When India became independent, the country faced two major nutritional problems: a threat of famine and the resultant acute starvation due to low food production and the lack of an appropriate food distribution system. The other was chronic under-nutrition due to poverty, food insecurity and inadequate food intake. Famine and starvation hit the headlines because they were acute, localised, caused profound suffering and fatalities. But chronic low food intake was a widespread silent problem leading to under-nutrition, ill health and many more deaths than starvation. Mutually reinforcing adverse consequences of under-nutrition and ill health resulted in high morbidity and mortality in all age groups and the longevity at birth was only 35 years.

The country adopted multi-sectoral, multi-pronged strategies to improve the nutritional and health status of the population.

All the national nutrition and health surveys carried out over the last four decades have documented that there have been steady but a slow decline in under-nutrition and micro-nutrient deficiencies, morbidity and mortality due to severe infections. Because of the synergistic interactions between nutrition and health, some health interventions resulted in improving both health and nutrition status and vice versa. In the last two decades, there has been a slow but steady increase in the prevalence of over-nutrition and Non-Communicable Diseases (NCD).

NCDs are asymptomatic in the initial phase; only after symptoms due to complications arise do patients seek health care. It is essential to improve awareness regarding health consequences of adiposity and initiate programmes for prevention and management of adiposity (adiposity). Interventions for regaining normal nutritional status in those with NCD will have to be initiated as a part of management of NCD.

A decline of under-nutrition:

The Integrated Child Development Scheme (ICDS) was aimed at providing food supplements to children from poor and marginalized sections to bridge the gap between requirement and actual dietary intake. Though initiated in the seventies, ICDS was universalized only in the first decade of the new century.

Prevention and treatment of infections reduced energy loss due to infection and prevented deterioration in nutritional status. Thus, improved access to health care played an important role in achieving a steady reduction in the under-nutrition rates in pre-school children in the last four decades.

Optimal nutrition in childhood:

As birth weight is a major determinant to growth, low birth weight children grow along a low trajectory of growth during infancy, childhood and adolescence. Height, weight and BMI are three parameters widely used for assessing the nutritional status. Of the three, BMI which is the indicator of current energy adequacy has long been accepted as the indicator for assessment of nutritional status in adults.

A case study for a health care intervention helping in achieving the nutritional goals:

During the 1960s poverty, household food insecurity and hunger were widespread among poorer segments of the population. Dietary intake of all nutrients was low and moderate and severe under-nutrition in young children were common. Poor green and yellow vegetable intake led to widespread Vitamin A deficiency. In the urban areas, the primary health care infrastructure to treat the infections was poor and in the rural areas, it was non-existent.

Untreated severe infections, especially measles, in the already severely under-nourished young children, led to Keratomalacia; those who survived the infection were often left with nutritional blindness.

Based on the findings of the National Institute of Nutrition, Massive Dose of Vitamin A Supplementation (MDVAS) for the children of the age group 1-5, once in 6 months was initiated in 1970. But the coverage under the programme was as low as less than 10%. During the 80’s there was a steep reduction in Keratomalacia. Over the next decade, blindness due to the deficiency of Vitamin A was not reported by major hospitals.

Though the coverage under MDVAS still persisted to be low, the primary health care infrastructure in urban and rural areas had been established and access to immunisation, treatment of infections, severe grades of under nutrition had improved substantially.

Universal Salt iodization:

Iodine deficiency disorders (IDD) have been recognised as a public health problem in India since the 1920s. Iodine Deficiency affects all socio-economic groups living in defined geographic areas. IDD during pregnancy was associated with high abortion and foetal wastage rates; some infants born to these mothers suffered from cretinism and mental retardation. In adults, IDD include hypothyroidism and goitre. Universal use of iodised salt is a simple, inexpensive method of preventing IDD.

A case study :

Initially, IDD in India was thought to be a problem in the sub Himalayan region. The National Goitre Control Programme initiated in 1962, focused on supplying iodised salt to those living in the goitre belt.  Studies over the next 2 decades showed a decline in the cretinism and mental retardation in children and some reduction in the prevalence of goitre in 6-12 year old children.

Considering the fact that IDD existed in pockets in all states of India, a National Iodine Deficiency Disorders Control Programme (NIDDCP) was initiated in 1992 with the goal of ensuring universal household access to iodised salt. However, over the next fifteen years, the household access to adequately iodised salt remained below 50%. In 2007 mandatory fortification of all salt for human consumption with iodine was notified. Universal salt iodization programme is an example of a nutrition programme not only achieving nutritional goals but also preventing mental retardation in children and IDD related health problems in adults.

Dual Nutrition and health burden:

Over the last three decades, there has been a progressive rise in over-nutrition both in men and in women. However, the overnutrition rates were higher in women, than in men.

India’s health system was built up with a focus on early detection and effective treatment for under-nutrition, infections and maternal child health problems. Most of these health problems are symptomatic and acute. Over the years, utilization of health care had improved and this led to a sustained reduction in under-nutrition, ill health and mortality rates.

In the coming years, Indians and Indian health system have to reorient and gear themselves for successfully managing the prevention, early detection and effective management of dual nutrition and disease burden.

In the dual nutrition and health burden era, assessment of nutritional status is an important component of both public health interventions and care of individuals seeking health care.  

Promoting synergy between health and nutrition services will enable the country to successfully face the nutrition challenges and achieve rapid improvement in health and nutritional status of the population.