The Prime Minister of India, Shri Narendra Modi unveiled a vision to fight malnutrition in India on 8th March 2018 with the launch of a new program called POSHAN ABHIYAAN or National Nutrition Mission (NNM). The program comes with a budget of ₹ 9000 crore (₹ 90,000 million or 1384 million US$) for three years and intends to have 10 crore (100 million) beneficiaries. The NNM draws heavily on the National Nutrition Strategy (NNS) which talks about life-course approach upfront. The NNS identifies the need to include nutrition-sensitive interventions (e.g. sanitation, immunization, women empowerment ) and an enabling environment (e.g. governance, effective policies ) along with the nutrition-specific components (like feeding programs, supplementation, fortification) to develop a holistic and effective approach for tackling all forms of malnutrition (underweight, stunted, wasted, overweight, obese, micro-nutrient deficient).NNS rightly identifies that these multiple forms of malnutrition (MFOM) are on a continuum and are not necessarily distinct outcomes. Thus, the need to move more sensitively towards finding solutions for the under nutrition and hunger as well as obesity or even metabolic obesity ( visibly thin/normal individuals with lots of stored fat ) in future is required.
If we aim for food security only , we will end up providing simple carbohydrates or cereal-heavy (mostly using polished or ultra-processed grains) diet to an undernourished population. We will perhaps be successful in providing enough calories but will unfortunately sow seeds of early onset of several chronic diseases. This portends major spikes in the already rising obesity and metabolic disease rates in the future. We have a huge body of evidence** including country cohorts from India (e.g. New Delhi Birth Cohort, Mysore Birth Records cohort etc) which show that low birth weight babies turn diabetic and hypertensive earlier than their normal birth weight counterparts. Additionally, Indians even at much lower levels of BMI and at younger ages (during their productive years thereby impacting county’s economy) are susceptible to non-communicable diseases (NCDs) like diabetes, cardiovascular problems etc.
Several programs or schemes (Integrated Child Development Scheme, Mid-day meal program, Public Distribution System) which address food security at various time points in the lifecourse already exist. Several states like Karnataka, Tamil Nadu, Telangana, Andhra Pradesh, Bihar, Odisha etc have provisions to provide 2-5 eggs per week in MDM but we often find reports (here and here ) that they are either replaced by bananas or skipped due to high prices.
The Food Safety and Standards Authority of India (FSSAI) has rolled out fortification of daily consumption items like flour, salt and edible oil etc for enhancing micronutrient status of masses. While the intention is to improve public health, we must tread this path cautiously. Mere supplementation or fortification programs without strong regulation of the food industry might backfire. The Big Food and Big Soda are using and will continue to mercilessly use this opportunity to market ultra-processed food rich in X, Y or Z nutrient and misguide consumers. More safeguards in this arena is much needed.
There is no shortcut for sustainable good health. We need to make the overall diet diverse – rich in high quality protein, fibre and micronutrients. This dietary diversity along with a physically active lifestyle will ensure a healthy nation free from any kind of malnutrition. Creating local nutrition gardens, preferring traditional foods which are locally available and rich in micronutrients, using schools and workplace canteens to provide subsidised healthy options, building capacity of the communities to choose foods wisely for themselves, creating subsidies for healthier foods and using taxation to curb the menace of ultra-processed (junk) foods- are some strategies which can be useful in this context. Unless this big picture is imbibed in our thinking at every stage and layer of the roll out, success might be few and far between.
Short term solutions come in handy and there’s no denying the fact that lives must be saved. But it is important to emphasize that ignoring the metabolic response of human body might be a costly mistake in the long run. NNM is a huge opportunity and has great potential to deliver if implemented well and monitored robustly. It is time for the decision makers to STAND up now and smell the coffee…. or should we say ‘khichdi’!
About the author: Shweta Khandelwal is an Associate Professor at Public Health Foundation of India and is a nutrition epidemiologist working in maternal & child health and nutrition. She serves on several government panels associated with public health and nutrition policy in India and tweets at: @shwetaPHN
Competing interests: I have read the BMJ Group Conflict of Interest form and declare that I have no conflict of interest to declare .
- Sinha S, Aggarwal AR, Osmond C, D Fall CH, Bhargava SK, Sachdev HS. Intergenerational Change in Anthropometric Indices and Their Predictors Among Children in New Delhi Birth Cohort. Indian Pediatr. 2017 Mar 15;54(3):185-192
- Huffman MD, Khalil A, Osmond C, Fall CH, Tandon N, Lakshmy R, Ramji S, Gera T, Prabhakaran P, Dey Biswas SK, Reddy KS, Bhargava SK, Sachdev HS, Prabhakaran D; New Delhi Birth Cohort. Association between anthropometry, cardiometabolic risk factors, & early life factors & adult measures of endothelial function: Results from the New Delhi Birth Cohort. Indian J Med Res. 2015 Dec;142(6):690-8.
- Khalil A, Huffman MD, Prabhakaran D, Osmond C, Fall CH, Tandon N, Lakshmy R, Prabhakaran P, Biswas SK, Ramji S, Sachdev HS, Bhargava SK; New Delhi Birth Cohort. Predictors of carotid intima-media thickness and carotid plaque in young Indian adults: the New Delhi birth cohort. Int J Cardiol. 2013 Aug 20;167(4):1322-8.
- Veena SR, Krishnaveni GV, Fall CH. Newborn size and body composition as predictors of insulin resistance and diabetes in the parents: Parthenon Birth Cohort Study, Mysore, India. Diabetes Care. 2012 Sep;35(9):1884-90.
- Stein CE, Fall CH, Kumaran K, Osmond C, Cox V, Barker DJ. Fetal growth and coronary heart disease in south India. Lancet. 1996 Nov 9;348(9037):1269-73
- Veena SR, Krishnaveni GV, Wills AK, Hill JC, Fall CH. A principal components approach to parent-to-newborn body composition associations in South India. BMC Pediatr. 2009 Feb 24;9:16
- Kumaran K, Fall CH, Martyn CN, Vijayakumar M, Stein C, Shier R. Blood pressure, arterial compliance, and left ventricular mass: no relation to small size at birth in south Indian adults. Heart. 2000 Mar;83(3):272-7.