Combating Malnutrition With ScientificIntervention And Community Participation

Mahtab s. Bamji and P.V.V.S. Murthy

TABLE 1Food Consumption Patterns in Intervention and Non-intervention Villages as Revealedby Children's Diet Diaries (Sample Size 60 Per Group).Frequency/

GVLOtherFruitsDalRotiwk

vegetables

%

INIINIINIINIINI

0

2742-847857182743

1

25232-2081151220

2

35237713532281715

33

1312928520250484522

I: Intervention Villages, NI: Non-intervention villages

Three important observationsemerge from the diet surveys con­ducted in India over the years'.

• Dietary protein deficiency is sec­ondary to calorie deficiency.

• Indian diets are qualitatively poorin micronutrients, particularly in iron,vitamin A riboflavin and perhaps evenfolic acid. The current recommenda­tion of folic acid requirement for Indi­ans is almost half of that in othercountries2,3 and there is a strong casefor raising it in the light of some recentfindings on the relationship betweenfolic acid deficiency and neural tubedefects and raised blood levels ofhomocysteine (a putative atheroscle­rotic agent)4.

• Within a family, deficiencies of allnutrients are more in the diets of preg­nant and lactating women and chil­dren, particularly the younger pre­school age children (six to 24 months),The latter is due to late introduction ofcomplementary foods to infants andthat too in insufficient quantities. WHOrecommends the introduction of comple­mentary foods by six months of agewithout discontinuing breastfeeding,However, most rural mothers in Indiado not give any complementary foodtill over one year of age. The aboveobservations on the diet of Indianssuggest that to address the problemof dietary deficiencies in the commu­nity, strategies have to be evolved toenrich the diet, particularly of women(including adolescent girls) and chil-

dren with micronutrient-dense foods,and promote complementary feedingof infants. Micronutrient intake can beenhanced through food diversifica­tion, food fortification and medicinalsupplements, Each strategy has itsmerits and limitations. The food diver­sification approach has a distinct ad­vantage in being sustainable becauseits implementation is in the hands ofthe community rather than an exter­nal agency,

THE MEDAK EXPERIMENT

Promotion of homestead nutritiongardening: In vegetarian diets, veg­etables and fruits are important sourcesof micronutrients, Promotion of nutri­tion gardening with emphasis on darkgreen leafy vegetables (GLVs), yel­low-orange fruits and vegetables andon vitamin C-rich fruits is being at­tempted by us in Narsapur Mandai ofMedak district in the South Indianstate of Andhra Pradesh5,6.

The demand for nutrient-rich veg­etables and fruits was created throughawareness generation, using a vari­ety of strategies such as sensitisationmeetings with government function­aries and medical professionals, fo­cus group discussions with the com­munity - particularly women, slide andsound shows on issues of health andnutrition, cookery demonstrations aswell as on feeding of young infants(six to 12 months), activity-orientedschool education, and periodic weighing

6

of pre-school children to educate themothers.

For promoting access to plant­ing material, decentralised (house­hold) nurseries and seed banks havebeen established. These bring someincome to the farmers, particularlywomen. Emphasis is on ~-carotene­rich varieties such as dark GLVs (drum­stick leaves, creeper spinach - Basel/aalba, Cassia sophera - a wild growinglocal shrub, 'agathi' - Sesbenia gran­diflora, spinach, amaranth, etc) andyellow-orange vegetables and fruitssuch as carrot, yellow pumpkin, pa­paya and mangoes. Dark GLVs arerich sources of many micronutrients.Locally available and inexpensive vi­tamin C-rich fruits such as guava andIndian gooseberry are also promoted.

Impact evaluation was donethrough knowledge, attitude and prac­tice (KAP) surveys of the mothers andhome gardens, and examination ofpre-school children for clinical signsof vitamin A deficiency. A novel methodof qualitative diet survey throughchildren's diet diaries was evolved.These records also help to educatechildren, teachers and the parents.

Initially only 14 and 27 per centof the households were raising p-caro­tene-rich perennial and seasonal va­rieties, respectively, This percentageincreased to 42 and 85 at the end of

three years, and 80 and 90 at the endof six years, This high level is notalways sustained. Loss due to ne­glect was more frequent with the pe­rennial varieties. The perennial variet­ies are grown in very little space in thebackyards, using wastewater. Manyfamilies, however, preferred to growboth seasonal and perennial varietiesin their farms, where there is betteraccess to water and protection frompests.

Impact evaluation done on moth­ers with pre-school children at theend of the first and second phasesshowed remarkable improvement inmothers' KAP of nutrition and childfeeding. Most mothers have overcomefood taboos during pregnancy, andinitiate breastfeeding soon after de­livery, Qualitative diet surveys throughchildren's diet diaries (comparison ofintervention vs non-intervention vil­lages) showed significant increasesin the frequency of consumption offruits, besides maize 'roti' in the inter­vention villages, Some improvement

TABLE 2Nutrient Content per 100 9 of Processed Foods, from Solar-dried GLV and Rice Bran

Nutrient

Rice branDrumstickAgathi*Rice bran'Iaddu'

leavesleavesdrumstick

chutneychutneychutney

Energy (kcal)

419367355339

Protein (g)

9.113.015.811.4

Fat (g)

14.820.319.8183

Calcium (mg)

14.05721250279.4

Iron (mg)

19.04.87.912.7

~-Carotene (~g)

-24000166009224

Thiamine (mg)

1.420.210.360.9

Riboflavin (mg)

0.260.160.200.2

Vitamin C (mg)

-271186107.4

Values based on those reported in Gopa/an, et ai, 1993.

*Agathi (Sesbania grandiflora).

in the consumption of GLVs was alsoseen but it was not as marked as thatseen with regard to fruits (Table 1).Children's diet diaries also showedthat more than 85 per cent of thefamilies consume vegetables more thanthree times a week, and more than 75per cent consumed dal (lentil soup)more than twice a week. However, thequantities consumed are generally lowdue to the high cost. The incidence ofBitot's spots (vitamin A deficiency) inpre-school children has shown steadydecline from 4.5 per cent initially to1.5 per cent in a recent survey.

Combating micronutrient deficien­cies through enhanced productionand social marketing: For wider out­reach of the concept of dietary diver­sification, a new project on 'Combat­ing micronutrient deficiencies throughenhanced production and social mar­keting' has been initiated. Farmers,particularly women, are being networkedand encouraged to diversify into nu­tritionally relevant horticulture by pro­viding training in good farming meth­ods and supplying planting material.It may be mentioned that farmers arehesitant to diversify into horticulturefrom paddy and sugarcane cultiva­tion, which provide greater price sta­bility and don't need daily tending.However, women are showing grow­ing interest and are realising the per­ils of indiscriminate mining of groundwater for these water-intensive crops.

A social marketing centre(Poshana bazar) has been established

in the village market for promotingmicronutrient-rich foods such as fruitsand vegetables, whole legumes, mil­lets and processed foods. Food pro­cessing is being promoted to preventwastage and for value addition. Ef­forts are being made to develop mi­cronutrient-rich recipes using solardried GLVs and rice bran. Apart fromthe known micronutrients, GLVs andrice bran are rich in health promotinganti-oxidants and detoxifyingphytochemicals7,8.

Tables 2 and 3 give the nutrientcontent of some of the micronutrient­rich, processed foods sold in the'Poshana bazar'. The values reportedare based on raw ingredients9 andallowance for cooking losses wouldneed to be made. Solar drying wasfound to reduce the ~-carotene con­tent of drumstick leaves by only 20 to30 per cent. Use of blue filter to cut offthe UV radiation further minimised theloss. However, traditional sun drying,even in shade, was recently reportedto result in loss of 70-75 per cent ~­carotene from GLVS10.Even with thisextent of loss, dehydrated GLVs are agood source of ~-carotene , besidesother nutrients.

An initial market survey done toassess the purchasing behaviour ofthe rural community did not revealpreference for processed foods. Yet,the demand for processed foods suchas chutneys made from tomato, cu­cumber (Curcumis sativus) and drum­stick; dry chutney powder made from

solar-dried GLVs with or without addedrice bran; rice bran biscuits; and ricebran jaggery laddus are surprisinglygood. Food processing has also be­come an income generation activityfor women. However, for marketing,small-scale production units wouldhave to be established to ensure qualitycontrol. Rural women would need helpin marketing.

Low cost cereal-pulse wean­ing food. A low-cost, cereal pulse­based complementary food under thebrand name 'Poshana' is being mar­keted by us in the 'Poshana bazar'.After paying Rs 5 per kg to the womenwho make this food and a margin ofprofit, it is being sold at Rs 25 to 27per kg. If made at home it would bemuch cheaper. The branded prod­ucts on the other hand sell for Rs 175per kg. Unfortunately, even thepaediatricians are hesitant to prescribeto these low-cost foods. Deficiency ofmicronutrients can, to a large extent,be made up by educating the moth­ers about adding fruits and vegetablesto these low-cost complementary foodswhile cooking.

Table 3 shows that 100 g of thiscomplementary food, in combinationwith 100 ml buffalo milk and 25 gamaranth, can meet more than 70 percent requirement of all nutrients ex­cept iron and riboflavin (60 per cent)for a 9 kg child. More work is neededto evolve food-based strategies to meetthe requirements of these two nutri­ents. Rice bran rich in iron, and thecombination of rice bran and jaggeryhas been used in Ayurveda for pre­venting anaemia. However, its suit­ability for complementary foods forinfants needs to be investigated inview of the high fibre content. Increasedproduction and promotion of livestock­based foods such as milk and eggswill help meet the nutrient needs ofthe children, besides bringing incometo the family.

India offers rich diversity in plantand animal foods. Imaginative policies,determination and concerted effort onthe part of nutrition/home scientists,farm scientists, food technologists andpolicy makers/administrators is neededto evolve strategies which can utilisethe vast human and natural resourcefor ensuring nutrition security for thepoor. Most importantly, communitiesshould be part of this planning andimplementation process from thebeginning. Establishment of mandal-

TABLE 3Nutrient from Weaning Foods Per 100

Nutrient

Commer-PoshanaBuffaloAmaranthBr milkA+B+C+D

cial100 9milk25 9600 mlRDA 9 kg

(A)

100 ml(C)(D)child

(B)Energy (kcal)

41736211710390100

Prot (g)

1513417168

Ca (mg)

75026210996885

Fe (mg)

7.52.20.20.91.260

Vit A (Ilg)

3607.1160500274269

B, (J.lg)

800200402.512080

B2 (J.lg)

600601004512060

Niacin

5.05.60.10.30.12112

(mg eq)Folate (pg)

22.523.15.637.57.8296

Vit C (mg)

351.01.0203.0100

Price (Rs/kg)

1752512-154-10--

ing of the Foundation was held onMarch 9.

Task Force Meeting

• Task Force Meeting to discuss theproject, 'Investigation of inter-stateand intra-state differences in the preva­lence of Pregnancy anaemia - a studyof possible contributing factors.' washeld on February 19.

President's Engagements

• Participated in the meeting of theSteering Committee on Nutrition ofthe Planning Commission for the For­mulation of the 10th Five Year Plan(2002-2007), on February 7, 2001.

• GavethefirstRajammal P. DevadasOration on 'Changing Nutrition Scenein India' on March 12, atAvinashalingamInstitute, Coimbatore.

• Participated in the National Con­sultation of the ICDS scheme on March16 and 17, 2001, in New Delhi.

level agricultural and food technologytraining institutes, besides industrialtraining institutes now being establishedin Andhra Pradesh could help generatethe right type of human resource tomeet the challenge.

Mehtab S. Bamji is Emeritus Scientist, Dangoria

charitable Trust, Hyderabad.

Based on a lecture by the first author in aplenary symposium at the Indian Science Con­gress, January 3 to 7, in New Delhi. Technical

support from Mr J. Veeraswamy and Mrs K. V. Lakshmi

is gratefully acknowledged.

References

1. National Institute of Nutrition, (ICMR) NationalNutrition Monitoring Bureau Report, 1999.

2. Indian Council of Medical Research. Nutrient

requirement and recommended dietary allowancesfor Indians - a report, 1989.

3. Food and Nutrition Board, USA. The recom­mended dietary allowances - a report, 1989.

4. McNulty, H.: Folate requirementfor healthy women.Proc Nutr Soc, 56:20-303, 1997.

5. Vijayraghavan, M., Nayak, U., Bamji, M.S., Ramana,G.N.V. and Reddy, v.: Home gardening for combat­ing vitamin A deficiency in rural India. Food ·andNutr Bull, 18:237-343,1997.

6. Murthy, P.V.V.S., Lakshmi, K'v. and Bamji, M.S.:Impact of home gardening and nutrition educationin a district of rural India. Bull of WHO, 77:784, 1999.

7. Gopalan, C.: The expanding frontiers of NutritionScience. In: Text Book of Human Nutrition. M.S.

Bamji, Rao N. Prahlad and V. Reddy (Eds). OxfordIBH Publications Pvt Ltd, New Delhi, 1996.

8. Narasinga Rao, B.S.: Nutritive value of rice bran.

NFl Bulletin, 21:(4), 5-8, 2000.

9. Gopalan, C., Rama Sastri, B.V. andBalasubramanium, S.C. (Revised and updated byNarasinga Rao, B.S., Deosthale, V.G. and Pant,K.C.): Nutritive value of Indian foods. Nationallnsti­tute of Nutrition, Hyderabad. 1993.

10. Balasasirekha, R., Kowsalya, S. andChandrashekhar, U.: ~-carotene retention in se­lected green leafy vegetables subjected to dehydra­tion. XXXIII Annual meeting of the Nutrition Societyof India, National Institute of Nutrition, Hyderabad,India, December 2000. Abstract Page 31.

FOUNDATIONNEWS

Study Circle Lectures

• Dr Siddharth Aggarwal, TechnicalSpecialist, Child and Neonatal Care,CARE, New Delhi, on 'Promotinggrassroot efforts for nutritionprogrammes', on January 19.

• Dr Jana Parizkova, Professor, De­partment of Medicine, Charles Uni­versity, Prague, on 'Nutrition and Physi­cal Fitness', on February 9.

• Dr Rakesh Tandon, Professor andHead, Department of Gastero­entorology, AIIMS on 'Nutrition sup­port in pancreatic disorders' onMarch 22.

• The Annual General Body Meet-

NUTRITIONNEWS

National Consultation to reviewthe Existing Guidelines in ICDSScheme in the Field of Health andNutrition was held on March 16-17,2001 at NFl. It was conducted to re­view the existing guidelines and rec­ommend operationally feasible andscientifically sound guidelines for ef­ficient implementation of the ICDSscheme. The broad areas of discus­sion were: utility of growth monitor­ing, impact of supplementary feed­ing, fortification of supplementary foodswith micronutrients, nutrition coun­seling of mothers, home based careof new-borns by anganwadi workers,early ch iIdhood acre for survival, growthand development of children in ICDS.Besides these issues, specific areasof strengths and weaknesses in theICDS scheme were also deliberatedupon. Leading nutrition scientists ofthe country participated in the con­sultation.

The Foundation is gratefulto FAO and WHO for

matching grants towardsthe cost of this publication

Edited by Ms Bani Aeri for the Nutrition Foundation of India, C-13 Qutab Institutional Area, New Delhi 110 016.Printed by Vashima Printers. Designed and produced by Media Workshop India Pvt Ltd.