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Indian Journal of Community Medicine

Vol. 28, No. 3 (2003-07 - 2003-09)


Combating Malnutrition in India Through Community Efforts

India has made a slow and steady progress in human development ever since independence. Severe and florid forms of malnutrition have declined substantially, infant mortality has declined from 146 per 1000 live births (1951) to 69 per 1000 live births (2000), life expectancy has risen from 37 years to 63 years and we have achieved self sufficiency in food production1-3. In spite of all these impressive developments on records, one third of newborns start their life with low birth weight, more than half of young children below five years of age continue to suffer from moderate and severe malnutrition, over 60% of women are anaemic and this figure rises to 85% during pregnancy state, 40-60% of adolescent girls tend to be anaemic. Malnutrition is thus wide spread in rural, tribal and urban slum areas and it is a significant public health problem described as silent killer, silent emergency, invisible enemy affecting those who cannot express, their voice and have to depend upon others for their advocacy.

Nutritional status of young children below 5 and 6 years of age has been monitored in the country through successive surveys undertaken on community basis by NNMB, ICDS, DNP, NFHS 1 & 2 and ICMR from 1975 onwards4-11. The severe undernutrition has declined favourably and stabilized around the figure indicated in Table I and II, due to overall socio-economic development, and focussed interventions. The fact of the matter is that much remains to be done as around 50% of young children are undernourished. Further, there are severe variations in prevalence of undernutrition in different regions, states and segments of population of the country.

Table I: Trends in prevalence (%) of under weight, stunting and wasting in children below five years of age in India.

  1975-79 1988-90 1994 1996-97 1995-96 1992-93 1998-99
Weight for age Underweight 77.5 68.6 63.6 62.4 49.2 53.4 47.0
Severely underweight 38.0 26.6 24.7 22.5 20.3 20.6 18.0
Height for age Stunted 78.6 65.1 63.0 57.7 56.5 52.0 45.5
Severely stunted 53.3 36.8 35.8 28.8 36.4 28.9 23.0
Weight for height Wasted 18.1 19.9 16.7 18.5 20.0 17.5 15.5
Severely wasted 2.9 2.4 2.6 2.5 7.1 3.2 2.8
n 6428 13422 1832 8664 46457 25578 24600

Table II: Nutritional status of pre-school children (1-6 years) in ICDS projects of different operational age compared with newly sanctioned projects (%).

Nutritional status wt. for age (IAP) Newly sanctioned   Operational age of ICDS projects
  projects 5-9 yrs. 10-14 yrs. 15-19 yrs.
Normal + Grade I 71.6 74.6 79.2 80.9
Grade II 20.6 17.8 15.1 14.8
Grade III and IV 9.1 7.6 5.7 4.3
n 15,299 27,162 18,187 10,152

Note: ICDS programme commenced in 1975 and then expanded in phases to acquire the status of world's largest outreach programme for mothers and children.

These surveys and ICDS surveys indicate widespread malnutrition in young children, adolescent age, pregnant women as also in adults.

Nutritional status of adult population as assessed by Body Mass Index (BMI) grades was quite distressing as 33% were classified in various states of chronic energy deficiency (CED), while 63% had normal BMI grades and 4% constituted obese grade of BMI. Problem of obesity is likely to increase further.

Due to the improvement of socio-economic conditions and change in dietary practices (particularly in urban areas) and life styles, the children and adult population stands exposed to the risk of developing obesity, thus we will have to fight the double burden of undernutrition and overnutrition in the community.

On account of prosperity and changing life styles in urban areas, obesity is emerging as substantial problem among several groups of women in India. On the basis of BMI, NFHS-2 data indicates that overall 10.6% of women between 15-49 years were obese and obesity was more pronounced in Delhi (33.8%), Punjab (30.2%), Kerala (20.6%), Haryana (16.66%), Tamil Nadu (14.7%), J&K (13.8%), Karnataka (13.6%) and Himachal Pradesh (13.1%). Around 6-7% of women have BMI of 30 or more6.

Chronic energy deficiency in women of 15-49 years is prevalent to the extent of 36% who have BMI value less than 18.57.

Anaemia among pregnant women continues to be unabated, as 84.9% of pregnant women were found to be anaemic according to ICMR study undertaken in 16 districts of 13 states. Anaemia amongst adolescents was a universal phenomenon as over 90% of adolescents were reported to be anaemic. Prevalence of goitre among 6-12 years children was 4.78% and night blindness in children (24-71 months of age) was 1.03% and bitot spots and night blindness were reported to be of the level of 0.34% and 0.71% respectively8.

Similarly, prevalence of Iodine deficiency disorders (IDD) in the country is widespread. Over 300 million people are exposed to the risk of goitre, 54 million have goitre, 2.2 million children are born cretins and 6.6 million have mild neurological disorders 12. Overall prevalence rate of vitamin

A deficiency in India has been reported as 0.21% but some areas like Madhya Pradesh, Tamil Nadu and Mizoram have high prevalence rates of 2.62 to 3.11 %.

Malnutrition results from combination of causes or factors and conditions. Low birth weight arise on account of poor nutritional state of pregnant women, early marriages, repeated pregnancies, small birth intervals apart from many other factors. Malnutrition in young children can be attributed to inadequate feeding; faulty feeding practices, repeated infections like diarrhoea) diseases, acute respiratory infections and worm infestations. Anaemia in pregnant women is mainly due to inadequate eating, small birth intervals and discriminatory food customs, excessive workload, worm infestation and endemic malaria. Insanitary conditions like unsafe water, indiscriminate excreta disposal and poor personal hygiene practices initiate and perpetuate infections and malnutrition. Economically weaker sections and illiterate families bear the burnt of malnutrition.

The consequences of malnutrition in young children are; high level of morbidity, mortality and disability apart from poor physical growth and development. In women, the serious consequences are of high maternal mortality and increased risk of giving birth to low birth weight babies as also increased risk of infections. In adults, it leads to poor physical capacity and low productivity. In many of the conditions and unfavourable outcomes, the underlying cause happens to be malnutrition. Lifestyle diseases of present day have the relationship with faulty diets and dietary habits.

To improve the nutritional status of young children and women in India several attempts have been made through different strategies.

In the beginning, we heavily relied on feeding programmes and overemphasized on "Protein component" and the wisdom soon prevailed and we realized that the real culprit was "Food Gap" rather than protein gap. Before the Protein fiasco, energies and resources got diverted towards growing and producing more of animals and vegetable proteins, standard teaching and training programmes also adhered to protein protocol. Subject of nutrition drew the attention of planners in successive five year plans and it was considered as an important area of "minimum need programme" under fifth five year plan. Food and nutrition was embodied as essential element of Primary Health Care. We have achieved marvels in food production to achieve not only self sufficiency but have adequate buffer food stocks, through Green revolution and white revolution. Food grain production of over 208 million tonnes during the year 2001, ensures reasonable food security at national level. Producing more food/adequate food is no absolute guarantee that it will wipe out malnutrition. The programmes of poverty alleviation and targeted public distribution system further ensure food security at "household level" through increased purchasing power. The public distribution system (PDS) with nearly 400,000 fair price hops is now targeting on below poverty line families and households to ensure access to essential food commodities at a fair price. The reach of targeted PDS is limited and the cost is enormous. Household food security is necessary, but not sufficient for adequate nutrition.

Access to highly subsidized food grain and improving quality of household diets remains as an important agenda and challenge for all of us. Thus graduating from "National Food Security" to "Household Food Security" to "Nutrition and Health Security of all" and more so of vulnerables becomes a prime task and agenda.

War against malnutrition has to be fought through integrated health, nutrition and educational activities focussed on vulnerable and BPL families. Convergence of services at village level through Integrated Child Development Services and self help groups of women and village Panchayats hold much more promise. Building capacities of mothers and women at household level through integrated efforts can enhance the nutritional status of women and children. Promotion of breast feeding, exclusive breast feeding up to six months of age, adequate home available, supplementary foods along with breast feeding, eating clean, washing of hands, drinking clean and safe water, having fewer children at appropriate interval, immunization at right age and household response to diarrhoea and acute respiratory infections and fevers can improve the level of malnutrition and ensure adequate growth and health of young children. Ultimately we adopted National Policy on Health in 1983, as also a National

Nutrition Policy in 1993; which identified the National Nutritional Goals in line with the world summit on children in 1990. We made commitment to achieve the following goals by 2000 AD13-17.

  1. Reduction in moderate and severe malnutrition among preschool children by half.
  2. Reduction of low birth weight babies below 10%.
  3. Eliminate blindness due to vitamin A deficiency.
  4. Reduce anaemia in expectant women to 25%.
  5. Universal iodization of salt and virtual elimination of iodine deficiency disorders.
  6. Achieving production of 250 million tonnes of food grains per year.
  7. Improving household food security through poverty alleviation programme, in urban and rural areas.
  8. Promoting appropriate diets and healthy life styles.

The overall strategy comprised of multisectoral approach envisaging sectoral plans of action. Each sector is required to achieve explicit nutritional goals. The sectors identified were: Agriculture, Civil Supplies, Education, Food, Women and Child Development, Health, Environment and Forest, Rural Development and Information and Broadcasting. National nutrition policy has set the agenda but the actions are awaited.

The National Nutritional Policy adopted in 1993 advocated comprehensive intersectoral strategy for alleviating the multifaceted problem of malnutrition. National plan of action on nutrition launched in 1995 has not resulted into actions on the ground level and most of the sectoral commitments are on paper. Sectoral commitments have not led to appropriate actions at community level. Intersectoral co-ordination at functional level and implementation level is negligible. Within the health sector itself the NIDDCP rests with deptt. of Health, the NNACP and Vit A prophylaxis is with Family Welfare. The nodal deptt. for policy implementation is Deptt. of Women and Child Development, Govt. of India which over the years has pursued welfare functions rather than development functions and consequently the priority for supplementary feeding programmes.

We have failed to achieve the set goals; it may take probably 10-20 years or even longer time to realize these goals. We have already crossed the mark of one billion in numbers. Where we have gone wrong? Problem of malnutrition may escalate further unless we ensure action at household level and change the current strategies and approaches. It requires drastic change in outlook and commitment at all the levels.

Though the Government has taken all possible steps to make available food grains to the poorest of poor, it has, however, been observed that off-take of food grains under BPL category has not gone beyond 55% during the preceding two years. On the one hand we have one of the largest Public Distribution System in the world with government spending over Rs. 2400 crores on food subsidy, yet many people are going without adequate food and half of young child population (0-5 years) suffers from malnutrition20. This is a paradoxical situation, which speaks of "Poverty in Plenty". Many of the States are unable to lift the food stocks collected by the central government due to their poor financial health and political will. Thus, the record production of food grains and adequate buffer stocks is no guarantee against malnutrition.

To ensure food security for all, under the centre sponsored "Antyodya Ann Yojna" 35 kg. food grains per family per month at the rate of Rs. 2 per kg. wheat and Rs. 3 for rice will be provided to all BPL families'. However, the undernutrition starts early and occurs in the first year or one and a half year of life. These children require enough food and frequent feeding and safe environments to ensure retention of nutrients obtained through food. Breast-feeding saves and prevents malnutrition and it is a good practice in our culture, its early initiation is good for young children.

Supplementary nutrition programmes (SNP) have been used as "Spring boards" to attract children and mothers to increase the attendance, to develop other activities like non-formal education and creative activities, growth monitoring (to be more precise weighing children), to demonstrate clean eating, developing good habits like washing of hands and brushing of teeth, to educate mothers on preparation of recipes, apart from cooking and testing of acceptability of, food items. Similarly, mid-day meals programmes have been used to enhance enrollment of school children, to increase their regularity, retention and promote literacy drives. These are the distinct advantages of SNP but how far SNP leads to improvement of nutritional status, still remains a debatable issue. NIPCCD study of 1992 observed that differences in the nutritional status amongst children below three years of age between ICDS and non ICDS blocks were marginal and there was no statistical significant differences21 . What and how much a child or woman eats at home is a critical issue.

All the supplementary nutrition programmes initiated nationwide by many states and continued for decades have succeeded marginally to improve the nutritional status of the target group (young children and pregnant women). Lot of resources have been wasted on this front, as these programmes were pursued in isolation, creating dependency, emphasis remained on distribution and not much was invested on nutrition education. Similarly, supplementing specific nutrients like iron and folic acid tablets have not produced much results to decrease anaemia in pregnant woman. Vitamin A supplementation is a war against specific nutrient deficiency and was advocated as fire fighting measure to tide over a situation; it cannot go on indefinitely and universally all over the country. Iodine deficiency disorders have been tackled through iodination of salt. All these programmer have been pursued as single purpose programme directed towards specific nutritional deficiency and improvement of malnutrition was not a goal of these programmes. Approach and strategy to fight malnutrition have been fragmented, centralized and responsibility given to different departments. The nodal department of nutrition is women and child development under Ministry of Human Resource Development. The effort should be made to use the existing infrastructures and resources, through better management techniques. Community based actions are called for. The answer to malnutrition is available within the family and household, as best of nutrition is available in home and farm,-one need not to go outside world in search of best nutrition or diet. Indigenous home available diets and whatever is cooked in the family is the best food for children and mothers. Women hold the key to improve nutritional status of young children as also of their own. Men and other family members must support the actions by the women. What women do with their lives and those of their young children affects their health far more than anything that government does. Women must have right kind of information on health and nutrition. Reorganizing women groups in villages like Mahila Mandals, Mahila Swasthya Sanghs (MSS), Yuvti Mandals (Youth Groups), Elected Women Leaders (Mahila Panches) of Panchayats Raj Institutions should become the prime activity. Women nutrition and development holds the key for child nutrition and development".

The system of Integrated Child Development Services (ICDS) which is the largest outreach programme in India for Nutrition, Health and Education for most vulnerables, has the potential to organize women, must take lead and all other sectors like health, education, development and Panchayti Raj Institution extend support to system of Anganwadis (village/slum center for 1000 population). Women groups should be organized for each area of Anganwadi by the Anganwadi worker. The MSS meeting grants and Mahila Mandal grant should be distributed to these groups for organizing their activities. These women groups should be empowered to disseminate key messages on Health and Nutrition, like exclusive breast feeding, early initiation of breast feeding, right age and food for weaning, clean food, hand washing, drinking clean water, immunization, spacing and limiting family size, eating enough during pregnancy and right age of marriage. The messages should be through demonstration and return demonstration. The prime activity of ICDS and health team at village level is to organize demonstration for women groups and train these groups to further disseminate key health and nutrition messages. Anganwadi should become the focal point for health, nutrition, contraceptives, ORS, education and growth monitoring. Once a week or once a fortnight the women, group must 'meet at the level of anganwadi along with functionaries of other sectors. Women of weaker sections and below poverty line must be the priority group. ICDS, Health and Family Welfare funds for education must be pooled for this purpose.

At the moment two third of the budget of ICDS gets spent on supplementary nutrition which consumes substantial time and efforts of anganwadi workers and the effects of supplementary nutrition programme in improving the nutrition of pregnant, lactating women and children is doubtful, hence this needs to be thought very seriously whether to continue this activity or could it be made more selective for households below poverty line and time and money thus saved could go for nutrition education/demonstration activities at the household level. Can we focus more on first and second year of life through regular and sustained contacts with mothers at home and this should become the prime activity of health and ICDS functionaries. Thus, the whole strategy of good nutrition is primarily community based communication strategy relying on home-based foods/diets. Reorientation training of health volunteers, women groups, health workers and supervisors to focus on this strategy is called for. ICDS programme laid more stress on detection and reporting of malnutrition by weighing children, rather than preventing malnutrition through supporting mothers and building their capacities at household level; wherever the anganwadi workers adopted this strategy the results were obvious and success was sure. Mothers and anganwadi workers together were winners to ensure healthy growth of young children. Mothers attributed the success to adequate feeding and adequate household response to illnesses along with utilization of health services.

Preparing adolescent girls and boys for safe parenthood is an onerous task. Adolescents in school system are easier to reach through a meaningful school health programme focussing on health and nutrition education through school teachers. Health sector functionaries should enable the teachers through training and retaining. Improving nutrition and health of adolescents could be better investment. Universalization of primary education and enhancing school enrollment and retention of girls should become the prime concern of ICDS and education system. Health workers and supervisors should have a regular contact programme with schools in their jurisdiction apart from TT10 and TTI6 and nutritional supplements. Whatever is built in the school curriculum that must be demonstrated and practised effectively. Prime activity of mid-day meal school programme should be education on health and nutrition, which is awfully lacking.

School children should be targeted for developing healthy life styles and cherished values for health & nutrition. Prime Minister announced on 15th August 2003 "There is need for a food chain revolution on the line of Green and White revolution so as to reduce wastage of food grain, fruits and vegetables worth thousands of crores each year". He further announced that countrywide expansion of mid-day meal scheme for school going children will be done. This affirms that national commitment is of highest order22.

Adolescents who are out of schools should be reached through non-formal education systems of literacy campaigns organized by Non-Governmental Organizations or ICDS system. This is the most difficult group to reach, Education of girls and boys hold key to good health and nutrition.

System of ICDS has focussed on adolescent girls out of school for their overall development including self esteems, vocational training, literacy and improvement of nutrition; through education and training activities. Hopefully it lays firm foundation of nutrition amongst adolescents. This model ensures large coverage and in fact ensurer of actions, what the ICMR Project on "Yuvti - Vikas Kendra discovered way back in 199023.

Fighting Hidden hunger (micronutrient deficiency) through food fortification technology is yet another gimmick to divert the attention of common man to obtain micronutrients through fortified food rather than promoting local initiatives24. It is killing of local initiatives and capacity to fight the scourge of anaemias, VAD, through consumption of green leafy vegetables, locally grown fruits and vegetables. Delivering micronutrients through lozenges, sugar, oil, wheat flour and other ready to eat foods appears to be a trap to eliminate local capacities and initiatives in a systematic manner, apart from changing dietary habits of people and promoting a particular product, which may have deleterious effect in the long run.

Though we have world reputed National Institute of Nutrition in India, Universities, Food and Nutrition Board, Home Science Colleges and Medical Colleges, District Training Centres, apart from Regional Training Centres and NIPCCD to train manpower on nutrition and health. Enough of ready-made nutritionists and evidence database on nutrition are available besides information technologies (mass media and print media), but still we are not able to communicate effectively with mothers or households who ultimately need out help to translate nutrition knowledge into action. The whole science of Nutrition is effective communication strategy. Invariably too much of technical knowledge and all book recipes are handed over to the mothers for improving dietary practices which are in conflict with the cultural and economic conditions of the family hence seldom acted upon. Local workers can communicate best on nutrition messages provided they are imparted training in their locale. Learning resource and communication material on nutrition is so much variable that there are conflicting messages and contents thereof. Standard communication on nutrition needs to be evolved and acted upon, in curricula of all categories of professionals and workers. Local data, workers own data and information must be put to use to increase the ownership and measure the success of practices adopted at local level/household level and success must be attributed to mothers and parents.

Fight against malnutrition and programmes to tackle malnutrition should become integral part of Primary Health Care. Package of services like immunization, nutrition supplements, contraceptives, ORS, basic medicines for childhood illnesses, nutrition and health education antenatal care should have convergence to have maximum impact on health and nutrition. Convergence of ICDS and Reproductive and Child Health services must be strengthened. Utilizing village self health groups to organize and provide basic services for reproductive and child health care combined with ongoing Integrated Child Development Services (ICDS). Similar infrastructure in urban slum areas can be thought of to reach urban slum areas where the conditions may be much worse than rural areas. ICDS projects in urban slums should have priority and should have convergence with Reproductive & Child health Project, Urban Health Posts, Urban Health Centres, Nagarpalika, Red Cross, Employee State Insurance, Non-Governmental Organizations as also with private practitioners and other agencies.

Prevention and treatment of malnutrition in essence should be community based25. Resources available in the community itself should be used maximally with active community participation, using village level workers/volunteers from slum areas trained in basic skills to deal with health problems including malnutrition. Government should extend all support to community based action programmes.

Answers to problem of malnutrition already exist within the community. Building capability of women in the household relying on good traditional dietary practices will have more impact in improving malnutrition as also self-reliance with ownership and responsibility resting with people26,27. In our experience this model yields more results than depending on nutrition supplements such as Iron and Folic Acid, Vitamin A and supplementary nutrition as advocated by so called 'external experts on nutrition'. Best nutrition experts are in the community, the mothers, the parents and the women. Let us support and learn more from them for wider application of community based actions, for better nutrition.


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  2. National Health Policy 2002 - Government of India, New Delhi.
  3. Ninth Five Year Plan 1997-2002 Volume II Thematic issues and sectoral programmes. Govt. of India, Planning Commission, New Delhi.
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  5. National Family Health Survey: Maternal and child health and Family Planning. India -1992-93. Bombay International Institute for Population Sciences (IIPS): 1994.
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  12. Policy guidelines on National Iodine Deficiency Disorders Control Programme. IDD and Nutrition Cell Directorate General of Health Services, Ministry of Health and Family Welfare, Govt. of India, New Delhi -1998.
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  14. Government of India -1993. National Nutrition Policy New Delhi: Department of Women and Child Development.
  15. Government of India - 1999. National plan of action for Nutrition New Delhi. Department of Women and Child Development.
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  17. Meashan Anthony R. Chatterjee M. Wasting away:" The crisis of Malnutrition in India. 1999. World Bank, Washington, DC.
  18. Hindustan Times Region Saturday, July 19, 2003, page 3 "Survey to identify BPL families on.Hindustan Times
  19. Hindustan Times, Monday, July 28, 2003, New Delhi, Pg 10, "Clean the Pippeline".
  20. Hindustan Times Saturday, July 26, 2003, Page 9, New Delhi, PM to States: Make sure food reaches targeted people, PTI. New Delhi July 25.
  21. National Evaluation of Integrated Child Development Services. NIPCCD New Delhi 1992
  22. Hindustan Times Saturday August 16, 2003 Page 1, New Delhi.
  23. Lal S. Public health aspect of nutrition. Souvenir XXX, National Conference of IAPSM 6-8 Feb. 2003, JNMCBelgaum. Karnataka, pp 74-7
  24. The Micronutrient Initiative, 208, Jorbagh, New Delhi
  25. Workshop organized by Department ofWomen and Child Development, GOI and CARE - India-March 6-8; 2000, Vigyan Bhawan, New Delhi
  26. Lal S et al. Incidence of low birth weights in rural ICDS block. Indian Journal of Maternal and ChildHealth Vol. 5 No.3, July Sept., 1994.
  27. Lal S et al. A study of attitudes of health and social status of children (11-18 years) in block Kathura Rohtak. Indian Journal of Maternal and Child Health,1992; 3(1):1-3.
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