India needs to scale up direct nutrition interventions

As India launches its 75th independence anniversary celebrations, there is much to be proud of; Significant advances have been made in science, technology and medicine, adding to the country’s ancient, traditional and civilizational knowledge base, wisdom and wealth.

Still, it is puzzling that even after seven decades of independence, India is plagued by public health problems such as child malnutrition (35.5% stunted, 67.1% anemic) attributed to 68.2% of infant mortality under five years of age. Poor nutrition not only negatively affects health and survival, but also leads to decreased learning ability and poor school performance. And in adulthood, it means reduced income and higher risks of chronic diseases such as diabetes, hypertension and obesity.

The good news is that the government seems determined to put it right, with an aggressive push for the National Nutrition Mission (NNM), renaming it the Prime Minister’s Comprehensive Scheme for Holistic Nutrition, or POSHAN Abhiyaan. Its objective is to reduce malnutrition in women, children and adolescent girls.

The Ministry of Women and Children (MWCD) continues to be the nodal ministry implementing the NNM with the vision of aligning different ministries to work together in the “window of opportunity” of the first 1000 days of life (270 days of pregnancy and 730 days; 0-24 months). Global and Indian evidence fully supports this strategy, which prevents the largely irreversible stunting that occurs by two years of age. POSHAN Abhiyaan (now known as POSHAN 2.0) places a special emphasis on selected high-impact essential nutrition interventions, combined with nutrition-sensitive interventions, that indirectly impact maternal, infant and young child nutrition, such as improving coverage of maternal and child health services. , improve women’s empowerment, availability and access to improved water, sanitation and hygiene, and improve household food production for a diversified diet.

NHFS data is a pointer

Data from the 2019-21 National Family Health Survey (NFHS)-5, compared to the 2015-16 NFHS-4, reveal substantial improvement over a four- to five-year period in several proxy indicators of women’s empowerment , for which the Government deserves credit. There is a substantial increase in prenatal service attendance (58.6 to 70.0%); women who have their own bank savings accounts (63.0 to 78.6%); women who own mobile phones that they use themselves (45.9% to 54.0%); women married before age 18 (26.8% to 23.3%); women with 10 or more years of schooling (35.7% to 41.0%) and access to clean fuel for cooking (43.8% to 68.6%).

But alarmingly, during this period, the country has not progressed well in terms of direct nutrition interventions. Preconception nutrition, maternal nutrition, and adequate infant and child feeding still need to be effectively addressed. India has 20-30% malnutrition even in the first six months of life, when exclusive breastfeeding is the only food needed. Neither maternal nutrition care interventions nor infant and young child feeding practices have shown the desired improvement. A maternal nutrition policy is still awaited.

Despite a policy on infant and young child feeding and a ban on the sale of commercial milk for infant feeding, there has been only marginal improvement in the practice of exclusive breastfeeding (EBF). Child malnutrition in the first three months remains high. Raising awareness of EBF, promoting the technique of properly holding, latching and manually emptying the breast is crucial for the optimal transfer of breast milk to the baby. Recent evidence from the IIT Mumbai team at the Center for Technology Alternatives for Rural Areas (CTARA) indicates that well-planned breastfeeding counseling given to pregnant women during antenatal care before delivery and at frequent follow-up home visits makes a difference significant. An infant’s daily weight gain was found to average between 30 and 35 grams per day and the prevalence rate of underweight was reduced by nearly two-thirds.

Another key intervention

NFHS-5 also confirms a gap in another nutritional intervention: complementary feeding practices, that is, supplementing semi-solid feeding with continuation of breast milk from six months. Poor complementary feeding is often due to a lack of awareness to start feeding at six to eight months, what and how to properly feed the family, how often and how much. The fact that 20% of children in higher socioeconomic groups are also stunted indicates poor knowledge in food selection and feeding practices and the child’s ability to swallow mashed foods. Where did we go wrong?

Therefore, raising awareness at the right time with the right tools and techniques regarding special care in the first 1,000 days deserves a very high priority. We must act now and invest finances and energy in a mission mode. The Prime Minister can give a big boost to POSHAN 2.0, as he did to Swachh Bharat Abhiyaan, using his ‘Mann Ki Baat’ programme.

There is a pressing need to review the system spearheaded by POSHAN 2.0 and review it to eliminate any flaws in its implementation. We need to see if we are making the most of the opportunity for service delivery contacts with mother and child in the first 1000 days. It is necessary to review the nodal system for the nutrition program that has existed since 1975, the Integrated Child Development Scheme (ICDS) under the Ministry of Women and Children, and examine whether it is the appropriate system to reach mother-child in the first 1,000 days of life By relying on ICDS, we are actually missing out on the frequent contacts with pregnant mothers and children that the public health sector provides during antenatal care services and childhood immunization services. There is also a need to explore whether there is an alternative way of distributing ICDS provided supplemental nutrition as take-home ration packs through public distribution (PDS) and freed ICDS anganwadi workers to receive timely advice on best practices of maternal and child nutrition.

We need to systematically review the state, and develop and test a new system that combines ICDS human resources and health from village to district to state level. This would address the mismatch that exists in focusing on service delivery in the first 1,000 days of life to prevent child malnutrition by having an effective accountable system in place.

It’s time to think outside the box and overcome systemic failures and our reliance on the antiquated 1970s system that is slowing things down. In addition, the media or television programs could organize speeches on care in the first 1,000 days to reach mothers outside the public health system.

Dr. Sheila C. Vir is an expert in nutrition for public health and the editor of the book “Nutrition for public health in developing countries.”