|Year : 2015 | Volume
| Issue : 1 | Page : 5-13
An overview of the development and status of national nutritional programs in India
Department of Community Medicine, Amrita Institute of Medical Sciences, Ponnekara PO, Amrita Vishwa Vidyapeetham, Kochi, Kerala, India
|Date of Web Publication||5-Dec-2014|
Community Medicine, Amrita School of Medicine, Amrita Institute of Medical Sciences, Ponnekara, Kochi 682 041
Source of Support: None, Conflict of Interest: None
Under nutrition is still a major problem in India and at the same time overweight and obesity are also beginning to affect a substantial proportion of the population. Macro and micronutrient deficiencies affect a significant proportion of the population. Children, pregnant, and lactating women are the most affected with the retardation of cognitive and physical growth, increased susceptibility to infections which ultimately affects productivity of the country. Hence, the Government has devised several national programs like Integrated Child development services (ICDS), National Iron + initiative, National Iodine deficiency disorder control program (NIDDCP) etc., The activities under each program have been listed and its impact as assessed by various evaluation programs has also been mentioned. The determinants of under nutrition are a result of a complex interaction between various factors articulated by UNICEF as immediate, underlying, and fundamental determinants. The fact remains that inspite of all the programs, household food security is determined by a more complex array of factors. Concerted effort and a convergence by all the programs are required with particular emphasis on gender equity. More attention is required in rural areas, scheduled caste and tribe people, very young children between 0-2 years, and the girl child.
Keywords: India, nutritional programs, undernutrition
|How to cite this article:|
Sreedevi A. An overview of the development and status of national nutritional programs in India. J Med Nutr Nutraceut 2015;4:5-13
|How to cite this URL:|
Sreedevi A. An overview of the development and status of national nutritional programs in India. J Med Nutr Nutraceut [serial online] 2015 [cited 2020 Jan 23];4:5-13. Available from: http://www.jmnn.org/text.asp?2015/4/1/5/146146
| Introduction|| |
Food security has been a major goal of development policy in India  which is still ranked 63 rd in the Global Hunger Index (GHI) of 2013.  Though, India overcame the Malthusian theory of food shortage by the green, white, and yellow revolution, the fact remains that 17% of the adults are undernourished and about half of our children under 5 years of age are undernourished.  The major public health problems related to nutrition are low birth weight, protein energy malnutrition (PEM), nutritional anemia, iodine deficiency disorders (IDD), endemic fluorosis, lathyrism etc.  Nutritional problems affected a substantial proportion of the population, particularly women and children. In this context, the Government of India (GOI) took pioneering steps to formulate national programs to combat macro and micronutrient under nutrition. These programs have evolved on the basis of research studies in the country, taking into account, the magnitude of the nutritional problems, ecological factors responsible, and feasible interventions that could be implemented within the existing infrastructure.  Over the past 15 years India's economic growth rate has been unprecedented from 6% in the 1990s to 8% in real gross domestic product (GDP) in 2000-2010 according to International Monetary Fund (IMF).  However, the economic growth has not been associated with corresponding reductions in the rates of childhood under nutrition.  The National Family Health Survey (NFHS) showed that 43% of children under 5-years-old were underweight for age in 1998-1999; by
2005-2006 the percentage had only dropped to 40%.  There is a wide gap in food production and consumption. The achievement of macro food grain security at the national level did not reach the household and the level of food insecurity in India is still high. 
Micronutrient deficiencies, called hidden hunger, are also widespread in India. Deficiencies of iodine, iron, folic acid, vitamin A, and zinc are the leading five causes of micronutrient deficiencies which constitute a global public health problem.  In India, more than 75% of preschool children suffer from iron deficiency anemia (IDA).  More than half (52%) of all married women aged 15-49 years have some degree of anemia, with the prevalence of anemia among pregnant women even higher (up to 87%). More than half (57%) of preschool children have sub-clinical Vitamin A deficiency (VAD). , Iodine deficiency is endemic in 85% of districts. 
| What Does Undernutrition Do to People and the Country?|| |
Child malnutrition is responsible for 22% of India's burden of disease.  Undernutrition affects people in the developmental stages the most, that is under 5 years of age children, adolescents, pregnant, and lactating women.  It affects many aspects of child's development. It retards their physical and cognitive growth as well as increases susceptibility to infection, further increasing the probability of malnutrition.  Thus, childhood nutritional status is intimately linked to infection rates and therefore, unsanitary conditions.  PEM weakens immune response and aggravates the effects of infection  and, so, children who are malnourished tend to have more severe diarrheal episodes and are at a higher risk of pneumonia. It is of concern that less than half (46%) of the children have access to safe drinking water.  It is interesting to note that within India the average difference in stunting between the high performing and low performing districts can be accounted for by the 35-55% difference in open defecation.  The socioeconomic distribution of underweight indicates that it is present throughout the wealth distribution, though it is as high as 60% in the lowest wealth quintile.  The geographic distribution shows an uneven distribution throughout India. Underweight is concentrated in a relatively small number of districts and villages with a mere 10% of villages and districts accounting for 27-28% of all underweight children, and a quarter of districts and villages accounting for more than half of all underweight children. 
Under nutrition in India is much higher, almost double than that of sub-Saharan African countries and this has been called the S. Asian enigma.  The three key differences which could account for the differences between S. Asia and sub-Saharan Africa are: (a) low birth weight which is the single largest predictor of under nutrition. About 22% of newborns are born low birth weight compared to only 13.65% in Sub Saharan Africa in 2009,  (b). Women have less decision making power, and (c) the prevalence of hygiene and sanitation are considerably less. 
Under nutrition reduces schooling attainment. An improvement in height for age z scores of one is a predictor of an extra half year of schooling; less schooling is a predictor of lower wages (46% in a longitudinal study from Guatemala) and lower lifetime income.  Underweight and stunted women are also at more risk of obstetric complications (because of smaller pelvic size) and low birth weight deliveries.  This results in an intergenerational cycle of malnutrition, since low birth weight infants tend to attain smaller stature as adults. In addition, malnutrition in early infancy is associated with increased susceptibility to chronic disease in adulthood, including coronary heart disease, diabetes, and high blood pressure. , With respect to timing, nutritional status in the period between the last trimester of pregnancy and 2-3 years of age are the most important for mental development.  While persistent under nutrition remains a public health problem, the slow and steady increase in over nutrition is a cause for concern. 
The micronutrient deficiencies, called hidden hunger due to the poor quality of food, is also an important problem affecting a vast majority of the Indian population.  They include VAD, IDA, IDD and this too adversely affects people's health, performance, and income.  Among them, anemia is a commonly prevalent problem. It impairs cognitive performance, behavior and physical growth of infants, preschool and school aged children. It affects adversely the immune status and increases morbidity. It also lowers physical capacity and work performance of adolescents and adults.  It is responsible for 18% of maternal mortality, maternal morbidity, low birth weight, and poor cognitive development. , VAD increases the incidence of morbidities, particularly respiratory infection, diarrhea, measles, and childhood mortality.  (IDD) are also a major public health problem. It leads to a number of disorders including increased incidence of abortion, still birth, congenital malformation, cretinism, mental retardation, and hypothyroidism.  Every year nine million pregnant women and eight million newborns are at risk of IDD in India.  Fortunately, though majority of consequences of IDD are invisible and irreversible they are preventable.  Zinc deficiency has also been receiving a lot of attention. Zinc deficiency can lead to stunted growth, poor immune system, and impaired physical and neural development leading to decreased brain function.  This can also be a health problem among adolescents particularly because of pubertal growth spurt. 
The consequences of child under nutrition for morbidity and mortality are enormous-and there is, in addition, an appreciable impact of under nutrition on productivity so that a failure to invest in combating nutrition reduces potential economic growth. 
| Determinants of under Nutrition in India|| |
Under nutrition, the factors of which go beyond nutrition to the causes of causes: Gender issues, social inclusiveness, public distribution system, economics, and to poverty eradication. The causes of India's under nutrition problems are historical, economic, epidemiological, behavioral, and governance related.  Additional income in poor households need not always result in more food as households may opt for consumer items such as mobile phones or television sets.  Female under nutrition to which childhood under nutrition is inextricably linked is equally worrying. Adolescent girls in India are among the most undernourished in the world and a third of adult women have low Body mass index (BMI). 
UNICEF's model of undernutrition which articulates three levels of determinants gives an excellent, indepth understanding of the problem. They are fundamental, underlying, and immediate.  Economic growth and governance are key fundamental drivers. Underlying factors include agriculture and food security, women's power in decision making, the provision of food to infants, health and psychosocial needs, clean water and sanitation, and access to effective and affordable health services. Immediate determinants include diet and infection.  But in India, an improvement in the underlying factors like agricultural growth has not improved infant under nutrition which is difficult to understand. This may be because agricultural growth is focused in the wrong regions, size of farms, wrong crops,  and also due to inadequate storage facilities. Thus, if agricultural growth is nutrition sensitive then household level availability can improve.  Food security for each and every household and within it to every member of the family is the objective of food security.  Every household should either have the capacity to produce enough food for all members or have the purchasing power to acquire it.
| Impact on Women|| |
In most parts of India, for a girl child, life is a constant fight for survival, growth and development from the time she is conceived till she attains 18 years.  Women bear the brunt of under nutrition, facing inequities from birth in terms of access to resources like care, food; access to health care services, household burden etc., This is reflected in the proportion of thin women which has hardly changed from 1998-1999 when the value was 36%.  In 2005-2006 according to NFHS 3 about three fourths (72%) of women 14-49 yrs of age had some form of anemia. In adolescent/pregnant or lactating women only 60-75% of the protein requirement was met.  In a educated state like Kerala the prevalence of malnutrition is still high, 25% of under 5 years of age are stunted, 23% are underweight and 18% of women are thin. The prevalence of anemia among women is the highest in eastern states, more than 60% in West Bengal, Jharkhand and Assam. Kerala ranks the best with only around 32% of women suffering from any form of anemia. Higher rates of malnutrition are in rural areas.  The role of women in nutrition includes what is available to the girl/woman because she is a woman and what she can make available to her children with her knowledge and resourcefulness. Studies have shown that the presence of an educated member in the household and women's empowerment strongly influence participation in education and child related safety nets.  If India could close the gender gap in <5 yearold mortality between girls and boys then it would save an estimated 130,000 lives  which is why gender mainstreaming has become an important component of the new RMNCH + A strategy which is the Reproductive, maternal, newborn, child health strategy with added emphasis on adolescence. 
The problem of hunger arises not from the non-availability of food but from the in accessibility of available food.  Malnutrition is a cumulative outcome determined by a complex interplay of multiple factors.
| What Has Been Done about It?|| |
The problem of under nutrition is enormous and many nutritional programs have been developed in this regard. The Department of Women and Child Development runs the Integrated child Development Schemes and Nutrition Program for Adolescent Girls. The Food and Nutrition Board runs nutrition advocacy and awareness programs.  The Ministry of Health and Family Welfare provides the iron deficiency disorders control program, Vitamin A supplementation of children of 9-60 months, Weekly iron and folic acid supplementation program, National Iodine Deficiency Disorder Control Program (NIDDCP). The department of elementary education and literacy provides mid-day meal scheme for primary children. 
National program of nutritional support to primary education (mid-day meal program)
This was launched as a centrally sponsored scheme in 1995 to boost universalization of education and also with the purpose of retention, enrolment, and attendance. This program benefits school children (6-14 years) who form a substantial 20% of the total population.  The erstwhile Madras presidency pioneered the mid-day meal program in schools. Later this was extended to the whole of Tamil Nadu. Now, all over the country all primary school children are given mid-day meals. This improves school attendance, reduces dropouts, and has a beneficial impact on children's nutrition. In addition to this, it also helps in social integration. Each mid-day meal provides a third of daily calorie requirement and half of protein requirement. However, disappointingly, even now school enrolment is not universal and about 40% of the children drop out of primary school. Poor enrolment and high school dropout rate is attributed to poor socioeconomic conditions, child labor, lack of motivation, and poor nutrition status of the children which affects the efficacy of the program.  Kitchen gardens are a feature in some of the schools. The mid-day meals scheme, which covers 139 million children aged 4-14 years in school has significantly reduced stunting and underweight rates among 4-5 yearolds but it does not help younger children, who are most vulnerable to the effect of undernutrition.  Ministry revised the scheme again in September 2006 with the objectives of: 1. Improving the nutritional status of children in classes I-V in government, local body, and government aided schools; encouraging poor children belonging to disadvantaged sections to attend school more regularly and help them concentrate on classroom activities; and providing nutritional support to children of primary stage in drought affected areas during summer vacation. 
The nutritional value of the cooked midday meal was increased from 300-450 calories and the protein content therein from 8-12 grams to 12 grams. The scheme of 2006 also provided for adequate quantities of micronutrients like iron, folic acid, vitamin-A etc. In 2007 children in the VI-VIII classes were included. 
The Integrated Child Development Services (ICDS) program was India's primary policy response to child malnutrition. It was well-conceived and well-placed to address the major causes of child under nutrition in India, though concerns remain regarding the quality of services.  This was an imaginative and ambitious program looking at 'total development' of the child  by making available, at the doorstep of poor communities, a coordinated package of mutually reinforcing child development services-health, nutrition and education. The emphasis was on the most crucial stages of child development; the intrauterine phase and early childhood (0-6 years).  The Department of Women and Child Development (DWCD) focused on the 'life-cycle approach' targeted at unmarried adolescent girls, pregnant women, mothers and, children aged 0-6 years. Thus, it was hoped to achieve adequate birth weight of babies through targeting the adolescent girls and pregnant women. This sought to break the intergenerational cycle of malnutrition, reduce morbidity, and mortality caused by nutritional deficiencies by providing six services as a package with the help of Anganwadi-supplementary nutrition, preschool education, immunization, health checkup, referral services, nutrition, and health education. Immunization, health checkup and referral were to be delivered through primary health care infrastructure. Supplementary nutrition, Non formal preschool education, nutrition and health education were the primary tasks of the anganwadi centre Fig 1.  The program focusses on the 'window of opportunity' -1000 days, starting from pregnancy till the child is 2-years-old as a critical period in the child's life when nutritional interventions should be targeted for maximum impact.  ICDS had a special program called the Kishori Shakti Yojana for adolescent girls (11-18 yrs) which was later on renamed Rajiv Gandhi Scheme for Empowrment of Adolescent Girls (SABLA) scheme in 2010. The objectives of the scheme are to: (i) enable self–development and empowerment of Adolescent girls, (ii) improve their nutrition and health status, (iii) spread awareness among them about health, hygiene, nutrition, Adolescent Reproductive and Sexual Health (ARSH), and family and child care.(iv) upgrade their home-based skills, life skills and vocational skills, (v) mainstream out-of-school Anganwadis into formal or non formal-education, and (vi) inform and guide them about existing public services, such as primary health centers (PHC), community health centers (CHC), Post Office, Bank, Police Station, etc. 
An evaluation by the planning commission showed that only 49% of the eligible groups were actually registered for ICDS benefits, about three fourths (78%) of the women (pregnant and lactating) and 42% of adolescent girls actually received benefits. The anganwadi infrastructure was an important precondition to the capacity to deliver the six designated services.  Positive outcomes in terms of the behavioral change was observed. The practice of breast feeding within an hour after childbirth is widespread among ICDS beneficiaries, a positive influence on formal school enrollment and reduction in early discontinuation among beneficiaries was observed.  The proportion of days that supplementary nutrition was available was more than 80% in the states of Haryana, Karnataka, Kerala, Maharashtra, Orissa, Tamil Nadu, and West Bengal. The survey indicated that four types of beneficiaries attend anganwadi: Children and other beneficiaries from poor families, children of mothers who work as daily wage earners for whom it is a safe place for children, beneficiaries for whom the services like immunization, pre and post natal care are not accessible through primary care, close proximity of anganwadi centers (AWC) influences attendance.  Hence, ICDS is also expected to contribute to attainment of the Millennium Development Goals (MDGs) 1,4 and 5; reduction in severe to moderate malnutrition among children (MDG-1), reduction in infant mortality rate, child mortality rate, maternal mortality rate (MDG 4,5), increase in enrollment, retention rates, and reduction in dropout (MDG-2) by laying foundation at AWC. 
ICDS has helped to reduce wasting by 6% in under 3 years yielding a 3.75 increase in initial investment though this is much less than what was achieved in Thailand at a ratio of 12.5 to 1.  The GOI World Bank reviews in 1997 and 2001 showed that the content and quality of resources under ICDS remain suboptimal because of gaps in training and supervision of anganwadi workers, and a lack of intersectoral coordination and community support. , Rural areas, girls, scheduled castes, and tribes are more affected by poor nutritional status. The emphasis should be on younger children (0-3yrs) when the nutrition insults are the highest. 
National Iron+ initiative
Anemia has major consequences on human health and social and economic development.  This was recognized and the iron deficiency control program was launched in 1970 to prevent nutritional anemia in mothers and children. Under this, the pregnant and lactating women are given 100 mg of elemental iron and 0.5 mg of folic acid and children in the age group 1-5 years are given one tablet of iron containing 20 mg elemental iron and 0.1 mg of folic acid for a period of 100 days. Folate is important for the development of spine, spinal cord ,brain and helps reduce neural tube defects. 
A 12 by 12 initiative was launched in 2007 with the view to ensure that every child had hemoglobin of 12 by 12 years. This initiative was jointly undertaken by Ministry of Health and Family Welfare and Federation of Obstetric and Gynaecological Societies of India (FOGSI).  The premise for such a program was that every child by 12 years should have a healthy hemoglobin level and this would result in far reaching benefits in terms of safe motherhood and healthier future generation. Though it may be pointed out that behavior communication strategies are important for demand creation and compliance. The national reports show poor compliance (20%) among women less than 20 years and only 22% among pregnant women for 90 days or more.  In a study in Karnataka only 45.3% of children had received iron supplements out of which 10% were from the public health system as compared to 3.7% at the national level.  There are significant challenges in reaching the at-risk population as well as improving compliance.
In view of the fact that more than half of the adolescent girls (56%) suffer from anemia and the highest prevalence of anemia is between 12-13 years in tandem with the average age of menarche the Weekly Iron and Folic Acid Supplementation (WIFS) program for adolescents is timely.  It is also based on empirical evidence that weekly supplementation of 100 mg iron and 500 μg folic acid is effective in decreasing prevalence of anemia in adolescent age group. Though an alternative policy is required in high malarial areas where iron supplementation can be risky for children.
In 2013 the national Iron + initiative was developed. This initiative proposed to bring together existing program (iron and folic acid supplementation for pregnant and lactating women and children in the age group of 6-60 months) and introduce new age groups. This followed the principle of continuum of care according to which a minimum service package for the management of anemia through the life stages and at different levels of care proposes given.  Thus National Iron + Initiative proposes to reach the following age groups for supplementation or preventive program: Bi-weekly iron supplementation for preschool children 6 months to 5 years; Weekly supplementation for children from 1-5 th grade in Government and Government-aided schools; weekly supplementation for out of school children (5-10 years) at AWC; weekly supplementation for adolescents (10-19 years); pregnant and lactating women and weekly supplementation for women in reproductive age.  [Figure 1] Along with this a lot of importance is also being given to behavior communication strategies to improve compliance including plans to position WIFS as 'Iron ki nili goli.'  Other than this a therapeutic approach is also advocated through the life cycle at the facility level and by Accredited social health activist (ASHA) workers and Auxiliary Nurse Midwifes (ANMs). 
|Figure 1: The nutritional programs as applicable to the life course of a person|
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Nutritional component of the RMNCH + A program
Adolescent nutrition is important for growth and sexual maturation. Inadequate nutrition can enhance the risk of chronic disease and future childbirth.  As part of the new adolescent strategy, it is proposed that nutrition education sessions be held at the community level using Village health Nutrition days, Kishori Diwas, school setting, AWC, and Nehru Yuva Kendra Sangathan.  Nutritional counselling on a dedicated quarterly Adolescent health day has been proposed. Nutrition education is also to be implemented through school curricula.  Emphasis is also to be given on the gender aspects of nutrition.
Interventions to prevent and correct iron deficiency and IDA through food-based approaches are also important in this context. They are dietary diversification and food fortification with iron; iron supplementation, improved health services, and sanitation. Dietary diversification helps in the consumption of dark-green-leafy vegetables, lentils and vitamin C rich fruits, which are rich in micronutrients and are available but underutilized by the deficient population. Food fortification refers to the addition of micronutrients to processed foods.  In many situations, this strategy can lead to relatively rapid improvements in the micronutrient status. Food supplements are highly concentrated vitamins and minerals produced by pharmaceutical manufacturers in the form of capsules, tablets, or injections and administered as part of health care or specific nutrition campaigns. 
Vitamin A deficiency control programme
Under the national program for prophylaxis against blindness in children due to VAD, every child has been provided prophylaxis against VAD in the form of oral 5 doses starting at 9 months with measles as a first dose, and then every 6 months as a second dose and then every 6 months till the age of 5 years [Figure 1].  The programme was started in 1970 with the objective of reducing keratomalacia. In 2006 the age group of eligible children was modified to 6-59 months.  And in the same year a study published by NIN showed that the prevalence of Bitot's spots was 0.8% in 8 states, above the WHO criterion of 0.5%.VAD was more prevalent in households belonging to SC/ST communities, those engaged in agricultural and other labour and in those with an illiterate adult female. 
National iodine deficiency disorder control program
The program launched as the national goiter control program in 1962 was renamed as the National Iodine Deficiency Disease Control Program (NIDDCP) with a view to cover a wide spectrum of IDD. Under this program it was understood that the best way to prevent and control IDD was to provide iodated salt to the entire country in a phased manner. Non-iodated salt has been banned under the Prevention of Food Adulteration Act. The components of a national IDD program are use of iodized salt in place of common salt, monitoring and surveillance, manpower training and mass communication. Each state has a IDD control cell which is responsible for checking iodine levels which is expected to be 30 ppm at the production level and 15 ppm at the consumer level. 
Zinc is another micronutrient that is gaining importance. Current evidence indicates that preventive zinc supplementation reduces the incidence of diarrhea by 27% among young children and acute lower respiratory infections by 15%.  Overall zinc supplementation reduces child mortality by 6%. A meta analysis on the zinc supplementation during pregnancy shows that it reduces preterm births by 14%.  Zinc deficiency in soils leads to poor zinc level in crops. The GOI has a initiative to provide zinc for diarrhea prevention through the health workers. It is also noteworthy that the Department of Agriculture in some parts of India has initiated steps for bio-fortification. 
Fluorosis is a problem in some areas of the country like Andhra Pradesh, Punjab, Haryana, Karnataka, Kerala, and Tamil Nadu.  This is seen in areas with a high level of fluoride in water exceeding 0.5-0.8 mg/dl. Dental fluorosis occurs when excess fluoride is ingested during the years of tooth calcification-during the first 7 years of life. A life time daily intake of 3-6 mg/l is associated with skeletal fluorosis. It is a double edged sword with both deficiency and excess being a problem. A new form of fluorosis characterized by genu valgum and osteoporosis of the lower limbs has been reported from some parts of Andhra Pradesh and Tamil Nadu. This was particularly common among the jowar eaters.  Nalgonda technique is the method of deflouridation developed in India.
A paralyzing disease of humans and animals due to the presence of the toxin β-oxalyl-amino alanine in the pulse, Lathyrus sativus (khesari dal). The pulse, is a good source of protein, but for its toxin which affects nerves.  This was given to bonded laborers as it is relatively cheap, but is no longer given due to the increased cost of the pulse. Scientists were not very successful in developing strains with low level of toxins.  In the 1950s the reported prevalence of lathyrism was 1.5% and following this there was a steep fall and in the 90s it became rare. 
It would be incomplete if the Applied Nutrition Program introduced in the 60s is not mentioned. This was a paradigm shift in the approach to tackle malnutrition. It included three thrust areas-production of food at the village level and household level, education for better consumption, and feeding the vulnerable. The idea was to provide better seeds and encourage kitchen gardens, poultry farms, and beehive keeping. But unfortunately, this program could not make much of an impact. 
Other indirect ways of intervention in the field of Nutrition include the targeted public Distribution system, Antodaya Anna Yojana and Annapurna scheme.  Food security in India is promoted by the targeted public distribution system, the National Rural Employment Guarantee Act, and the midday meal scheme. An evaluation of the targeted public distribution system by the Indian Planning Commission concluded that more than half (57%) of subsidized grain does not reach its intended recipients through a combination of technical targeting errors and deliberate diversion. 
The new National Employment Guarantee Program, which guarantees rural households 100 days of unskilled manual work a year at a given wage, has the potential to improve food consumption, but the two high quality impact studies so far show contrasting effects on household expenditure. 
In spite of all the available nutritional programs, food security at the household level is determined by a more complex array of factors than agricultural production, including local prices (of food and
other goods), income, and an effective trade and transport infrastructure.  Moreover, household food security is not in itself sufficient to assure that the nutritional needs of every child and adult, living in a particular household will be met. Also, detrimental to equity in food is the current wave of liberalization and globalization that is occurring in the context of massive concentration and control of the food system by corporations based in developed countries.  Multilateral collective strategies are necessary to protect and promote national food security and public health. 
The right to food and the right to health are perhaps the need of the day. During the 1960s India was the largest importer of food aid so much so that India was labeled as a country surviving on a ship to mouth basis.  Today, India is self-sufficient in food production, though it is not equitably distributed. Food Security Act implemented in India will operate the largest social protection program against hunger in human history. The Food security Act will confer double-benefits procurement at a remunerative price for the Public Distribution System (PDS) which will stimulate production and consumers who need social support to ward of hunger will be able to have economic access to the food needed for a productive life. 
Extent of poverty in a layman's language is perhaps about people who have to go to bed hungry, people who do not know if they will get work the next day, people who do not possess minimum clothes to wear, people with no access to potable water, primary health care etc. Households which could have afforded enough food if priority was given to food or where the male provider is a drunkard or where some members do not get enough due to gender bias.  Concerted effort and a convergence by all the programs is required with particular emphasis on gender equity. More attention is required to rural areas, scheduled caste and tribe people, very young children between 0-2 years and the girl child.
High levels of capacity are required with a coherent investment in reducing under nutrition.  Intersectoral coordination in investments between the various departments like sanitation, water, agriculture, women's status etc., are necessary. Any weak links in the chain can undermine all investments. 
National Nutrition Policy was formulated in 1993 and a National Nutrition Mission to coordinate the activities related to nutrition by several departments, the results are yet to be seen. The Iron + initiative is a result of this, though unless a rigorous monitoring and evaluation system is in place, progress may elude us. India being a large country with each region and district having different needs it is important to have district specific goals and an accountable built in monitoring and evaluation system.
| Acknowledgement|| |
Author of the above-mentioned review article Aswathy Sreedevi is supported by Fogarty International Centre, National Institutes of Health, under Award Number: D43TW008332 (ASCEND Research Network). The contents of this publication is solely the responsibility of the author(s) and does not necessarily represent the official views of the National Institutes of Health or the ASCEND Research Network.
| References|| |
Radhakrishna R. Food and nutrition security of the poor, emerging perspectives and policy issues. Econ Pol Weekly. 2005;40:1817-23.
India still far behind in the Global Hunger index. The Hindu. Oct 14, 2013.
Park K. Park's text book of preventive and social medicine. 22 nd
ed. Jabalpur, India: M/s Banarsidas Bhanot Publishers; 2013.
Evaluation of National Nutrition programmes; 1980-2005. Nutrition Foundation of India.
Swaminathan MS. Food as people's right. Editorial page. The Hindu; Jan 3, 2012.
Haddad L. Why India needs a national nutrition strategy. BMJ 2011;343:d6687.
Nutrition in India. Ministry of Health and Family Welfare, Government of India. National Family Health Survey (NFHS-3). India 2005-06. Deonar, Mumbai, India: International Institute for Population Sciences; 2009.
New Delhi: Micronutrient Initiative; Investing in the future - a united call to action on vitamin and mineral deficiencies. Global report, 2009. Available from: http://www.unitedcalltoaction.org/documents/Investing_in_the_future.pdf [Last accessed on 2011 Jul 01].
UNICEF and MI (Micronutrient Initiative). 2004. Vitamin and mineral deficiency: A global progress report. Available from: http://www.micronutrient.org/reports/reports/Full_e.pdf [Last accessed on 2013 Sept 24].
West KP Jr. Extent of vitamin A deficiency among preschool children and women of reproductive age. J Nutr 2002;132:2857-66S.
Michele G, Meera S, Monica DG, Caryn B, Lee YK. India's undernourished children: A call for reform and action. Health Nutrition and Population Discussion Paper. The World Bank; 2005.
Pelletier DL, Frongillo EA. Changes in child survival are strongly associated with changes in malnutrition in developing countries. J Nutr 2003;113:107-19.
Spears D, Ghosh A, Cumming O. Open defaecation and childhood stunting in India: An ecological analysis of new data from 112 districts. PLoS One 2013;8:e73784.
World Bank. Attaining the Millennium Development Goals in India: How likely and what will it take to reduce infant mortality, child malnutrition, gender disparities and hunger-poverty and to increase school enrollment and completion; 2004.
Ramalingaswami V, Jonson U, Rohde J. The Asian enigma. In: The Progress of Nations New York: United Nations Children's Fund; 1996.
Available from: http://www.tradingeconomics.com/sub-saharan-africa/low-birthweight -babies -percent -of-births- wb-data.html [Last accessed on 2014 Mar 18].
Victoria CG, Adair L, Fall C, Hallal PC, Martorell R, Richter L, et al
. Maternal and Child Undernutrition Study Group. Maternal and child under nutrition: Consequences for adult health and human capital. Lancet 2008;371:340-57.
United Nations - Administrative Committee on Coordination/Standing committee on Nutrition. Third Report on the World Nutrition Situation. Geneva: ACC/SCN; 1997.
Agarwal S, Agarwal A, Bansal AK, Agarwal DK, Agarwal KN. Birth weight patterns in rural undernourished pregnant women. Indian Pediatr 2002;39:244-53.
Barker DJ, Forsèn T, Uutela A, Osmond C, Eriksson JG. Size at birth and resilience to effects of poor living conditions in adult life: Longitudinal study. BMJ 2001;323:1273-6.
Prema R. Food security outcomes: Are we using the right indicators? NFI Bull 2013;34:2.
Bowley A. Alliances against hunger. Editorial. Nutriview 2008;4:2.
Padam S. Micronutrient deficiency in India. J Ind Soc Agril Statis 2007;61:128-31.
WHO. Global health risks: Mortality and burden of disease attributable to selected major risks. Geneva: World Health Organisation; 2009.
Ezzati M, Lopez AD, Rodgers A, Murray CJ. Comparative quantification of health risks: Global and regional burden of disease attributable to selected major risk factors. Geneva: Vol. 2. World Health Organization; 2004.
Gupta P, Indrayan A. Effect of Vitamin A supplementation on childhood morbidity and mortality: Critical review of Indian studies. Indian Pediatr 2002;39:1099-118.
Arlappa N, Laxmaiah A, Balakrishna N, Harikumar R, Kodavanti MR, Gal Reddy Ch, et al
. Micronutrient deficiency disorders among the rural children of West Bengal, India. Ann Hum Biol 2011;38:281-9.
Pandav CS, Yadav K, Srivastava R, Pandav R, Karmarkar MG. Iodine deficiency disorders (IDD) control in India. Indian J Med Res 2013;138:418-33.
Available from: http://www.zinc.org/info/zni_india_program [Last accessed on 2014 Feb 21].
Kawade R. Zinc status and its association with the health of adolescents: A review of studies in India. Glob Health Action 2012;5:7353.
Rao V. Commentary: Cultural change is essential. BMJ 2011;343:d7242.
UNICEF. Strategy for Improved Nutrition of Children and Women in Developing Countries. New York, USA: UNICEF; 1990.
Indian experience on household food and nutrition security. Regional office for Asia and the pacific, FAO. Available from: http://www.fao.org/docrep/x0172e/x0172e01.htm [Last accessed on 2013 Aug 27].
Gulati A, Ganesh-Kumar A, Shreedhar G, Nandakumar T. Agriculture and malnitrition in India. Food Nutr Bull 2012;33:74-86.
Dev SM, Subbarao K, Galab S, Ravi C. Safety net programmes: Outreach and effectiveness. Econ Poli Weekly. 2007;42:3555-65.
Antony GM, Laxmiah A. Human development, poverty, health and nutrition situation in India. Indian J Med Res 2008;128:198-205.
A strategic approach to reproductive, Maternal, Newborn, Child and Adolescent health (RMNCH+A) in India. MOHFW, GOI; 2013.
Mishra S. Hunger, ethics and the right to food. Indian J Med Ethics 2012;9:32-7.
Kishore J. Textbook on National Nutritional Programmes. 10 th
ed. New Delhi: Century Publications; 2012.
Performance Audit on National Programme for Nutritional Support to Primary Education (midday meal scheme). Report No.PA 13; 2008. Available from: http://www.icisa.cag.gov.in/performance%20audit/ Performance%20Audit%20Reports/. [Last accessed on 2014 Jul 12].
Evaluation Study on Integrated Child Development Schemes. PEO report No. 218.Vol. 1. New Delhi: Programme Evaluation Organization, Planning Commission, GOI; 2011.
Shrimpton R, Victora CG, de Onis M, Lima RC, Blossner M, Clugston G. Worldwide timing of growth faltering: Implications for nutritional interventions. Pediatr 2001;107:E75.
Rajiv Gandhi Scheme For Empowerment of Adolescent Girls (RGSEAG) - Sabla Implementtion guidelines for state governments. UT administrations. Towards a new dawn. MOWCD. GOI; 2010.
National Iron + initiative. Guidelines for control of iron deficiency anaemia. NRHM Adolescent division, MOHFW, GOI; 2013.
Pasrischa SR, Biggs BA, Prasanth NS, Sudarshan H, Moodie R, Black J, et al
. Factors influencing receipt of iron supplementation by young children and their mothers in rural India: Local and national cross-sectional studies. BMC Public Health 2011;11:617.
Available from: http://nrhm.gov.in/nrhm-components/rmnch-a/adolescent-health/weekly-iron-folic-acid-supplementation-wifs/background.html [Last accessed on 2013 Sep 30].
NNMB Technical Report No: 23. Prevalence of Vitamin A Deficiency among Preschool Children in Rural Areas. National Nutrition Monitoring Bureau, National Institute of Nutrition. Hyderabad: ICMR; 2006.
Awasthi S, Peto R, Read S, Clark S, Pande V, Bundy D. DEVTA (Deworming and Enhanced Vitamin A) team. Vitamin A supplementation every 6 months with retinol in 1 million pre-school children in north India: DEVTA, a cluster randomised trial. Lancet 2013;381:1469-77.
Browne KH, Peerson JM, Baker SK, Hess SY. Preventive zinc supplementation among infants, zinc supplementation preschoolers, and older prepubertal children. Food Nutr Bull 2009;30:S12-40.
Mahomed K, Bhutta Z, Middleton P. Zinc supplementation for improving pregnancy and infant outcome. Cochrane Database Syst Rev 2007:CD000230.
Available from: http://nihfw.nic.in/ndc-nihfw/html/Programmes/AppliedNutritionProgramme.htm [Last accessed on 2014 Jan 05].
Performance evaluation of Targeted Public Distribution System (TPDS). New Delhi: Programme Evaluation Organisation, Planning Commission. Government of India; 2005.
Hagen-Zanker J, McCord A, Holmes R, Booker F, Molinari E. Systematic Review of the Impact of Employment Guarantee Schemes and Cash Transfers on the Poor. London: Overseas Development Institute; 2011.