|DR. J E PARK MEMORIAL ORATION
|Year : 2017 | Volume
| Issue : 3 | Page : 155-162
Malnutrition-free India: Dream or reality
Professor, Department of Community Medicine, Institute of Medical Sciences, Banaras Hindu University, Varanasi, Uttar Pradesh, India
|Date of Web Publication||15-Sep-2017|
C P Mishra
Department of Community Medicine, Institute of Medical Sciences, Banaras Hindu University, Varanasi - 221 005, Uttar Pradesh
Source of Support: None, Conflict of Interest: None
| Abstract|| |
In spite of great efforts done by the Government of India to tackle the problem of malnutrition, proportion of population normal on nutrition scale has been stationary; nearly half of them have been a victim of under- and over-nutrition. Over a period, undernutrition has declined but this has been compensated by overnutrition. Hidden hunger is a still an unfinished agendum. The achievement of food grain security at the national level did not percolate down, and households' food insecurity and level of chronic food insecurity are still high. High economic growth rates have failed to improve food security in India. There is a need and scope for organizational, financial, and managerial reforms in this direction. The repercussion of malnutrition is not limited to physical deterioration, but it also affects the psychological level of victims. The legislative, service, and educational approaches should be optimized to fulfill the dream of malnutrition-free India.
Keywords: Energy balance, food security, malnutrition, nutritional imbalance, parental paradox, poverty
|How to cite this article:|
Mishra C P. Malnutrition-free India: Dream or reality. Indian J Public Health 2017;61:155-62
| Conceptual Framework|| |
Indian population are witnessing demographic, epidemiological, and nutritional transition. Therefore, the problem of malnutrition is of serious concern. Malnutrition in one form or the other is common in India. Mechanistically, malnutrition is defined as “a state wherein adequate nutrients are not delivered to the cells to provide the substrate for optimal functioning.” It refers to pathological state arising from deficiency/excess of one or more nutrients over an extended period. It can occur at any age as either general malnutrition, i.e., starvation, or as a syndrome due to the deficit of specific nutrients such as calories, protein, vitamins, and minerals. Types of malnutrition are a spectrum in itself, namely, undernutrition, overnutrition, specific deficiency diseases, and nutritional imbalance. Historically, undernutrition has been associated with higher prevalence of infectious diseases, whereas overnutrition has been associated with a chronic degenerative disease process.
| Existing Scenario|| |
Although great efforts have been made by the Government of India within the past few years to tackle the problem and burden of malnutrition, it is still present in the country and remains a major public health issue. The 2016 Global Hunger Index Report ranked India 97th among 118 countries. Misdiagnosed and unrecognizing cases are also a substantial factor for the persistence of the problem.
| Child Malnutrition|| |
In spite of progress in reducing the prevalence of underweight among children under five from over 67.3% in 1974–1975 to 41% in 1996–1997, the proportion of underweight children rose to 44.4 in 1998–1999, and remained almost unchanged at 43.5% in 2005–2006. The National Family and Health Survey (NFHS) 1, 2, and 3 also recorded the marginal change in the situation of underweight among under three, i.e., 53.4%, 47.0%, and 45.9%, respectively. In the case of wasting in under three children, corresponding values were 17.5%, 15.5%, and 19.1%, whereas 52.0%, 45.5%, and 38.4%, under three children in respective categories were stunted. An overview of child malnutrition in 0–5 years [Table 1] clearly reflects that nutrition and health policies and programs have not been able to reduce this problem to the desired extent.,, This has been corroborated by the findings of Rapid Survey on Children (RSoC) as well. This situation stated earlier refers to the overall situation in India. There has been wide variation in the extent of underweight (14%–44%), wasting (14%–26%), and stunting (20%–48%) in different states.
Hidden hunger in terms of deficiency of vitamins and minerals remains a perpetual problem. Vitamin A deficiency expressed in terms of the prevalence of Bitot's spot has been 0.7% (NIN, 1997), 0.21% (India Nutrition Profile, 1998), 0.70% (District Survey, 2001 [ICMR]), and 0.2% (National Nutrition Monitoring Bureau Survey, 2011–2012). As far as iodine deficiency disorder (IDD) is concerned, the whole population is at risk, but 200 million people are at a serious risk of IDD. There are 71 million people suffering from goiter and other IDDs, whereas 6.6 million and 2.2 million people have mild neurological deficit and cretins, respectively. Zinc deficiency results in impaired immunity, which may increase the risk of infections. It is quite prevalent among children below 5 years of age; the overall prevalence of zinc deficiency was reported to be 42.6%, whereas this was 43.8% in children below 5 years of age in five states. As per the NFHS-3 (2005–2006) and NFHS-4 (2015–2016), children aged 6–59 months who are anemic (hemoglobin <11.0 gm/dl) were 69.4% and 58.4%, respectively.,
| Adolescent Malnutrition|| |
Inadequate nutrition in adolescence can potentially retard growth and sexual maturation. Although these are likely consequences of chronic malnutrition in infancy and childhood, this can put them at high risk of chronic diseases, particularly if combined with other adverse lifestyle behaviors. Several studies conducted in different rural and urban settings also substantiated the fact that problem of malnutrition in adolescents is quite prevalent in general and adolescent girls in particular. A study conducted on 400 adolescent girls of urban Varanasi revealed that 62.5% of adolescent girls were underweight (body mass index [BMI] <18.5 kg/m 2); this study also explored that in the case of 48% of individuals, weight for age was <80%. According to a cross-sectional study on 270 adolescent girls in the rural area of Varanasi, 68.5% of adolescent girls were undernourished. As per the WHO report, India has shown deficiencies in the intake of all nutrients, particularly iron, calcium, Vitamin A, and Vitamin C among adolescent age group. The main reasons are low educational level of their parents and low family income. Although there is a disparity in iron deficiency anemia in rural and urban areas as well as school and nonschoolgoing children, it is still a prominent issue in adolescent age group, especially in adolescent girls. As much as 55.8% of adolescent girls aged 15–19 years were anemic and 1.7% were severely anemic. A cross-sectional study from urban Varanasi reported that 49.5% of individuals had at least one nutritional deficiency sign. Adolescent girls belonging to Muslim religion, middle socioeconomic status, and having mother's occupation as homemaker and business plus labor had significantly higher risk of nutritional abnormality in the logistic model. Dietary intake of individuals in terms of energy, protein, and fat was 56.0%, 67.2%, and 67.1% of respective estimated recommended dietary allowances (RDAs), whereas dietary inadequacy of micronutrients in adolescent urban girls in the concerned study from Varanasi reported that, in 72.8%, 71.2%, 88.2%, and 6.2% of individuals, calcium, iron, Vitamin A, and Vitamin C intakes, respectively, were <50% of RDAs. The dietary diversity of urban adolescent girls has been far from being satisfactory. According to a study on urban adolescent girls of Varanasi, milk, other vegetables, and fruits were consumed by 37.2%, 47.8%, and 11.2% of girls, respectively. One out of ten individuals consumed green vegetables on a daily basis.
| Adult Malnutrition|| |
There are several scientific evidences which highlight the problem of under- and over-nutrition in adult population both in urban and rural settings. Nutritional profile of adult women from 1975 onward is given in [Table 2]. Overall nutritional status of adult population as per the NFHS-3 and 4 clearly reflects decline in the extent of chronic energy deficiency (CED) (BMI <18.5 kg/m 2) in males (34.2%–20.2%) and females (35.5%–22.9%). On the contrary, there has been increase in the proportion of overweight or obese (BMI >25.0 kg/m 2) in men (9.3%–18.6%) and women (12.6%–20.7%)., Linkages of negative energy balance with under nutrition and CED in rural reproductive age group females has been established by taking caste as a proxy indicator of socioeconomic status. Adverse nutritional status based on BMI as well as waist–hip ratio has been also observed in rural women of Varanasi. A recent countrywide survey reported that 53% of women (15–49 age group) and 22.7% of men were anemic.
Well-developed nutrition programs for women need to ensure adequate consumption of macro- and micro-nutrients. Deficiency of both macro- and micro-nutrients is conspicuous in rural women of reproductive age group.,
Malnutrition in geriatric individuals
The vulnerability of geriatric individuals in terms of under- and over-nutrition can be internalized by findings of several studies conducted in urban and rural settings of India [Table 3].
| Malnutrition Versus Food and Nutrition Security|| |
Considering the fact that nutrition is directly linked to the human resource development, productivity, and prosperity of a country, raising the nutritional status of the population has been a global concern, and therefore, food security has been the major concern of governments, particularly in developing countries. A group of experts primarily consider food security synonym to the availability of food at national, regional, household, and individual levels. Food security exists when all people, at all times, have physical and economic access to sufficient safe and nutritious food to meet their dietary needs and food preferences for an active and healthy life. The amount and quality of food available globally, nationally, and locally can be affected temporarily or for long periods by many factors including climate, disasters, wars, civil upset, population size and growth, agricultural practices, environment, social status, and trade.
There are evidences based on program evaluations of Applied Nutrition Program, green, white, and blue revolutions that even those who produce food do not consume adequately in terms of quality and quantity for economic gains. It is not necessary that the money generated out of this will be judiciously used for improving nutritional status. For those who are not directly involved in food production, food security primarily depends on their capacity to purchase food which is a function of their purchasing power. Food security has three components, namely, availability of food in the home and market, access to food through adequate purchasing power, and absorption of the food in the body. Even if the required quantities of macro- and micro-nutrients are met, a serious disability in achieving nutrition security arises from poor sanitation, environmental hygiene, and lack of clean drinking water. Thus, nutrition security involving physical, economic, and social access to balance diet, clean drinking water, sanitation, and primary health care for every child, woman, and man is fundamental and thus gives all citizens an opportunity for healthy and productive life. The costs of death, hygiene-related illness, reduced productivity, and reduced tourism revenues as a result of inadequate sanitation facilities were estimated by World Bank Study to be 6.4% of the gross domestic product, not to mention the social costs of the issue.
Food security has been the major developmental objective of the India since the beginning of the planning. India achieved self-sufficiency in food production during the 1970s and has sustained it since then. However, the achievement of food grain security at the national level did not percolate down to the households, and the level of chronic food insecurity is still high. India's malnutrition and CED figures are not coming down despite a number of government programs. The body adapts to the low level of energy by limiting its size with the following inherent drawbacks: severe undernutrition in early childhood often leads to defects in cognitive development; stunted individuals suffer a far higher rate of disease and illness than those who have not undergone stunting; premature failure of vital organs occurs during adulthood.
India's progress has been remarkable in the green revolution. In fact, 4000 years of progress in wheat production, since Mohenjo-daro excavations, was repeated in 4 years. India has launched a campaign “Hunger-free India” on February 20, 2009, to rededicate its efforts in terms of Public Distribution System (PDS), Integrated Child Development Scheme (ICDS), and Mid-Day Meal Program for improved performance. The National Research Agricultural System (NARS) has been playing a catalytic role in the overall growth and development of agriculture through the generation of technologies for enhancing the production and productivity by overcoming production constraints. The Indian Council of Agricultural Research continues to lead the country in the area of agricultural research, education, and extension through its wide network of 98 research institutes and 578 Krishi Vigyan Kendras across the country. In addition, it supports 45 State Agricultural Universities. Intensive farming often leads to a vicious cycle of exhaustion of soil fertility and decline in agricultural yields. The land available for agricultural use is also declining very fast due to urbanization and industrialization. Droughts, floods, cyclones, and pests can quickly wipe out large quantities of food as it grows or when it is in storage for later use. Similarly, seeds can be destroyed by such environmental dangers. These along with improper storage account for 30%–40% wastage of food. Many agrarian policies, especially the pricing of agricultural commodities, discriminate against rural areas. Governments often keep prices of basic grains at such artificially low levels that subsistence producers cannot accumulate enough capital to make investments to improve their production. Women play a vital role in providing food and nutrition for their families through their roles as food producers, processors, traders, and income earners.
| Poverty Estimates and Household Food Insecurity in India|| |
Considering poverty as the root cause of undernutrition, several anti-poverty and income generation activities were initiated in India. In spite of various poverty reduction programs in India, poverty remains a major threat to food security. Poverty in India is widespread with the nation estimated to have a third of the world's poor. According to a 2005 World Bank estimate, 42% of India falls below the international poverty line of US$ 1.25 a day (purchasing power parity, in nominal terms, 21.6 a day in urban areas and 14.3 in rural areas); having reduced from 60% in 1981. This is corroborated by the existing scenario of household food insecurity in India [Table 4].
| Major Concerns in Relation to Malnutrition|| |
Lack of awareness and knowledge of feeding recommendations for children during sickness and health contributes significantly to under-five mortality and morbidity. Adverse child feeding practices still prevail in India and are one of the most important root causes of malnutrition in early childhood (NFHS-4; RSoC)., Research done in the urban area of Varanasi district revealed that awareness and utilization of ICDS service were not up to the mark [Figure 1].
|Figure 1: Awareness and utilization of Integrated Child Development Scheme services for 0–6-year-old children in urban Varanasi.|
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Currently, India accounts for about 12% wheat, 21% paddy, 25% pulses, 10% fruits, 22% sugarcane, and 16% milk of global production. This is being achieved from 2.3% global land, 4.2% of water, and little over 11% of arable land having only 50% potential for irrigation to support 18% of the world's population. India has been self-sufficient in terms of per capita availability of food grains [Table 5]. However, this has not been the case for other nutrients.
Effect of globalization and technological revolution brought significant changes in nutrition transition, and consumption of fast food and lifestyle changes have been responsible for obesity and its consequences.
Globalization of fast food has provided the flexibility of having many consumption alternatives at reasonable prices and created a slew of expectations moving forward. Fast food consumption has a significant impact on physical as well as mental health. It leads to fatigue feeling and craving for sugar, adult obesity, hypertension, noncommunicable diseases, effect on kidney and liver, carbonyl stress, caffeine toxicity, type 2 diabetes mellitus, gastritis, dental carries, cancers, childhood obesity, allergic manifestations, osteoporosis, growth retardation, disruption of cellular environment structure and function, drowsiness, and infertility in young men and women. Researches on junk food consumption and their impact on mental health have shown that too much of junk food alters the chemistry of the brain and are addictive like cocaine. Monosodium glutamate, hydrogenated oils, refined salt, and other chemical preservatives in processed junk food do the same thing to a person's brain as cocaine does. Trans fats present in fast food can shrink the brain. The impact of trans fatty acids begins to take place at the fetal stage. Hydrogenated fats and kind of food children eat are responsible for the attention-deficit hyperactive disorder. Junk food contains low nutrition value, hence tends to reduce the intelligence quotient level of children. Losses of essential nutrients like amino acid tryptophan and the lack of which may increase the feeling of depression. On the other hand, imbalanced fatty acids in junk food cause depression in the adult population [Figure 2].
To control the adverse effect of malnutrition, especially effect of obesity and its relative/associated risk in any age group, physical activity should be promoted. It helps to control weight, improves blood circulation, increases flexibility, lowers blood pressures, lowers blood sugar level, improves emotional well-beings, relieves stress, increases energy level, improves balance thereby dangers of falls, and improves bone density thereby preventing osteoporosis.
| Consequences of Malnutrition|| |
Chronic malnutrition results in growth failure and stunting, delayed sexual development, reduced muscle mass and strength, impaired intellectual development, in early childhood and in adolescent age group, and increased lifetime osteoporosis which are the common consequences of malnutrition in adulthood. In addition to these physical consequences, malnutrition also results in psychological effects such as apathy, depression, anxiety, and self-neglect. Due to malnutrition, several other nutrition disorders may develop, depending on which nutrients are lacking or consumed in excess. Malnutrition is the gravest single threat to public health during childhood. It usually results in worse health in children who are severely malnourished and typically experiences slow behavioral and intellectual development, which may lead to intellectual disabilities and lower educational achievement results during adulthood. Malnutrition follows a vicious cycle, namely, malnourished children tend to become adults who have small babies.
| Reforms for Ensuring Food and Nutrition Security|| |
Several programs enacted by the Government of India in the field of food and nutrition providing food security to different age groups of people have not been able to tackle the problem of malnutrition, particularly undernutrition. Persistence of the problem of undernutrition in any age group clearly indicates that there is a need of reforms of existed programs for ensuring food and nutrition security at micro- and macro-levels. The restructuring of the programs includes: (a) Reforms for enhancing productivity by ensuring land reforms, blending traditional and modern technologies, harnessing production of urban agriculture, increasing productivity without ecological harms, transforming micro successes into macro movements, and prioritizing varietal improvement programs; (b) organizational reforms by harnessing indigenous food preservation practices, expanding storage facilities for both perishable and nonperishable items, cooperative movement initiatives, establishing e-PDS through computerized record, biometric and smart cards, and geographic information system tracking system for enhancing transparency, efficiency, and accountability; (c) financial reforms through expanding productive and remunerative employments, assistance to small and medium enterprises and self-employed groups, addressing issues pertaining to payment of wages, promoting productivity in the unorganized sector, ensuring microfinance and loan requirements, improving efficiency of ongoing anti-poverty and income generation activities, instituting macroeconomic policy framework and economic reforms inclusive of urban development; (d) managerial reforms emphasizing on capacity building of both for the self-employed and those seeking or already in wage employment, promoting just governance in general and for PDS in particular, efficient monitoring and supportive mechanisms for midterm corrections; (e) reforms for enhancing coverage and content include broadening the food basket to ensure dietary diversity, emphasis on micronutrient deficiencies, safe water supply, basic sanitation, and access to health services. Elected urban local bodies should involve local communities in promoting hygiene and sanitation. Special attention has to be paid on small and medium towns which have poor access to safe drinking water and basic sanitation. Advance contingency plans for vulnerable populations in terms of geographical inaccessibility, climate adversities and natural calamities, and community-based nutrition education programs should be executed to build awareness about existing income generation activities and social safety nets and to remove socio-cultural barriers and reverse parental paradox.,
| Approaches for Malnutrition-Free India|| |
In any country, primarily, three types of strategies (viz., legislative, service, and educational) can be adopted for freedom from malnutrition. If these approaches are executed optimally, they can serve as effective tools toward the fulfillment of the dream of malnutrition-free India.
A legislative framework should be in existence to minimize the threat of undernutrition often resulting due to food deprivation, particularly in vulnerable (viz., under five, women, and geriatric individuals) section of the society. The Indian government has taken a historical step in 2013 in the form of National Food Security Act (2013). Right to food and legal entitlement deliver grains to 67% of the population (75% rural and 50% urban) and ensures economic access to basic staples by providing food at subsidized price. On the other hand, globalization of fast food consumption has raised the problem of overweight and obesity in the young generation of India; it can be potentially reduced by imposing regulatory measures such as a heavy tax on imported and manufactured readymade junk/fast food items. There should be a rigorous control on media advertisements and publicity by the Ministry of Information and Broadcasting. Media rules and regulations set by Cable Television Network Act (1994) and Advertising Standard Council of India (1994) should be strictly enforced and guidelines related to the quality of food products advertised in Indian media should be urgently evolved, implemented, and evaluated for midterm corrections.
Since independence, the Government of India has initiated several anti-poverty, nutrition, and health programs; however, desired outputs were not achieved in terms of nutritional well-being. To do so, rigorous implementation, monitoring, and surveillance of ongoing programs should be ensured.
In the development of any nation, citizen education plays a foremost role. Unfortunately, large section of Indian people is still living in an educationally deprived condition which is responsible for their poor nutritional status. As time passes, development in information technology has brought changes in the society, thus there should be a strategy to use media to combat the problem of malnutrition in different age groups. To improve the nutritional status, educational material and messages should be disseminated by television, newspaper, posters, and campaigns. Multi-sectoral and multidimensional information education and communication approach should be involved to wipe out the problem of malnutrition from India.
Besides these approaches to cut down the problem of malnutrition, energy balance of the individuals should be given due consideration in view of the increasing burden of noncommunicable diseases. This is likely to reverse the existing trend of compensation of decrease in undernutrition by increasing the prevalence of overnutrition; in fact, half of the population are normal on nutrition scale. It is not essential that human should be in energy balance on a day-to-day basis. However, over a period of a week or a fortnight, one can be in energy balance, that is his/her daily energy expenditure and daily intake averaged over this period should be in a state of balance. There is a strength of evidence as convincing (regular physical activity and high intake of dietary fiber), probable (home and school environment that support healthy food choices for children), and possible (low glycemic index foods) for factors protecting against weight gain.
| Conclusion|| |
Making India malnutrition free is possible, but it is not easy. It requires great and target-oriented efforts toward every relevant field. Besides monitoring and surveillance of ongoing programs, a comprehensive approach involving legislative, service, and educational inputs is also needed. To curtail the problem of undernutrition which has persisted since the independence of India and to tackle the emerging problem of overweight and its relative health risks as results of nutrition transition require grass-root level planning considering the rationale behind the problem instead of blanket approach. In spite of agricultural country and having enough grain availability, unfortunately, a large section of the country is in the condition of food deprivation; thus, there is a need to adopt modified strategies to ensure food and nutrition security to people living in India. This also requires organizational, financial, and managerial reforms. Considering the statement “if one dreams, it is dream, if all start dreaming, it becomes a reality,” calls for concerted efforts by all stakeholders to make malnutrition-free India.
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Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]