutrition - infection interactions and their implications to health and nutritional problems; evolving and testing appropriate intervention strategies;
3. Changing dietary habit and lifestyle and their impact on nutritional status especially obesity and micronutrient deficiencies.
4. Increasing longevity and changing lifestyles - their impact on nutrition and risk of non-communicable diseases.
5. Nutrition-environment interactions and their health implications.
6. Improvement in the methods of assessment of nutritional status of the individual and the community.
7. Studies on determinants of nutritional status under varying conditions and effective modification of the adverse influences.
8. Operational and socio-behavioural research to improve performance of the ongoing interventions.

Funding

4.3.164 Food Supplementation costs under the ICDS scheme is borne by the State Governments; the infrastructural costs are borne by the Department of Women and Child Development. The Mid-Day Meal Programme costs are borne by the Department of Education. The Anaemia Prophylaxis Programme and Massive Dose Vitamin A Programme are funded by the Department of Family Welfare and the Department of Health provides the funds for Health Component of Iodine Deficiency Disorder Control Programme. It is obvious that different Departments are funding different programmes for improvement of nutritional status of the population. Different departments will continue to fund these ongoing nutrition programmes during the Ninth Plan period. The funding for infrastructure for the ICDS will continue to be borne by the Deptt of Women and Child Development and the state Govt continue to provide funds for food Supplementation.

4.3.165 During the Ninth Plan efforts will have to be made by the States to improve regularity of supply of food to ICDS centres and improve the availability of food supplements to the most needy by identifying `at risk' individuals and families, providing food supplements to them on priority basis and monitoring their improvement. Better targetting, reducing the wastage, building up of the mechanisms for identification and provision of supplements according to the needs, participation of the Panchyati Raj /Nagar Palikas and the people themselves in the ongoing efforts to improve their nutritional status are some of the mechanisms through which more effective utilisation of available resources will be ensured during the Ninth Plan.

4.3.166 It is expected that with funds made available by the States, Centre and EAPs it will be possible to universalise food supplementation component of the ICDS, improve the quality and coverage of the programmes so that the country will quickly move towards achievement of the nutrition and health goals specified in the National Nutrition Policy; however it may not be possible to achieve all the goals with in the Ninth Plan period. During the Tenth plan period, further efforts will be made to rapidly bridge the existing gaps. It is anticipated that accelerated economic development, improvement in employment generation, rise in Gross Domestic Product and per capita income will make it possible both for the country and for the individual to invest more in nutrition and health and achieve substantial improvement in both.

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