NATIONAL NUTRITION POLICY

The National Nutrition Policy adopted by the Government of India in 1993 under the aegis of
the Department of Women and Child Development

▸ The strategy of NNP was a multi-sectoral

strategy for eradicating malnutrition and

achieving optimum nutrition for all.

The implementation strategy involves

✓ setting up Inter Sectoral Coordination mechanism at Centre, State and District levels, Advocacy
and sensitisation of policy makers and

programme managers, intensifying micronutrient malnutrition control activities,

✓ reaching nutrition information to people,

✓ establishing nutrition monitoring and mapping at State, District and Community level, and

✓ developing district-wise disaggregated data on nutrition.

Objectives

To reduce the incidence of severe (8.7 per cent) and moderate (43.8 per cent) malnutrition
by half by the year 2000 A.D.

All adolescent girls from poor families to be covered through the ICDS by 2000 A.D. in all CD
blocks ofthe country and 50% of urban slums

To increase per capita availability of 215Kg, for that,to achieve production targets of 230 MT
by 2000

At least 100 days of employment created for eachrural landless family, employment
opportunities in urban slum dwellers and urban poor

▸ Distribution of iodized salt to cover all endemic areas

Nutritional blindness to be completely eradicated by 2000 A.D. To expand the Nutrition

intervention net through ICDS so as to cover all vulnerable children in the age
group 0 to 6 years.

AIM
It aims to address this problem by utilising direct (short term) and indirect (long term)
interventions.

Direct interventions short term:

1. Ensuring proper nutrition of target groups (Vulnerable groups): The National

Nutritional Policy has paid special attention towards the vulnerable groups and
implemented many nutritional programmes to improve the health status of these
target groups like children, adolescents, pregnant and nursing mothers etc.
Expanding the safety net for children - proper

implementation of universal immunization, oral

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rehydration and ICDS services have been expanded to cover all vulnerable children in
the age group 0 to 6 years. Presently ICDS covers around 15.3 million children from
rural and urban slums. ICDS aims at covering the remaining 15.46 nutritionally at risk
children by extending ICDS blocks of the country. Growth monitoring in 0-3 year age
group: Growth monitoring aims at identification of malnourished children and
provision of nutritional management for the children especially 0-3 years of age
group. This includes Provision of adequate nutrition for the children, health education
of mothers, empowerment of the mother to manage nutritional needs of her children
effectively.
Nutrition of adolescent girls to enable them to attain safe motherhood: The policy has
expanded the ICDS services for the adolescent girls to improve their nutritional
status, to prepare them for safe motherhood by providing basic education about
nutrition, fertility, Iron supplementation etc.

Nutrition of pregnant women to decrease incidence of low birth weight: Under the

policy the government has taken measures to improve the nutritional status of the
pregnant mothers right from 1st trimester, supplementation of iron and folic acid,
frequent health checkups etc.
2. Food fortification: Fortification of essential food items with appropriate nutrients is
essential to avoid deficiency disorders like iodine deficiency, iron deficiency etc.
Example, common Salt with iodine or iron.

3. Provision of low cost nutritious food: Majority of the Indian population belongs to
low socio economic status and they cannot afford for the expensive food products.
So there is a need to provide low cost and nutritious food products for the people to
maintain and improve the health of the individual, family and the community by
developing indigenous systems and with locally available foods.
4. Combating micro nutrient deficiency in vulnerable group: Control of micronutrient
deficiencies among the vulnerable groups especially Vitamin A, Iron, lodine, Folic
acid among the pregnant, nursing mothers and children through various nutritional
prophylaxis programmes is essential.
Example Vitamin A prophylaxis programme, The nutritional anaemia prophylaxis
programme etc.
Indirect policy interventions - long

term: 1. Food Security: In order to ensure aggregate food security per capita
availability of 215 kg/person/year of food grains needs to be attained. This requires
production of 250 million tones of food grains per year by 2000 AD.

2. Improving the dietary pattern: The dietary pattern of the people should be improved
by promoting the production and increasing the per capita availability of nutritionally
rich foods. Provision of nutritionally rich foods at affordable cost. Production of
pulses, oilseeds and other food crops will be increased. The production of protective
food crops, such as vegetables, fruits, milk, meat, fish and poultry shall be
augmented. Preference shall be given to green leafy vegetables and fruits such as
guava, papaya and amla with the help of Hatest and improved techniques.
▸ PRESENT SCENARIO: Net per capita availability of food grains has decline to 159.2
kgsin 2002-03 from 170 kgs in 1998- 99.

Recommendation

Strengthening agricultural policies:

▸ Insufficient food production, inadequate food handling, processing, storage,

distribution or

marketing should be tackled.

▸ Reduce post-harvest losses > Stabilization of food supplies

3. Improving the purchasing power: One of the main causes of under nutrition is low
purchasing power of the poor. So to increase their purchasing power, Government
should generate jobs for them.

Poverty alleviation programme like Integrated Rural

Development Programme and employment

generation schemes like Jewahar Rozgar yojana,

Nehru Rozgar Yojana and DWCRA are to be reoriented

and restructured.

It is necessary to improve the purchasing power of the landless and the rural and
urban poor by implementing employment generation programmes.

4. Small and medium enterprises (SME): Small and medium enterprises are essential
for dynamic economic growth and job creation. Improving access to finance for this
sector will be key factor for growth.
5. Agriculture and rural development: two-thirds of India's people depend on rural
employment for their living. While the agriculture sector grew at only about 2.5
percent a year for a number of years, recent growth has touched 4.7 percent a year,
facilitated by good monsoons, greater production of high-value crops, an increase in
the minimum support prices for grains, and the rise in global prices for agricultural
products.

Rural livelihoods projects support the empowerment of the rural poor and the
development of their livelihoods. Encouraging policies that promote competition in
agricultural marketing will also ensure farmers receive better prices.
6. Informal Sector Jobs: While the services sector has been offering promising job
opportunities for skilled workers, some 90 percent of India's labor force remains
trapped in low-productivity jobs in the informal sector. India's labor regulations
among the most restrictive and complex in the world - have constrained the growth of
the formal manufacturing sector, where these laws have their widest application.

Better-designed labor regulations can attract more labor-intensive investment and

create jobs for India's unemployed millions and those trapped in poor quality jobs.
7. Prevention of Food Adulteration:

Government responsibility is to assure that food will not cause harm to the consumer
when it is prepared and/or eaten according to its intended use. Under the provision of
the PFA Act, the Government of India has promulgated PFA rules which specifies the
following details Qualification, duties and functions of food analysts, food inspectors
and central food

laboratory.

Procedure for drawing test samples and sending them to the analyst and laboratory.
Specification for the identity and purity of food.

Tolerance for contaminants, preservatives, emulsifiers and other additives.

▸ Present scenario demands gearing up the

enforcement
8. Nutrition education: World Bank reports that Indonesia spent only 15% of its
national budget on nutrition education and they reduced the prevalence of under-
nutrition by 40%. Hence it is a very cost effective method in the Indian context also.

The education strategies to make nutrition the

central talking point are: Social marketing Communication for behavior change

Advocacy. The services of nutrition specialists and local community leaders should
be used to counsel about improving the dietary practices, sanitation and hygiene,
encourage breast feeding, birth spacing, deworming of children, gender sensitivity
promoting use of fortified foods, mineral and vitamin supplements.
Recommendations

Focus on 3-6 yr age group children rather than since birth in ICDS because mal
nutritional ready sets in by then.

⚫ Focus on mild to moderate malnutrition and not just on severe malnutrition.

Establish regional, zonal centers' with

nutritionists/ scientists and use the expertise

of bio-technologists and genetic engineers.

Empower Panchayati raj institutions and form village level nutrition committees for
micro planning and formulating short term goals. . A compulsory course on nutrition
literacy at

the UGC level.

⚫ Form a nutrition council of India like MCI for

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quality management of training. 5 states and 50% villages contribute to more than
80% of malnutrition cases. Special focus on these hunger hot spots and tribal areas.
Obtaining information using civil registration system for audit. Vigorous awareness
campaigns and setting up community grain banks

accordingly. . Over-nutrition, obesity and lifestyle related diseases are emerging as a

threatening menace with rapid urbanization. The target population should be
sensitized about this cause of concern.
9. Land reforms: Implementing land reform measures so that the vulnerability of the landless
and the landed poor can be reduced. The major objectives of land reforms have been:

⚫ Reordering of agrarian relations in order to

achieve a democratic social structure

Elimination of exploitation in land relations

and enlarging the land base of the rural poor • Increasing agricultural productivity and
infusing an element of equality in local institutions.
10. Health and Family welfare: Women's poor reproductive health in India is affected by a
variety of socio cultural and biological factors.
Thus, efforts to improve women's education, raise enrollment and attendance rates of girls in
school and reduce the drop-out rate on the one hand and enhance women's income
autonomy on the other are fundamental, in the long run, for improvements in women's and
family health.
11. Nutritional surveillance: Nutritional surveillance is necessary to understand the nutritional
status of the people. The policy should be strengthened to conduct nutritional surveillance of
children, adolescent girls, pregnant and lactating mothers.

The nutritional surveillance should include the following:

A. Anthropometry is relevant to programme management for three reasons: i) to identify

target groups, ii) in monitoring progress, and ii) in assessing overall programme effects. B.
Indicators used must relate to the objectives of the programme.
12. Research: Research into various nutritional aspects should be developed to identify
various deficiency disorders, planning and implementing the nutritional supplementation
programmes, develop extensive methods of food production, fortification of foods, production
of nutritious food for low cost etc.

13. Minimum wage administration: To improve the purchasing power of the poor minimum
wage legislation should be administered. Example at least 60 days leave for pregnant
women by the employer in the last trimester.
14. Communication: The dept. of National Food and Nutrition should take measures to
communicate the public regarding the nutritional deficiency disorders, its prevention, and
information regarding the nutritional programmes through effective methods of information,
education and communication. All the outreach health care centers should be provided with
adequate facilities for this

purpose. 15. Community participation: For the effectiveness of the services provided for the
public the government should create awareness among the public so as to gain their
participation. Encourage the public to avail the nutritional health care services and for their
maximum utilization.
16. Equal remuneration for women: The govt. of India should take measures to empower
women by providing equal remuneration with that of men. So that she can fulfill the
nutritional needs of the family.

17. Improvement of literacy, especially for women: Women should be provided with basic
education, since literate women will make the entire family as literates and she will fulfill the
nutritional requirements of the family, so that nutritional status of the community can be
maintained.
18. Improving the status of women: Women should be empowered by providing basic
education, equal preference for the women that of males, employment services, enhancing
the health care services for the women etc.

19. Basic health and nutrition Knowledge: To improve the purchasing power as well as the
consumption of nutritional rich foods health education should be provided to the public
especially women regarding the importance of nutrition for maintenance of health, various
nutritional deficiency disorders, its prevention, preservation and storage of Autrients while
cooking etc.
20. Monitoring of nutrition programmes: The govt. of India through the Nutritional Monitoring
Bureau supervises and evaluates the effective functioning of nutritional programmes and
recommends the necessary. actions required to improve and maintain the health of all age
groups.
NATIONAL NUTRITION MONITORING BUREAU
Nutrition monitoring is the measurement of the changes in the nutritional status of a
population or a specific group of individuals over time- WHO, 1984

The National Nutrition Monitoring Bureau was established under the aegis of Indian Council
of Medical Research in the year 1972, with the Central Reference Laboratory at the National
Institute of Nutrition (NIN), Hyderabad.
The bureau is currently in operation in the States of Andhra Pradesh, Gujarat, Karnataka,
Kerala, Madhya Pradesh, Maharashtra, Orissa, Tamil Nadu, Uttar Pradesh and West
Bengal.

The Bureau carries out surveys under the guidance of a Steering Committee and has been
generating dynamic database on diet and nutritional status of the communities regularly,
since 1975.
Objectives

To collect, on a continuous basis, onl representative segments of population in each of the

states data on dietary pattern and nutritional status, adopting standardized and uniform
procedures and techniques, and

To periodically evaluate the ongoing National Nutrition Programmes to identify their

strengths and weaknesses, and to recommend appropriate corrective measures.
In fulfillment of its objectives, the Bureau undertook the following activities, in the past:

› Rural Surveys Regular Diet and Nutritional

assessment surveys were carried out in the

rural areas on a continuous basis. > Time Trends Considering the surveys carried out during
1975-79 as baseline, first repeat survey was carried out during 1988-89 and the second
repeat survey was carried out during 1996-97, by covering the same villages surveyed at
baseline.
Evaluation of Nutrition Intervention programs Applied Nutrition programme in the States of

Kerala, Uttar Pradesh, Maharashtra, Orissa,

Himachal Pradesh, and Manipur (1977-78).

› Vitamin A prophylaxis programme in the States of Andhra Pradesh, Gujarat, Karnataka,

Kerala, Orissa, Rajasthan, and West Bengal

(1977-78). Supplementary Nutrition Programme in Urban Karnataka (1980-81)

World Food Programme assisted supplementary Nutrition Programme in Bihar Gujarat,
Kerala, Madhya Pradesh, Maharashtra, Orissa, Rajasthan, Uttar Pradesh and West Bengal
(1981-82)

› Integrated Child Development Services -

Status Appraisal in the States of Andhra

Pradesh, Bihar, Madhya Pradesh and Orissa

(1992) Impact Evaluation of mid-day meal programme in the States of Andhra Pradesh,
Gujarat, Tamil Nadu, Orissa, Karnataka and Kerala (1991-92).
THE MAJOR NUTRITION PROBLEMS PREVAILING IN INDIA

The major nutrition problems of India can be classified as follows:- (1) Under-nutrition
resulting in

(a) Protein Energy Malnutrition (PEM)

(b) Iron deficiency

(c) Iodine deficiency

(d) Vit. "A" deficiency

(e) Low Birth Weight Children.

(2) Seasonal dimensions of Nutrition.

(3) Natural calamities & the landless. (4) Market Distortion and Disinformation.

(5) Urbanization.

no (6) Special Nutritional Problems of Hill People, Industrial Workers, Migrant Workers, and
other special categories.

(7) Problems of overnutrition, overweight and obesity for a small section of trong urban
population. For India and much of the Third World, nutrition status is characterised by
varying degrees of under nutrition for women and children.

(1) Under-nutrition Resulting in :

1.1 PEM: Protein Energy Malnutrition is the most widespread form of malnutrition among
pre-school children of our country. A majority of them suffer from varying
grades of malnutrition. As many as 43.8 % children suffer from moderate degress of PEM
and 8.71% suffer from severe extreme forms of malnutrition. The prevalence of malnutrition
in children as reported in various survey reports is given in Table Surveys conducted
between 1975 and 1990 indicated that the percentage of normal children (for both the series
pooled) has increased from 5.9% to 9.9% while the moderate form of malnutrition declined
from 47.5% to 43,8%. The percentage of severely malnourished children declined from 15%
to 8.7% (Table 2.1) the child population of urban slums had the lowest proportion of children
with normal body weight and recorded the highest proportion of severely malnourished
children (Table Between 1975 and 1990, increase in the percentage of normal children was
appreciable in all the States, except Karnataka and Orissa, where the increase was marginal
as shown in Table 2.1 The percentage of severely malnourished children in the States of
Gujarat and Madhya Pradesh failed to show any marked upward 2.1) trend.

Based on NCHS standards National Nutrition Monitoring Bureau Report of Repeat Surveys
(1988-90) published by National Institute of Nutrition Council of Medical Research,
Hyderabad.

Source:

1.2 Iron Deficiency-Nutritional Anemia: Nutritional anemia among the school children and
expectant and nursing mothers is one of the major preventable pre- health problems in India.
It has been estimated in various studies, particularly those conducted by NIN, that roughly
56 per cent pre-school children and almost 50 per cent of the expectant mothers in the third
trimester of pregnancy suffer from iron
deficiency, which is basically due to inadequate or poor absorption of iron from a
predominantly cereal-based diet. Low iron intake, coupled with hookworm infestation and
infections, further aggravates the problem. According to NNMB Report of repeat surveys
(1989-90), between 1975 and 1990, a marginal decline to 1.8 mg/cu was observed in the
mean Iron intake at an over-all level. During 1989- 90, the intakes were above the RDI levels
in only Karnataka, Maharashtra, Gurjarat and Madhya Pradesh.

1.3 Iodine Deficiency Disorder: In India, nearly 40 million persons are estimated to be
suffering from goitre and 145 million are living in the known goitre endemic regions. The
prevalence of goitre in these endemic regions ranges from 1.5 per cent in Assam (Cachar
Distt.) to 68.9% in Mizoram. it is also estimated that 2.2 million children are afflicted with
cretinism and about 6.6 million are mildly retarded and suffer from varied degrees of motor
handicaps. It is estimated that iodine deficiency also accounts for 90,000 still births and neo-
natal deaths every year.

1.4 Vitamin 'A' Deficiency: Nutritional blindness affects to over seven million children in India
per year that results mainly from the deficiency of Vitamin A coupled with protein energy
malnutrition. In its severest form, it often results in loss of vision and it has been estimated
that around 60,000 children become blind every year (Source, NIPCCD: Situational Analysis
of children: March 1989). Vitamin A deficiency is assessed on the basis of conjuctival xerosis
and Bitot's spot. A study of NNMB has indicated that while there were no manifestations of
Vitamin A deficiency in infants, its prevalence increased with age (Table Further, a higher
prevalence was seen in school age children in all the income groups. In the urban areas it
was the highest among slum children (7.8%), followed by industrial labour (6.3%), the middle
income group (4.7%) and the low income group (4.1%) According to NNMB (1990), in none
of the states was the average intake comparable to the recommended level

Figures indicated are the median values of the prevalence levels in the surveyed Sources:
Rao, N, Pralahad and Gowrinath, S.J. Diet and Nutrition Profile in Ten aid states of India
over a Decade in the implementation of a National Nutrition Policy

bestates.

in India, October 28-30, 1985, Srinagar.

1.5 Prevalence of Low Birth Weight Children: The prevalence of low birth weight children is
still unacceptably high for India. The nutritional status is closely related to material nutritional
status during pregnancy and infancy. In India, 30%
of all the infants born are low birth weight babies (Weight less than 2500 gms.) and this
pattern is almost constant since 1979, An ICMR study reported that the average birth weight
ranged between 2.5 and 2.6 kg and the prevalence of low birth weight ranged between 26
and 57 per cent in the urban slums and 35 to 41 per cent in the rural communities. This is a
matter of concern since 90 per cent of the deaths occur among infants with birth weight
below 2000 gms. Low birth weight was found to be connected with several factors such as
age of the mother, maternal weight gain during pregnancy, interpregnancy interval,
haemoglobin less than 8 gms percent and maternal illiteracy.

Keeping in view the fact that birth weight is the most important determinant of child survival
and that the material nutritional status is the most decisive factor in preventing low birth
weight, the National Health Policy has set a goal of bringing down the incidence of low birth
weight by 10 per cent and the present maternal mortality rate from existing rate of 4 per
1000 to 2 per 1000 live births by 2000 A.D. It was found by the NNMB in 1989 that in State
of Karnataka, consumption of energy by women was the highest, i.e., 2792 k calories, as
compared to that of other States, viz. West Bengal (2580 k calories) and Orissa (2468 k
calories). In the rest of the States, the consumption of calories was less than the
recommended 2400 k calories. Women face high risks of malnutrition and disease at all the
three critical stages,

viz.. infancy and childhood, adolescence and reproductive phase. Child mortality rate is high
in female children than males. This is perhaps indicative of social prejudices leading to
neglect of female babies. When the girls attain adolescence, they go through a second spurt
of growth and their bodies grow much more rapidly to prepare them for child bearing. But,

unfortunately, the intake of nutrients during this period is significantly low.

1.6 Endemic Fluorosis: Due to excessive amounts of fluorine in drinking water, endemic
fluorosis has been reported to be an important health problem in certain parts of India, e.g.,
Andhra Pradesh, Punjab, Haryana, Kerala and Tamil Nadu. Toxic manifestation of fluorosis
comprise dental fluorosis, skeletal fluorosis and genu valgum. Fluorosis of dental enamel
occurs when excess fruoride is ingested during the year of tooth calcification. It is
characterised by mottling of dental enamel. The teeth lose their shiny appearance and chalk
white patches develop on them. In skeletal fluorosis, there is heavy fluoride deposition in the
skeleton. When its concentration exceeds 10 mg/h it leads to crippling fluorosis and
permanent disability. Genu valgum is a new form of fluorosis characterised by osteoporosis
of the lower limbs and it has been reported in Andhra pradesh and Tamil nadu where staple
food was sorghum (Jowar).

1.7 Lathyrism: Lathyrism is a paralysing disease of humans and animals. In humans, it is

referred to as neurolathyrism, crippling disease of the nervous system characterised by
gradually developing spastic paralysis of lower limbs. This disease occurs in adults who
consume the pulse Lathyrus sativus, commonly known as 'khesari dhal'. Seeds of Lathyrus
are triangular and grey in colour. When dehusked,, the pulse looks similar to red gram dhal.
This pulse is good source of protein but its toxin affects the nerves. This toxin has been
identified as Beta oxalyl amine alanine (BOAA) which is soluble in water. This property has
been made use in removing the toxin from pulse by soaking it in hot water and throwing the
soak water.

2. Seasonal Dimensions- In the duality of the Indian situation, where high- yielding modern
agriculture co-exists with rain-fed subsistence farming, there are serious seasonal
dimensions of the nutrition question. In large parts of India, the
rainy months are the worst months for the rural, landless poor. This is when cultivation,
deseeding, ploughing and other works demand maximum energy from them, while food
stocks at home dwindle and market prices rise. These are the months when water-borne
diseases are so frequent. This condition goes on aggravating till late October or even
November. These are the months of rural indebtedness and compulsive market involvement
of the landless and the small/ marginal cultivators. When the first Kharif harvest arrives, the
situation is no better with wide spread distress sales by the small/marginal farmers. All these
make nutrition a casualty during this period. Seasonality of employment in subsistence
agriculture affects nutrition through the double jeopardy of high energy demand of peak work
seasons and fluctuation in household level food availability, which tend to exacerbate
differential food intake among men, women and children. As a result, in very poor
households, women & children may actually fall below the survival line during lean periods.

NATIONAL NUTRITIONAL POLICY (NNP)

3. Natural Calamities & Nutrition- This same group of rural landless poor is most vulnerable
to droughts, floods and famines. As has been established in famine periods, worst affected
groups are the landless agricultural labourers, artisans, craftsmen and non-agricultural
labourers in that order.

4. Market Distortion & Disinformation- A striking feature which has now

been established is that famines are caused not so much by any poverty of these marginal
groups who compulsively depend on the market (landless labourers, etc.). In fact, lesions
from all over the world have proved that it is not only substantial food shortage, but the
psychosis of food shortage and widespread belief regarding crop failure that triggers off price
rise spirals resulting in major malnutrition situations.

5. Urbanisation- Under-nutrition in urban areas is a major area of concern. Studies by NNMB

have actually shown that the nutritional status of urban slum dwellers in India is almost as
bad as that of rural poor. This is borne out both by figures relating to intake of food (Table
2.1) as well as intake of nutrients (Table 2.2 & 2.3). The deleterious effects of rural urban
movements on nutrition, in much of the third world, is quite well known. The children of urban
slum dwellers and of the urban informal sector are nutritionally the most fragile of all groups.
Uncertainty of income and the absence of informal nutritional support system within society,
so common to rural areas of India, place many of these families on the very edge of survival.
The fallout of a spreading urban culture, which encourages diversion of high proportion of
family expenditure to luxury goods & entertainment, aggravates the situation. Poor sanitary
conditions, acute respiratory infections and communicable diseases characterize these
urban settlements.

6. There are some regional and occupational specificities of the problems of nutrition. The
nutritional imbalance of hill people engaged in very strenuous labour, the special nutritional
problems of some categories of industrial workers and migrant workmen are other examples
which need a detailed and specific response.

7. With the burgeoning size of Indian middle class, overnutrition with attendants of
cardiovascular problems and other health hazards are affecting large number of people
particularly in the cities.