Malnutrition, particularly under nutrition, is still a significant cause of disease and death in India. The vulnerable groups are infants and young children (under 5 years), adolescent girls, pregnant and lactating women, elderly and socio-economically deprived groups.
We still have a relatively high Infant Mortality Rate (IMR) - 47/1000 live births. While most of the southern states have an IMR less than the national average, a few northern states have unacceptably high IMR. The same is the case for under-5 mortality and maternal mortality.
Nutritional deficiency always contributes to these poor statistics. Undernutrition extends across the entire lifecycle. An undernourished adolescent girl enters early motherhood and delivers a low birth weight baby. Even though exclusive breastfeeding is practiced, 30% infants under six months are malnourished due to improper breastfeeding. The incidence of undernutrition goes up to almost 40% after six months due to inadequate complementary feeding.
These children also have frequent infections which worsens the nutritional status to such an extent that about 75 for every 1,000 live born never reach their fifth birthday. All this despite the Integrated Child Development Scheme covering the entire country. This is possibly due to poor implementation and a lack of ownership by the local leaders and communities and absolutely no systematic monitoring. In some states, these programmes are going well and the results are visible.
Food intake data from the National Nutrition Monitoring Bureau (which has been wound up recently due to administrative and legal issues), indicate that cereal intakes are satisfactory both in adults and children due to highly subsidised availability through PDS. However, this meets only 70% of the energy requirements and a fallaciously high intake of protein due to the proteins coming from cereals.
The energy deficit gap can be met only by increasing the intake of fat in some form. The cereal proteins are inadequate in some essential amino acids. This can be offset if they can eat pulses along rice/ wheat. Both fats and pulses are expensive and unaffordable to many. Consumption of milk, fruits and vegetables including the least expensive gre-en leafy ones are also very low.
All these lead to low energy which cannot promote growth. Low and poor quality protein again does not promote growth of the child at all stages of its life cycle. Milk and eggs are the best forms of protein apart from meat. The only other vegetable source of good protein is soya.
Lifecycle approach
As we observe Nutrition Week 2016 from September 1 to 7, where can we intervene the most, in the entire lifecycle approach? The general consensus among public health professionals is that while everyone should have access to good nutrition, the adolescent girl should be the focus if we have to break this cycle of malnutrition.
The best solution and something which has solved micronutrient deficiencies both in Europe and North America is by fortifying basic foods like rice, wheat, oil, milk, salt and other processed foods. Without adequate micronutrients, the body physiology cannot even utilise the protein and energy to promote growth and well-being.
This is relatively inexpensive and will yield results quickly. Since the risks for excessive intakes are very unlikely for most nutrients, one need not make that an issue to scuttle this intervention.
Even in the USA where almost everything is fortified, an Institute of Medicine report of 2015 has not found any micro nutrients to be excessively consumed. Millets which are healthy cereals in terms of their micronutrient content, need to be promoted by encouraging cultivation as well as distribution and consumption.
All these deficiencies lead to a chain of disadvantages. The baby will have low birth weight and is born with more body fat than muscle which is a huge life-time disadvantage, the children are stunted (about 40%), and are underweight. They grow up as shorter adults and when they do increase their energy intakes without matching physical activity, they tend to be at risk of developing diseases like diabe-tes, high BP, heart disease, stroke and even some cancers. Underweight mothers give birth to these smaller babies.
Large numbers of children lead a life way below their potential. Targeting adolescent girls could lift an entire generation out of this preventable misery. It’s high time we act.
(The writer is former Director, National Institute of Nutrition, Indian Council of Medical Research, Hyderabad)
