Mere food schemes, free cereals, fortification will never work not because they are too tangled in red tapism but because they are too centralised and designed with a tunnel vision. Measures such as food fortification and food supplementation with vitamins, iron, Omega 3 fatty acids, flax seed oil are steps taken in the right direction and will support in improving nutrition.
For years together two biggest fallacies we are facing in understanding, interpreting malnutrition while deciding policies on nutrition are the definition of malnutrition and the blinkered focus on few specific food items. The first misunderstanding is that malnutrition necessarily means undernutrition. Rather it envisages a whole spectrum of disturbances in nutrition ranging from extremely malnourished socially deprived children to obese over nourished or rather wrongly nourished sedentary children from affluent society. Although undernourished children starving to death definitely deserves attention but the later should also not be neglected. The much controversial food security Bill promises to secure these undernourished class but the Bill might meet the same fate like many other previous food schemes our policy makers have thrust upon the nation. The simple reason being we have mistaken the cause of malnutrition as mere scarcity of food without analysing whether it is a scarcity of food or scarcity of hunger.
Even if we revise a few pages of our final MBBS curriculum from the subject Preventive and Social Medicine on nutrition we will realize the history of bad science and misconceived advice that has long dominated India’s nutrition policies, be it food security of mid-day meal scheme or ekatmik bal vikas yojana. Like all other social health problems in case of malnutrition too, we have generalised the problem and provided quick fix solutions one of which is providing cereals through food security or khichdi through mid-day meal. Any child or human being for that matter needs a diverse and balanced diet including protein, carbohydrates, calories, fibre and most importantly micronutrients. Also before providing food have we assessed the medical condition of malnourished children? Most of these children are suffering from chronic intracellular infections like tuberculosis, brucellosis, listerosis. All these infections kill appetite of the child and also make their digestion feeble. Pouring cereals on these ill-malnourished children is like making a lame horse run a race. The very first thing for treating malnutrition is to identify and treat the infections in these children to make the cells of their body viable for digestion.
After treatment of infections two things should be prioritised in nutritional rehabilitation – first availability of local food from family pot and secondly considering the food which best suits the body structure classified as vata, pitta and kapha in ancient science of Ayurveda. A food which best suits a vata natured person might be a curse for a pitta natured one and vice versa. Also locally available pulses, vegetables, fruits have to be added to the dish of malnourished child. Although malnutrition is a generalized social problem but to solve it nutritionally every child has to be personalized because every child is unique. Generalising the problem and focus on a single food item has given rise to a hidden hunger – micronutrient deficiencies which is as severe as malnutrition. Vitamin and mineral deficiencies are emerging as a new public health issue. Iron deficiency anemia, Vitamin A deficiency and iodine deficiency disorders have been public health problems since years. Other micronutrient deficiencies such as Vitamin B group, folic acid, calcium and Vitamin D are widely prevalent in our country and have serious impact on health and productivity of the population. Micronutrient malnutrition is prevalent in all age groups but its consequences are more severe when it affects children below 24 months of age, since they are largely irreversible. About 70% of pre-school children suffer from iron deficiency anemia and 37% of pre-school children have Vitamin A deficiency. With almost 75% of children affected with one or more micronutrient deficiency in a country with largest population of young, these deficiencies hold the potential to severely challenge India’s future.
The solution to these problems is quiet simple. Adding fruits, vegetables and broadening the food basket is an easy option. Expense data reveals that monthly per capita expense on fruit is Rs 26 for rural and Rs 63 for urban population. This implies an average expense of less than Re 1 and Rs 2 in rural and urban areas per person per day. For vegetables the expense is Rs 3 and Rs 4 for rural and urban population. Looking at the crores being pumped for food security this expense is merely peanuts. One problem that definitely remains unsolved, inspite of the food diversification, is processing of food leading to major loss of micronutrient content. Substantial amount of Vitamin A in seeds is lost during the process of refining oil. Double toned/skimmed milk loses Vitamin D when fat is removed.
With a large class unable to eat enough, what about those who are able to choose what to eat and have enough to eat. The sad part of the story is that even those who have the choice of what to eat, don’t always eat right. The affluent children driven in air conditioned luxury cars to international schools and spending rest of the time glued to computers, video games, mobile phones, television are equally and literally ‘mal’nourished. The chain of multinational food outlets -- McDonalds, KFC, Dominos, Subway to name a few -- have provided options of easily available, packed, easy to carry food for this population. Excessive trans-fat, salt to increase their shelf life and sugar for taste has made these best packages of lifestyle diseases at an younger age. The lighted menu of these food stores are a perfect epitaph of diabetics and hypertensive’s. To make the situation worse, sedentary lifestyle makes the ground fertile for seeds of all lifestyle diseases in these children.
There is also a big wave of food fortification and food supplementation with vitamins, iron, Omega 3 fatty acids, flax seed oil and all. All these measures can be a step towards improving nutrition but they can’t be the only and final step on the way to healthy life. Mere food schemes, free cereals, fortification will never work not because they are too tangled in red tapism but because they are too centralised and designed with a tunnel vision. Human civilisation has evolved from moving around in search of food and eating the diverse things that nature has provided around us. We need to get back to the same principle.
Dr Amol A Annadate, Pediatrician and Neonatologist and Director, Aanaand Charitable Trust, Anand Multispeciality Hospital and Postgraduate Teaching Institute, Vaijapur Academy Of Higher Education, Mumbai