The recent release of The Lancet’s special edition on Maternal and Child Nutrition in Delhi provided an occasion to debate the relevance of its recommendations for India.
The discourse was enlivened by a statement, released ahead of the event by several Indian health experts, challenging the content and intent of some of the suggested interventions.
Three authors of The Lancet series and many of the critics who issued that statement participated in a discussion that engaged a packed hall of nutrition and health experts, administrators, civil society and media representatives, and identified areas of agreement and discord.
Maternal and child undernutrition was unanimously identified as a major, as-yet-unresolved public health challenge in India. While the latest countrywide National Family Health Survey data is nearly a decade old, more selective recent surveys like HUNGaMA (2011) have reinforced the prime minister’s description of child undernutrition as a “national shame”.
Though economists like Arvind Panagariya challenge the estimates of childhood malnutrition derived from applying global growth standards, the appalling picture of undernutrition in the first three years of life can only be corrected if we recognise the right of every child to develop to her full potential.
The widespread prevalence of anaemia and micronutrient deficiencies among children, adolescents and women in the reproductive age group is a reminder that malnutrition exists in measures beyond weight and can have adverse intra-and inter-generational effects.
The paradox of childhood undernutrition extending to another form of malnutrition — excess body fat and low muscle mass — was also noted by the experts.
This is relevant in India, where several studies show that low birth weight followed by ‘rebound adiposity’ during 2 to 12 years of age increases the risk of developing diabetes and heart disease in adulthood.
This ‘metabolic mismatch’ often occurs in the absence of overt obesity and is frequently associated with the accumulation of fat in the abdomen.
The challenge is to identify a balanced diet which, along with adequate physical activity, can enable undernourished infants to grow to their full physical and intellectual potential, without becoming ‘stunted obese’ children or metabolically compromised adults.
The nutritional needs of the adolescent girl also need more attention.
These perspectives led to the shared view that a ‘life course’ approach to nutrition must be adopted instead of narrowly focused and disconnected programmes.
This can only happen when policy-makers recognise every citizen’s right to access a combination of foods adequate in calories and nutrition at every stage of life.
The main recommendations of The Lancet were divided into nutrition-specific and nutrition-sensitive interventions.
The former dealt with actions that address the immediate causes of sub-optimum growth and development, while the latter covered the underlying determinants which span several development sectors.
Everyone agreed that nutrition-sensitive interventions were essential but neglected.
These include: agriculture and food security, social safety nets, early child development, maternal mental health, women’s empowerment, child protection, schooling, water, sanitation and hygiene, and health and family planning services.
Jairam Ramesh, minister for rural development, made a strong case for prioritising nutrition-sensitive interventions in India.
Providing a scholarly summation of evidence linking the lack of sanitation to malnutrition, he called for multi-sectoral convergence to meet the population goals for nutrition.
He, however, cautioned that an emphasis on nutrition-sensitive agriculture may provide an unquestioning invitation to potentially hazardous GM foods.
The Lancet’s menu of nutrition-specific recommendations proved more contentious.
Accepted measures included adequate food and nutrient intake, good feeding, care-giving and parenting practices, the control of infectious diseases, the promotion of breastfeeding and complementary feeding and responsive feeding practices.
However, multiple micronutrient supplementation and the use of ‘ready-to-use therapeutic foods’ (RUTF) for treating acute malnutrition were vigorously contested.
Indian experts said the preventive use of Vitamin A and zinc supplements was not acceptable in India, where trials had failed to demonstrate benefits.
The use of commercial RUTF for treating acute malnutrition was opposed in the absence of convincing proof of their superiority over conventional feeding with nutritionally-balanced natural foods.
Civil society representatives were concerned that promoting public-private partnerships in nutrition may allow the food industry to frame the agenda for action to promote micronutrient supplements and RUTF.
The dismal record of some industries in promoting baby milk foods at the expense of exclusive breastfeeding and of aggressively marketing junk food and soft drinks, was cited to sound a warning against reposing faith in public private partnerships (PPP) for nutrition.
While recognising this concern, Jairam Ramesh observed that the PPP debate ignored the role of community-led action in promoting healthy nutrition practices.
He agreed that large national programmes like ICDS (Integrated Child Development Services) and mid-day meal schemes needed methodologically-sound evaluation.
A positive story emerged from Maharashtra, where multi-sectoral action has led to a decline in child malnutrition. Political will and administrative skill effectively mobilised the community and led to the integrated implementation of diverse nutrition relevant programmes.
There is no room for complacency in meeting the challenge of malnutrition. Nutrition-sensitive interventions have to be promoted by aligning policies and programmes across multiple sectors, with greater policy coherence.
Relevant nutrition-specific interventions have to be judiciously employed and nutritious diets be prioritised over commercial supplements.
In promoting healthy nutrition, the public sector needs to be more responsive, the private sector more responsible, and the community empowered to become more resourceful.
K Srinath Reddy is president, Public Health Foundation of India.
The views expressed by the author are personal.