Prospects for better nutrition in India
Author:Rajan Sankar MD, Tina van den Briel PhD
Keywords:micronutrient deficiencies, stunting, nutrition programs, India
Abstract:Being home to 31% of the world’s children who are stunted and 42% of those who are underweight, and with
many children and adults affected by micronutrient deficiencies, I ndia is facing huge challenges in the field of nutrition. Even though the I ndian Government is investing vast amounts of money into programs that aim to enhance food security, health and nutrition (the I ntegrated Child Development Services program alone costs 3 bil lion USD per year), overall impact has been rather disappointing. However, there are some bright spots on the
horizon. The recent District Level Health Surveys (DLHS-4) do show significant progress, ie a reduction in stunting of around 15% over the past 6 years in a few states for which preliminary results are available. The reasons
for this reduction are not unambiguous and appear to include state government commitment, focus on the ‘window of opportunity’, improved status and education of women, a lowered fertility rate, and combinations of nutrition-specific and nutrition-sensitive interventions. Apart from the government many other agencies play a role in
driving improvements in nutrition. Since 2006 the Global Alliance for Improved Nutrition (GAIN) has worked
with a range of partners to improve access to nutritious foods for large parts of the population, through public and
private delivery channels. This supplement presents a selection of these activities, ranging from a capacityassessment of frontline workers in the I CDS system, large scale staple food fortification, salt iodization, fortification of mid-day meals for school children and decentralized complementary food production.
Asia Pac J Clin Nutr. 2014;23(5):S1-S3.doi: 10.6133/apjcn.2014.23.s1.06
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Food fortification as a complementary strategy for the
elimination of micronutrient deficiencies: case studies of
large scale food fortification in two Indian States
Author:Sadhana Bhagwat MD, Deepti Gulati MSc, Ruchika Sac
Keywords:micronutrient malnutrition, staple food fortification, India
Abstract:The burden of micronutrient malnutrition is very high in I ndia. Food fortification is one of the most cost-effective
and sustainable strategies to deliver micronutrients to large population groups. Global Alliance for Improved Nutrition (GAI N) is supporting large-scale, voluntary, staple food fortification in Rajasthan and Madhya Pradesh because of the high burden of malnutrition, availability of industries capable of and willing to introduce fortified
staples, consumption patterns of target foods and a conducive and enabling environment. High extraction wheat
flour from roller flour mills, edible soybean oil and milk from dairy cooperatives were chosen as the vehicles for
fortification. Micronutrients and levels of fortification were selected based on vehicle characteristics and consumption levels. I ndustry recruitment was done after a careful assessment of capability and willingness. Production units were equipped with necessary equipment for fortification. Staffs were trained in fortification and quality control. Social marketing and communication activities were carried out as per the strategy developed. A state
food fortification alliance was formed in Madhya Pradesh with all relevant stakeholders. Over 260,000 MT of edible oil, 300,000 MT of wheat flour and 500,000 MT of milk are being fortified annually and marketed. Rajasthan
is also distributing 840,000 MT of fortif ied wheat flour annually through its Public Distribution System and 1.1
million fortif ied Mid-day meals daily through the centralised kitchens. Concurrent monitoring in Rajasthan and
Madhya has demonstrated high compliance with all quality standards in fortified foods.
Asia Pac J Clin Nutr. 2014;23(5):S4-S11.doi: 10.6133/apjcn.2014.23.s1.03
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Improving the nutrition quality of the school feeding
program (Mid-Day Meal) in India through fortification:
a case study
Author:Sadhana Bhagwat MD, Rajan Sankar MD, Ruchika Sachd
Keywords:school feeding, food fortification, mid-day meal, India
Abstract:Micronutrient malnutrition is widely prevalent in school children in I ndia. I ndia’s national school feeding program, the Mid-Day Meal (MDM) scheme, is the largest in the world and caters to 120 million children in primary
schools. Complementary strategies such as deworming or fortifying meals provided through the MDM scheme
could increase the nutritional impact of this program. I ndia’s Supreme Court has directed that only hot, cooked
meals be provided in MDM, through a decentralised model. However, in urban areas, big centralised kitchens
cook and serve a large number of schools, with some kitchens serving up to 150,000 children daily. The objective
of this project was to test the operational feasibility of fortifying the school meal in centralised kitchens, as well
as the acceptability of fortified meals by recipients. A pilot was conducted in 19 central kitchens run by the
Naandi Foundation in four different States. Several food vehicles were used for fortification: wheat flour, soyadal-analogue and biscuits. More than 750, 000 children were reached with fortified food on all school days for a
period of one year. Fortified food was found to be acceptable to all stakeholders. The government is in favour of
continuing fortification. The Naandi Foundation has adopted fortif ication as their norm and continues to forti fy
all meals provided from their central kitchens. I n conclusion: fortification of school meals with micronutrients
can be integrated in the normal cooking process and is well accepted by all stakeholders. This pilot could hold
lessons for other states in adopting fortification in MDM.
Asia Pac J Clin Nutr. 2014;23(5):S12-S19.doi: 10.6133/apjcn.2014.23.s1.01
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Production of fortified food for a public supplementary
nutrition program: performance and viability of a
decentralised production model for the Integrated Child
Development Services Program, India
Author:Clémentine Antier MD, Salil Kumar CA, Sadhana Bha
Keywords:decentralised complementary food production, viability , women empowerment, India, ICDS
Abstract:I ntegrated Child Development Services in I ndia through its supplementary nutrition programme covers over
100 million children, pregnant and lactating women across the country . Providing a hot cooked meal each day
to children aged between 3-6 years and a take-home ration to children aged between 6-36 months, pregnant and
lactating women, the I ntegrated Child Development Services faces a monumental task to deliver this component of services of desired quality and regularity at scale. From intermediaries or contractors who acted as
agents for procuring and distributing food to procurement directly from large food manufacturers to using
women groups as food producers, dif ferent State Governments have adopted a variety of strategies to procure
and distribute food, especially the take-home ration. I ndia’ s Supreme Court, through its directive of 2004, encouraged the Government to engage women’ s groups for the production of the supplementary food. This study
was conducted to determine the operational performance, economic sustainability and social impact of a decentralised production model for I ndia’ s Supplementary Nutrition Program, in which women groups run smallscale industrialised units. Data were collected through observation, interviews and group discussions with key
stakeholders. Operational performance was analysed through standard performance indicators that measured
consistency in production, compliance with quality standards and distribution regularity . Assessment of the
economic viability included cost structure analysis, five-year projections, and financial ratios. Social impact
was assessed using a qualitative approach. The pilot unit has demonstrated its operational performance and
cost-efficiency . More data is needed to evaluate the scalability and sustainability of this decentralised model.
Asia Pac J Clin Nutr. 2014;23(5):S20-S28.doi: 10.6133/apjcn.2014.23.s1.05
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Capacity of frontline ICDS functionaries to support
caregivers on infant and young child feeding (IYCF)
practices in Gujarat, India
Author:Anuraag Chaturvedi MPH, N Nakkeeran PhD, Minal Dos
Keywords:infant and young child feeding practices, knowledge, skills, ICDS, Anganwadi Workers, India
Abstract:Improved infant and young child feeding practices have the potential to improve child growth and development
outcomes in I ndia. Anganwadi Workers, the frontline government functionaries of the national nutrition supplementation programme in I ndia, play a vital role in promoting infant and young child feeding practices in the
community. The present study assessed the Anganwadi Workers’ knowledge of infant and young child feeding
practices, and their ability to counsel and influence caregivers regarding these practices. Eighty Anganwadi
Workers from four districts of Gujarat participated in assessment centres designed to evaluate a range of competencies considered necessary for the successful promotion of infant and young child feeding practices. The results
of the evaluation showed the Anganwadi Workers possessing more knowledge about infant and young child feeding practices like initiation of breastfeeding, pre-lacteal feeding and colostrum, age of introduction of complementary foods, portion size and feeding frequency than about domains which appear to have a direct bearing on
practices. A huge contrast existed between the Anganwadi Workers’ knowledge and their ability to apply this in
formal counselling sessions with caregivers. I nability to empathetically engage with caregivers, disregard for taking the feeding history of children, poor active listening skills and inability to provide need-based advice were
pervasive during counselling. I n conclusion, to ensure enhanced interaction between the Anganwadi Workers and
caregivers on infant and young child feeding practices, a paradigm shift in training is required, making communication processes and counselling skills central to the training.
Asia Pac J Clin Nutr. 2014;23(5):S29-S37.doi: 10.6133/apjcn.2014.23.s1.04
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The National Coalition for Sustained Optimal Iodine
intake (NSOI): a case study of a successful experience
from India
Author:Kapil Yadav MBBS, MD, Arijit Chakrabarty MBBS, Je
Keywords:universal salt iodisation, iodine deficiency disorders, multi-sectoral, national coalition
Abstract:Iodine deficiency disorders (I DD) constitute the single most important preventable cause of mental handicap at
global level. Recognizing the importance of coordination and synergy of the activities of wide range of universal
salt iodisation (USI ) stakeholders, WHO/ Unicef/ I CCI DD has prescribed a national multi-sectoral coalition as
one of the ten indicators essential for attaining sustainable elimination of I DD at national level. Challenge for coordination among different stakeholders of IDD/USI is even greater in democratic and diverse country like I ndia.
I n the present article we present successful experience from I ndia regarding formation of a national coalition and
contributions made by the coalition towards promoting USI in I ndia. The activities of the national coalition in I ndia are classified into three phases; 1) Phase 1- year 2006 to 2009- the inception; 2) Phase 2- year 2009 to 2012-consolidation; 3) Phase 3- year 2013 and ongoing- expansion. The National coalition for Sustained Optimal I odine I ntake (NSOI ) has been instrumental in ensuring greater coordination and synergy amongst I DD and USI
stakeholders in I ndia and partially responsible for the current 71 percentage household level coverage of adequately iodised salt. The most significant contribution of the national coalition has been to act as a high level advocacy channel and provide a platform for regular dialogue for all partners of the coalition. With “mission” approach and allocation of optimal resource, I ndia can achieve and should achieve USI by 2015, an apt culmination
of a decade of existence of the national coalition.
Asia Pac J Clin Nutr. 2014;23(5):S38-S45.doi: 10.6133/apjcn.2014.23.s1.02
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