Leader of the Green Revolution Dr. M.S Swaminathan and Padma Shri Dr. H Sudarshan, launched the National Nutrition Strategy, along with Vice Chairman Dr. Rajiv Kumar and Member Dr. Vinod Paul.
With a benefit to cost ratio of 16:1 for 40 low and middle-income countries, there is a well recognized rationale, globally, for investing in Nutrition.
The recently published NFHS-4 results reflect some progress, with a decline in the overall levels of under nutrition in both women and children. However, the pace of decline is far below what numerous countries with similar growth trajectories to India have achieved. Moreover, India pays an income penalty of 9% to 10% due to a workforce that was stunted during their childhood.
To address this and to bring nutrition to the centre-stage of the National Development Agenda, NITI Aayog has drafted the National Nutrition Strategy.
Formulated through an extensive consultative process, the Strategy lays down a roadmap for effective action, among both implementers and practitioners, in achieving our nutrition objectives.
The nutrition strategy envisages a framework wherein the four proximate determinants of nutrition – uptake of health services, food, drinking water & sanitation and income & livelihoods – work togetherto accelerate decline of under nutrition in India.
Currently, there is also a lack of real time measurement of these determinants, which reduces our capacity for targeted action among the most vulnerable mothers and children.
Supply side challenges often overshadow the need to address behavioural change efforts to generate demand for nutrition services. This strategy, therefore, gives prominence to demand and community mobilisation as a key determinant to address India’s nutritional needs.
The Nutrition Strategy framework envisages a Kuposhan Mukt Bharat – linked to Swachh Bharat and Swasth Bharat. The aim isensure that States create customized State/ District Action Plans to address local needs and challenges. This is especially relevant in view of enhanced resources available with the States, to prioritise focussed interventions with agreater role for panchayats and urban local bodies.
The strategy enables states to make strategic choices, through decentralized planning and local innovation, with accountability for nutrition outcomes.
It is widely recognized that Maternal and Child Under nutrition is the underlying cause of nearly half (45%) of the mortality of children under five years and that one fifth of maternal mortality can be averted by addressing maternal stunting and iron deficiency anemia.
The link between the vicious cycle of under nutrition, disease/infections and mortality has also been highlighted in the Nutrition Situation Analysis. In this perspective, the National Nutrition Strategy will therefore contribute to key national development goals for more inclusive growth, such as the reduction of maternal, infant and young child mortality, through its focus on the following monitorable targets-:
- To prevent and reduce under nutrition (underweight prevalence) in children (0- 3 years) by 3 percentage points per annum from NFHS 4 levels by 2022.
- To reduce the prevalence of anemia among young children, adolescent girls and women in the reproductive age group (15- 49 years) by one third of NFHS 4 levels by 2022.
- The achievement of the above monitorable targets will contribute to improved learning outcomes in elementary education, improved adult productivity, women’s empowerment and gender equality and the National Development Agenda.
- Achievement of these national development goals will also significantly shape progress towards global sustainable development goals.
- In a longer term perspective, the strategy will also aim to progressively reduce all forms of under nutrition by 2030.
- The focus of this strategy over the next five years is on preventing and reducing child under nutrition. While under nutrition affects large segments of the population – the strategy accords priority to and focus on the most vulnerable and critical age groups, which also determine nutrition in later life and inter generationally.
The specified a set of six global nutrition targets for 2025 that aim to:
– Achieve a 40% reduction in the number of children under-5 who are stunted;
– Achieve a 50% reduction of anemia in women of reproductive age;
– Achieve a 30% reduction in low birth weight;
– Ensure that there is no increase in childhood overweight;
– Increase the rate of exclusive breastfeeding in the first 6 months up to at least 50%;
– Reduce and maintain childhood wasting to less than 5%.
Deficiencies of Key Vitamins And Minerals: Deficiencies of key vitamins and minerals such as Vitamin A, Iron, Iodine and Zinc continue to coexist and interact with protein and energy deficits and need to be addressed synergistically, through a multipronged approach.
- Vitamin A: Sub-clinical Vitamin A Deficiency (VAD) is a well-known cause of morbidity and mortality, especially among young children and pregnant women. Vitamin A deficiency limits the growth of young children, weakening their immunity and in cases of acute deficiency, leading to blindness and to increased mortality. Vitamin A supplementation has proven successful in reducing the incidence and severity of illness. It has been associated with an overall reduction in child mortality, especially from diarrhoea, measles and malaria. As per NFHS-4, 60.2% children aged 9-59 months received the six monthly Vitamin A supplement in the six months before the survey. However, inter-state variation in Vitamin A Supplementation for children aged 9-59 months continues with Goa at 89.5% and Nagaland at 27.1%
- Iron: Iron Deficiency Anemia (IDA) is common across all age groups, but highest among more vulnerable young children, adolescent girls, pregnant and lactating women. The consequences of IDA in pregnant women are increased risk of low birth weight or premature delivery, peri-natal and neonatal mortality, inadequate iron stores for the new-born, lowered physical activity, fatigue and increased risk of maternal morbidity. Iron deficiency impairs growth, cognitive development and immune function. It reduces the performance level of children in school and makes them less productive as adults. India is among the countries with the highest prevalence of anemia in the world which needs to be addressed in a life cycle approach. Anemia is a major health problem affecting 53% of women (15-49 years) and 22.7% of men in India as per NFHS-4. 50.3% of pregnant women were found to be anaemic, as per NFHS-4. Anemia was found to be considerably higher in rural areas than urban areas, for disadvantaged groups (particularly scheduled tribes) and for children and women in households in the lower wealth quintiles.
- Iodine Deficiency Disorders: IDD constitute the single largest cause of preventable brain damage worldwide, leading to learning disabilities and psychomotor impairment. As per NFHS 4, 93.1% households were using salt that was adequately iodized; others were using salt that was either inadequately iodized or was not iodized at all.
- Zinc: Zinc deficiency results in the stunted growth of children. Zinc deficiency compromises the effectiveness of the immune system, increasing the incidence and severity of infections such as diarrhea disease and pneumonia. Therefore, as per MHFW guidelines, diarrhea management is envisaged through ORS with zinc supplementation, which is used as a key indicator of programme interventions. As per NFHS 4, the percentage of children with diarrhea in the last 2 weeks preceding the survey who received zinc supplementation is found to be 20.3%. However, inter-state variation in the ‘children with diarrhea in the last two weeks who received zinc’ continues with Puducherry at 69.6% and Andaman and Nicobar Islands at 8.3%.
NUTRITION INTERVENTIONS:
The National Nutrition Strategy identifies key nutrition interventions that will be undertaken or WHAT will be done. The concept of direct and indirect interventions was envisaged in India’s National Nutrition Policy 1993 and the proposed interventions include both direct or nutrition specific interventions and indirect or nutrition sensitive interventions.
Infant and Young Child Care and Nutrition: These interventions will focus on children under 3 years, through the promotion of –
- Universal early initiation (within 1 hour of birth) and exclusive breastfeeding for the first six months of life.
- Universal timely and appropriate complementary feeding after six months, along with continued breastfeeding for two years or beyond.
- Universal growth monitoring and promotion of young children-using WHO CGS with counseling of mothers/families using the Mother Child Protection Card.
- Universal access to infant and young child care (including ICDS, crèches, linkages with MGNREGA), with improved supplementary nutritional support/THR through ICDS.
- Enhanced care, improved feeding during and after illness, nutritional support, referrals and management of severely and acutely undernourished and/or sick children.
Infant and Young Child Health: The set of interventions related to Infant and Young Child Health therefore envisage the promotion of-
- Improved new born care and care of low birth weight babies.
- Bi annual vitamin A supplementation for children 9-59 months
- Universal, timely and complete immunization of infants against vaccine preventable diseases (and subsequent booster doses) with quality assurance.
- Ensuring that young children receive micronutrient supplementation and bi annual deworming as per MHFW guidelines. This includes-
- IFA supplementation for children 6-59 months.
- Bi annual deworming for children Over 1 year-59 months (linked to bi annual VAS rounds).
- Prevention and management of common neonatal and childhood illnesses such as diarrhoea (with ORS and zinc supplementation) and Acute Respiratory Infections (ARI) and severe acute malnutrition, at community and facility levels.
Maternal Care, Health and Nutrition: Interventions for maternal care, health and nutrition therefore include the promotion of-
- Improved supplementary nutritional support during pregnancy and lactation (ICDS).
- Improved antenatal care – including health and nutrition counseling (also family support for extra diet and rest to ensure adequate weight gain), IFA supplementation, consumption of adequately iodized salt and screening /management of severe anemia.
- Enhanced maternity protection (through the effective implementation of PMMVY)
- Institutional deliveries, lactation management, improved post-natal and new born care.
- Promoting marriage at the right age, first pregnancy at the right age, inter pregnancy recoupment/ birth spacing and shared care/ parenting responsibilities.
- Promoting Women’s Literacy and Empowerment.
Adolescent Nutrition: The interventions here – especially for improving the nutrition status of adolescent girls- will focus on the promotion of-
- Equal care of the girl child at different stages of the life cycle- linked to the Beti Bachao Beti Padhao initiative.
- Improved access to health care, counseling support through school health programmes, ARSH and deworming as per MHFW National Deworming Initiative.
- Improved access to nutritional support through Mid-Day Meals in schools (MHRD) and through SABLA for out of school girls.
- Universal access of girls in school and girls out of school to IFA supplementation.
- Girls’ education, skill development and female literacy.
- Changing gender constructs -Gender sensitization and life skills for adolescents.
- No Child Marriage- Marriage of young women after the age of 18 years. The above will also have a positive inter-generational impact.
Iodine Deficiency: Interventions under the NHM National Iodine Deficiency Disorders Control Programme will be strengthened. These include the promotion of –
- Universal household consumption of adequately iodised salt.
- Special focus on reaching pregnant women, young children and adolescent girls, through food supplementation programmes such as ICDS, MDM, SABLA and vulnerable community groups.
- Health and nutrition education.
- Community based monitoring- especially through salt testing in schools, health centres and panchayats.
- Here the aim will be to achieve universal access to adequately iodised salt by 2018 and to reduce prevalence of iodine deficiency disorders in the country to less than 5 per cent by 2022.
Zinc Deficiency: As outlined in the NHM RMNCH+ A National Programme, the major interventions will be the use of ORS with zinc supplementation for diarrhoea management.
Community Nutrition: These interventions include, among others-
- Ensuring universal access to safe drinking water, sanitation and hygiene, in an open defecation free environment, through Swachh Bharat.
- Prevention and treatment for malaria through the –
- Use of bed-nets and/or intermittent preventive therapy for malaria (as per MHFW protocols) in malaria-endemic areas
- Facilitating mosquito control measures.
- Other relevant health /disease control measures specific for the state/district, relevant for improving nutrition at community levels – such as JE, kala azar etc.
- Ensuring access to household food security, social protection systems and safety nets.
- Nutrition Education to ensure that optimal feeding and caring practices, dietary diversity nutritious foods; sanitation and hygiene and healthy lifestyles are promoted-addressing undernutrition and also the dual burden of malnutrition. (This includes Nutrition Education in the school curriculum and in colleges).
- Focused Interventions to reaching the most nutritionally vulnerable community groups (such as SC, STs, minorities, others) and address multiple nutritional vulnerabilities such as those related to seasonal distress, disease outbreaks, natural disasters (such as floods, drought, earthquakes) and other situations.
- Flexible responses to other State/district specific needs for improving nutrition at community levels.