IMPROVING NUTRITIONAL STATUS CHALLENGE OR OPPORTUNITY

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IMPROVING NUTRITIONAL STATUS
CHALLENGE OR
OPPORTUNITY Prema Ramachandran Director
Nutrition Foundation of India
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• Major nutritional problems in 1950
• Threat of famine acute starvation due to
• low agricultural production
• lack of appropriate food distribution system.
• Chronic macro micronutrient deficiency due to
• low dietary intake because of poverty and low
  purchasing power
• high prevalence of infection due to poor
  access to safe-drinking water, sanitation and
  health care
• poor utilization of available facilities due to
  low literacy and lack of awareness.

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• Initiatives to improve nutritional status of the
  population during the last five decades include
• Increasing food production- building buffer
  stocks
• Improving food distribution- building up the
  Public Distribution System (PDS)
• Improving household food security through
• Improving purchasing power
• Food for work programme
• Direct or indirect food subsidy

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• Other Initiatives to improve nutritional status
  of the population include
• Food supplementation to address special needs of
  the vulnerable groups-Integrated Child
  Development Services (ICDS), Mid-Day Meals
• Nutrition education especially through Food and
  Nutrition Board (FNB) and ICDS
• Efforts of the health sector to tackle
• Adverse health consequences of undernutrition
• Adverse effects of infection and unwanted
  fertility on the nutritional status
• Micronutrient deficiencies and their health
  consequences

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• Over the last three decades there has been
• Substantial reduction in severe grades of chronic
  energy deficiency (CED),kwashiorkor, marasmus
• Blindness due to Vit A deficiency is rare
• BUT
• 1/3rd of children weigh lt than 2.5 kg at birth,
• half of the pre school children suffer from mild
  and moderate under nutrition.
• More than 2/3rd of women and children are
  anaemic.
• Vitamin A deficiency and IDD still remain
  important public health problems

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• Nutrition-Problems
• Mortality has come down by 50 and fertility by
  40, reduction in under nutrition is only 20.
• With the reduction in mortality undernourished
  persons survive and increase the UN pool .
• While some of the factors such as dietary
  intake and anaemia can be modified rapidly,
  other determinants of nutritional status like
  parents stature, birth weight , growth in
  infancy and childhood cannot be altered
  rapidly.
• Focus of interventions now may therefore have be
  on those factors which are amenable for
  correction and have functional significance.

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• Paradigm shift in the Tenth Plan
• household food security and freedom from hunger
  to nutrition security for the family and the
  individual
• untargeted food supplementation to screening of
  all persons from vulnerable groups,
  identification of those with various grades of
  under-nutrition and appropriate management
• focus on better implementation of programmes for
  prevention ,detection and management of
  micronutrient deficiencies
• lack of focused interventions on the prevention
  of over-nutrition to the promotion of appropriate
  lifestyles and dietary intakes for the prevention
  and management of over-nutrition and obesity.

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• Path for nutrition security Ensure adequate
  access to foodstuffs by
• Improving production of cereals, pulses and
  seasonal vegetables to meet nutritional needs
• making them available throughout the year at
  affordable cost through reduction in post harvest
  losses and appropriate processing
• more cost-effective and efficient targeting of
  the PDS to address macro and micronutrient
  deficiencies (This may include providing coarse
  grains, pulses and iodised/ double fortified
  salt to below poverty line (BPL) families through
  the targeted PDS (TPDS))
• improving purchasing power through programmes
  ( Employment guarantee)

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Low birth weight Causes, consequences
interventions
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Over the last three decades there is no
significant change in mean birth weight or
incidence of LBW
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Time trends in IMR
Source RGI 2002
However there has been a steep decline in
IMR In India intrauterine growth retardation
is the major cause of LBW so improvement in BW
is not essential prerequisite for reduction in
IMR
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• Birth weight and health
• With improvement in survival new questions
  emerge.LBW is associated with
• Low growth trajectory what is its contribution
  to under nutrition in later life
• ?Increased risk of obesity, diabetes and
  coronary heart disease in later life
• RD to assess these are needed
• Mother child dyad is an inseparable unit
  To achieve reduction in LBW and further
  decline in IMR, there is a need to to improve
  nutrition and health care for mother.

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Breast feeding protection from under and over
nutrition Exclusive breast feeding for first six
months holds the key for infant survival and
growth Adequate complementary feeding will
prevent early onset of under nutrition How do we
ensure improve IYCF
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Infant feeding practices -NFHS -2
Source NFHS 1998-99
Breast feeding is universal in India but
exclusive breast feeding upto six months and
introduction of complementary feeds at six months
is not common
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Prevalence of undernutrition (Weight for age
below -2 SD)
Source NFHS 1998-99
As a result there is steep increase in under
nutrition between 6-23 months of age
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• Tenth Plan- major focus on Prevention of
  undernutrition in infancy through
• promotion of exclusive breast feeding in the
  first six months
• nutrition education for the introduction of
  appropriate low-cost, energy dense (home
  available) complementary food at 6 months
• focus on nutrition education by AWW/ ANM/doctor
  during each contact with mother .
• Yet to be operationalised under ICDS /NRHM
• Needed clear crisp messages AWW to district
  doctor should all say the same things repeatedly
  to bring about behavioral change
• Use of mass media (as in NRHM)or ITES (MP
  experience) - will it help in bring uniformity
  in messages of health and ICDS workers rapidly?

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Mean Energy Consumption- NNMB 2000
The gap between RDA and the actual energy
intake is greatest in preschool children and
lowest in adults Poor knowledge of child feeding
practices rather than poverty appear to be the
major factor for low energy intake in
preschool children
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Nutritional Status of children by Income
Source NFHS 1998-99
Undernutrition rates among poor in Kerala are
similar to undernutrition rates among the rich
in UP. Appropriate IYCF and caring can lead to
steep fall in undernutrition rates in
preschoolers
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ICDS IN THE ELEVENTH PLAN Main factor
responsible for under nutrition in children is
poor feeding and caring practices and not
poverty Ongoing supplementation at anganwadi
where those children who come to anganwadi
share the food available will not achieve any
reduction in under nutrition rates The programme
has to operationalise the paradigm shift from
social welfare to nutrition mode to improve
nutritional status District is the unit of
planning implementation Specify the
investments needed to operationalise
interventions to improve nutritional status-
monitor investments, nutrition outputs and
nutrition outcomes
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Prevention of under nutrition with focus on 0
36month old children major intervention -
ensuring appropriate IYCF. How to cook low
cost balanced tasty meals from locally
available cereal, pulse and vegetables and how
to feed the young children can be demonstrated
in the anganwadi on immunisation, health and
nutrition days Detection of under nutrition At
least once in three months all children should be
weighed (provision for functional balances)
skill upgradation of AWW in weighing and
monitoring growth in individual childs card
(cards should be made available)
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AWW should identify children with growth
faltering and teach the mothers on care of these
children with home available food Children with
moderate and severe under nutrition should be
identified and given appropriate nutrition and
health care take home food supplements may have
to be given for the initial period and the
children carefully monitored Severely
undernourished infants/ children who fail to
improve under home management,those with
infections and other complications should be
referred to hospitals for care
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While under-nutrition remains the major problem
is rural children and poor children, over
nutrition is emerging as a problem even among
children especially among urban affluent
children. Changes in life style and reduction in
physical activity are the major factors
responsible for over-nutrition If health and
nutrition education on correction of eating
habits and increase in physical activity
results in appropriate life styles it is possible
to combat the emerging problem of
over-nutrition
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Time trends in energy intake
Source NNMB Reports
Over years there has been decline cereal and
pulse intake some increase in fat intake over
all energy intake has declined both in urban
and rural areas
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Nutrient intake as percent of energy
Source NNMB Reports
Inspite of some increase in fat intake over time
, fat contributes less than 15 of the energy

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Comparison of the BMI of women (state-wise)
Source NFHS -2
While under-nutrition continues to be a major
public health problem, in some states
over-nutrition is emerging as a major problem
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Promotion of appropriate dietary intake and
lifestyles is the intervention needed for the
prevention and management of obesity and
chronic diseases For better health,it is
desirable to increase physical work and
exercise so that the muscle mass improves rather
than decrease food intake and reduce fat.
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Micronutrient deficiencies All effort for
combating anaemia Review Vitamin A
supplementation Universal access to iodised
salt
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Anaemia is a major problem right from childhood
it worsen during adolescence in girls Advent
of pregnancy further aggravates anaemia
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Combating anaemia Prevention of anemia Promote
breastfeeding, improve complementary feeding
Dietary diversification Double fortified salt
ICDS, MDM , progress towards universal use
fortification of other food stuffs with iron,
folate ? Weekly once IFA supplement
? Detection of anaemia Screen children,women when
ever possible school, hospitals OPDs Treat
anaemic persons and follow them up until
recovery
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Coverage Under Massive dose of Vitamin A
Coverage can be improved -Orissa, UP But
overall coverage remains low
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Prevalence of Bitot spot has declined This
may be the right time to review the massive
dose vitamin A programme ?
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Many coastal , salt manufacturing states with
good health indices have low iodised salt use.
Prevalence of goitre in these non endemic states
is relatively high
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There was a decline in household access to
iodised salt after the ban on sale of non-
iodised salt was lifted Reimposition of ban is
under way
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India has entered the demographic opportunity
window. Almost all the increase in population in
the next decade will be in the 15-59 age group
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Under-nutrition in children is mainly due to
poor child feeding and caring problem can be
solved through nutrition education and health
care Poverty associated under nutrition in
adults can be improved through improved access
to livelihood Micro-nutrient deficiency can be
combated through dietary diversification and
food fortification Over nutrition is just
emerging as a problem and is mainly due to
reduction in physical activity
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There are tried, time tested cost effective
interventions to improve nutritional
status. Country has the infrastructure to
undertake these interventions Population is
rational, aware and will strive to improve their
health and nutritional status Importance of
human resources as engines driving national
development is well recognised there is a
willingness to invest for improving health
and nutritional status of the population
Improving nutritional status- is it not an
opportune period
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THANK YOU