Gist of Kurukshetra JANUARY 2020- Health and Nutrition Overview and Way-forward.

Double Burden of Malnutrition challenges

Introduction:

• The inter-linkage between health and nutrition has been recognized since ages. Good nutritional status ensures that individual can fight disease-causing agents, stays healthy, be productive to the society and contribute to overall development.

• Under-nutrition in children, especially in fetus during pregnancy and up to 2 years of age, can take away upto 15 IQ points.

Overview by World View:

• A study by the World Bank has estimated that annual cost of malnutrition in India is at least US$ 10 billion and is driven by loss of productivity, illness and premature deaths. Alongside, illnesses in an otherwise ‘normal weight’ person can lead to under-nutrition, which can spiral into a vicious cycle. Clearly, the challenge of nutrition is multi-layered.

• It is not the under-nutrition only, the over-nutrition (obesity), ‘protein hunger’ and ‘hidden hunger’ (or micronutrient deficiencies) in otherwise normal weight persons are the other dimensions.

• The terminology of malnutrition is commonly used to capture the under and over nutrition and the related challenges. However, in a particular setting, burden was predominately of one type of malnutrition. It is being recognized that in many settings and countries, both under and over-nutrition are increasing as an emerging challenge, described as ‘Double Burden of Malnutrition (DBM).

• The DBM co-exist in many settings and affects the health outcomes and survival of population. While under-nutrition continues to be major and pressing challenge in India, the issue of over-nutrition is also real. Therefore, it is time that India also shifts attention on holistic approach of targeting malnutrition with focus and appropriate strategies to tackle DBM.

Under Nutrition as Persistent Challenge:

• India had poor health and nutritional indicators at the time of independence in 1947. Around 1950s, the life expectancy in India was 32 years (which has increased to 68 years in 2017).

• The infant mortality rate (IMR) was nearly 200 per 1,000 live births and maternal mortality ratio (MMR) around 2,000 per 100,000 live births. The IMR in India in 2017 was 33/1,000 live births and MMR was 130 per 100,000 LB during the period of 2014-16. Over these years, through targeted interventions, the proportion of population living below poverty line has declined and even the food production and availability has drastically increased.

• However, nutritional status of population has not witnessed the commensurate decline. India has had high rate of under-nourished population, with marginal improvement in situation in last 25 years. The prevalence of underweight, stunted and wasted is higher in rural than urban populations.

• The progress on other parameters of the nutritional status such as level of anemia in population groups and birth-weight of newborns is also slow. Recognizing the challenge, India had a series of initiatives and programmes since independence which focused on improving nutritionai status of the population.

Diseases Linked to Under-nutrition:

• The nutritional status of an individual affects his/her health status and outcomes A poorly nourished person has weak immunity and immune defence system. An undernourished individual, including those with micronutrient deficiency, are at higher risk of majority of infectious diseases including tuberculosis, viral and all other infections. An underweight and under-nourished child is at higher risk of diarrhea and pneumonia. The chances of recovery in such children are slower.

• They are more likely to become under-nourished after such disease spell. While the poor nutrition affects the health outcomes in all population sub-groups, it is the women in reproductive age and newborn and children, who are most commonly and adversely affected. The public health science has generated evidence that it is vicious cycle of under-nutrition which starts at the time of pregnancy (in mother’s womb) and continues to affect the newborn for the rest of the life and for many generations.

• Understandably, the initiatives to tackle under-nutrition are targeted/focused/prioritized for women in reproductive age groups, children and adolescent girls. There are emerging evidence that under-nourished and under-weight children are at higher risk of non-communicable diseases such as cardio vascular strokes and diabetes in adult age.

Initiatives to Improve Nutritional Status:

• The efforts to tackle under-nutrition in India have been partially successful so far and recent and new attempts are being made to accelerate the progress. The Govt of India had launched National Nutrition Strategy in Aug 2017 and then National Nutrition Mission (NNM) in March 2018.

• NNM aimed at 2-3 per cent annual reduction in the rate of low birth-weight, stunting, undernourishment and anaemia amongst women. NNM is now being implemented as POSHAN Abhiyaan, under Ministry of Women and Child Development, aiming for Kuposhan Mukt Bharat (Malnutrition free India) by year 2022. The programme aims at reducing levels of underweight, stunted, low birthweight and anaemia in population. As part of this POSHAN Abhiyaan, nutrition is proposed to be a Jan Aandolan or mass movement and the month of September has been designated as POSHAN Maah.

• In addition, Pradhan Mantri Matru Vandan Yojana (also known as Maternity Benefit Scheme) was announced in late 2016 and launched in 2017, aims to provide financial assistance to pregnant women for the first pregnancy and ensure good nutritional status. There is renewed attention on reducing prevalence of anaemia through Anaemia Mukt Bharat. There are a number of complimentary initiatives under different ministries to focus on improved nutritional status though approaches such as Eat Healthy and Fit India initiative. The Aspirational District programme also has nutritional status as a performance indicator.

Discussion:

• Health and nutrition (and education) contribute to human capital formation, and the growth and development of a nation. The malnutrition results in making people prone to various adverse health outcomes, as described in earlier section. Specially, the first 1000 days of children (Nutritional status in 270 days of nine months in pregnancy and 730 days of first two years of a child’s life are very crucial for health and childhood development related outcomes for rest of life). Much of the development of brain happens either in pregnancy or first two years of life. Therefore, the poor nutrition affects the newborn for rest of life and not only physical but brain development and other social milestones as well. This is increasingly being understood and realized and a compelling reason for taking urgent actions.

• The inter-generational effects of malnutrition can be devastating not only for affected families, but also the national productivity, growth and development. Poor maternal nutrition in pregnancy results in low birth weight, which in turn results in risk of poor growth, infections and low educational outcomes and development deficit and more prone to cardiovascular diseases and diabetes in adulthood. The adverse effect of pregnant woman’s (mother’s) nutritional status carries with the child for rest of the life but on the next generations as well through epigenetic effects. This situation clearly demands that interventions to tackle under-nutrition in India are implemented in life cycle approach from nutritional status of women in reproductive age, pregnant women, breast feeding and complementary feeding. In this process, the societal dimension of nutrition i.e., maternal literacy, women empowerment and prevention of child marriage etc. also need to be given due attention and interventions.

• The need for sustaining the multi-sectoral engagement for better health and nutritional outcomes are being recognized. The nutritional status is inter-play of at least three broad factors; dietary intake contributes to 45-50 per cent, poor maternal health results in low birth-weight which accounts for another 25 per cent and illnesses amongst children such as diarrhoea for another 25-30 per cent of under-nutrition. Thus, there is a need for targeted interventions for reducing the proportion of low birth weight babies, which constituent nearly 30 per cent of total newborns in India.
• Overweight and obesity are other and increasingly recognized spectrum of malnutrition. These were earlier reported from affluent and urban population and are now slowly extending to poor and rural counterparts as well. There are nutritional deficiencies in people who otherwise overweight as their diet may be rich in calorie but deficient in specific micronutrients. Even in ‘normal body weight’ people, there are high level of body fat and reduced muscle mass indicating a nutritional imbalance that place such individuals at increased risk of obesity related diseases. No wonder we see many faces of malnutrition in our population.
• Under-nutrition is not only cause but effect as well. Enteric infections such as diarrhea and typhoid are more common in children who are under-nourished. As well as a healthy child who gets such infections can become under-nourished afterwards. Therefore, to tackle under-nutrition, there is a need to improve water and sanitation. Similarly, problem of stunting cannot be solved by increased access to nutritious food, it requires better housing and improved water and sanitation.

Way Forward:

• There has been some progress on improving nutritional status of population in India. However, India of 2020 needs to do more than what has been done in the past.