Every year, India observes September as Poshan Maah (nutritional month) to raise awareness about proper eating habits and also about nutrition. Speaking to ARCHANA JYOTI, ICMR-National Institute of Nutrition Director, Dr R Hemalatha, discusses in length about the nutrition landscape of India, the proposed revision of the dietary guidelines, the need for increased focus on maternal nutrition and the reasons behind India's sluggish performance on key maternal and child nutrition indicators among others.
ICMR-NIN is revising the dietary guidelines after a decade, which are practical recommendations for ensuring holistic nutrition to maintain health. Could you share in detail about the new regulations and when are those being released and the envisioned impact?
Dietary guidelines are a translation of scientific knowledge on nutrients into specific dietary advice. The present guidelines focus on a food-based approach (in terms of quantity and quality) for attaining optimal nutrition; and represent the recommended amounts of nutrients in terms of foods that should be consumed. Emphasis is on positive recommendations which can maximize protective effects through use of a variety of foods in tune with traditional habits. The goals set with respect to certain food groups and food items such as whole grains, legumes, milk and vegetables/fruits are intended to encourage appropriate policy decisions. Suitable messages for each of the guidelines have been highlighted.
Malnutrition affects women and girls disproportionately. Could you elaborate on ways to take a more holistic approach on addressing malnutrition, specifically from a gender perspective?
Yes, women are more vulnerable to nutritional deficiencies due to dietary inadequacies coupled with inequitable practices at the individual, household, and community levels. A girl child or adolescent’s undernutrition will perpetuate the intergenerational cycle of malnutrition. If a pregnant woman is undernourished, by the time she receives any nutrition advice or supplement, she is well into the second trimester of pregnancy by which time most of her baby’s organ development and imprinting has occurred. Hence, in addition to the critical 1000 days window (from conception to 2 years of age of the child), safety networks must prioritize the pre-conception period for optimal outcomes. This period could be several months before conception. When a young woman is planning for pregnancy, she must be screened for anemia, undernutrition, thyroid dysfunction, and PCOD. She also needs to be counseled about the right age for her first pregnancy, treated for anemia and must receive adequate training on healthy dietary habits, personal hygiene, and infant care. In addition, other issues such as overweight/obesity, smoking, alcohol consumption, lack of adequate physical activity, sanitation, and hygiene should be addressed.
It is imperative that the nutritional status of women before pregnancy or pre-conception period is prioritized.
Women and children in India bear an enormously high burden of anemia despite several innovative and far-reaching measures by the government. What, according to you, is the way forward to tackle this persistent problem?
Despite programmatic efforts and substantial economic progress, our progress toward reducing anemia has been sluggish. Although iron and folic acid (IFA) supplements are provided to women, their intake and compliance have been poor. Moreover, NIN’s DFS (double fortified salt), which was earlier used in supplementation programs in various states, is now discontinued. These apart, there are non-nutritional factors such as helminths, malaria, and fluorosis, which also need adequate attention.
At the programmatic level fortified rice has been rolled out in some districts; alongside, studies are being planned to assess its effectiveness, acceptability, and side effects if any. However, corresponding improvement in availability and affordability of nutritious foods even in the remotest areas would be the key to a sustainable long-term strategy.
At an individual level, our diets are monotonous and lack diversity. While the deprived communities subsist on cereal-based diets with little diet diversity (DD), people who can afford to spend on foods that are low in nutrients. These factors can be attributed to the high prevalence of anemia, apart from chronic low-grade inflammation (due to unhealthy diets), which hinders nutrient absorption and hemoglobin formation.
The NFHS-5 survey also showed limited gains in child nutrition indicators including stunting and wasting – in fact, some states have performed very poorly. Where are we missing in our efforts? What are your views on this trend? What more needs to be done?
The level of stunting among children under 5 years has declined from 38 to 36 percent. Although the overall average appears small, there has been a striking five to seven percent decrease in stunting in several states, especially in low-index states. And the prevalence of overweight has increased in most states.
However, in order to understand the lacunae in the population’s health and nutrition and to effectively and efficiently improve and sustain optimal nutrition, the collection of accurate and relevant dietary intake data in a periodic and systematic manner is required. The development of effective nutrition policies depends on the availability of good and robust dietary intake data from systematic surveillance. Regular dietary surveillance is carried out by several countries. The NFHS surveys do not collect dietary data. Dietary surveillance is an important requirement to plan for nutrition actions. Now the ICMR has granted and approved a surveillance system to study the indices such as consumption patterns, dietary intakes, nutritional quality, and food supply. Country-wide data, generated from this survey, on nutrient intake and food intake will help us identify existing food and nutrient gaps in the population. This survey, which will be initiated soon, may also help identify good regional dietary practices that can be mainstreamed. In addition, information on the level of aflatoxins in foods that we eat, which could be contributing to persistent anemia, will be obtained.
This data on the quantity and quality of our food is crucial for nutrition policy interventions and to address multiple, and different, district-specific determinants of malnutrition.
Dietary diversity continues to be poor in the country. According to NFHS-5 less than half of Indians consume milk or pulses on a daily basis. What is the way forward for making micronutrient-rich foods affordable and accessible to our population? How important is the role of agricultural policies and practices in all this? How can the private sector help in this regard?
The inclusion of legumes, dairy, fish, poultry, and flesh foods in diets can help reduce stunting and anemia. Policies influencing production, marketing, and trade to improve accessibility and affordability of these foods are being deliberated. Shifting the focus of the agriculture sector from the current system of staple-food production to a diversified cropping pattern is also under active consideration. This apart, community involvement, improvement in nutrition knowledge, attitude and practices (KAP), and behavior change communication (BCC) would lead to the much-required systemic change in our food system.
Furthermore, women’s participation in decision-making, regarding what to produce and purchase, can enhance diet diversity. Mainstreaming women in agriculture and increasing their autonomy will greatly improve the nutrition profile of the country.
As for the private sector, a lot can be done. Technological innovations to improve nutrient contents of the agricultural produce, maximizing production with less water and the land area will help. The private sector can also play a significant role in increasing the access and availability of low-calorie, nutrient-rich foods. They should move from HFSS (high fat, high sugar, salt) foods and highly processed foods to nutrient-dense healthy foods. Innovation to improve shelf life of foods without additives and chemicals is also the need of the hour.
